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District Court for the Northern District of California vacated the IFR.[] The Department announced on December how to get a viagra prescription from your doctor 4, 2020, that it would fully comply with the court's decision vacating the October how long does viagra last for 2020 IFR. However, changes to the regulatory text as set forth in the IFR are still reflected in the Code of Federal Regulations (CFR) at 8 CFR 214.2. This rule removes from the CFR the regulatory text that the Department promulgated in the October 2020 IFR and restores the regulatory text to appear as it did before the October 2020 IFR, and consistent with the rules that remain valid subsequent to the court's vacatur.

DHS is how to get a viagra prescription from your doctor not required to provide notice and comment or delay the effective date of this rule because this rule simply implements the court's vacatur of the IFR and restores the regulatory text so that it correctly reflects the regulatory text that predates the vacatur and remains valid. The changes made by the IFR do not have any legal effect. Moreover, good cause exists here for bypassing any otherwise applicable requirements of notice and comment and a delayed effective date.

Notice and comment and a delayed effective date are unnecessary for the implementation of the court's order vacating the rule how to get a viagra prescription from your doctor and would be impracticable and contrary to the public interest in light of the agency's immediate need to implement the final judgment. See 5 U.S.C. 553(b)(B), (d).

DHS believes that delaying the ministerial act of restoring the regulatory text how to get a viagra prescription from your doctor in the Federal Register is contrary to the public interest because it could lead to confusion, particularly among the regulated public, as to the eligibility requirements for the H-1B classification. DHS has concluded that each of those three reasons—that notice and comment and a delayed effective date are unnecessary, impracticable, and contrary to the public interest—independently provides good cause to bypass any otherwise applicable requirements of notice and comment and a delayed effective date. Start List of Subjects Administrative practice and procedureAliensCultural exchange programEmploymentForeign officialsHealth professionsReporting and recordkeeping requirementsStudents End List of Subjects Accordingly, for the reasons set forth in the preamble, DHS amends chapter I of title 8 of the Code of Federal Regulations as follows.

Start Part End Part Start Amendment how to get a viagra prescription from your doctor Part1. The authority citation for part 214 continues to read as follows. End Amendment Part Start Authority 8 U.S.C.

1101, 1102, how to get a viagra prescription from your doctor 1103, 1182, 1184, 1186a, 1187, 1221, 1281, 1282, 1301-1305 and 1372. Sec. 643, Pub.

1477-1480. Section 141 of the Compacts of Free Association with the Federated States of Micronesia and the Republic of the Marshall Islands, and with the Government of Palau, 48 U.S.C. 1901 note, and 1931 note, respectively.

8 CFR part 2. End Authority Start Amendment Part2. Amend § 214.2 by.

End Amendment Part Start Amendment Parta. Revising paragraph (h)(2)(i)(B). End Amendment Part Start Amendment Partb.

Removing paragraph (h)(4)(i)(B)( 7);End Amendment Part Start Amendment Partc. In paragraph (h)(4)(ii). End Amendment Part Start Amendment Parti.

Removing the definition of “Employer-employee relationship”. End Amendment Part Start Amendment Partii. Revising the definition of “Specialty Occupation”;End Amendment Part Start Amendment Partiii.

Removing the definition of “Third-party worksite”;End Amendment Part Start Amendment Partiv. Revising the definition of “United States employer”. AndEnd Amendment Part Start Amendment Partv.

Removing the definition of “Worksite.” End Amendment Part Start Amendment Partd. Revising paragraph (h)(4)(iii)(A). End Amendment Part Start Amendment Parte.

Removing paragraph (h)(4)(iv)(C). End Amendment Part Start Amendment Partf. Amending paragraph (h)(9) by.

End Amendment Part Start Amendment Parti. Redesignating paragraph (h)(9)(i)(A) as paragraph (h)(9)(i), and removing paragraph (h)(9)(i)(B), and End Amendment Part Start Amendment Partii. Revising paragraph (h)(9)(iii)(A)(1).

AndEnd Amendment Part Start Amendment Partg. Removing and reserving paragraph (h)(24)(ii). End Amendment Part The revisions read as follows.

Special requirements for admission, extension, and maintenance of status. * * * * * (h) * * * (2) * * * (i) * * * (B) Service or training in more than one location. A petition that requires services to be performed or training to be received in more than one location must include an itinerary with the dates and locations of the services or training and must be filed with USCIS as provided in the form instructions.

The address that the petitioner specifies as its location on the Form I-129 shall be where the petitioner is located for purposes of this paragraph. (4) * * * (i) * * * (B) * * * (ii) * * *Start Printed Page 27028 Specialty occupation means an occupation which requires theoretical and practical application of a body of highly specialized knowledge in fields of human endeavor including, but not limited to, architecture, engineering, mathematics, physical sciences, social sciences, medicine and health, education, business specialties, accounting, law, theology, and the arts, and which requires the attainment of a bachelor's degree or higher in a specific specialty, or its equivalent, as a minimum for entry into the occupation in the United States. * * * * * United States employer means a person, firm, corporation, contractor, or other association or organization in the United States which.

(1) Engages a person to work within the United States. (2) Has an employer-employee relationship with respect to employees under this part. As indicated by the fact that it may hire, pay, fire, supervise, or otherwise control the work of any such employee.

And (3) Has an Internal Revenue Service Tax identification number. * * * * * (iii) * * * (A) Standards for specialty occupation position. To qualify as a specialty occupation, the position must meet one of the following criteria.

(1) A baccalaureate or higher degree or its equivalent is normally the minimum requirement for entry into the particular position. (2) The degree requirement is common to the industry in parallel positions among similar organizations or, in the alternative, an employer may show that its particular position is so complex or unique that it can be performed only by an individual with a degree. (3) The employer normally requires a degree or its equivalent for the position.

Or (4) The nature of the specific duties are so specialized and complex that knowledge required to perform the duties is usually associated with the attainment of a baccalaureate or higher degree. * * * * * (9) * * * (iii) * * * (A)(1) H-1B petition in a specialty occupation. An approved petition classified under section 101(a)(15)(H)(i)(b) of the Act for an alien in a specialty occupation shall be valid for a period of up to three years but may not exceed the validity period of the labor condition application.

* * * * * Start Signature Alejandro N. Mayorkas, Secretary, U.S. Department of Homeland Security.

End Signature End Supplemental Information [FR Doc. 2021-10489 Filed 5-18-21. 8:45 am]BILLING CODE 9111-97-P.

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Marie Bashir Institute for Emerging Infectious Diseases and natural viagra gnc Biosecurity, University of Sydney, Sydney click now NSW, Australia. 3. Immunotherapy Programme, Champalimaud Centre for the Unknown, Lisbon, Portugal, I Med Clinic, University of Mainz, Mainz, Germany 4. Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK 5 natural viagra gnc. Zambia National Public Health Institute, Ministry of Health, Lusaka, Zambia 6.

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Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, Division of , Royal London Hospital, Barts Health NHS Trust, London, UK, , Email. [email protected]Publication date:01 August 2020More about this publication?.

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Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, how to get a viagra prescription from your doctor Varese, 10. Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy 11. Institute for Clinical Medicine, Faculty of Health Sciences, University of Aarhus, Denmark, Department of Melecular Medicine, University of Pavia, Italy 12.

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Hong Kong Tuberculosis, Chest and Heart Diseases Association, Hong Kong, China 15. Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of how to get a viagra prescription from your doctor London, London, Division of , Royal London Hospital, Barts Health NHS Trust, London, UK, , Email. [email protected]Publication date:01 August 2020More about this publication?.

