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How to how to buy cheap lasix online cite this article:Singh OP is salix the same as lasix. The National Commission for Allied and Healthcare Professions Act, 2020 and its implication for mental health. Indian J how to buy cheap lasix online Psychiatry 2021;63:119-20The National Commission for Allied and Healthcare Professions Act, 2020 has been notified on March 28, 2021, by the Gazette of India published by the Ministry of Law and Justice.

This bill aims to “provide for regulation and maintenance of standards of education and services by allied and healthcare professionals, assessment of institutions, maintenance of a Central Register and State Register and creation of a system to improve access, research and development and adoption of latest scientific advancement and for matters connected therewith or incidental thereto.”[1]This act has created a category of Health Care Professionals which is defined as. €œhealthcare professional” includes a scientist, therapist, or other professional who studies, advises, researches, supervises or provides preventive, curative, rehabilitative, therapeutic or promotional health services and who has obtained any qualification of degree under this Act, the duration of which shall not be <3600 h spread over a period of 3 years to 6 years divided into specific semesters.[1]According to the act, “Allied health professional” includes an associate, technician, or technologist who is trained to perform any technical and practical task to support diagnosis and treatment of illness, disease, injury or impairment, and to support implementation of any healthcare treatment and referral plan recommended by a medical, nursing, or any other healthcare professional, and who has obtained any how to buy cheap lasix online qualification of diploma or degree under this Act, the duration of which shall not be less than 2000 h spread over a period of 2 years to 4 years divided into specific semesters.”[1]It is noticeable that while the term “Health Care Professionals” does not include doctors who are registered under National Medical Council, Mental Health Care Act (MHCA), 2017 includes psychiatrists under the ambit of Mental Health Care Professionals.[2] This discrepancy needs to be corrected - psychiasts, being another group of medical specialists, should be kept out of the broad umbrella of “Mental Healthcare Professionals.”The category of Behavioural Health Sciences Professional has been included and defined as “a person who undertakes scientific study of the emotions, behaviours and biology relating to a person's mental well-being, their ability to function in everyday life and their concept of self. €œBehavioural health” is the preferred term to “mental health” and includes professionals such as counselors, analysts, psychologists, educators and support workers, who provide counseling, therapy, and mediation services to individuals, families, groups, and communities in response to social and personal difficulties.”[1]This is a welcome step to the extent that it creates a diverse category of trained workforce in the field of Mental Health (Behavioural Health Science Professionals) and tries to regulate their training although it mainly aims to promote mental wellbeing.

However there how to buy cheap lasix online is a huge lacuna in the term of “Mental Illness” as defined by MHCA, 2017. Only severe disorders are included as per definition and there is no clarity regarding inclusion of other psychiatric disorders, namely “common mental disorders” such as anxiety and depression. This leaves a strong possibility of concept of “psychiatric illnesses” being limited to only “severe psychiatric disorders” (major psychoses) thus perpetuating the stigma and alienation associated with psychiatric how to buy cheap lasix online patients for centuries.

Psychiatrists being restricted to treating severe mental disorders as per MHCA, 2017, there is a strong possibility that the care of common mental disorders may gradually pass on under the care of “behavioural health professionals” as per the new act!. There is need to look into this aspect by the leadership in psychiatry, both organizational and academic psychiatry, and how to buy cheap lasix online reduce the contradictions between the MHCA, 2017 and this nascent act. All disorders classified in ICD 10 and DSM 5 should be classified as “Psychiatric Disorders” or “Mental Illness.” This will not only help in fighting the stigma associated with psychiatric illnesses but also promote the integration of psychiatry with other specialties.

References 1.The how to buy cheap lasix online National Commission for Allied and Healthcare Professions Act, 2021. The Gazette of India. Published by Ministry of Law and how to buy cheap lasix online Justice.

28 March, 2021. 2.The Mental Healthcare Act, how to buy cheap lasix online 2017. The Gazette of India.

Published by Ministry of Law and how to buy cheap lasix online Justice. April 7, 2017. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - how to buy cheap lasix online 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_268_21Abstract Thiamine is essential for the activity of how to buy cheap lasix online several enzymes associated with energy metabolism in humans.

Chronic alcohol use is associated with deficiency of thiamine along with other vitamins through several mechanisms. Several neuropsychiatric syndromes how to buy cheap lasix online have been associated with thiamine deficiency in the context of alcohol use disorder including Wernicke–Korsakoff syndrome, alcoholic cerebellar syndrome, alcoholic peripheral neuropathy, and possibly, Marchiafava–Bignami syndrome. High-dose thiamine replacement is suggested for these neuropsychiatric syndromes.Keywords.

Alcohol use disorder, alcoholic cerebellar syndrome, alcoholic peripheral neuropathy, Marchiafava–Bignami syndrome, thiamine, Wernicke–Korsakoff syndromeHow to how to buy cheap lasix online cite this article:Praharaj SK, Munoli RN, Shenoy S, Udupa ST, Thomas LS. High-dose thiamine strategy in Wernicke–Korsakoff syndrome and related thiamine deficiency conditions associated with alcohol use disorder. Indian J Psychiatry 2021;63:121-6How to cite this URL:Praharaj SK, Munoli how to buy cheap lasix online RN, Shenoy S, Udupa ST, Thomas LS.

High-dose thiamine strategy in Wernicke–Korsakoff syndrome and related thiamine deficiency conditions associated with alcohol use disorder. Indian J Psychiatry [serial online] how to buy cheap lasix online 2021 [cited 2021 May 15];63:121-6. Available from.

Https://www.indianjpsychiatry.org/text.asp?. 2021/63/2/121/313716 Introduction Thiamine is a water-soluble vitamin (B1) that plays a key role in the activity of several enzymes associated with energy metabolism. Thiamine pyrophosphate (or diphosphate) is the active form that acts as a cofactor for enzymes.

The daily dietary requirement of thiamine in adults is 1–2 mg and is dependent on carbohydrate intake.[1],[2] The requirement increases if basal metabolic rate is higher, for example, during alcohol withdrawal state. Dietary sources include pork (being the major source), meat, legume, vegetables, and enriched foods. The body can store between 30 and 50 mg of thiamine and is likely to get depleted within 4–6 weeks if the diet is deficient.[2] In those with alcohol-related liver damage, the ability to store thiamine is gradually reduced.[1],[2]Lower thiamine levels are found in 30%–80% of chronic alcohol users.[3] Thiamine deficiency occurs due to poor intake of vitamin-rich foods, impaired intestinal absorption, decreased storage capacity of liver, damage to the renal epithelial cells due to alcohol, leading to increased loss from the kidneys, and excessive loss associated with medical conditions.[2],[3] Furthermore, alcohol decreases the absorption of colonic bacterial thiamine, reduces the enzymatic activity of thiamine pyrophosphokinase, and thereby, reducing the amount of available thiamine pyrophosphate.[4] Since facilitated diffusion of thiamine into cells is dependent on a concentration gradient, reduced thiamine pyrophosphokinase activity further reduces thiamine uptake into cells.[4] Impaired utilization of thiamine is seen in certain conditions (e.g., hypomagnesemia) which are common in alcohol use disorder.[2],[3],[4] This narrative review discusses the neuropsychiatric syndromes associated with thiamine deficiency in the context of alcohol use disorder, and the treatment regimens advocated for these conditions.

A PubMed search supplemented with manual search was used to identify neuropsychiatric syndromes related to thiamine deficiency in alcohol use disorder patients. Neuropsychiatric Syndromes Associated With Thiamine Deficiency Wernicke–Korsakoff syndromeWernicke encephalopathy is associated with chronic alcohol use, and if not identified and treated early, could lead to permanent brain damage characterized by an amnestic syndrome known as Korsakoff syndrome. Inappropriate treatment of Wernicke encephalopathy with lower doses of thiamine can lead to high mortality rates (~20%) and Korsakoff syndrome in ~ 80% of patients (ranges from 56% to 84%).[5],[6] The classic triad of Wernicke includes oculomotor abnormalities, cerebellar dysfunction, and confusion.

Wernicke lesions are found in 12.5% of brain samples of patients with alcohol dependence.[7] However, only 20%–30% of them had a clinical diagnosis of Wernicke encephalopathy antemortem. It has been found that many patients develop Wernicke–Korsakoff syndrome (WKS) following repeated subclinical episodes of thiamine deficiency.[7] In an autopsy report of 97 chronic alcohol users, only16% had all the three “classical signs,” 29% had two signs, 37% presented with one sign, and 19% had none.[8] Mental status changes are the most prevalent sign (seen in 82% of the cases), followed by eye signs (in 29%) and ataxia (23%).[8] WKS should be suspected in persons with a history of alcohol use and presenting with signs of ophthalmoplegia, ataxia, acute confusion, memory disturbance, unexplained hypotension, hypothermia, coma, or unconsciousness.[9] Operational criteria for the diagnosis of Wernicke encephalopathy have been proposed by Caine et al.[10] that requires two out of four features, i.e., (a) dietary deficiency (signs such as cheilitis, glossitis, and bleeding gums), (b) oculomotor abnormalities (nystagmus, opthalmoplegia, and diplopia), (c) cerebellar dysfunction (gait ataxia, nystagmus), and (d) either altered mental state (confusion) or mild memory impairment.As it is very difficult to clinically distinguish Wernicke encephalopathy from other associated conditions such as delirium tremens, hepatic encephalopathy, or head injury, it is prudent to have a lower threshold to diagnose this if any of the clinical signs is seen. Magnetic resonance imaging (MRI) brain scan during Wernicke encephalopathy shows mammillary body atrophy and enlarged third ventricle, lesions in the medial portions of thalami and mid brain and can be used to aid diagnosis.[11],[12] However, most clinical situations warrant treatment without waiting for neuroimaging report.

The treatment suggestions in the guidelines vary widely. Furthermore, hardly any evidence-based recommendations exist on a more general use of thiamine as a preventative intervention in individuals with alcohol use disorder.[13] There are very few studies that have evaluated the dose and duration of thiamine for WKS, but higher doses may result in a greater response.[6],[14] With thiamine administration rapid improvement is seen in eye movement abnormalities (improve within days or weeks) and ataxia (may take months to recover), but the effects on memory, in particular, are unclear.[4],[14] Severe memory impairment is the core feature of Korsakoff syndrome. Initial stages of the disease can present with confabulation, executive dysfunction, flattened affect, apathy, and poor insight.[15] Both the episodic and semantic memory are affected, whereas, procedural memory remains intact.[15]Thomson et al.[6] suggested the following should be treated with thiamine as they are at high risk for developing WKS.

(1) all patients with any evidence of chronic alcohol misuse and any of the following. Acute confusion, decreased conscious level, ataxia, ophthalmoplegia, memory disturbance, and hypothermia with hypotension. (2) patients with delirium tremens may often also have Wernicke encephalopathy, therefore, all of these patients should be presumed to have Wernicke encephalopathy and treated, preferably as inpatients.

And (3) all hypoglycemic patients (who are treated with intravenous glucose) with evidence of chronic alcohol ingestion must be given intravenous thiamine immediately because of the risk of acutely precipitating Wernicke encephalopathy.Alcoholic cerebellar syndromeChronic alcohol use is associated with the degeneration of anterior superior vermis, leading to a clinical syndrome characterized by the subacute or chronic onset of gait ataxia and incoordination in legs, with relative sparing of upper limbs, speech, and oculomotor movements.[16] In severe cases, truncal ataxia, mild dysarthria, and incoordination of the upper limb is also found along with gait ataxia. Thiamine deficiency is considered to be the etiological factor,[17],[18] although direct toxic effects of alcohol may also contribute to this syndrome. One-third of patients with chronic use of alcohol have evidence of alcoholic cerebellar degeneration.

However, population-based studies estimate prevalence to be 14.6%.[19] The effect of alcohol on the cerebellum is graded with the most severe deficits occurring in alcohol users with the longest duration and highest severity of use. The diagnosis of cerebellar degeneration is largely clinical. MRI can be used to evaluate for vermian atrophy but is unnecessary.[20] Anterior portions of vermis are affected early, with involvement of posterior vermis and adjacent lateral hemispheres occurring late in the course could be used to differentiate alcoholic cerebellar degeneration from other conditions that cause more diffuse involvement.[21] The severity of cerebellar syndrome is more in the presence of WKS, thus could be related to thiamine deficiency.[22],[23] Therefore, this has been considered as a cerebellar presentation of WKS and should be treated in a similar way.[16] There are anecdotal evidence to suggest improvement in cerebellar syndrome with high-dose thiamine.[24]Alcoholic peripheral neuropathyPeripheral neuropathy is common in alcohol use disorder and is seen in 44% of the users.[25] It has been associated predominantly with thiamine deficiency.