The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research. The IJTLD is dedicated how to get a viagra prescription from your doctor to the continuing education of physicians and health personnel and the dissemination of information on lung health world-wide. To share scientific research of immediate concern as rapidly as possible, The Union is fast-tracking the publication of certain articles from the IJTLD and publishing them on The Union website, prior to their publication in the Journal.

Read fast-track articles.Certain IJTLD articles are also selected for translation into French, Spanish, Chinese or Russian. These are available on the Union website.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websitesDownload Article.

Viagra stories

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

Within the guideline there is agreement that optimisation of expertise and care can be achieved through centralisation, for example, by limiting analysis of next-generation sequencing (NGS)-based diagnostic panels to only a few centres and by centralising pathological review of gonadal tissues. International networks such as the European Reference Network for rare endocrine conditions (EndoERN), in which DSD is embedded, may facilitate the expansion of this kind of collaboration across Europe.This paper highlights key discussion points in the Dutch-Flemish guideline that have been insufficiently addressed in the literature thus far because they reflect viagra stories evolving technologies or less visible stakeholders. For example, prenatal observation of an atypical aspect of the genitalia indicating a possible DSD is becoming increasingly common, and we discuss appropriate counselling and a diagnostic approach for these cases, including the option of using NGS-based genetic testing. So far, little attention has been paid to this process.20 21 Furthermore, informing patients and/or their parents about atypical sex development and why this viagra stories may warrant referral to a specialised team may be challenging, especially for professionals with limited experience in DSD.22 23 Therefore, a section of the Dutch-Flemish guideline was written for these healthcare providers.

Moreover, this enables DSD specialists to refer to the guideline when advising a referral. Transition from the prenatal to the postnatal team and from the paediatric viagra stories to the adult team requires optimal communication between the specialists involved. Application of NGS-based techniques may lead to a higher diagnostic yield, providing a molecular genetic diagnosis in previously unsolved cases.16 We address the timing of this testing and the problems associated with this technique such as the interpretation of variants of unknown clinical significance (VUS). Similarly, histopathological interpretation and classification of removed gonadal tissue is challenging and would benefit from international collaboration and centralisation of expertise.MethodsFor the guideline revision, an interdisciplinary multicentre group was formed with all members responsible for updating the literature for a specific part of the guideline viagra stories.

Literature search in PubMed was not systematic, but rather intended to be broad in order to cover all areas and follow expert opinions. This approach is more in line viagra stories with the Clinical Practice Advisory Document method described by Burke et al24 for guidelines involving genetic practice because it is often troublesome to substantiate such guidelines with sufficient evidence due to the rapid changes in testing methods, for example, gene panels. All input provided by the group was synthesised by the chairperson (YvB), who also reviewed abstracts of papers on DSD published between 2010 and September 2017 for the guideline and up to October 2019 for this paper. Abstracts had to be written in English and were identified viagra stories using a broad range of Medical Subject Headings terms (eg, DSD, genetic, review, diagnosis, diagnostics, 46,XX DSD, 46,XY DSD, guideline, multidisciplinary care).

Next, potentially relevant papers on diagnostic procedures in DSD were selected. Case reports were viagra stories excluded, as were articles that were not open access or retrievable through institutional access. Based on this, a draft guideline was produced that was in line with the international principles of good diagnostic care in DSD. This draft was discussed by the writing committee and, after having obtained agreement on viagra stories remaining points of discussion, revised into a final draft.

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

In certified laboratories, the possibility of a sample switch is extremely low but should be ruled out immediately. More often, the discrepancy will be due to sex-chromosome mosaicism or a true form of DSD.A situation now occurring with increasing frequency is a discrepancy between the genotypic sex revealed by non-invasive prenatal testing (NIPT), which is now available to high-risk pregnant viagra stories women in the Netherlands and to all pregnant women in Belgium, and later ultrasound findings. NIPT screens for CNVs in the fetus. However, depending on legal restrictions and/or ethical considerations, the X and viagra stories Y chromosomes are not always included in NIPT analysis and reports.

If the X and Y chromosomes are included, it is important to realise that the presence of a Y-chromosome does not necessarily imply male fetal development. At the time that NIPT is performed (usually 11–13 weeks), genital development cannot be reliably appreciated by ultrasound, so any discrepancy or atypical aspect of the genitalia will only be noticed later in pregnancy and should prompt further evaluation.Counselling and diagnosticsIf a DSD is suspected, first-line sonographers and obstetricians should refer the couple to their colleague viagra stories prenatal specialists working with or in a DSD team. After confirming an atypical genital on ultrasound, the specialist team should offer the couple a referral for genetic counselling to discuss the possibility of performing invasive prenatal testing (usually an amniocentesis) to identify an underlying cause that fits the ultrasound findings.22 23 To enable the parents to make a well-informed decision, prenatal counselling should, in our opinion, include. Information on the ultrasound findings and the limitations of this technique viagra stories.

The procedure(s) that can be followed, including the risks associated with an amniocentesis. And the type of information genetic viagra stories testing can and cannot provide. Knowing which information has been provided and what words have been used by the prenatal specialist is very helpful for those involved in postnatal care.It is important that parents understand that the biological sex of a baby is determined by a complex interplay of chromosomes, genes and hormones, and thus that assessment of the presence or absence of a Y-chromosome alone is insufficient to assign the sex of their unborn child or, as in any unborn child, say anything about the child’s future gender identity.Expecting parents can be counselled by the clinical geneticist and the psychologist from the DSD team, although other DSD specialists can also be involved. The clinical geneticist should be experienced in prenatal counselling and well informed about the diagnostic possibilities given viagra stories the limited time span in which test results need to be available to allow parents to make a well-informed decision about whether or not to continue the pregnancy.

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

In our experience, parents appreciate having already spoken viagra stories to some members of the DSD team during pregnancy and having a contact person before birth.After expert prenatal counselling, a significant number of pregnant couples decline prenatal testing (personal experience IALG, MK, ABD, YvB, MC and HC-vdG). At birth, umbilical cord blood is a good source for (molecular) karyotyping and storage of DNA and can be obtained by the obstetrician, midwife or neonatologist. The terminology used in communication with parents should be carefully chosen,22 23 and midwives and staff of neonatal and delivery units should be clearly instructed to use gender-neutral and non-stigmatising vocabulary (eg, ‘your baby’) as long as sex assignment is pending.An algorithm for diagnostic evaluation of a suspected DSD in the viagra stories prenatal situation is proposed in figure 1. When couples opt for invasive prenatal diagnosis, the genetic analysis usually involves an (SNP)-array.

It was recently estimated that >30% of individuals who have a DSD have additional viagra stories structural anomalies, with cardiac and neurological anomalies and fetal growth restriction being particularly common.27 28 If additional anomalies are seen, the geneticist can consider specific gene defects that may underlie a known genetic syndrome or carry out NGS. NGS-based techniques have also now made their appearance in prenatal diagnosis of congenital anomalies.29 30 Panels using these techniques can be specific for genes involved in DSD, or be larger panels covering multiple congenital anomalies, and are usually employed with trio-analysis to compare variants identified in the child with the parents’ genetics.29–31 Finding a genetic cause before delivery can help reduce parental stress in the neonatal period and speed up decisions regarding gender assignment. In such cases there is no tight time limit, and we propose completing the analysis well before the expected delivery.Disorders/differences of viagra stories sex development (DSD) in the prenatal setting. A diagnostic algorithm.

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

A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

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

The medical issues in DSD can be very challenging, and the social and psychological impact is high. For neonates with ambiguous genitalia, sex assignment is an urgent and crucial issue, and it is mandatory that parents are informed that it is possible to postpone registration of their child’s sex. In cases where sex assignment has already taken place, the message that the development of the gonads or genitalia is still atypical is complicated and distressing for patients and parents or carers. A list of contact details for DSD centres and patient organisations in the Netherlands and Flanders is attached to the Dutch-Flemish guideline.

Publishing such a list, either in guidelines or online, can help healthcare professionals find the nearest centres for consultations and provide patients and patient organisations with an overview of the centres where expertise is available.Timing and place of genetic testing using NGS-based gene panelsThe diagnostic workup that is proposed for 46,XX and 46,XY DSD is shown in figures 2 and 3, respectively. Even with the rapidly expanding molecular possibilities, a (family) history and a physical examination remain the essential first steps in the diagnostic process. Biochemical and hormonal screening aim at investigating serum electrolytes, renal function and the hypothalamic-pituitary-gonadal and hypothalamic-pituitary-adrenal axes. Ultrasound screening of kidneys and internal genitalia, as well as establishing genotypic sex, should be accomplished within 48 hours and complete the baseline diagnostic work-up of a child born with ambiguous genitalia.1 16 32 3346,XX disorders/differences of sex development (DSD) in the postnatal setting.

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

A diagnostic algorithm. NGS, next-generation sequencing. CAH, Congenital adrenal hyperplasia. AMH, Anti-Müllerian Hormone.46,XY disorders/differences of sex development (DSD) in the postnatal setting.

A diagnostic algorithm. * SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

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

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

Laboratories also differ in what class of variants they report.39 In our experience, the fear of incidental findings is a major reason why some parents refrain from genetic testing.Timing of the DSD gene panel analysis is also important. While some patients or parents prefer that all diagnostic procedures be performed as soon as possible, others need time to reflect on the complex information related to more extensive genetic testing and on its possible consequences. If parents or patients do not consent to panel-based genetic testing, analysis of specific genes, such as WT1, should be considered when appropriate in view of the clinical consequences if a mutation is present (eg, clinical surveillance of renal function and screening for Wilms’ tumour in the case of WT1 mutations). Genes that are more frequently involved in DSD (eg, SRY, NR5A1) and that match the specific clinical and hormonal features in a given patient could also be considered for sequencing.

Targeted gene analysis may also be preferred in centres located in countries that do not have the resources or technical requirements to perform NGS panel-based genetic testing. Alternatively, participation by these centres in international collaborative networks may allow them to outsource the molecular genetic workup abroad.Gene panels differ between centres and are regularly updated based on scientific progress. A comparison of DSD gene panels used in recent studies can be found at https://www.nature.com/articles/s41574-018-0010-8%23Sec46.15 The panels currently used at the coauthors’ institutions can be found on their respective websites. Given the pace of change, it is important to regularly consider repeating analysis in patients with an unexplained DSD, for example, when they transition into adult care or when they move from one centre to another.

This also applies to patients in whom a clinical diagnosis has never been genetically confirmed. Confusion may arise when the diagnosis cannot be confirmed or when a mutation is identified in a different gene, for example, NR5A1 in someone with a clinical diagnosis of CAIS that has other consequences for relatives. Hence, new genetic counselling should always accompany new diagnostic endeavours.Class 3 variants and histopathological examinationsThe rapidly evolving diagnostic possibilities raise new questions. What do laboratories report?.

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

This was recently demonstrated by the identification of the NR5A1 mutation, R92W, in individuals with 46,XX testicular and ovotesticular DSD.40 This gene had previously been associated with 46,XY DSD. In diagnostic laboratories, there is usually no capacity or expertise to conduct large-scale functional studies to determine pathogenicity of these unique class 3 VUS in the different genes involved in DSD. Functional validation of variants identified in novel genes may be more attractive in a research context. However, for individual families with VUS in well-established DSD genes such as AR or HSD17B3, functional analysis may provide a confirmed diagnosis that implies for relatives the option of undergoing their own DNA analysis and estimating the genetic risk of their own future offspring.

This makes genetic follow-up important in these cases and demonstrates the usefulness of international databases and networks and the centralisation of functional studies of genetic variants in order to reduce costs and maximise expertise.The same is true for histopathological description, germ-cell tumour risk assessment in specific forms of DSD and classification of gonadal samples. Germ-cell tumour risk is related to the type of DSD (among other factors), but it is impossible to make risk estimates in individual cases.41–44 Gonadectomy may be indicated in cases with high-risk dysgenetic abdominal gonads that cannot be brought into a stable superficial (ie, inguinal, labioscrotal) position that allows clinical or radiological surveillance, or to avoid virilisation due to 5-alpha reductase deficiency in a 46,XY girl with a stable female gender identity.45 Pathological examination of DSD gonads requires specific expertise. For example, the differentiation between benign germ cell abnormalities, such as delayed maturation and (pre)malignant development of germ cells, is crucial for clinical management but can be very troublesome.46 Centralised pathological examination of gonadal biopsy and gonadectomy samples in one centre, or a restricted number of centres, on a national scale can help to overcome the problem of non-uniform classification and has proven feasible in the Netherlands and Belgium. We therefore believe that uniform assessment and classification of gonadal differentiation patterns should also be addressed in guidelines on DSD management.International databases of gonadal tissues are crucial for learning more about the risk of malignancy in different forms of DSD, but they are only reliable if uniform criteria for histological classification are strictly applied.46 These criteria could be incorporated in many existing networks such as the I-DSD consortium, the Disorders of Sex Development Translational Research Network, the European Reference Network on Urogenital Diseases (eUROGEN), the EndoERN and COST actions.15–17 47Communication at the transition from paediatric to adult carePaediatric and adult teams need to collaborate closely to facilitate a well-organised transition from paediatric to adult specialist care.15 48–50 Both teams need to exchange information optimally and should consider transition as a longitudinal process rather than a fixed moment in time.

Age-appropriate information is key at all ages, and an overview of topics to be discussed at each stage is described by Cools et al.15 Table 1 shows an example of how transition can be organised.View this table:Table 1 Example of transition table as used in the DSD clinic of the Erasmus Medical CenterPsychological support and the continued provision of information remains important for individuals with a DSD at all ages.15 22 In addition to the information given by the DSD team members, families and patients can benefit from resources such as support groups and information available on the internet.47 Information available online should be checked for accuracy and completeness when referring patients and parents to internet sites.Recommendations for future actionsMost guidelines and articles on the diagnosis and management of DSD are aimed at specialists and are only published in specialist journals or on websites for endocrinologists, urologists or geneticists. Yet there is a need for guidelines directed towards first-line and second-line healthcare workers that summarise the recommendations about the first crucial steps in the management of DSD. These should be published in widely available general medical journals and online, along with a national list of DSD centres. Furthermore, DSD (expert) centres should provide continuous education to all those who may be involved in the identification of individuals with a DSD in order to enable these healthcare professionals to recognise atypical genitalia, to promptly refer individuals who have a DSD and to inform the patient and parents about this and subsequent diagnostic procedures.As DSD continues to be a rare condition, it will take time to evaluate the effects of having such a guideline on the preparedness of first-line and second-line healthcare workers to recognise DSD conditions.

One way to evaluate this might be the development and use of questionnaires asking patients, carers and families and referring physicians how satisfied they were with the initial medical consultation and referral and what could be improved. A helpful addition to existing international databases that collect information on genetic variations would be a list of centres that offer suitable functional studies for certain genes, ideally covering the most frequently mutated genes (at minimum).Patient organisations can also play an important role in informing patients about newly available diagnostic or therapeutic strategies and options, and their influence and specific role has now been recognised and discussed in several publications.17 47 However, it should be kept in mind that these organisations do not represent all patients, as a substantial number of patients and parents are not member of such an organisation.Professionals have to provide optimal medical care based on well-established evidence, or at least on broad consensus. Yet not everything can be regulated by recommendations and guidelines. Options, ideas and wishes should be openly discussed between professionals, patients and families within their confidential relationship.