However, deficiency of other B vitamins (pyridoxine and cobalamin) and direct toxic effect of alcohol is also implicated.[26] Clinically, onset of symptoms is gradual with the involvement of both sensory and motor fibers and occasionally autonomic fibers. Neuropathy can affect both small and large peripheral nerve fibers, leading to different clinical manifestations. Thiamine deficiency-related neuropathy affects larger fiber types, which results in motor deficits and sensory ataxia.

On examination, large fiber involvement is manifested by distal limb muscle weakness and loss of proprioception and vibratory sensation. Together, these can contribute to the gait unsteadiness seen in chronic alcohol users by creating a superimposed steppage gait and reduced proprioceptive input back to the movement control loops in the central nervous system. The most common presentations include painful sensations in both lower limbs, sometimes with burning sensation or numbness, which are early symptoms.

Typically, there is a loss of vibration sensation in distal lower limbs. Later symptoms include loss of proprioception, gait disturbance, and loss of reflexes. Most advanced findings include weakness and muscle atrophy.[20] Progression is very gradual over months and involvement of upper limbs may occur late in the course.

Diagnosis begins with laboratory evaluation to exclude other causes of distal, sensorimotor neuropathy including hemoglobin A1c, liver function tests, and complete blood count to evaluate for red blood cell macrocytosis. Cerebrospinal fluid studies may show increased protein levels but should otherwise be normal in cases of alcohol neuropathy and are not recommended in routine evaluation. Electromyography and nerve conduction studies can be used to distinguish whether the neuropathy is axonal or demyelinating and whether it is motor, sensory, or mixed type.

Alcoholic neuropathy shows reduced distal, sensory amplitudes, and to a lesser extent, reduced motor amplitudes on nerve conduction studies.[20] Abstinence and vitamin supplementation including thiamine are the treatments advocated for this condition.[25] In mild-to-moderate cases, near-complete improvement can be achieved.[20] Randomized controlled trials have showed a significant improvement in alcoholic polyneuropathy with thiamine treatment.[27],[28]Marchiafava–Bignami syndromeThis is a rare but fatal condition seen in chronic alcohol users that is characterized by progressive demyelination and necrosis of the corpus callosum. The association of this syndrome with thiamine deficiency is not very clear, and direct toxic effects of alcohol are also suggested.[29] The clinical syndrome is variable and presentation can be acute, subacute, or chronic. In acute forms, it is predominantly characterized by the altered mental state such as delirium, stupor, or coma.[30] Other clinical features in neuroimaging confirmed Marchiafava–Bignami syndrome (MBS) cases include impaired gait, dysarthria, mutism, signs of split-brain syndrome, pyramidal tract signs, primitive reflexes, rigidity, incontinence, gaze palsy, diplopia, and sensory symptoms.[30] Neuropsychiatric manifestations are common and include psychotic symptoms, depression, apathy, aggressive behavior, and sometimes dementia.[29] MRI scan shows lesions of the corpus callosum, particularly splenium.

Treatment for this condition is mostly supportive and use of nutritional supplements and steroids. However, there are several reports of improvement of this syndrome with thiamine at variable doses including reports of beneficial effects with high-dose strategy.[29],[30],[31] Early initiation of thiamine, preferably within 2 weeks of the onset of symptoms is associated with a better outcome. Therefore, high-dose thiamine should be administered to all suspected cases of MBS.

Laboratory Diagnosis of Thiamine Deficiency Estimation of thiamine and thiamine pyrophosphate levels may confirm the diagnosis of deficiency. Levels of thiamine in the blood are not reliable indicators of thiamine status. Low erythrocyte transketolase activity is also helpful.[32],[33] Transketolase concentrations of <120 nmol/L have also been used to indicate deficiency, while concentrations of 120–150 nmol/L suggest marginal thiamine status.[1] However, these tests are not routinely performed as it is time consuming, expensive, and may not be readily available.[34] The ETKA assay is a functional test rather than a direct measurement of thiamin status and therefore may be influenced by factors other than thiamine deficiency such as diabetes mellitus and polyneuritis.[1] Hence, treatment should be initiated in the absence of laboratory confirmation of thiamine deficiency.

Furthermore, treatment should not be delayed if tests are ordered, but the results are awaited. Electroencephalographic abnormalities in thiamine deficiency states range from diffuse mild-to-moderate slow waves and are not a good diagnostic option, as the prevalence of abnormalities among patients is inconsistent.[35]Surrogate markers, which reflect chronic alcohol use and nutritional deficiency other than thiamine, may be helpful in identifying at-risk patients. This includes gamma glutamate transferase, aspartate aminotransferase.

Alanine transaminase ratio >2:1, and increased mean corpuscular volume.[36] They are useful when a reliable history of alcohol use is not readily available, specifically in emergency departments when treatment needs to be started immediately to avoid long-term consequences. Thiamine Replacement Therapy Oral versus parenteral thiamineIntestinal absorption of thiamine depends on active transport through thiamine transporter 1 and 2, which follow saturation kinetics.[1] Therefore, the rate and amount of absorption of thiamine in healthy individuals is limited. In healthy volunteers, a 10 mg dose results in maximal absorption of thiamine, and any doses higher than this do not increase thiamine levels.

Therefore, the maximum amount of thiamine absorbed from 10 mg or higher dose is between 4.3 and 5.6 mg.[37] However, it has been suggested that, although thiamine transport occurs through the energy-requiring, sodium-dependent active process at physiologic concentrations, at higher supraphysiologic concentrations thiamine uptake is mostly a passive process.[38] Smithline et al. Have demonstrated that it is possible to achieve higher serum thiamine levels with oral doses up to 1500 mg.[39]In chronic alcohol users, intestinal absorption is impaired. Hence, absorption rates are expected to be much lower.

It is approximately 30% of that seen in healthy individuals, i.e., 1.5 mg of thiamine is absorbed from 10 mg oral thiamine.[3] In those consuming alcohol and have poor nutrition, not more than 0.8 mg of thiamine is absorbed.[2],[3],[6] The daily thiamine requirement is 1–1.6 mg/day, which may be more in alcohol-dependent patients at risk for Wernicke encephalopathy.[1] It is highly likely that oral supplementation with thiamine will be inadequate in alcohol-dependent individuals who continue to drink. Therefore, parenteral thiamine is preferred for supplementation in deficiency states associated with chronic alcohol use. Therapy involving parenteral thiamine is considered safe except for occasional circumstances of allergic reactions involving pruritus and local irritation.There is a small, but definite risk of anaphylaxis with parenteral thiamine, specifically with intravenous administration (1/250,000 intravenous injections).[40] Diluting thiamine in 50–100 mg normal saline for infusion may reduce the risk.

However, parenteral thiamine should always be administered under observation with the necessary facilities for resuscitation.A further important issue involves the timing of administration of thiamine relative to the course of alcohol abuse or dependence. Administration of thiamine treatment to patients experiencing alcohol withdrawal may also be influenced by other factors such as magnesium depletion, N-methyl-D-aspartate (NMDA) receptor upregulation, or liver impairment, all of which may alter thiamine metabolism and utilization.[6],[14]Thiamine or other preparations (e.g., benfotiamine)The thiamine transporters limit the rate of absorption of orally administered thiamine. Allithiamines (e.g., benfotiamine) are the lipid-soluble thiamine derivatives that are absorbed better, result in higher thiamine levels, and are retained longer in the body.[41] The thiamine levels with orally administered benfotiamine are much higher than oral thiamine and almost equals to intravenous thiamine given at the same dosage.[42]Benfotiamine has other beneficial effects including inhibition of production of advanced glycation end products, thus protecting against diabetic vascular complications.[41] It also modulates nuclear transcription factor κB (NK-κB), vascular endothelial growth factor receptor 2, glycogen synthase kinase 3 β, etc., that play a role in cell repair and survival.[41] Benfotiamine has been found to be effective for the treatment of alcoholic peripheral neuropathy.[27]Dosing of thiamineAs the prevalence of thiamine deficiency is very common in chronic alcohol users, the requirement of thiamine increases in active drinkers and it is difficult to rapidly determine thiamine levels using laboratory tests, it is prudent that all patients irrespective of nutritional status should be administered parenteral thiamine.

The dose should be 100 mg thiamine daily for 3–5 days during inpatient treatment. Commonly, multivitamin injections are added to intravenous infusions. Patients at risk for thiamine deficiency should receive 250 mg of thiamine daily intramuscularly for 3–5 days, followed by oral thiamine 100 mg daily.[6]Thiamine plasma levels reduce to 20% of peak value after approximately 2 h of parenteral administration, thus reducing the effective “window period” for passive diffusion to the central nervous system.[6] Therefore, in thiamine deficient individuals with features of Wernicke encephalopathy should receive thiamine thrice daily.High-dose parenteral thiamine administered thrice daily has been advocated in patients at risk for Wernicke encephalopathy.[43] The Royal College of Physicians guideline recommends that patients with suspected Wernicke encephalopathy should receive 500 mg thiamine diluted in 50–100 ml of normal saline infusion over 30 min three times daily for 2–3 days and sometimes for longer periods.[13] If there are persistent symptoms such as confusion, cerebellar symptoms, or memory impairment, this regimen can be continued until the symptoms improve.

If symptoms improve, oral thiamine 100 mg thrice daily can be continued for prolonged periods.[6],[40] A similar treatment regimen is advocated for alcoholic cerebellar degeneration as well. Doses more than 500 mg intramuscular or intravenous three times a day for 3–5 days, followed by 250 mg once daily for a further 3–5 days is also recommended by some guidelines (e.g., British Association for Psychopharmacology).[44]Other effects of thiamineThere are some data to suggest that thiamine deficiency can modulate alcohol consumption and may result in pathological drinking. Benfotiamine 600 mg/day as compared to placebo for 6 months was well tolerated and found to decrease psychiatric distress in males and reduce alcohol consumption in females with severe alcohol dependence.[45],[46] Other Factors During Thiamine Therapy Correction of hypomagnesemiaMagnesium is a cofactor for many thiamine-dependent enzymes in carbohydrate metabolism.

Patients may fail to respond to thiamine supplementation in the presence of hypomagnesemia.[47] Magnesium deficiency is common in chronic alcohol users and is seen in 30% of individuals.[48],[49] It can occur because of increased renal excretion of magnesium, poor intake, decreased absorption because of Vitamin D deficiency, the formation of undissociated magnesium soaps with free fatty acids.[48],[49]The usual adult dose is 35–50 mmol of magnesium sulfate added to 1 L isotonic (saline) given over 12–24 h.[6] The dose has to be titrated against plasma magnesium levels. It is recommended to reduce the dose in renal failure. Contraindications include patients with documented hypersensitivity and those with heart block, Addison's disease, myocardial damage, severe hepatitis, or hypophosphatemia.

Do not administer intravenous magnesium unless hypomagnesemia is confirmed.[6]Other B-complex vitaminsMost patients with deficiency of thiamine will also have reduced levels of other B vitamins including niacin, pyridoxine, and cobalamin that require replenishment. For patients admitted to the intensive care unit with symptoms that may mimic or mask Wernicke encephalopathy, based on the published literature, routine supplementation during the 1st day of admission includes 200–500 mg intravenous thiamine every 8 h, 64 mg/kg magnesium sulfate (≈4–5 g for most adult patients), and 400–1000 μg intravenous folate.[50] If alcoholic ketoacidosis is suspected, dextrose-containing fluids are recommended over normal saline.[50] Precautions to be Taken When Administering Parenteral Thiamine It is recommended to monitor for anaphylaxis and has appropriate facilities for resuscitation and for treating anaphylaxis readily available including adrenaline and corticosteroids. Anaphylaxis has been reported at the rate of approximately 4/1 million pairs of ampoules of Pabrinex (a pair of high potency vitamins available in the UK containing 500 mg of thiamine (1:250,000 I/V administrations).[40] Intramuscular thiamine is reported to have a lower incidence of anaphylactic reactions than intravenous administration.[40] The reaction has been attributed to nonspecific histamine release.[51] Administer intravenous thiamine slowly, preferably by slow infusion in 100 ml normal saline over 15–30 min.

Conclusions Risk factors for thiamine deficiency should be assessed in chronic alcohol users. A high index of suspicion and a lower threshold to diagnose thiamine deficiency states including Wernicke encephalopathy is needed. Several other presentations such as cerebellar syndrome, MBS, polyneuropathy, and delirium tremens could be related to thiamine deficiency and should be treated with protocols similar to Wernicke encephalopathy.

High-dose thiamine is recommended for the treatment of suspected Wernicke encephalopathy and related conditions [Figure 1]. However, evidence in terms of randomized controlled trials is lacking, and the recommendations are based on small studies and anecdotal reports. Nevertheless, as all these conditions respond to thiamine supplementation, it is possible that these have overlapping pathophysiology and are better considered as Wernicke encephalopathy spectrum disorders.Figure 1.

Thiamine recommendations for patients with alcohol use disorder. AHistory of alcohol use, but no clinical features of WE. BNo clinical features of WE, but with risk factors such as complicated withdrawal (delirium, seizures).