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

Guidelines can provide a framework within which individualised patient care should be discussed with all stakeholders.AcknowledgmentsThe authors would like to thank the colleagues of the DSD teams for their input in and critical reading of the Dutch-Flemish guideline. Amsterdam University Center (AMC and VU), Maastricht University Medical Center, Erasmus Medical Center Rotterdam, Radboud University Medical Center Nijmegen, University Medical Center Groningen, University Medical Center Utrecht, Ghent University Hospital. The authors would like to thank Kate McIntyre for editing the revised manuscript and Tom de Vries Lentsch for providing the figures as a PDF. Three of the authors of this publication are members of the European Reference Network for rare endocrine diseases—Project ID 739543.IntroductionEndometrial cancer is the most common gynaecological malignancy in the developed world.1 Its incidence has risen over the last two decades as a consequence of the ageing population, fewer hysterectomies for benign disease and the obesity epidemic.

In the USA, it is estimated that women have a 1 in 35 lifetime risk of endometrial cancer, and in contrast to cancers of most other sites, cancer-specific mortality has risen by approximately 2% every year since 2008 related to the rapidly rising incidence.2Endometrial cancer has traditionally been classified into type I and type II based on morphology.3 The more common subtype, type I, is mostly comprised of endometrioid tumours and is oestrogen-driven, arises from a hyperplastic endometrium, presents at an early stage and has an excellent 5 year survival rate.4 By contrast, type II includes non-endometrioid tumours, specifically serous, carcinosarcoma and clear cell subtypes, which are biologically aggressive tumours with a poor prognosis that are often diagnosed at an advanced stage.5 Recent efforts have focused on a molecular classification system for more accurate categorisation of endometrial tumours into four groups with distinct prognostic profiles.6 7The majority of endometrial cancers arise through the interplay of familial, genetic and lifestyle factors. Two inherited cancer predisposition syndromes, Lynch syndrome and the much rarer Cowden syndrome, substantially increase the lifetime risk of endometrial cancer, but these only account for around 3–5% of cases.8–10 Having first or second degree relative(s) with endometrial or colorectal cancer increases endometrial cancer risk, although a large European twin study failed to demonstrate a strong heritable link.11 The authors failed to show that there was greater concordance in monozygotic than dizygotic twins, but the study was based on relatively small numbers of endometrial cancers. Lu and colleagues reported an association between common single nucleotide polymorphisms (SNPs) and endometrial cancer risk, revealing the potential role of SNPs in explaining part of the risk in both the familial and general populations.12 Thus far, many SNPs have been reported to modify susceptibility to endometrial cancer. However, much of this work predated genome wide association studies and is of variable quality.

Understanding genetic predisposition to endometrial cancer could facilitate personalised risk assessment with a view to targeted prevention and screening interventions.13 This emerged as the most important unanswered research question in endometrial cancer according to patients, carers and healthcare professionals in our recently completed James Lind Womb Cancer Alliance Priority Setting Partnership.14 It would be particularly useful for non-endometrioid endometrial cancers, for which advancing age is so far the only predictor.15We therefore conducted a comprehensive systematic review of the literature to provide an overview of the relationship between SNPs and endometrial cancer risk. We compiled a list of the most robust endometrial cancer-associated SNPs. We assessed the applicability of this panel of SNPs with a theoretical polygenic risk score (PRS) calculation. We also critically appraised the meta-analyses investigating the most frequently reported SNPs in MDM2.

Finally, we described all SNPs reported within genes and pathways that are likely involved in endometrial carcinogenesis and metastasis.MethodsOur systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) collaboration 2009 recommendations. The registered protocol is available through PROSPERO (CRD42018091907).16Search strategyWe searched Embase, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases via the Healthcare Databases Advanced Search (HDAS) platform, from 2007 to 2018, to identify studies reporting associations between polymorphisms and endometrial cancer risk. Key words including MeSH (Medical Subject Heading) terms and free-text words were searched in both titles and abstracts. The following terms were used.

€œendomet*”,“uter*”, “womb”, “cancer(s)”, “neoplasm(s)”, “endometrium tumour”, “carcinoma”, “adenosarcoma”, “clear cell carcinoma”, “carcinosarcoma”, “SNP”, “single nucleotide polymorphism”, “GWAS”, and “genome-wide association study/ies”. No other restrictions were applied. The search was repeated with time restrictions between 2018 and June 2019 to capture any recent publications.Eligibility criteriaStudies were selected for full-text evaluation if they were primary articles investigating a relationship between endometrial cancer and SNPs. Study outcome was either the increased or decreased risk of endometrial cancer relative to controls reported as an odds ratio (OR) with corresponding 95% confidence intervals (95% CIs).Study selectionThree independent reviewers screened all articles uploaded to a screening spreadsheet developed by Helena VonVille.17 Disagreements were resolved by discussion.

Chronbach’s α score was calculated between reviewers and indicated high consistency at 0.92. Case–control, prospective and retrospective studies, genome-wide association studies (GWAS), and both discovery and validation studies were selected for full-text evaluation. Non-English articles, editorials, conference abstracts and proceedings, letters and correspondence, case reports and review articles were excluded.Candidate-gene studies with at least 100 women and GWAS with at least 1000 women in the case arm were selected to ensure reliability of the results, as explained by Spencer et al.18 To construct a panel of up to 30 SNPs with the strongest evidence of association, those with the strongest p values were selected. For the purpose of an SNP panel, articles utilising broad European or multi-ethnic cohorts were selected.

Where overlapping populations were identified, the most comprehensive study was included.Data extraction and synthesisFor each study, the following data were extracted. SNP ID, nearby gene(s)/chromosome location, OR (95% CI), p value, minor or effect allele frequency (MAF/EAF), EA (effect allele) and OA (other allele), adjustment, ethnicity and ancestry, number of cases and controls, endometrial cancer type, and study type including discovery or validation study and meta-analysis. For risk estimates, a preference towards most adjusted results was applied. For candidate-gene studies, a standard p value of<0.05 was applied and for GWAS a p value of <5×10-8, indicating genome-wide significance, was accepted as statistically significant.

However, due to the limited number of SNPs with p values reaching genome-wide significance, this threshold was then lowered to <1×10-5, allowing for marginally significant SNPs to be included. As shown by Mavaddat et al, for breast cancer, SNPs that fall below genome-wide significance may still be useful for generating a PRS and improving the models.19We estimated the potential value of a PRS based on the most significant SNPs by comparing the predicted risk for a woman with a risk score in the top 1% of the distribution to the mean predicted risk. Per-allele ORs and MAFs were taken from the publications and standard errors (SEs) for the lnORs were derived from published 95% CIs. The PRS was assumed to have a Normal distribution, with mean 2∑βipI and SE, σ, equal to √2∑βi2pI(1−pi), according to the binomial distribution, where the summation is over all SNPs in the risk score.

Hence the relative risk (RR) comparing the top 1% of the distribution to the mean is given by exp(Z0.01σ), where Z is the inverse of the standard normal cumulative distribution.ResultsThe flow chart of study selection is illustrated in figure 1. In total, 453 text articles were evaluated and, of those, 149 articles met our inclusion criteria. One study was excluded from table 1, for having an Asian-only population, as this would make it harder to compare with the rest of the results which were all either multi-ethnic or Caucasian cohorts, as stated in our inclusion criteria for the SNP panel.20 Any SNPs without 95% CIs were also excluded from any downstream analysis. Additionally, SNPs in linkage disequilibrium (r2 >0.2) with each other were examined, and of those in linkage disequilibrium, the SNP with strongest association was reported.

Per allele ORs were used unless stated otherwise.View this table:Table 1 List of top SNPs most likely to contribute to endometrial cancer risk identified through systematic review of recent literature21–25Study selection flow diagram. *Reasons. Irrelevant articles, articles focusing on other conditions, non-GWAS/candidate-gene study related articles, technical and duplicate articles. GWAS, genome-wide association study.

Adapted from. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement.

PLoS Med 6(6). E1000097. Doi:10.1371/journal.pmed1000097." data-icon-position data-hide-link-title="0">Figure 1 Study selection flow diagram. *Reasons.

Irrelevant articles, articles focusing on other conditions, non-GWAS/candidate-gene study related articles, technical and duplicate articles. GWAS, genome-wide association study. Adapted from. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009).

Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement. PLoS Med 6(6). E1000097.

Doi:10.1371/journal.pmed1000097.Top SNPs associated with endometrial cancer riskFollowing careful interpretation of the data, 24 independent SNPs with the lowest p values that showed the strongest association with endometrial cancer were obtained (table 1).21–25 These SNPs are located in or around genes coding for transcription factors, cell growth and apoptosis regulators, and enzymes involved in the steroidogenesis pathway. All the SNPs presented here were reported on the basis of a GWAS or in one case, an exome-wide association study, and hence no SNPs from candidate-gene studies made it to the list. This is partly due to the nature of larger GWAS providing more comprehensive and powered results as opposed to candidate gene studies. Additionally, a vast majority of SNPs reported by candidate-gene studies were later refuted by large-scale GWAS such as in the case of TERT and MDM2 variants.26 27 The exception to this is the CYP19 gene, where candidate-gene studies reported an association between variants in this gene with endometrial cancer in both Asian and broad European populations, and this association was more recently confirmed by large-scale GWAS.21 28–30 Moreover, a recent article authored by O’Mara and colleagues reviewed the GWAS that identified most of the currently known SNPs associated with endometrial cancer.31Most of the studies represented in table 1 are GWAS and the majority of these involved broad European populations.

Those having a multi-ethnic cohort also consisted primarily of broad European populations. Only four of the variants in table 1 are located in coding regions of a gene, or in regulatory flanking regions around the gene. Thus, most of these variants would not be expected to cause any functional effects on the gene or the resulting protein. An eQTL search using GTEx Portal showed that some of the SNPs are significantly associated (p<0.05) with modified transcription levels of the respective genes in various tissues such as prostate (rs11263761), thyroid (rs9668337), pituitary (rs2747716), breast mammary (rs882380) and testicular (rs2498794) tissue, as summarised in table 2.View this table:Table 2 List of eQTL hits for the selected panel of SNPsThe only variant for which there was an indication of a specific association with non-endometrioid endometrial cancer was rs148261157 near the BCL11A gene.

The A allele of this SNP had a moderately higher association in the non-endometrioid arm (OR 1.64, 95% CI 1.32 to 2.04. P=9.6×10-6) compared with the endometrioid arm (OR 1.25, 95% CI 1.14 to 1.38. P=4.7×10-6).21Oestrogen receptors α and β encoded by ESR1 and ESR2, respectively, have been extensively studied due to the assumed role of oestrogens in the development of endometrial cancer. O’Mara et al reported a lead SNP (rs79575945) in the ESR1 region that was associated with endometrial cancer (p=1.86×10-5).24 However, this SNP did not reach genome-wide significance in a more recent larger GWAS.21 No statistically significant associations have been reported between endometrial cancer and SNPs in the ESR2 gene region.AKT is an oncogene linked to endometrial carcinogenesis.

It is involved in the PI3K/AKT/mTOR pro-proliferative signalling pathway to inactivate apoptosis and allow cell survival. The A allele of rs2494737 and G allele of rs2498796 were reported to be associated with increased and decreased risk of endometrial cancer in 2016, respectively.22 30 However, this association was not replicated in a larger GWAS in 2018.21 Nevertheless, given the previous strong indications, and biological basis that could explain endometrial carcinogenesis, we decided to include an AKT1 variant (rs2498794) in our results.PTEN is a multi-functional tumour suppressor gene that regulates the AKT/PKB signalling pathway and is commonly mutated in many cancers including endometrial cancer.32 Loss-of-function germline mutations in PTEN are responsible for Cowden syndrome, which exerts a lifetime risk of endometrial cancer of up to 28%.9 Lacey and colleagues studied SNPs in the PTEN gene region. However, none showed significant differences in frequency between 447 endometrial cancer cases and 439 controls of European ancestry.33KRAS mutations are known to be present in endometrial cancer. These can be activated by high levels of KLF5 (transcriptional activator).

Three SNPs have been identified in or around KLF5 that are associated with endometrial cancer. The G allele of rs11841589 (OR 1.15, 95% CI 1.11 to 1.21. P=4.83×10-11), the A allele of rs9600103 (OR 1.23, 95% CI 1.16 to 1.30. P=3.76×10-12) and C allele of rs7981863 (OR 1.16, 95% CI 1.12 to 1.20.

P=2.70×10-17) have all been found to be associated with an increased likelihood of endometrial cancer in large European cohorts.21 30 34 It is worth noting that these SNPs are not independent, and hence they quite possibly tag the same causal variant.The MYC family of proto-oncogenes encode transcription factors that regulate cell proliferation, which can contribute to cancer development if dysregulated. The recent GWAS by O’Mara et al reported three SNPs within the MYC region that reached genome-wide significance with conditional p values reaching at least 5×10–8.35To test the utility of these SNPs as predictive markers, we devised a theoretical PRS calculation using the log ORs and EAFs per SNP from the published data. The results were very encouraging with an RR of 3.16 for the top 1% versus the mean, using all the top SNPs presented in table 1 and 2.09 when using only the SNPs that reached genome-wide significance (including AKT1).Controversy surrounding MDM2 variant SNP309MDM2 negatively regulates tumour suppressor gene TP53, and as such, has been extensively studied in relation to its potential role in predisposition to endometrial cancer. Our search identified six original studies of the association between MDM2 SNP rs2279744 (also referred to as SNP309) and endometrial cancer, all of which found a statistically significant increased risk per copy of the G allele.

Two more original studies were identified through our full-text evaluation. However, these were not included here as they did not meet our inclusion criteria—one due to small sample size, the other due to studying rs2279744 status dependent on another SNP.36 37 Even so, the two studies were described in multiple meta-analyses that are listed in table 3. Different permutations of these eight original studies appear in at least eight published meta-analyses. However, even the largest meta-analysis contained <2000 cases (table 3)38View this table:Table 3 Characteristics of studies that examined MDM2 SNP rs2279744In comparison, a GWAS including nearly 13 000 cases found no evidence of an association with OR and corresponding 95% CI of 1.00 (0.97 to 1.03) and a p value of 0.93 (personal communication).21 Nevertheless, we cannot completely rule out a role for MDM2 variants in endometrial cancer predisposition as the candidate-gene studies reported larger effects in Asians, whereas the GWAS primarily contained participants of European ancestry.