CClinical features of WE (ataxia, opthalmoplegia, global confusion)Click here to viewFinancial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Frank LL. Thiamin in clinical practice.

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38.Hoyumpa AM Jr., Strickland R, Sheehan JJ, Yarborough G, Nichols S. Dual system of intestinal thiamine transport in humans. J Lab Clin Med 1982;99:701-8.

39.Smithline HA, Donnino M, Greenblatt DJ. Pharmacokinetics of high-dose oral thiamine hydrochloride in healthy subjects. BMC Clin Pharmacol 2012;12:4.

40.Latt N, Dore G. Thiamine in the treatment of Wernicke encephalopathy in patients with alcohol use disorders. Intern Med J 2014;44:911-5.

41.Raj V, Ojha S, Howarth FC, Belur PD, Subramanya SB. Therapeutic potential of benfotiamine and its molecular targets. Eur Rev Med Pharmacol Sci 2018;22:3261-73.

42.Xie F, Cheng Z, Li S, Liu X, Guo X, Yu P, et al. Pharmacokinetic study of benfotiamine and the bioavailability assessment compared to thiamine hydrochloride. J Clin Pharmacol 2014;54:688-95.

43.Cook CC, Hallwood PM, Thomson AD. B Vitamin deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol Alcohol 1998;33:317-36.

44.Lingford-Hughes AR, Welch S, Peters L, Nutt DJ, British Association for Psychopharmacology, Expert Reviewers Group. BAP updated guidelines. Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity.

Recommendations from BAP. J Psychopharmacol 2012;26:899-952. 45.Manzardo AM, He J, Poje A, Penick EC, Campbell J, Butler MG.

Double-blind, randomized placebo-controlled clinical trial of benfotiamine for severe alcohol dependence. Drug Alcohol Depend 2013;133:562-70. 46.Manzardo AM, Pendleton T, Poje A, Penick EC, Butler MG.

Change in psychiatric symptomatology after benfotiamine treatment in males is related to lifetime alcoholism severity. Drug Alcohol Depend 2015;152:257-63. 47.Dingwall KM, Delima JF, Gent D, Batey RG.

Hypomagnesaemia and its potential impact on thiamine utilisation in patients with alcohol misuse at the Alice Springs Hospital. Drug Alcohol Rev 2015;34:323-8. 48.Flink EB.

Magnesium deficiency in alcoholism. Alcohol Clin Exp Res 1986;10:590-4. 49.Grochowski C, Blicharska E, Baj J, Mierzwińska A, Brzozowska K, Forma A, et al.

Serum iron, magnesium, copper, and manganese levels in alcoholism. A systematic review. Molecules 2019;24:E1361.

50.Flannery AH, Adkins DA, Cook AM. Unpeeling the evidence for the banana bag. Evidence-based recommendations for the management of alcohol-associated vitamin and electrolyte deficiencies in the ICU.

Crit Care Med 2016;44:1545-52. 51.Lagunoff D, Martin TW, Read G. Agents that release histamine from mast cells.

Annu Rev Pharmacol Toxicol 1983;23:331-51. Correspondence Address:Samir Kumar PraharajDepartment of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_440_20 Figures [Figure 1].

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This is a collaboration http://www.em-hangenbieten.ac-strasbourg.fr/?page_id=984 between KHN and “Science Friday.” Listen to the conversation between KHN senior correspondent Christina Jewett and Science Friday’s host lasix allergy and executive producer, Ira Flatow. As students return to school, parents are getting a lot of mail about what schools are doing to better protect kids in the classroom — including details on mask policies and how kids will sit at lunch. One item on many administrators’ lasix allergy lists of protective measures is improving ventilation in the classroom.

Many studies have shown that better ventilation and air circulation can greatly reduce hypertension medications transmission. But rather than stocking up on HEPA filters, some school districts are turning to high-tech air purification strategies, including the use of untested electronic methods and airborne chemicals. KHN has written extensively about school air fiation lasix allergy.

Senior correspondent Christina Jewett joins Ira Flatow to explain why some air-quality experts are less than convinced by the marketing claims made by many electronic air purifier companies. Don’t miss the simple snail-mail hack Jewett shares to gauge whether the device your school is using might be of concern. Related Topics Contact Us Submit a Story TipA Florida orthopedic surgeon and designer of costly spinal surgery implants was arrested Tuesday and charged with paying lasix allergy millions of dollars in kickbacks and bribes to surgeons who agreed to use his company’s devices.

Dr. Kingsley R. Chin, 57, lasix allergy of Fort Lauderdale, Florida, is the founder, chief executive officer and owner of SpineFrontier, a device company based in Malden, Massachusetts.

He and the company’s chief financial officer, Aditya Humad, 36, of Cambridge, Massachusetts, were each indicted on one count of conspiring to violate federal anti-kickback laws, six counts of violating the kickback statute and one count of conspiracy to commit money laundering, officials said. The indictment alleges that SpineFrontier, Chin and Humad paid surgeons between $250 and $1,000 per hour in sham consulting fees for work they did not perform. In exchange, lasix allergy the surgeons agreed to use SpineFrontier’s products in operations paid for by federal health care programs such as Medicare and Medicaid.

Surgeons accepted between $32,625 and $978,000 in improper payments, according to the indictment. €œKickback arrangements pollute federal health care programs and take advantage of patient needs for financial gains,” said Nathaniel Mendell, acting U.S. Attorney for lasix allergy the District of Massachusetts.

€œMedical device manufacturers must play by the rules, and we will keep pursuing those who fail to do so, regardless of how their corruption is disguised.” Chin and SpineFrontier were the subjects of a KHN investigation published in June that found that manufacturers of hardware for spinal implants, artificial knees and hip joints had paid more than $3.1 billion to orthopedic and neurosurgeons from August 2013 through 2019. These surgeons collected more than half a billion dollars in industry consulting fees, federal payment records show. Chin, a self-styled “doctorpreneur,” formed SpineFrontier about a decade after completing his training at lasix allergy Harvard Medical School.

Chin has patented dozens of pieces of spine surgery hardware, such as doughnut-shaped plastic cages, titanium screws and other products that generated some $100 million in sales for SpineFrontier, according to government officials. In 2018, SpineFrontier valued Chin’s ownership of the company at $75 million, though its current worth is unclear. He maintains a medical lasix allergy practice in Hollywood, Florida.

Neither Chin nor Humad could be reached for comment Tuesday. [embedded content] Seth Orkand, a Boston attorney who represents Humad, said his client lasix allergy “denies all charges, and looks forward to his day in court.” The Department of Justice filed a civil lawsuit against Chin and SpineFrontier in March 2020, accusing the company of illegally funneling more than $8 million to nearly three dozen spine surgeons through the “sham” consulting fees. Chin and SpineFrontier have yet to file a response to that suit.

However, at least six surgeons have admitted wrongdoing in the civil case and paid a total of $3.3 million in penalties. Another, Dr lasix allergy. Jason Montone, 45, of Lawson, Missouri, pleaded guilty to criminal kickback charges and is set to be sentenced early next year.

Federal law prohibits doctors from accepting anything of value from a device-maker for agreeing to use its products, though most offenders don’t face criminal prosecution. The grand jury indictment lists seven surgeons as lasix allergy having received bribes totaling $2,747,463 to serve as “sham consultants.” One doctor, identified only as “surgeon 7,” received $978,831, according to the indictment. Many of the illicit payments were made through a Fort Lauderdale company controlled by Chin and Humad, according to the indictment.

The SpineFrontier executives set up the separate company partly to evade requirements for device companies to report payments to surgeons to the government, according to the indictment. Some surgeons were told they lasix allergy could bill for more consulting hours if they used more expensive SpineFrontier products, officials said. Conspiring to violate the kickback laws can bring a sentence of up to five years in prison, while violating the kickback laws can result in a sentence of up to 10 years, officials said.

€œKickbacks paid to surgeons as sham medical consultants, as alleged in this case, cheat patients and taxpayers alike,” said Phillip Coyne, special agent in charge of the U.S. Department of lasix allergy Health and Human Services Office of Inspector General. €œWorking with our law enforcement partners, we will continue to investigate kickback schemes that threaten the integrity of our federal health care system, no matter how those schemes are disguised.” Fred Schulte.

fschulte@kff.org, @fredschulte Related Topics Contact Us Submit a Story TipOAKLAND, Calif. €” Living unmedicated with schizophrenia and bipolar disorder, Eugenia Hunter has a hard time recalling how long she’s been staying lasix allergy in the tent she calls home at the bustling intersection of San Pablo Avenue and Martin Luther King Jr. Way in Oakland’s hip Uptown neighborhood.

Craft coffee shops and weed dispensaries are plentiful here and one-bedroom apartments push $3,000 per month. “At least the rats aren’t all over me in here,” the 59-year-old lasix allergy Oakland native said on a bright August afternoon, stretching her arm to grab the zipper to her front door. It was hot inside and the stench of wildfire smoke hung in the air.

Still, after sleeping on a nearby bench for the better part of a year, she felt safer here, Hunter explained as she rolled a joint she’d use to ease the pain from also living with what she said is untreated pancreatic cancer. Hunter has lasix allergy been hospitalized repeatedly, including once last summer after she overdosed on alcohol and lay unconscious on a sidewalk until someone stopped to help. But she is reluctant to see a doctor or use Medi-Cal, California’s health insurance program for low-income and disabled people, largely because it would force her to leave her tent.

€œMy stuff lasix allergy keeps on getting taken when I’m not around and, besides, I’m waiting until I got a place to live to start taking my medication again,” Hunter said, tearing up. €œI can’t get anything right out here.” Hunter slept on an Oakland bench for nearly a year before moving a few feet away into a bright-red tent. When she slept on the bench, rats crawled over her at night and her belongings were sometimes stolen.

She feels much safer in her tent, she lasix allergy says. (Angela Hart / California Healthline) Oakland is home to more than 4,000 homeless people, according to 2019 data, an 86% increase since 2015. But the city has not conducted an official count since 2019, and local officials say the population of homeless people has grown dramatically during the hypertension medications lasix.

(Angela Hart / California Healthline) Hunter’s long and complex list lasix allergy of ailments, combined with her mistrust of the health care system, make her an incredibly difficult and expensive patient to treat. But she is exactly the kind of person California intends to prioritize under an ambitious experiment to move Medi-Cal beyond traditional doctor visits and hospital stays into the realm of social services. Under the program, vulnerable patients like Hunter will be assigned a personal care manager to coordinate their health care treatments and daily needs like paying bills and buying groceries.

And they will receive services that aren’t typically covered by health insurance plans, such as getting security deposits paid, receiving deliveries of fruits and vegetables, and having toxic mold removed from lasix allergy homes to reduce asthma flare-ups. Over the next five years, California is plowing nearly $6 billion in state and federal money into the plan, which will target just a sliver of the 14 million low-income Californians enrolled in Medi-Cal. Homeless people or those at risk of losing their homes.

Heavy users of lasix allergy hospital emergency rooms. Children and seniors with complicated physical and mental health conditions. And people in — or at risk of landing in — expensive institutions like jails, nursing homes or mental health crisis centers.

Gov. Gavin Newsom is trumpeting the first-in-the-nation initiative as the centerpiece of his ambitious health care agenda — and vows it will help fix the mental health and addiction crisis on the streets and get people into housing, all while saving taxpayer money. His top health care advisers have even cast it as an antidote to California’s worsening homelessness crisis.

But the first-term Democrat, who faces a Sept. 14 recall election, is making a risky bet. California does not have the evidence to prove this approach will work statewide, nor the workforce or infrastructure to make it happen on such a large scale.

Critics also fear the program will do nothing to improve care for the millions of other Medi-Cal enrollees who won’t get help from this initiative. Medi-Cal has been slammed for failing to provide basic services, including vaccinations for kids, timely appointments for rural residents and adequate mental health treatment for Californians in crisis. Yet the managed-care insurance companies responsible for most enrollees’ health will nonetheless be given massive new power as they implement this experiment.

The insurers will decide which services to offer and which high-needs patients to target, likely creating disparities across regions and further contributing to an unequal system of care in California. €œThis will leave a lot of people behind,” said Linda Nguy, a policy advocate at the Western Center on Law &. Poverty.

€œWe haven’t seen health plans excel in even providing basic preventative services to healthy people,” she said. €œI mean, do your basic job first. How can they be expected to successfully take on these additional responsibilities for people with very high health needs?.

€ Hunter has tried to make her tent a home, filling it with a bed frame and foam mattress, keeping her laundry clean and stocking up on fruit juices that help keep her energy up. (Angela Hart / California Healthline) This revolution in Medi-Cal’s scope and mission is taking place alongside a parallel initiative to hold insurance companies more accountable for providing quality health care. State health officials are forcing Medi-Cal managed-care plans to reapply and meet stricter standards if they want to continue doing business in the program.