There is also some suggestion that the SNP309 variant is in linkage disequilibrium with another variant, SNP285, which confers an opposite effect.It is worth noting that the SNP285C/SNP309G haplotype frequency was observed in up to 8% of Europeans, thus requiring correction for the confounding effect of SNP285C in European studies.39 However, aside from one study conducted by Knappskog et al, no other study including the meta-analyses corrected for the confounding effect of SNP285.40 Among the studies presented in table 3, Knappskog et al (2012) reported that after correcting for SNP285, the OR for association of this haplotype with endometrial cancer was much lower, though still significant. Unfortunately, the meta-analyses which synthesised Knappskog et al (2012), as part of their analysis, did not correct for SNP285C in the European-based studies they included.38 41 42 It is also concerning that two meta-analyses using the same primary articles failed to report the same result, in two instances.38 42–44DiscussionThis article represents the most comprehensive systematic review to date, regarding critical appraisal of the available evidence of common low-penetrance variants implicated in predisposition to endometrial cancer. We have identified the most robust SNPs in the context of endometrial cancer risk. Of those, only 19 were significant at genome-wide level and a further five were considered marginally significant.

The largest GWAS conducted in this field was the discovery- and meta-GWAS by O’Mara et al, which utilised 12 096 cases and 108 979 controls.21 Despite the inclusion of all published GWAS and around 5000 newly genotyped cases, the total number did not reach anywhere near what is currently available for other common cancers such as breast cancer. For instance, BCAC (Breast Cancer Association Consortium) stands at well over 200 000 individuals with more than half being cases, and resulted in identification of ~170 SNPs in relation to breast cancer.19 45 A total of 313 SNPs including imputations were then used to derive a PRS for breast cancer.19 Therefore, further efforts should be directed to recruit more patients, with deep phenotypic clinical data to allow for relevant adjustments and subgroup analyses to be conducted for better precision.A recent pre-print study by Zhang and colleagues examined the polygenicity and potential for SNP-based risk prediction for 14 common cancers, including endometrial cancer, using available summary-level data from European-ancestry datasets.46 They estimated that there are just over 1000 independent endometrial cancer susceptibility SNPs, and that a PRS comprising all such SNPs would have an area under the receiver-operator curve of 0.64, similar to that predicted for ovarian cancer, but lower than that for the other cancers in the study. The modelling in the paper suggests that an endometrial cancer GWAS double the size of the current largest study would be able to identify susceptibility SNPs together explaining 40% of the genetic variance, but that in order to explain 75% of the genetic variance it would be necessary to have a GWAS comprising close to 150 000 cases and controls, far in excess of what is currently feasible.We found that the literature consists mainly of candidate-gene studies with small sample sizes, meta-analyses reporting conflicting results despite using the same set of primary articles, and multiple reports of significant SNPs that have not been validated by any larger GWAS. The candidate-gene studies were indeed the most useful and cheaper technique available until the mid to late 2000s.

However, a lack of reproducibility (particularly due to population stratification and reporting bias), uncertainty of reported associations, and considerably high false discovery rates make these studies much less appropriate in the post-GWAS era. Unlike the candidate-gene approach, GWAS do not require prior knowledge, selection of genes or SNPs, and provide vast amounts of data. Furthermore, both the genotyping process and data analysis phases have become cheaper, the latter particularly due to faster and open-access pre-phasing and imputation tools being made available.It is clear from table 1 that some SNPs were reported with wide 95% CI, which can be directly attributed to small sample sizes particularly when restricting the cases to non-endometrioid histology only, low EAF or poor imputation quality. Thus, these should be interpreted with caution.

Additionally, most of the SNPs reported by candidate-gene studies were not detected by the largest GWAS to date conducted by O’Mara et al.21 However, this does not necessarily mean that the possibility of those SNPs being relevant should be completely dismissed. Moreover, meta-analyses were attempted for other variants. However, these showed no statistically significant association and many presented with high heterogeneity between the respective studies (data not shown). Furthermore, as many studies utilised the same set of cases and/or controls, conducting a meta-analysis was not possible for a good number of SNPs.

It is therefore unequivocal that the literature is crowded with numerous small candidate-gene studies and conflicting data. This makes it particularly hard to detect novel SNPs and conduct meaningful meta-analyses.We found convincing evidence for 19 variants that indicated the strongest association with endometrial cancer, as shown in table 1. The associations between endometrial cancer and variants in or around HNF1B, CYP19A1, SOX4, MYC, KLF and EIF2AK found in earlier GWAS were then replicated in the latest and largest GWAS. These SNPs showed promising potential in a theoretical PRS we devised based on published data.

Using all 24 or genome-wide significant SNPs only, women with a PRS in the top 1% of the distribution would be predicted to have a risk of endometrial cancer 3.16 and 2.09 times higher than the mean risk, respectively.However, the importance of these variants and relevance of the proximate genes in a functional or biological context is challenging to evaluate. Long distance promoter regulation by enhancers may disguise the genuine target gene. In addition, enhancers often do not loop to the nearest gene, further complicating the relevance of nearby gene(s) to a GWAS hit. In order to elucidate biologically relevant candidate target genes in endometrial cancer, O’Mara et al looked into promoter-associated chromatin looping using a modern HiChIP approach.47 The authors utilised normal and tumoural endometrial cell lines for this analysis which showed significant enrichment for endometrial cancer heritability, with 103 candidate target genes identified across the 13 risk loci identified by the largest ECAC GWAS.

Notable genes identified here were CDKN2A and WT1, and their antisense counterparts. The former was reported to be nearby of rs1679014 and the latter of rs10835920, as shown in table 1. Moreover, of the 36 candidate target genes, 17 were found to be downregulated while 19 were upregulated in endometrial tumours.The authors also investigated overlap between the 13 endometrial cancer risk loci and top eQTL variants for each target gene.47 In whole blood, of the two particular lead SNPs, rs8822380 at 17q21.32 was a top eQTL for SNX11 and HOXB2, whereas rs937213 at 15q15.1 was a top eQTL for SRP14. In endometrial tumour, rs7579014 at 2p16.1 was found to be a top eQTL for BCL11A.

This is particularly interesting because BCL11A was the only nearby/candidate gene that had a GWAS association reported in both endometrioid and non-endometrioid subtypes. The study looked at protein–protein interactions between endometrial cancer drivers and candidate target gene products. Significant interactions were observed with TP53 (most significant), AKT, PTEN, ESR1 and KRAS, among others. Finally, when 103 target candidate genes and 387 proteins were combined together, 462 pathways were found to be significantly enriched.

Many of these are related to gene regulation, cancer, obesity, insulinaemia and oestrogen exposure. This study clearly showed a potential biological relevance for some of the SNPs reported by ECAC GWAS in 2018.Most of the larger included studies used cohorts primarily composed of women of broad European descent. Hence, there are negligible data available for other ethnicities, particularly African women. This is compounded by the lack of reference genotype data available for comparative analysis, making it harder for research to be conducted in ethnicities other than Europeans.

This poses a problem for developing risk prediction models that are equally valuable and predictive across populations. Thus, our results also are of limited applicability to non-European populations.Furthermore, considering that non-endometrioid cases comprise a small proportion (~20%) of all endometrial cancer cases, much larger cohort sizes are needed to detect any genuine signals for non-endometrioid tumours. Most of the evaluated studies looked at either overall/mixed endometrial cancer subtypes or endometrioid histology, and those that looked at variant associations with non-endometrioid histology were unlikely to have enough power to detect any signal with statistical significance. This is particularly concerning because non-endometrioid subtypes are biologically aggressive tumours with a much poorer prognosis that contribute disproportionately to mortality from endometrial cancer.

It is particularly important that attempts to improve early detection and prevention of endometrial cancer focus primarily on improving outcomes from these subtypes. It is also worth noting that, despite the current shift towards a molecular classification of endometrial cancer, most studies used the overarching classical Bokhman’s classification system, type I versus type II, or no histological classification system at all. Therefore, it is important to create and follow a standardised and comprehensive classification system for reporting tumour subtypes for future studies.This study compiled and presented available information for an extensively studied, yet unproven in large datasets, SNP309 variant in MDM2. Currently, there is no convincing evidence for an association between this variant and endometrial cancer risk.