Together, these initiatives will fundamentally reinvent the biggest Medicaid program in the country, which serves about one-third of the state population at a cost of $124 billion this fiscal year. If California’s experiment succeeds, other states will likely follow, national Medicaid experts say. But if the richest state in the country can’t pull off better health outcomes and cost savings, the movement to put health insurers into the business of social work will falter.

***** When Newsom signed the “California Advancing and Innovating Medi-Cal” initiative into law in late July — “CalAIM” for short — he celebrated it as a “once-in-a-generation opportunity to completely transform the Medicaid system in California.” He declined an interview request. Beginning next year, public and private managed health care plans will pick high-need Medi-Cal enrollees to receive nontraditional services from among 14 broad categories, including housing and food benefits, addiction care and home repairs. The approach is known as “whole person care,” and insurers will be required to assign patients a personal care manager to help them navigate the system.

Insurers will receive incentive payments to offer new services and boost provider networks and, over time, the program will expand to more people and services. For instance, members of Native American tribes will eventually be eligible to receive treatment for substance misuse from natural healers, and inmates will be enrolled in Medi-Cal automatically upon release. The insurers — currently 25 are participating — will focus most intensely on developing housing programs to combat the state’s worsening homelessness epidemic.

The state was home to at least 162,000 homeless people in 2020, a 6.8% increase since Newsom took office in 2019. Jacey Cooper, the state’s Medicaid director, said all Medi-Cal members will eventually be eligible for housing services. Initially, though, they will be available only to the costliest patients.

State Medi-Cal expenditure data shows that 1% of Medi-Cal enrollees, many of the homeless patients who frequently land in hospitals, account for a staggering 21% of overall spending. And 5% account for 44% of the budget. €œYou really need to focus on your top 1% to 5% of utilizers — that’s your most vulnerable,” Cooper said.

€œIf you generally focus on that group, you will be able to yield better health outcomes for those individuals and, ultimately, cost savings.” State officials do not have a savings estimate for the program, nor a projection of how many people will be enrolled. The plan, Cooper said, builds on more than 25 successful regional experiments underway since 2016. From Los Angeles to rural Shasta, big and small counties have provided vulnerable Medi-Cal patients with different services based on their communities’ needs, from job placement services to providing a safe place for a homeless person to get sober.

Cooper highlighted interim data from the experiments that showed patients hospitalized due to mental illness were more likely to receive follow-up care, obtain treatment for substance abuse, avoid hospitalizations and emergency department visits, and see improvements in chronic diseases like diabetes. She argued that data — even though it is not comprehensive — is enough to prove the initiative will work on a statewide scale. However, studies of similar programs elsewhere have yielded mixed results.

New York provided housing services to high-cost Medicaid enrollees with chronic diseases and mental health and substance use disorders and found major reductions in hospital admissions and emergency department visits between 2012 and 2017, and saw a 15% reduction in Medicaid spending. In Camden, New Jersey, an early test of the “whole person care” approach provided expensive Medicaid patients with intensive care coordination, but not nontraditional services. A study concluded in 2020 that it hadn’t lowered hospital readmissions — and thus didn’t save health care dollars.

€œWe found we just couldn’t help people with housing as quickly as they needed help,” said Kathleen Noonan, CEO of the Camden Coalition of Healthcare Providers. €œMany of these clients have bad credit, they may have a record, and they’re still using. Those are huge challenges.” California may find success where the coalition hadn’t because it will offer social services, she said, which the coalition has also started doing.

But it will take time. California will have five years to prove to the federal government it can save money and improve health care quality. Insurers will be required to track health outcomes and savings, and can boost services over time or drop programs that don’t work.

So far, the regional experiments have failed to serve low-income Black and Latino residents, according to the interim assessments conducted by Nadereh Pourat, director of the UCLA Center for Health Policy Research. She concluded that they have primarily benefited white, English-speaking, middle-aged men. Cooper said the statewide initiative will tackle “systemic racism,” initially as it targets homeless people, who are disproportionately Black.

Consider Eugenia Hunter, who is African American, and whose many untreated mental and physical illnesses, intertwined with her addictions, mean it will take a herculean effort — and cost — to get her off the street. Hunter has been homeless for at least three years. Or maybe it’s five.

Her mental illness clouds her memory, and she erupts in anger when pressed for details. She eases her frustration sometimes with sleep, sometimes by smoking crystal meth. A stack of unopened health insurance letters sat beside Hunter one evening in late August.

Her eyes were glassy when she struggled to remember when she received a cancer diagnosis — if she ever did at all. ***** Health insurers will not be required to offer social services to patients like Hunter because federal law requires nontraditional Medicaid services to be optional. But California is enticing insurers with bigger payouts and higher state rankings.

€œWe are asking the plans and providers to stretch. We’re asking them to reform,” Cooper said. The state is urging insurers to start with the roughly 130,500 Medi-Cal patients already enrolled in the local experiments.

To prepare, they are cobbling together networks of nonprofits and social service organizations to provide food, housing and other services — much as they do with doctors and hospitals contracted to deliver medical care. Services will vary by insurer and region. The Inland Empire Health Plan, for example, will offer some patients home repairs that reduce asthma triggers, such as mold removal and installing air filters.

But Partnership HealthPlan of California will not offer those benefits in its wildfire-prone Northern California region because it doesn’t have an adequate network of organizations equipped to provide those services. In interviews with nearly all of California’s Medi-Cal managed-care plans, executives said they support the dual goals of helping patients get healthier while saving money, but “it is a lot to take on,” said Richard Sanchez, CEO of CalOptima, which serves Orange County and will start modestly, primarily with housing services. €œThe last thing I want to do is make promises that we can do all these things and not come through.” Nearly all the health plans will offer housing services right away, focusing on three categories of aid.

Helping enrollees secure housing and rent subsidies. Providing temporary rent and security deposit payments. And helping tenants stay housed, like intervening with a landlord if a patient misses rent.

Partnership HealthPlan, which serves 616,000 Medi-Cal patients in 14 Northern California counties, will prioritize its most at-risk enrollees with housing services, food deliveries and a “homemaker” benefit to help them cook dinner, do laundry and pay bills. €œIt’s a great deal of money for a small number of members and, frankly, there’s no guarantee it’s going to work,” said Dr. Robert Moore, the plan’s chief medical officer.

€œWe are building something extraordinarily ambitious quickly, without the infrastructure in place to make it successful.” Eugenia Hunter sheds tears in late August as she discusses a fight that broke out in her encampment the night before, which forced her to move her tent to a different location. Hunter says these kinds of brawls trigger her mental illness. (Angela Hart / California Healthline) Even if offering new services costs more money than it saves, it’s a worthwhile investment, said John Baackes, CEO of L.A.

Care Health Plan, the largest Medi-Cal plan, which serves more than 2 million patients in Los Angeles County. €œWhen somebody has congestive heart failure, their diet should be structured around alleviating that chronic condition,” he said, explaining his plan to offer patients healthful food. €œWhat are we going to do — let them eat ramen noodles for the rest of their lives?.

€ In Alameda County, two plans are available to serve Hunter. The Alameda Alliance for Health, a public insurer established by the county, and Anthem Blue Cross, a private insurance company, will expand housing services. €œPeople like Eugenia Hunter are exactly who we want to serve, and we’re prepared to go out and help her,” said Scott Coffin, CEO of the Alameda Alliance, who is also on a local street medicine team.

But they’d have to find her first — chaos and homeless encampment sweeps force her to move her tent frequently. And then they’d have to win her trust. In one moment, Hunter angrily described how health plans have tried to enroll her in services, but she declined, mistrustful of their motives.

In the next moment, fighting back voices in her head, she said she desperately wants care. €œSomeone is going to help me?. € she asked.

€œAll I want to do is pay my rent and succeed.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Angela Hart. ahart@kff.org, @ahartreports Related Topics Contact Us Submit a Story TipCOMMERCE CITY, Colo.

€” In her 19 years of living with cerebral palsy, scoliosis and other ailments, Cynthia Enriquez De Santiago has endured about 60 surgeries and her heart has flatlined at least four times. But the most unusual doctor’s referral of her life came last year. Go see an attorney.

Enriquez De Santiago sought help at a Colorado health clinic that takes a novel approach to improving the health of its patients. It incorporates legal assistance into its medical practice for patients facing eviction or deportation proceedings, among other legal woes. And the state’s Medicaid program helps fund the initiative.

Although Medicaid traditionally doesn’t fund clinics to supply legal assistance, Colorado is one of several states that have been given permission to use some of their Medicaid money to help pay for such programs. Every day in Commerce City, four lawyers join the physicians, psychiatrists and social workers at Salud Family Health Centers’ clinic in this suburb north of Denver, as part of Salud’s philosophy that mending legal ills is as important for health as diet and exercise. The goal.

Reduce toxic stress and keep families intact, on the premise that it will serve their health for years to come, said Marc Scanlon, the attorney who directs the program. Attorney Marc Scanlon meets with client Kimberly Ledezma at Salud Family Health Centers’ clinic in Commerce City. He helped her prepare for a U.S.

Citizenship test. (Jakob Rodgers for KHN) Mostly, that has meant helping people with unemployment benefit claims and Social Security Disability Insurance denials. But it also regularly entails helping patients — many of whom speak only Spanish after having arrived here from Mexico or Central America — with immigration hearings.

The program is among at least 450 existing medical-legal partnerships across the nation that typically serve impoverished people and migrants. The vast majority don’t rely on Medicaid dollars, which are used only in fewer than 10 states, according to the National Center for Medical-Legal Partnership. The role of these sorts of medical-legal partnerships has grown over the past year as millions of people in the U.S.

Have faced lost income and the threat of losing their homes during the hypertension medications lasix. Some partnerships have helped patients secure unemployment checks, while others have fought some of the evictions that weren’t already barred by state or federal moratoriums. €œAll the issues that people are struggling with in the lasix are all the same issues that medical-legal partnerships have been trying to work with forever,” said Vicki Girard, a law professor and co-director of the Georgetown University Health Justice Alliance in Washington, D.C.

In Montana, Kallie Dale-Ramos helped persuade a primary care association, the state’s legal aid organization and six community health centers operating in cities across Montana to pool $20,000 to help hire an attorney, who can split time among the clinics to help patients affected by the lasix. Since the start of 2020, that investment has helped more than 130 patients seek unemployment claims — and potentially stave off financial ruin. One woman had been waiting for unemployment assistance since applying in March 2020, and only recently received her first check, said Dale-Ramos.

Without legal help along the way, the woman “would have just been like, ‘I can’t do this anymore,’” Dale-Ramos said. This sort of legal-medical partnership is centered on the notion that doctors can do only so much to keep their patients healthy. Proponents See Lasting Impact Advocates for such programs cite the example of a child suffering from asthma caused by mold in a dilapidated apartment.

While a doctor couldn’t force a landlord to clean up the property or break the lease, a letter from a lawyer might be persuasive, said Dr. Tillman Farley, Salud’s chief medical officer. €œSome of these impacts carry out for decades,” Farley said.

€œAnd once you get into effects like that, then you’re really talking generational changes in health outcomes.” Beyond common sense, evidence from emerging research suggests the approach can work. Patients at Veterans Affairs clinics in Connecticut and New York, for example, saw their mental health improve significantly within three months of consulting a clinic attorney, according to a 2017 study in Health Affairs. And at Colorado’s partnership, a survey of patients from 2015 to 2020 found statistically significant drops in stress and poor physical health, as well as fewer missed medical appointments among its 69 respondents, said Dr.

Angela Sauaia, a professor at the Colorado School of Public Health who led the research. The possible reasons for missing fewer doctor appointments after getting the legal help, Sauaia said, included patients having more income, being less depressed and having an improved immigration status that made them less fearful to venture into public. Medical-legal partnerships should be considered part of health care, Sauaia believes.

€œYou should be referring to them the same way a provider would be referring a patient to a specialty, such as endocrinology or surgery.” The biggest challenge for these programs is securing stable funding. Many are funded with a small amount of seed money, or by grants that run only a year or two. Medicaid, established in 1965, is a nationwide health care program for people who have low incomes or are disabled.

It’s jointly funded by the federal government and each state, and traditionally has covered medical costs such as physician visits and hospital stays. In recent years, though, some states have increasingly sought to use Medicaid dollars to fund initiatives such as using social workers or offering legal assistance to address the social determinants of health. That includes North Carolina, which is using a federal waiver and hundreds of millions of dollars in a highly scrutinized effort to transform its Medicaid program.

Among its strategies is more legal aid for patients. Some Critics See Overreach by Medicaid Plans The nationwide shift has prompted some health policy experts to question whether Medicaid is beginning to run too far afield of its purpose. €œEverybody agrees that social factors play a very large role in health outcomes.

The question is what to do about it,” said James Capretta, a resident fellow of the American Enterprise Institute who was an associate director of the Office of Management and Budget during the George W. Bush administration. €œMedicaid is already an immense program with lots of financial challenges,” Capretta noted.

€œThe program was not built for Medicaid to pay for too many services beyond the more direct services that are related to a medical condition or a disability.” The small-scale use of waivers and supplemental Medicaid dollars to fund programs aimed at the social factors of poor health — such as housing for people with severe mental illness — works in some places, said Matt Salo, executive director of the National Association of Medicaid Directors. But for Medicaid to provide widespread funding for such social service programs would be unsustainable, and shouldn’t happen, he said. €œIt is not — and should not be — Medicaid’s responsibility to figure out how to pay for it,” he said.

Some advocates for legal assistance programs and health policy experts worry about a potential public backlash based on misperceptions about how the little-known medical-legal partnerships use Medicaid. For one, the programs generally aren’t reimbursed for services in the same way traditional Medicaid programs are, said Sara Rosenbaum, a health law and policy professor at George Washington University. Medicaid is more of “an indirect funder,” she said.

A 2019 Manatt Health Strategies report on funding for medical-legal partnerships said “the time is ripe” for these partnerships to explore the little-used avenues available in Medicaid. The states that administer the Medicaid programs and the managed care organizations that contract with them have some discretion to fund non-clinical services that improve access or outcomes for social determinants of health, according to the report. States also can write the medical-leaderships programs into a larger federal waiver application for experimental, pilot or demonstration projects that promote Medicaid’s objectives.

€œThe dollars are minimal,” said Ellen Lawton, former director of the National Center for Medical-Legal Partnership, and a senior fellow at HealthBegins, a consulting firm. €œAnd I think what we’re seeing is that — appropriately — the Medicaid programs are pacing themselves. They’re looking to see what works — what works in our state, what works in our region, what works with the populations that we’re focused on.” States have been creative in funding these sorts of legal assistance programs.

Colorado officials said they amended their Medicaid spending plan to provide grants to two such partnerships. Other states have sought federal waivers allowing them to support those programs. The Department of Veterans Affairs also offers the services of medical-legal partnerships funded by outside organizations.

Scanlon, the attorney at the Salud clinic, is part of a nonprofit organization called Medical Legal Partnership Colorado that operates under a joint agreement with the clinic. Colorado’s Medicaid program approved a $300,000 grant to the partnership that was renewed this year to pay for three attorneys’ salaries. Authorizing the funding took little convincing, said Michelle Miller, chief nursing officer for the state’s Medicaid program.

€œWhen we were asked to approve funding for this, I jumped at it,” Miller said. One Woman’s Story For Cynthia Enriquez De Santiago, the 19-year-old patient from Salud’s Commerce City clinic, legal advice made all the difference in her medical care. In addition to her cerebral palsy, the teen is blind and has difficulty speaking.

She needs round-the-clock care, including help eating and using the bathroom. Her doctor at the clinic put Rafaela De Santiago, Cynthia’s mother, in touch with an attorney who could help her continue to be her daughter’s legal guardian after the teen turned 18 last year. The timing of that legal help proved critical.

Several months after seeing the attorney, Enriquez De Santiago was rushed to a hospital. For no obvious reason, she had become hypothermic. Her blood pressure dropped and her blood-oxygen levels cratered.

€œThe doctors were telling me I had to be ready for the worst,” the teen’s mother said through a Spanish-to-English interpreter. Because she was Enriquez De Santiago’s legal guardian, her mother was able to sign off on follow-up tests after that emergency to quickly get to the root of the medical problem and help prevent it from happening again. Without guardianship, “it would have been really, really hard, because I wouldn’t know where to begin the process,” Rafaela De Santiago said.

Jakob Rodgers. @JakobRodgers Related Topics Contact Us Submit a Story TipThe Allie Henderson who stepped out of her mother’s car to a driveway full of cheering friends and family holding “Welcome Home” signs was a wisp of her former self. After 10 days in the hospital with a near-fatal case of hypertension medications inflammatory syndrome, the then-13-year-old softball phenom and beloved, straight-A student was lethargic and frail and braced herself against the car’s door frame.

But six months later, as the highly contagious delta variant swarms Mississippi, the state has one of the highest per capita rates in the nation and one of the lowest vaccination rates. In Hinds County, where the Hendersons live, the vaccination rate is 45%, well below the national average of 53%, as of last week. Some of Allie’s closest friends and family remain unvaccinated.

€œI feel like it hasn’t been tested enough,” said Erin Acey, 16, of the treatment. Erin is a cousin of Allie’s who lives a block away and grew up playing whiffle ball with Allie in the backyard. Erin’s parents are also not vaccinated, nor is another cousin, Cara McClure, 23, a hairstylist in nearby Clinton who is suspicious of conflicting information she’s heard about the treatment.

€œI try not to watch the news. I get it from Facebook,” said McClure. €œI really try not to talk about it at work because it’s like politics.

You don’t talk about politics at work.” *** The gravity of Allie’s condition last winter became clear when the prayer requests went out, months before treatments were widely available. Congregations across the area in Crystal Springs, Hazelhurst, Wesson and Georgetown prayed for Allie. Teachers at her small, independent Christian school in Gallman, Copiah Academy, prayed before class.

Allie’s grandmother texted Wayne Hall, the pastor at Jackson First, where the Hendersons have been regular parishioners. Allie was a fixture in the Children’s Ministry, a vivacious child always in the middle of the action, and the Hendersons are an admired family of go-getters. €œPlease pray,” the text said.

€œAllie is in the hospital.” “When the request went out, it was all hands on deck,” said Hall, who hunts with Allie’s dad, Brook. He said his own prayers. €œWe believe in God to heal her body and are praying for Mom and Dad, who are walking through this, because there are a lot of unknowns.” Allie had felt crummy at school on a Monday in late January but still managed to play in a basketball game that evening.

A few days later, she was doubled over with stomach pain and no remedy — Tylenol, Motrin, baths — would break her 104-degree fever. LeAnn Henderson, Allie’s mother, asked her best friend, Caroline Young, a nurse and fellow softball mom, “Why can’t we get this fever to go away?. € At the emergency room, Allie tested negative for hypertension medications, strep and influenza, and doctors settled on removing her inflamed appendix.

But soon after the surgery, her fever spiked again, her blood pressure and oxygen levels dropped, her eyes were eerily bloodshot, her hands splotchy. €œAllie was so weak, she was talking about giving up,” said LeAnn. An ambulance whisked Allie to Children’s of Mississippi, a hospital in Jackson with a pediatric intensive care unit where doctors diagnosed her with multisystem inflammatory syndrome in children.

MIS-C, as it is known, appears to affect children two to eight weeks after an asymptomatic or mild hypertension medications . A blood test found hypertension medications antibodies, and Allie began receiving steroids, blood pressure medication and intravenous antibiotics to fight the syndrome. McClure, who often styled Allie’s hair and took her to the local waterpark, video chatted with her cousin.

€œShe looked tired, drained, her face was white,” said McClure. Already thin, Allie was losing weight. At the hair salon, McClure tried to keep the unfolding family crisis away from clients already spooked by the lasix.

Her co-workers would see her crying between appointments. Outside the hospital windows, friends and family stood on the grass and held up signs that Allie could see from her room. There was an endless stream of food deliveries for the family.

Chick-fil-A, chili from Wendy’s, seafood pasta from Biaggi’s. €œEverybody in Allie’s world knew about this — softball, school, church — it was on our doorstep,” said LeAnn. €œPeople had known adults who had gotten sick and been in the hospital, but not sick like Allie.

I think it was like, ‘Wow, this is real and this happened to her.’ They know how strong and athletic [she is]. She’s a power hitter.” In late January, Allie Henderson of Terry, Mississippi, was hospitalized with MIS-C (multisystem inflammatory syndrome in children). MIS-C appears to affect children two to eight weeks after an asymptomatic or mild hypertension medications .

(LeAnn Henderson) Hospital aides help Allie Henderson of Terry, Mississippi, during her hospitalization with near-fatal hypertension medications inflammatory syndrome in late January. (LeAnn Henderson) At Copiah Academy, Allie’s absence registered with growing fear. €œParents began to get scared,” said Rita Henley, a school administrator.

The school had taken precautions, sanitizing classrooms, requiring students to wear masks and to physically distance. Students who tested positive for hypertension medications and those who shared classrooms or sports teams had to quarantine at home. €œSome of the parents embraced it and some didn’t,” said Henley.

€œIt reflected the differences in opinion that we have right now in our country.” As Allie came in and out of consciousness at the hospital, she fretted about her grades and missing the remainder of basketball season and the upcoming softball season. €œAllie is a very aggressive athlete, always ready to practice and play hard,” said Caroline Young, LeAnn’s friend whose daughter plays on the same travel softball team as Allie. €œThat was the most poignant thing about the illness — we saw a really strong teammate become weak.” On Feb.

7, LeAnn drove her daughter home to the cheers and open arms of a loving gaggle of friends and family. €œI started crying, she started crying, everyone started crying,” said Allie’s cousin Erin. LeAnn shared her family’s ordeal with a local television station.

€œI immediately went to the media and said, ‘This is something else hypertension medications can do. This happened to my 13-year-old. We need to look out for this.’” Allie returned to school for a few hours each day and grew stronger.

On occasion, she was overcome by seizures, passing out once in the bathroom at home and once on her way to her bedroom. One night, Allie woke and couldn’t feel her legs. €œI was screaming,” LeAnn said, whose usual unflappable disposition had finally caved.

By spring break, in mid-March, after neurology appointments and brain scans and heart scans, Allie started coming back to herself. She and her family got the treatments when they became available. At school, the questions overwhelmed her.

€œWe had a little joke. I said I had a bad haircut and couldn’t come to school,” Allie said. But she didn’t feel the urge to proselytize about the dangers of hypertension medications.

€œI don’t like to go public about personal stuff.” She suited up for a softball scrimmage and could barely hoist the bat above her shoulder. €œIt was very difficult because I couldn’t do what I could do before,” said Allie. She told her mom, “I just suck at this.” The crowd of softball dads teared up when Allie tried to swing the bat.

€œIt’s amazing that she’s out there,” LeAnn said they told her. *** Students returned to Copiah Academy in early August. Masks are not required, nor is the hypertension medications treatment for those eligible.

€œOur internal conversation is that we do not feel we can require the treatment unless the state requires it,” said Henley. But “because of Allie, people — without question — know that this is a real thing.” Still, the shifting nature of the lasix — the arrival of the delta variant, the news that vaccinated people can spread hypertension medications — has brewed confusion. €œI truly think that we see too much back-and-forth on the news.

I think it hurts people,” said Henley, who is vaccinated. €œPeople don’t know what to believe.” Federal health officials say millions of Americans have been safely vaccinated, and vaccination reduces the risk of severe complications from hypertension medications. Pastor Hall is reluctant to direct his parishioners to get vaccinated.

€œWe believe in healing, we believe in the power of God, and we also know God gives wisdom,” he said. €œIf the CDC is saying things we need to abide by, we need to really listen.” He added, “Allie’s story has helped a lot of people really understand, ‘Hey, this is not a pick-and-choose kind of deal. It can hit home anywhere.’” Allie Henderson of Terry, Mississippi, was hospitalized with near-fatal hypertension medications inflammatory syndrome in late January.

After 10 days, she was released, lethargic and frail. Cheering friends and family welcomed her home. Six months later, the state has one of the nation’s lowest vaccination rates ― and the unvaccinated include several people in Allie’s close circle of contacts.

(Imani Khayyam for KHN) At the hair salon in Clinton, McClure shares more openly now about her cousin’s illness with her clients. €œI’ll say my little cousin had it and we get to talking about it,” said McClure. But she doesn’t push it.

€œWhen clients come in, we want it to be about them. We ask, ‘Are you going on vacation?. €™ We focus on them to make them feel good.” But she notices those around her have dropped their guard.

€œThey take everything for granted. €˜Oh, we’re good. We’re fine.

We don’t have to sanitize,’” she said. €œEven now at the salon we try to make people sanitize, and they’re like, ‘Ugh.’” McClure had a mild hypertension medications last Thanksgiving — headache and nausea — but it passed. Even now, she’s in no rush to get vaccinated.

€œEven with the treatment, you can still get it. Every day I feel like something about it is changing, there’s a new strand,” she said. Erin, Allie’s 16-year-old cousin, isn’t sure when — or if — she’ll get vaccinated.

She’s nervous about the side effects and wants to wait and see. In her view, the lasix has “died down” and she’s unfamiliar with the delta variant. €œI’d rather read about it and see it myself,” she said.

€œI know she has a different perspective,” Allie said about her cousin Erin. €œI would have a different perspective if it hadn’t happened to me. I just know some people are like, ‘My body, my choice.’ Everything these days is about politics and nobody likes to be wrong.

It’s very confusing for my part. I want people to get vaccinated because I know what it feels like.” Some of her closest friends have gotten the treatment. Was it because of what happened to her?.

Allie responded, “Yes, ma’am.” PBS NewsHour producer Jason Kane contributed to this report. Sarah Varney. svarney@kff.org, @SarahVarney4 Related Topics Contact Us Submit a Story Tip.