Additionally, of all the studies, only one accounted for the opposing effect of a nearby variant SNP285 in their analyses. Thus, we conclude that until confirmed by a sufficiently large GWAS, this variant should not be considered significant in influencing the risk of endometrial cancer and therefore not included in a PRS. This is also true for the majority of the SNPs reported in candidate-gene studies, as the numbers fall far short of being able to detect genuine signals.This systematic review presents the most up-to-date evidence for endometrial cancer susceptibility variants, emphasising the need for further large-scale studies to identify more variants of importance, and validation of these associations. Until data from larger and more diverse cohorts are available, the top 24 SNPs presented here are the most robust common genetic variants that affect endometrial cancer risk.

The multiplicative effects of these SNPs could be used in a PRS to allow personalised risk prediction models to be developed for targeted screening and prevention interventions for women at greatest risk of endometrial cancer..

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

Within the guideline there is agreement that optimisation of expertise and care can be achieved through centralisation, for example, by limiting analysis of next-generation sequencing (NGS)-based diagnostic panels to only a few centres and by centralising pathological review of gonadal tissues. International networks such as the European Reference Network for rare endocrine conditions (EndoERN), in which how to get a viagra prescription from your doctor DSD is embedded, may facilitate the expansion of this kind of collaboration across Europe.This paper highlights key discussion points in the Dutch-Flemish guideline that have been insufficiently addressed in the literature thus far because they reflect evolving technologies or less visible stakeholders. For example, prenatal observation of an atypical aspect of the genitalia indicating a possible DSD is becoming increasingly common, and we discuss appropriate counselling and a diagnostic approach for these cases, including the option of using NGS-based genetic testing. So far, little attention has been paid to this process.20 21 Furthermore, informing patients and/or their parents about atypical sex how to get a viagra prescription from your doctor development and why this may warrant referral to a specialised team may be challenging, especially for professionals with limited experience in DSD.22 23 Therefore, a section of the Dutch-Flemish guideline was written for these healthcare providers.

Moreover, this enables DSD specialists to refer to the guideline when advising a referral. Transition from the prenatal to the postnatal team and from the paediatric to the how to get a viagra prescription from your doctor adult team requires optimal communication between the specialists involved. Application of NGS-based techniques may lead to a higher diagnostic yield, providing a molecular genetic diagnosis in previously unsolved cases.16 We address the timing of this testing and the problems associated with this technique such as the interpretation of variants of unknown clinical significance (VUS). Similarly, histopathological interpretation and classification of removed gonadal tissue is challenging and would benefit from international collaboration and centralisation of expertise.MethodsFor the guideline revision, an interdisciplinary multicentre group was formed with how to get a viagra prescription from your doctor all members responsible for updating the literature for a specific part of the guideline.

Literature search in PubMed was not systematic, but rather intended to be broad in order to cover all areas and follow expert opinions. This approach is more in line with the Clinical Practice how to get a viagra prescription from your doctor Advisory Document method described by Burke et al24 for guidelines involving genetic practice because it is often troublesome to substantiate such guidelines with sufficient evidence due to the rapid changes in testing methods, for example, gene panels. All input provided by the group was synthesised by the chairperson (YvB), who also reviewed abstracts of papers on DSD published between 2010 and September 2017 for the guideline and up to October 2019 for this paper. Abstracts had to be written in English and were identified using a broad range of Medical Subject Headings terms (eg, DSD, genetic, review, diagnosis, diagnostics, 46,XX DSD, how to get a viagra prescription from your doctor 46,XY DSD, guideline, multidisciplinary care).

Next, potentially relevant papers on diagnostic procedures in DSD were selected. Case reports were excluded, as how to get a viagra prescription from your doctor were articles that were not open access or retrievable through institutional access. Based on this, a draft guideline was produced that was in line with the international principles of good diagnostic care in DSD. This draft was discussed by the writing committee how to get a viagra prescription from your doctor and, after having obtained agreement on remaining points of discussion, revised into a final draft.

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

In certified laboratories, the possibility of a sample switch is extremely low but should be ruled out immediately. More often, the discrepancy will be due to sex-chromosome mosaicism or a true form of DSD.A situation now occurring with increasing frequency is a discrepancy between the genotypic sex revealed by non-invasive prenatal testing (NIPT), which is now available to high-risk pregnant women in the Netherlands and to how to get a viagra prescription from your doctor all pregnant women in Belgium, and later ultrasound findings. NIPT screens for CNVs in the fetus. However, depending on legal restrictions and/or how to get a viagra prescription from your doctor ethical considerations, the X and Y chromosomes are not always included in NIPT analysis and reports.

If the X and Y chromosomes are included, it is important to realise that the presence of a Y-chromosome does not necessarily imply male fetal development. At the time that NIPT is performed (usually 11–13 weeks), genital development cannot be reliably appreciated by ultrasound, so any discrepancy or atypical aspect of the genitalia will only be noticed later in pregnancy and should prompt further evaluation.Counselling and diagnosticsIf a DSD is suspected, first-line sonographers and obstetricians should refer the couple to their colleague prenatal specialists working with or in a DSD team how to get a viagra prescription from your doctor. After confirming an atypical genital on ultrasound, the specialist team should offer the couple a referral for genetic counselling to discuss the possibility of performing invasive prenatal testing (usually an amniocentesis) to identify an underlying cause that fits the ultrasound findings.22 23 To enable the parents to make a well-informed decision, prenatal counselling should, in our opinion, include. Information on the ultrasound findings how to get a viagra prescription from your doctor and the limitations of this technique.

The procedure(s) that can be followed, including the risks associated with an amniocentesis. And the type of information genetic testing can and how to get a viagra prescription from your doctor cannot provide. Knowing which information has been provided and what words have been used by the prenatal specialist is very helpful for those involved in postnatal care.It is important that parents understand that the biological sex of a baby is determined by a complex interplay of chromosomes, genes and hormones, and thus that assessment of the presence or absence of a Y-chromosome alone is insufficient to assign the sex of their unborn child or, as in any unborn child, say anything about the child’s future gender identity.Expecting parents can be counselled by the clinical geneticist and the psychologist from the DSD team, although other DSD specialists can also be involved. The clinical geneticist should be experienced in prenatal counselling and well informed about the diagnostic possibilities given the limited time span in which test results need to be available how to get a viagra prescription from your doctor to allow parents to make a well-informed decision about whether or not to continue the pregnancy.

Termination of pregnancy can be considered, for instance, in a syndromic form of DSD with how to get a viagra prescription from your doctor multiple malformations, but when the DSD occurs as an apparently isolated condition, expecting parents may also consider termination of pregnancy, which, although considered controversial by some, is legal in Belgium and the Netherlands. The psychologist of the DSD team can support parents during and after pregnancy and help them cope with feelings of uncertainty and eventual considerations of a termination of pregnancy, as well as with practical issues, for example, how to inform others. The stress of not knowing exactly what the child’s genitalia will look like and uncertainty how to get a viagra prescription from your doctor about the diagnosis, treatment and prognosis cannot be avoided completely. Parents are informed that if the postnatal phenotype is different from what was prenatally expected, the advice given about diagnostic testing can be adjusted accordingly, for example, if a hypospadias is milder than was expected based on prenatal ultrasound images.

In our experience, parents appreciate having already spoken to some members of the how to get a viagra prescription from your doctor DSD team during pregnancy and having a contact person before birth.After expert prenatal counselling, a significant number of pregnant couples decline prenatal testing (personal experience IALG, MK, ABD, YvB, MC and HC-vdG). At birth, umbilical cord blood is a good source for (molecular) karyotyping and storage of DNA and can be obtained by the obstetrician, midwife or neonatologist. The terminology used in communication with parents should be carefully chosen,22 23 and midwives and how to get a viagra prescription from your doctor staff of neonatal and delivery units should be clearly instructed to use gender-neutral and non-stigmatising vocabulary (eg, ‘your baby’) as long as sex assignment is pending.An algorithm for diagnostic evaluation of a suspected DSD in the prenatal situation is proposed in figure 1. When couples opt for invasive prenatal diagnosis, the genetic analysis usually involves an (SNP)-array.

It was recently estimated that >30% of individuals who have a DSD have additional structural anomalies, with cardiac how to get a viagra prescription from your doctor and neurological anomalies and fetal growth restriction being particularly common.27 28 If additional anomalies are seen, the geneticist can consider specific gene defects that may underlie a known genetic syndrome or carry out NGS. NGS-based techniques have also now made their appearance in prenatal diagnosis of congenital anomalies.29 30 Panels using these techniques can be specific for genes involved in DSD, or be larger panels covering multiple congenital anomalies, and are usually employed with trio-analysis to compare variants identified in the child with the parents’ genetics.29–31 Finding a genetic cause before delivery can help reduce parental stress in the neonatal period and speed up decisions regarding gender assignment. In such cases there is no tight time limit, and we propose completing the analysis how to get a viagra prescription from your doctor well before the expected delivery.Disorders/differences of sex development (DSD) in the prenatal setting. A diagnostic algorithm.

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

A diagnostic algorithm. *SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

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

The medical issues in DSD can be very challenging, and the social and psychological impact is high. For neonates with ambiguous genitalia, sex assignment is an urgent and crucial issue, and it is mandatory that parents are informed that it is possible to postpone registration of their child’s sex. In cases where sex assignment has already taken place, the message that the development of the gonads or genitalia is still atypical is complicated and distressing for patients and parents or carers. A list of contact details for DSD centres and patient organisations in the Netherlands and Flanders is attached to the Dutch-Flemish guideline.

Publishing such a list, either in guidelines or online, can help healthcare professionals find the nearest centres for consultations and provide patients and patient organisations with an overview of the centres where expertise is available.Timing and place of genetic testing using NGS-based gene panelsThe diagnostic workup that is proposed for 46,XX and 46,XY DSD is shown in figures 2 and 3, respectively. Even with the rapidly expanding molecular possibilities, a (family) history and a physical examination remain the essential first steps in the diagnostic process. Biochemical and hormonal screening aim at investigating serum electrolytes, renal function and the hypothalamic-pituitary-gonadal and hypothalamic-pituitary-adrenal axes. Ultrasound screening of kidneys and internal genitalia, as well as establishing genotypic sex, should be accomplished within 48 hours and complete the baseline diagnostic work-up of a child born with ambiguous genitalia.1 16 32 3346,XX disorders/differences of sex development (DSD) in the postnatal setting.

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

A diagnostic algorithm. NGS, next-generation sequencing. CAH, Congenital adrenal hyperplasia. AMH, Anti-Müllerian Hormone.46,XY disorders/differences of sex development (DSD) in the postnatal setting.

A diagnostic algorithm. * SOX9. Upstream anomalies and balanced translocations at promotor sites!. Conventional karyotyping can be useful.

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

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

Laboratories also differ in what class of variants they report.39 In our experience, the fear of incidental findings is a major reason why some parents refrain from genetic testing.Timing of the DSD gene panel analysis is also important. While some patients or parents prefer that all diagnostic procedures be performed as soon as possible, others need time to reflect on the complex information related to more extensive genetic testing and on its possible consequences. If parents or patients do not consent to panel-based genetic testing, analysis of specific genes, such as WT1, should be considered when appropriate in view of the clinical consequences if a mutation is present (eg, clinical surveillance of renal function and screening for Wilms’ tumour in the case of WT1 mutations). Genes that are more frequently involved in DSD (eg, SRY, NR5A1) and that match the specific clinical and hormonal features in a given patient could also be considered for sequencing.

Targeted gene analysis may also be preferred in centres located in countries that do not have the resources or technical requirements to perform NGS panel-based genetic testing. Alternatively, participation by these centres in international collaborative networks may allow them to outsource the molecular genetic workup abroad.Gene panels differ between centres and are regularly updated based on scientific progress. A comparison of DSD gene panels used in recent studies can be found at https://www.nature.com/articles/s41574-018-0010-8%23Sec46.15 The panels currently used at the coauthors’ institutions can be found on their respective websites. Given the pace of change, it is important to regularly consider repeating analysis in patients with an unexplained DSD, for example, when they transition into adult care or when they move from one centre to another.

This also applies to patients in whom a clinical diagnosis has never been genetically confirmed. Confusion may arise when the diagnosis cannot be confirmed or when a mutation is identified in a different gene, for example, NR5A1 in someone with a clinical diagnosis of CAIS that has other consequences for relatives. Hence, new genetic counselling should always accompany new diagnostic endeavours.Class 3 variants and histopathological examinationsThe rapidly evolving diagnostic possibilities raise new questions. What do laboratories report?.

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

This was recently demonstrated by the identification of the NR5A1 mutation, R92W, in individuals with 46,XX testicular and ovotesticular DSD.40 This gene had previously been associated with 46,XY DSD. In diagnostic laboratories, there is usually no capacity or expertise to conduct large-scale functional studies to determine pathogenicity of these unique class 3 VUS in the different genes involved in DSD. Functional validation of variants identified in novel genes may be more attractive in a research context. However, for individual families with VUS in well-established DSD genes such as AR or HSD17B3, functional analysis may provide a confirmed diagnosis that implies for relatives the option of undergoing their own DNA analysis and estimating the genetic risk of their own future offspring.

This makes genetic follow-up important in these cases and demonstrates the usefulness of international databases and networks and the centralisation of functional studies of genetic variants in order to reduce costs and maximise expertise.The same is true for histopathological description, germ-cell tumour risk assessment in specific forms of DSD and classification of gonadal samples. Germ-cell tumour risk is related to the type of DSD (among other factors), but it is impossible to make risk estimates in individual cases.41–44 Gonadectomy may be indicated in cases with high-risk dysgenetic abdominal gonads that cannot be brought into a stable superficial (ie, inguinal, labioscrotal) position that allows clinical or radiological surveillance, or to avoid virilisation due to 5-alpha reductase deficiency in a 46,XY girl with a stable female gender identity.45 Pathological examination of DSD gonads requires specific expertise. For example, the differentiation between benign germ cell abnormalities, such as delayed maturation and (pre)malignant development of germ cells, is crucial for clinical management but can be very troublesome.46 Centralised pathological examination of gonadal biopsy and gonadectomy samples in one centre, or a restricted number of centres, on a national scale can help to overcome the problem of non-uniform classification and has proven feasible in the Netherlands and Belgium. We therefore believe that uniform assessment and classification of gonadal differentiation patterns should also be addressed in guidelines on DSD management.International databases of gonadal tissues are crucial for learning more about the risk of malignancy in different forms of DSD, but they are only reliable if uniform criteria for histological classification are strictly applied.46 These criteria could be incorporated in many existing networks such as the I-DSD consortium, the Disorders of Sex Development Translational Research Network, the European Reference Network on Urogenital Diseases (eUROGEN), the EndoERN and COST actions.15–17 47Communication at the transition from paediatric to adult carePaediatric and adult teams need to collaborate closely to facilitate a well-organised transition from paediatric to adult specialist care.15