This is a collaboration between KHN and “Science Friday.” Listen to the conversation between KHN senior correspondent Christina Jewett and Science Friday’s host and executive producer, how to buy cheap lasix online Ira Flatow. As students return to school, parents are getting a lot of mail about what schools are doing to better protect kids in the classroom — including details on mask policies and how kids will sit at lunch. One item on how to buy cheap lasix online many administrators’ lists of protective measures is improving ventilation in the classroom. Many studies have shown that better ventilation and air circulation can greatly reduce hypertension medications transmission.

But rather than stocking up on HEPA filters, some school districts are turning to high-tech air purification strategies, including the use of untested electronic methods and airborne chemicals. KHN has written extensively about school air how to buy cheap lasix online fiation. Senior correspondent Christina Jewett joins Ira Flatow to explain why some air-quality experts are less than convinced by the marketing claims made by many electronic air purifier companies. Don’t miss the simple snail-mail hack Jewett shares to gauge whether the device your school is using might be of concern.

Related Topics Contact Us Submit a Story TipA Florida orthopedic surgeon and designer of costly spinal surgery implants was arrested Tuesday how to buy cheap lasix online and charged with paying millions of dollars in kickbacks and bribes to surgeons who agreed to use his company’s devices. Dr. Kingsley R. Chin, 57, of Fort Lauderdale, Florida, is the founder, chief executive officer how to buy cheap lasix online and owner of SpineFrontier, a device company based in Malden, Massachusetts.

He and the company’s chief financial officer, Aditya Humad, 36, of Cambridge, Massachusetts, were each indicted on one count of conspiring to violate federal anti-kickback laws, six counts of violating the kickback statute and one count of conspiracy to commit money laundering, officials said. The indictment alleges that SpineFrontier, Chin and Humad paid surgeons between $250 and $1,000 per hour in sham consulting fees for work they did not perform. In exchange, the surgeons agreed to use SpineFrontier’s products in operations paid for by federal health care how to buy cheap lasix online programs such as Medicare and Medicaid. Surgeons accepted between $32,625 and $978,000 in improper payments, according to the indictment.

€œKickback arrangements pollute federal health care programs and take advantage of patient needs for financial gains,” said Nathaniel Mendell, acting U.S. Attorney for the District of Massachusetts how to buy cheap lasix online. €œMedical device manufacturers must play by the rules, and we will keep pursuing those who fail to do so, regardless of how their corruption is disguised.” Chin and SpineFrontier were the subjects of a KHN investigation published in June that found that manufacturers of hardware for spinal implants, artificial knees and hip joints had paid more than $3.1 billion to orthopedic and neurosurgeons from August 2013 through 2019. These surgeons collected more than half a billion dollars in industry consulting fees, federal payment records show.

Chin, a how to buy cheap lasix online self-styled “doctorpreneur,” formed SpineFrontier about a decade after completing his training at Harvard Medical School. Chin has patented dozens of pieces of spine surgery hardware, such as doughnut-shaped plastic cages, titanium screws and other products that generated some $100 million in sales for SpineFrontier, according to government officials. In 2018, SpineFrontier valued Chin’s ownership of the company at $75 million, though its current worth is unclear. He maintains a medical practice in how to buy cheap lasix online Hollywood, Florida.

Neither Chin nor Humad could be reached for comment Tuesday. [embedded content] Seth Orkand, a Boston attorney who represents Humad, said his client “denies all charges, and looks forward to his day in court.” The Department of Justice filed a civil lawsuit against Chin and SpineFrontier in March 2020, accusing the company of illegally funneling more than $8 million to nearly three dozen spine surgeons through the how to buy cheap lasix online “sham” consulting fees. Chin and SpineFrontier have yet to file a response to that suit. However, at least six surgeons have admitted wrongdoing in the civil case and paid a total of $3.3 million in penalties.

Another, Dr how to buy cheap lasix online. Jason Montone, 45, of Lawson, Missouri, pleaded guilty to criminal kickback charges and is set to be sentenced early next year. Federal law prohibits doctors from accepting anything of value from a device-maker for agreeing to use its products, though most offenders don’t face criminal prosecution. The grand jury indictment how to buy cheap lasix online lists seven surgeons as having received bribes totaling $2,747,463 to serve as “sham consultants.” One doctor, identified only as “surgeon 7,” received $978,831, according to the indictment.

Many of the illicit payments were made through a Fort Lauderdale company controlled by Chin and Humad, according to the indictment. The SpineFrontier executives set up the separate company partly to evade requirements for device companies to report payments to surgeons to the government, according to the indictment. Some surgeons were told they could bill for more consulting hours if they used how to buy cheap lasix online more expensive SpineFrontier products, officials said. Conspiring to violate the kickback laws can bring a sentence of up to five years in prison, while violating the kickback laws can result in a sentence of up to 10 years, officials said.

€œKickbacks paid to surgeons as sham medical consultants, as alleged in this case, cheat patients and taxpayers alike,” said Phillip Coyne, special agent in charge of the U.S. Department of how to buy cheap lasix online Health and Human Services Office of Inspector General. €œWorking with our law enforcement partners, we will continue to investigate kickback schemes that threaten the integrity of our federal health care system, no matter how those schemes are disguised.” Fred Schulte. fschulte@kff.org, @fredschulte Related Topics Contact Us Submit a Story TipOAKLAND, Calif.

€” Living unmedicated with schizophrenia and bipolar disorder, Eugenia Hunter has a hard time recalling how long she’s been staying in the tent she calls home at the bustling intersection of San Pablo Avenue how to buy cheap lasix online and Martin Luther King Jr. Way in Oakland’s hip Uptown neighborhood. Craft coffee shops and weed dispensaries are plentiful here and one-bedroom apartments push $3,000 per month. “At least the rats aren’t all over me in here,” the 59-year-old Oakland native said on a bright how to buy cheap lasix online August afternoon, stretching her arm to grab the zipper to her front door.

It was hot inside and the stench of wildfire smoke hung in the air. Still, after sleeping on a nearby bench for the better part of a year, she felt safer here, Hunter explained as she rolled a joint she’d use to ease the pain from also living with what she said is untreated pancreatic cancer. Hunter has been hospitalized repeatedly, including once last summer after she overdosed on alcohol and lay unconscious how to buy cheap lasix online on a sidewalk until someone stopped to help. But she is reluctant to see a doctor or use Medi-Cal, California’s health insurance program for low-income and disabled people, largely because it would force her to leave her tent.

€œMy stuff keeps on getting taken when I’m not around and, besides, I’m waiting until I got a place to live to start taking my medication again,” Hunter said, how to buy cheap lasix online tearing up. €œI can’t get anything right out here.” Hunter slept on an Oakland bench for nearly a year before moving a few feet away into a bright-red tent. When she slept on the bench, rats crawled over her at night and her belongings were sometimes stolen. She feels much safer in her how to buy cheap lasix online tent, she says.

(Angela Hart / California Healthline) Oakland is home to more than 4,000 homeless people, according to 2019 data, an 86% increase since 2015. But the city has not conducted an official count since 2019, and local officials say the population of homeless people has grown dramatically during the hypertension medications lasix. (Angela Hart / California Healthline) Hunter’s long how to buy cheap lasix online and complex list of ailments, combined with her mistrust of the health care system, make her an incredibly difficult and expensive patient to treat. But she is exactly the kind of person California intends to prioritize under an ambitious experiment to move Medi-Cal beyond traditional doctor visits and hospital stays into the realm of social services.

Under the program, vulnerable patients like Hunter will be assigned a personal care manager to coordinate their health care treatments and daily needs like paying bills and buying groceries. And they will receive services that aren’t typically covered by health insurance plans, such as getting security deposits paid, receiving deliveries of fruits and vegetables, and having toxic mold removed from homes to reduce how to buy cheap lasix online asthma flare-ups. Over the next five years, California is plowing nearly $6 billion in state and federal money into the plan, which will target just a sliver of the 14 million low-income Californians enrolled in Medi-Cal. Homeless people or those at risk of losing their homes.

Heavy users how to buy cheap lasix online of hospital emergency rooms. Children and seniors with complicated physical and mental health conditions. And people in — or at risk of landing in — expensive institutions like jails, nursing homes or mental health crisis centers. Gov.

Gavin Newsom is trumpeting the first-in-the-nation initiative as the centerpiece of his ambitious health care agenda — and vows it will help fix the mental health and addiction crisis on the streets and get people into housing, all while saving taxpayer money. His top health care advisers have even cast it as an antidote to California’s worsening homelessness crisis. But the first-term Democrat, who faces a Sept. 14 recall election, is making a risky bet.

California does not have the evidence to prove this approach will work statewide, nor the workforce or infrastructure to make it happen on such a large scale. Critics also fear the program will do nothing to improve care for the millions of other Medi-Cal enrollees who won’t get help from this initiative. Medi-Cal has been slammed for failing to provide basic services, including vaccinations for kids, timely appointments for rural residents and adequate mental health treatment for Californians in crisis. Yet the managed-care insurance companies responsible for most enrollees’ health will nonetheless be given massive new power as they implement this experiment.

The insurers will decide which services to offer and which high-needs patients to target, likely creating disparities across regions and further contributing to an unequal system of care in California. €œThis will leave a lot of people behind,” said Linda Nguy, a policy advocate at the Western Center on Law &. Poverty. €œWe haven’t seen health plans excel in even providing basic preventative services to healthy people,” she said.

€œI mean, do your basic job first. How can they be expected to successfully take on these additional responsibilities for people with very high health needs?. € Hunter has tried to make her tent a home, filling it with a bed frame and foam mattress, keeping her laundry clean and stocking up on fruit juices that help keep her energy up. (Angela Hart / California Healthline) This revolution in Medi-Cal’s scope and mission is taking place alongside a parallel initiative to hold insurance companies more accountable for providing quality health care.

State health officials are forcing Medi-Cal managed-care plans to reapply and meet stricter standards if they want to continue doing business in the program. Together, these initiatives will fundamentally reinvent the biggest Medicaid program in the country, which serves about one-third of the state population at a cost of $124 billion this fiscal year. If California’s experiment succeeds, other states will likely follow, national Medicaid experts say. But if the richest state in the country can’t pull off better health outcomes and cost savings, the movement to put health insurers into the business of social work will falter.

***** When Newsom signed the “California Advancing and Innovating Medi-Cal” initiative into law in late July — “CalAIM” for short — he celebrated it as a “once-in-a-generation opportunity to completely transform the Medicaid system in California.” He declined an interview request. Beginning next year, public and private managed health care plans will pick high-need Medi-Cal enrollees to receive nontraditional services from among 14 broad categories, including housing and food benefits, addiction care and home repairs. The approach is known as “whole person care,” and insurers will be required to assign patients a personal care manager to help them navigate the system. Insurers will receive incentive payments to offer new services and boost provider networks and, over time, the program will expand to more people and services.

For instance, members of Native American tribes will eventually be eligible to receive treatment for substance misuse from natural healers, and inmates will be enrolled in Medi-Cal automatically upon release. The insurers — currently 25 are participating — will focus most intensely on developing housing programs to combat the state’s worsening homelessness epidemic. The state was home to at least 162,000 homeless people in 2020, a 6.8% increase since Newsom took office in 2019. Jacey Cooper, the state’s Medicaid director, said all Medi-Cal members will eventually be eligible for housing services.

Initially, though, they will be available only to the costliest patients. State Medi-Cal expenditure data shows that 1% of Medi-Cal enrollees, many of the homeless patients who frequently land in hospitals, account for a staggering 21% of overall spending. And 5% account for 44% of the budget. €œYou really need to focus on your top 1% to 5% of utilizers — that’s your most vulnerable,” Cooper said.

€œIf you generally focus on that group, you will be able to yield better health outcomes for those individuals and, ultimately, cost savings.” State officials do not have a savings estimate for the program, nor a projection of how many people will be enrolled. The plan, Cooper said, builds on more than 25 successful regional experiments underway since 2016. From Los Angeles to rural Shasta, big and small counties have provided vulnerable Medi-Cal patients with different services based on their communities’ needs, from job placement services to providing a safe place for a homeless person to get sober. Cooper highlighted interim data from the experiments that showed patients hospitalized due to mental illness were more likely to receive follow-up care, obtain treatment for substance abuse, avoid hospitalizations and emergency department visits, and see improvements in chronic diseases like diabetes.

She argued that data — even though it is not comprehensive — is enough to prove the initiative will work on a statewide scale. However, studies of similar programs elsewhere have yielded mixed results. New York provided housing services to high-cost Medicaid enrollees with chronic diseases and mental health and substance use disorders and found major reductions in hospital admissions and emergency department visits between 2012 and 2017, and saw a 15% reduction in Medicaid spending. In Camden, New Jersey, an early test of the “whole person care” approach provided expensive Medicaid patients with intensive care coordination, but not nontraditional services.

A study concluded in 2020 that it hadn’t lowered hospital readmissions — and thus didn’t save health care dollars. €œWe found we just couldn’t help people with housing as quickly as they needed help,” said Kathleen Noonan, CEO of the Camden Coalition of Healthcare Providers. €œMany of these clients have bad credit, they may have a record, and they’re still using. Those are huge challenges.” California may find success where the coalition hadn’t because it will offer social services, she said, which the coalition has also started doing.

But it will take time. California will have five years to prove to the federal government it can save money and improve health care quality. Insurers will be required to track health outcomes and savings, and can boost services over time or drop programs that don’t work. So far, the regional experiments have failed to serve low-income Black and Latino residents, according to the interim assessments conducted by Nadereh Pourat, director of the UCLA Center for Health Policy Research.

She concluded that they have primarily benefited white, English-speaking, middle-aged men. Cooper said the statewide initiative will tackle “systemic racism,” initially as it targets homeless people, who are disproportionately Black. Consider Eugenia Hunter, who is African American, and whose many untreated mental and physical illnesses, intertwined with her addictions, mean it will take a herculean effort — and cost — to get her off the street. Hunter has been homeless for at least three years.

Or maybe it’s five. Her mental illness clouds her memory, and she erupts in anger when pressed for details. She eases her frustration sometimes with sleep, sometimes by smoking crystal meth. A stack of unopened health insurance letters sat beside Hunter one evening in late August.

Her eyes were glassy when she struggled to remember when she received a cancer diagnosis — if she ever did at all. ***** Health insurers will not be required to offer social services to patients like Hunter because federal law requires nontraditional Medicaid services to be optional. But California is enticing insurers with bigger payouts and higher state rankings. €œWe are asking the plans and providers to stretch.

We’re asking them to reform,” Cooper said. The state is urging insurers to start with the roughly 130,500 Medi-Cal patients already enrolled in the local experiments. To prepare, they are cobbling together networks of nonprofits and social service organizations to provide food, housing and other services — much as they do with doctors and hospitals contracted to deliver medical care. Services will vary by insurer and region.

The Inland Empire Health Plan, for example, will offer some patients home repairs that reduce asthma triggers, such as mold removal and installing air filters. But Partnership HealthPlan of California will not offer those benefits in its wildfire-prone Northern California region because it doesn’t have an adequate network of organizations equipped to provide those services. In interviews with nearly all of California’s Medi-Cal managed-care plans, executives said they support the dual goals of helping patients get healthier while saving money, but “it is a lot to take on,” said Richard Sanchez, CEO of CalOptima, which serves Orange County and will start modestly, primarily with housing services. €œThe last thing I want to do is make promises that we can do all these things and not come through.” Nearly all the health plans will offer housing services right away, focusing on three categories of aid.

Helping enrollees secure housing and rent subsidies. Providing temporary rent and security deposit payments. And helping tenants stay housed, like intervening with a landlord if a patient misses rent. Partnership HealthPlan, which serves 616,000 Medi-Cal patients in 14 Northern California counties, will prioritize its most at-risk enrollees with housing services, food deliveries and a “homemaker” benefit to help them cook dinner, do laundry and pay bills.

€œIt’s a great deal of money for a small number of members and, frankly, there’s no guarantee it’s going to work,” said Dr. Robert Moore, the plan’s chief medical officer. €œWe are building something extraordinarily ambitious quickly, without the infrastructure in place to make it successful.” Eugenia Hunter sheds tears in late August as she discusses a fight that broke out in her encampment the night before, which forced her to move her tent to a different location. Hunter says these kinds of brawls trigger her mental illness.

(Angela Hart / California Healthline) Even if offering new services costs more money than it saves, it’s a worthwhile investment, said John Baackes, CEO of L.A. Care Health Plan, the largest Medi-Cal plan, which serves more than 2 million patients in Los Angeles County. €œWhen somebody has congestive heart failure, their diet should be structured around alleviating that chronic condition,” he said, explaining his plan to offer patients healthful food. €œWhat are we going to do — let them eat ramen noodles for the rest of their lives?.

€ In Alameda County, two plans are available to serve Hunter. The Alameda Alliance for Health, a public insurer established by the county, and Anthem Blue Cross, a private insurance company, will expand housing services. €œPeople like Eugenia Hunter are exactly who we want to serve, and we’re prepared to go out and help her,” said Scott Coffin, CEO of the Alameda Alliance, who is also on a local street medicine team. But they’d have to find her first — chaos and homeless encampment sweeps force her to move her tent frequently.

And then they’d have to win her trust. In one moment, Hunter angrily described how health plans have tried to enroll her in services, but she declined, mistrustful of their motives. In the next moment, fighting back voices in her head, she said she desperately wants care. €œSomeone is going to help me?.

€ she asked. €œAll I want to do is pay my rent and succeed.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Angela Hart. ahart@kff.org, @ahartreports Related Topics Contact Us Submit a Story TipCOMMERCE CITY, Colo.

€” In her 19 years of living with cerebral palsy, scoliosis and other ailments, Cynthia Enriquez De Santiago has endured about 60 surgeries and her heart has flatlined at least four times. But the most unusual doctor’s referral of her life came last year. Go see an attorney. Enriquez De Santiago sought help at a Colorado health clinic that takes a novel approach to improving the health of its patients.

It incorporates legal assistance into its medical practice for patients facing eviction or deportation proceedings, among other legal woes. And the state’s Medicaid program helps fund the initiative. Although Medicaid traditionally doesn’t fund clinics to supply legal assistance, Colorado is one of several states that have been given permission to use some of their Medicaid money to help pay for such programs. Every day in Commerce City, four lawyers join the physicians, psychiatrists and social workers at Salud Family Health Centers’ clinic in this suburb north of Denver, as part of Salud’s philosophy that mending legal ills is as important for health as diet and exercise.

The goal. Reduce toxic stress and keep families intact, on the premise that it will serve their health for years to come, said Marc Scanlon, the attorney who directs the program. Attorney Marc Scanlon meets with client Kimberly Ledezma at Salud Family Health Centers’ clinic in Commerce City. He helped her prepare for a U.S.

Citizenship test. (Jakob Rodgers for KHN) Mostly, that has meant helping people with unemployment benefit claims and Social Security Disability Insurance denials. But it also regularly entails helping patients — many of whom speak only Spanish after having arrived here from Mexico or Central America — with immigration hearings. The program is among at least 450 existing medical-legal partnerships across the nation that typically serve impoverished people and migrants.

The vast majority don’t rely on Medicaid dollars, which are used only in fewer than 10 states, according to the National Center for Medical-Legal Partnership. The role of these sorts of medical-legal partnerships has grown over the past year as millions of people in the U.S. Have faced lost income and the threat of losing their homes during the hypertension medications lasix. Some partnerships have helped patients secure unemployment checks, while others have fought some of the evictions that weren’t already barred by state or federal moratoriums.

€œAll the issues that people are struggling with in the lasix are all the same issues that medical-legal partnerships have been trying to work with forever,” said Vicki Girard, a law professor and co-director of the Georgetown University Health Justice Alliance in Washington, D.C. In Montana, Kallie Dale-Ramos helped persuade a primary care association, the state’s legal aid organization and six community health centers operating in cities across Montana to pool $20,000 to help hire an attorney, who can split time among the clinics to help patients affected by the lasix. Since the start of 2020, that investment has helped more than 130 patients seek unemployment claims — and potentially stave off financial ruin. One woman had been waiting for unemployment assistance since applying in March 2020, and only recently received her first check, said Dale-Ramos.

Without legal help along the way, the woman “would have just been like, ‘I can’t do this anymore,’” Dale-Ramos said. This sort of legal-medical partnership is centered on the notion that doctors can do only so much to keep their patients healthy. Proponents See Lasting Impact Advocates for such programs cite the example of a child suffering from asthma caused by mold in a dilapidated apartment. While a doctor couldn’t force a landlord to clean up the property or break the lease, a letter from a lawyer might be persuasive, said Dr.

Tillman Farley, Salud’s chief medical officer. €œSome of these impacts carry out for decades,” Farley said. €œAnd once you get into effects like that, then you’re really talking generational changes in health outcomes.” Beyond common sense, evidence from emerging research suggests the approach can work. Patients at Veterans Affairs clinics in Connecticut and New York, for example, saw their mental health improve significantly within three months of consulting a clinic attorney, according to a 2017 study in Health Affairs.

And at Colorado’s partnership, a survey of patients from 2015 to 2020 found statistically significant drops in stress and poor physical health, as well as fewer missed medical appointments among its 69 respondents, said Dr. Angela Sauaia, a professor at the Colorado School of Public Health who led the research. The possible reasons for missing fewer doctor appointments after getting the legal help, Sauaia said, included patients having more income, being less depressed and having an improved immigration status that made them less fearful to venture into public. Medical-legal partnerships should be considered part of health care, Sauaia believes.

€œYou should be referring to them the same way a provider would be referring a patient to a specialty, such as endocrinology or surgery.” The biggest challenge for these programs is securing stable funding. Many are funded with a small amount of seed money, or by grants that run only a year or two. Medicaid, established in 1965, is a nationwide health care program for people who have low incomes or are disabled. It’s jointly funded by the federal government and each state, and traditionally has covered medical costs such as physician visits and hospital stays.

In recent years, though, some states have increasingly sought to use Medicaid dollars to fund initiatives such as using social workers or offering legal assistance to address the social determinants of health. That includes North Carolina, which is using a federal waiver and hundreds of millions of dollars in a highly scrutinized effort to transform its Medicaid program. Among its strategies is more legal aid for patients. Some Critics See Overreach by Medicaid Plans The nationwide shift has prompted some health policy experts to question whether Medicaid is beginning to run too far afield of its purpose.

€œEverybody agrees that social factors play a very large role in health outcomes. The question is what to do about it,” said James Capretta, a resident fellow of the American Enterprise Institute who was an associate director of the Office of Management and Budget during the George W. Bush administration. €œMedicaid is already an immense program with lots of financial challenges,” Capretta noted.

€œThe program was not built for Medicaid to pay for too many services beyond the more direct services that are related to a medical condition or a disability.” The small-scale use of waivers and supplemental Medicaid dollars to fund programs aimed at the social factors of poor health — such as housing for people with severe mental illness — works in some places, said Matt Salo, executive director of the National Association of Medicaid Directors. But for Medicaid to provide widespread funding for such social service programs would be unsustainable, and shouldn’t happen, he said. €œIt is not — and should not be — Medicaid’s responsibility to figure out how to pay for it,” he said. Some advocates for legal assistance programs and health policy experts worry about a potential public backlash based on misperceptions about how the little-known medical-legal partnerships use Medicaid.

For one, the programs generally aren’t reimbursed for services in the same way traditional Medicaid programs are, said Sara Rosenbaum, a health law and policy professor at George Washington University. Medicaid is more of “an indirect funder,” she said. A 2019 Manatt Health Strategies report on funding for medical-legal partnerships said “the time is ripe” for these partnerships to explore the little-used avenues available in Medicaid. The states that administer the Medicaid programs and the managed care organizations that contract with them have some discretion to fund non-clinical services that improve access or outcomes for social determinants of health, according to the report.

States also can write the medical-leaderships programs into a larger federal waiver application for experimental, pilot or demonstration projects that promote Medicaid’s objectives. €œThe dollars are minimal,” said Ellen Lawton, former director of the National Center for Medical-Legal Partnership, and a senior fellow at HealthBegins, a consulting firm. €œAnd I think what we’re seeing is that — appropriately — the Medicaid programs are pacing themselves. They’re looking to see what works — what works in our state, what works in our region, what works with the populations that we’re focused on.” States have been creative in funding these sorts of legal assistance programs.

Colorado officials said they amended their Medicaid spending plan to provide grants to two such partnerships. Other states have sought federal waivers allowing them to support those programs. The Department of Veterans Affairs also offers the services of medical-legal partnerships funded by outside organizations. Scanlon, the attorney at the Salud clinic, is part of a nonprofit organization called Medical Legal Partnership Colorado that operates under a joint agreement with the clinic.

Colorado’s Medicaid program approved a $300,000 grant to the partnership that was renewed this year to pay for three attorneys’ salaries. Authorizing the funding took little convincing, said Michelle Miller, chief nursing officer for the state’s Medicaid program. €œWhen we were asked to approve funding for this, I jumped at it,” Miller said. One Woman’s Story For Cynthia Enriquez De Santiago, the 19-year-old patient from Salud’s Commerce City clinic, legal advice made all the difference in her medical care.

In addition to her cerebral palsy, the teen is blind and has difficulty speaking. She needs round-the-clock care, including help eating and using the bathroom. Her doctor at the clinic put Rafaela De Santiago, Cynthia’s mother, in touch with an attorney who could help her continue to be her daughter’s legal guardian after the teen turned 18 last year. The timing of that legal help proved critical.

Several months after seeing the attorney, Enriquez De Santiago was rushed to a hospital. For no obvious reason, she had become hypothermic. Her blood pressure dropped and her blood-oxygen levels cratered. €œThe doctors were telling me I had to be ready for the worst,” the teen’s mother said through a Spanish-to-English interpreter.

Because she was Enriquez De Santiago’s legal guardian, her mother was able to sign off on follow-up tests after that emergency to quickly get to the root of the medical problem and help prevent it from happening again. Without guardianship, “it would have been really, really hard, because I wouldn’t know where to begin the process,” Rafaela De Santiago said. Jakob Rodgers. @JakobRodgers Related Topics Contact Us Submit a Story TipThe Allie Henderson who stepped out of her mother’s car to a driveway full of cheering friends and family holding “Welcome Home” signs was a wisp of her former self.

After 10 days in the hospital with a near-fatal case of hypertension medications inflammatory syndrome, the then-13-year-old softball phenom and beloved, straight-A student was lethargic and frail and braced herself against the car’s door frame. But six months later, as the highly contagious delta variant swarms Mississippi, the state has one of the highest per capita rates in the nation and one of the lowest vaccination rates. In Hinds County, where the Hendersons live, the vaccination rate is 45%, well below the national average of 53%, as of last week. Some of Allie’s closest friends and family remain unvaccinated.

€œI feel like it hasn’t been tested enough,” said Erin Acey, 16, of the treatment. Erin is a cousin of Allie’s who lives a block away and grew up playing whiffle ball with Allie in the backyard. Erin’s parents are also not vaccinated, nor is another cousin, Cara McClure, 23, a hairstylist in nearby Clinton who is suspicious of conflicting information she’s heard about the treatment. €œI try not to watch the news.

I get it from Facebook,” said McClure. €œI really try not to talk about it at work because it’s like politics. You don’t talk about politics at work.” *** The gravity of Allie’s condition last winter became clear when the prayer requests went out, months before treatments were widely available. Congregations across the area in Crystal Springs, Hazelhurst, Wesson and Georgetown prayed for Allie.

Teachers at her small, independent Christian school in Gallman, Copiah Academy, prayed before class. Allie’s grandmother texted Wayne Hall, the pastor at Jackson First, where the Hendersons have been regular parishioners. Allie was a fixture in the Children’s Ministry, a vivacious child always in the middle of the action, and the Hendersons are an admired family of go-getters. €œPlease pray,” the text said.

€œAllie is in the hospital.” “When the request went out, it was all hands on deck,” said Hall, who hunts with Allie’s dad, Brook. He said his own prayers. €œWe believe in God to heal her body and are praying for Mom and Dad, who are walking through this, because there are a lot of unknowns.” Allie had felt crummy at school on a Monday in late January but still managed to play in a basketball game that evening. A few days later, she was doubled over with stomach pain and no remedy — Tylenol, Motrin, baths — would break her 104-degree fever.

LeAnn Henderson, Allie’s mother, asked her best friend, Caroline Young, a nurse and fellow softball mom, “Why can’t we get this fever to go away?. € At the emergency room, Allie tested negative for hypertension medications, strep and influenza, and doctors settled on removing her inflamed appendix. But soon after the surgery, her fever spiked again, her blood pressure and oxygen levels dropped, her eyes were eerily bloodshot, her hands splotchy. €œAllie was so weak, she was talking about giving up,” said LeAnn.

An ambulance whisked Allie to Children’s of Mississippi, a hospital in Jackson with a pediatric intensive care unit where doctors diagnosed her with multisystem inflammatory syndrome in children. MIS-C, as it is known, appears to affect children two to eight weeks after an asymptomatic or mild hypertension medications . A blood test found hypertension medications antibodies, and Allie began receiving steroids, blood pressure medication and intravenous antibiotics to fight the syndrome. McClure, who often styled Allie’s hair and took her to the local waterpark, video chatted with her cousin.

€œShe looked tired, drained, her face was white,” said McClure. Already thin, Allie was losing weight. At the hair salon, McClure tried to keep the unfolding family crisis away from clients already spooked by the lasix. Her co-workers would see her crying between appointments.

Outside the hospital windows, friends and family stood on the grass and held up signs that Allie could see from her room. There was an endless stream of food deliveries for the family. Chick-fil-A, chili from Wendy’s, seafood pasta from Biaggi’s. €œEverybody in Allie’s world knew about this — softball, school, church — it was on our doorstep,” said LeAnn.

€œPeople had known adults who had gotten sick and been in the hospital, but not sick like Allie. I think it was like, ‘Wow, this is real and this happened to her.’ They know how strong and athletic [she is]. She’s a power hitter.” In late January, Allie Henderson of Terry, Mississippi, was hospitalized with MIS-C (multisystem inflammatory syndrome in children). MIS-C appears to affect children two to eight weeks after an asymptomatic or mild hypertension medications .

(LeAnn Henderson) Hospital aides help Allie Henderson of Terry, Mississippi, during her hospitalization with near-fatal hypertension medications inflammatory syndrome in late January. (LeAnn Henderson) At Copiah Academy, Allie’s absence registered with growing fear. €œParents began to get scared,” said Rita Henley, a school administrator. The school had taken precautions, sanitizing classrooms, requiring students to wear masks and to physically distance.

Students who tested positive for hypertension medications and those who shared classrooms or sports teams had to quarantine at home. €œSome of the parents embraced it and some didn’t,” said Henley. €œIt reflected the differences in opinion that we have right now in our country.” As Allie came in and out of consciousness at the hospital, she fretted about her grades and missing the remainder of basketball season and the upcoming softball season. €œAllie is a very aggressive athlete, always ready to practice and play hard,” said Caroline Young, LeAnn’s friend whose daughter plays on the same travel softball team as Allie.

€œThat was the most poignant thing about the illness — we saw a really strong teammate become weak.” On Feb. 7, LeAnn drove her daughter home to the cheers and open arms of a loving gaggle of friends and family. €œI started crying, she started crying, everyone started crying,” said Allie’s cousin Erin. LeAnn shared her family’s ordeal with a local television station.

€œI immediately went to the media and said, ‘This is something else hypertension medications can do. This happened to my 13-year-old. We need to look out for this.’” Allie returned to school for a few hours each day and grew stronger. On occasion, she was overcome by seizures, passing out once in the bathroom at home and once on her way to her bedroom.

One night, Allie woke and couldn’t feel her legs. €œI was screaming,” LeAnn said, whose usual unflappable disposition had finally caved. By spring break, in mid-March, after neurology appointments and brain scans and heart scans, Allie started coming back to herself. She and her family got the treatments when they became available.

At school, the questions overwhelmed her. €œWe had a little joke. I said I had a bad haircut and couldn’t come to school,” Allie said. But she didn’t feel the urge to proselytize about the dangers of hypertension medications.

€œI don’t like to go public about personal stuff.” She suited up for a softball scrimmage and could barely hoist the bat above her shoulder. €œIt was very difficult because I couldn’t do what I could do before,” said Allie. She told her mom, “I just suck at this.” The crowd of softball dads teared up when Allie tried to swing the bat. €œIt’s amazing that she’s out there,” LeAnn said they told her.

*** Students returned to Copiah Academy in early August. Masks are not required, nor is the hypertension medications treatment for those eligible. €œOur internal conversation is that we do not feel we can require the treatment unless the state requires it,” said Henley. But “because of Allie, people — without question — know that this is a real thing.” Still, the shifting nature of the lasix — the arrival of the delta variant, the news that vaccinated people can spread hypertension medications — has brewed confusion.

€œI truly think that we see too much back-and-forth on the news. I think it hurts people,” said Henley, who is vaccinated. €œPeople don’t know what to believe.” Federal health officials say millions of Americans have been safely vaccinated, and vaccination reduces the risk of severe complications from hypertension medications. Pastor Hall is reluctant to direct his parishioners to get vaccinated.

€œWe believe in healing, we believe in the power of God, and we also know God gives wisdom,” he said. €œIf the CDC is saying things we need to abide by, we need to really listen.” He added, “Allie’s story has helped a lot of people really understand, ‘Hey, this is not a pick-and-choose kind of deal. It can hit home anywhere.’” Allie Henderson of Terry, Mississippi, was hospitalized with near-fatal hypertension medications inflammatory syndrome in late January. After 10 days, she was released, lethargic and frail.

Cheering friends and family welcomed her home. Six months later, the state has one of the nation’s lowest vaccination rates ― and the unvaccinated include several people in Allie’s close circle of contacts. (Imani Khayyam for KHN) At the hair salon in Clinton, McClure shares more openly now about her cousin’s illness with her clients. €œI’ll say my little cousin had it and we get to talking about it,” said McClure.

But she doesn’t push it. €œWhen clients come in, we want it to be about them. We ask, ‘Are you going on vacation?. €™ We focus on them to make them feel good.” But she notices those around her have dropped their guard.

€œThey take everything for granted. €˜Oh, we’re good. We’re fine. We don’t have to sanitize,’” she said.

€œEven now at the salon we try to make people sanitize, and they’re like, ‘Ugh.’” McClure had a mild hypertension medications last Thanksgiving — headache and nausea — but it passed. Even now, she’s in no rush to get vaccinated. €œEven with the treatment, you can still get it. Every day I feel like something about it is changing, there’s a new strand,” she said.

Erin, Allie’s 16-year-old cousin, isn’t sure when — or if — she’ll get vaccinated. She’s nervous about the side effects and wants to wait and see. In her view, the lasix has “died down” and she’s unfamiliar with the delta variant. €œI’d rather read about it and see it myself,” she said.

€œI know she has a different perspective,” Allie said about her cousin Erin. €œI would have a different perspective if it hadn’t happened to me. I just know some people are like, ‘My body, my choice.’ Everything these days is about politics and nobody likes to be wrong. It’s very confusing for my part.

I want people to get vaccinated because I know what it feels like.” Some of her closest friends have gotten the treatment. Was it because of what happened to her?. Allie responded, “Yes, ma’am.” PBS NewsHour producer Jason Kane contributed to this report. Sarah Varney.

svarney@kff.org, @SarahVarney4 Related Topics Contact Us Submit a Story Tip.

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In a joint statement, the International Labour Organization (ILO), Food and Agriculture Organization (FAO), International Fund for Agricultural Development (IFAD) and World Health Organization (WHO) highlighted that tens of millions are at risk of falling into extreme poverty.“Now is the time for global solidarity and support, especially with the most vulnerable in our societies, particularly in the emerging and developing world”, the statement said.Smallholder farmers need to be linked to markets so that they can improve their farming and sell their products.IFAD supports projects that connect rural people to markets and services so they can grow more and earn more.#InvestInRuralPeople pic.twitter.com/WYAnXq8k4y— International Fund for Agricultural Development (@IFAD) October 13, 2020 “Only together can we overcome the intertwined health and social and economic impacts of the lasix and lasix rash picture prevent its escalation into a protracted humanitarian and food security catastrophe, with the potential loss of already achieved development gains”.Jobs decimatedThe lasix has decimated jobs and placed millions of livelihoods at risk, the UN agencies attested.Pointing out that “millions of enterprises face an existential threat”, they indicated that nearly half of the world’s 3.3 billion workforce risks losing its livelihood.Unable to earn an income during lockdowns and without sufficient social protections or health care, informal economy workers are particularly vulnerable – many powerless to feed themselves and their families. Agricultural workers At the same time millions of wage-earning and self-employed agricultural workers face high levels of poverty, malnutrition and poor health.With low or irregular incomes and no social support, many are spurred to continue working in unsafe conditions, exposing themselves and their families to lasix rash picture additional risks. Moreover, amidst income losses, the agencies flagged that they may resort to unwise strategies, such as lasix rash picture panic-selling of possessions, predatory loans or child labour. €œMigrant agricultural workers are lasix rash picture particularly vulnerable, because they face risks in their transport, working and living conditions and struggle to access support measures put in place by governments”, the statement detailed.

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Food systemsThe lasix has also how to buy cheap lasix online laid bare the fragility of the entire food system. Border closures, trade restrictions how to buy cheap lasix online and confinement measures have disrupted domestic and international food supply chains and reduced access to healthy, safe and diverse diets.The UN agencies underscored that long-term strategies must be developed to “address the challenges facing the health and agri-food sectors” with priority given to underlying food security, malnutrition challenges, rural poverty and social protections, among other things. Coming back stronger, togetherThe UN is committed to pooling its expertise and experience to help countries respond to the crisis and achieve the Sustainable Development Goals (SDGs).“We must recognize this opportunity how to buy cheap lasix online to build back better”, the statement stressed.The only way to protect human health, livelihoods, food security and nutrition while ensuring a ‘new normal’, is to “rethink the future of our environment and tackle climate change and environmental degradation with ambition and urgency”, the joint statement declared.WFP/Vanessa VickThe World Food Programme (WFP) assists local farmers with maize crops in Kapchorwa, Uganda..

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Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication..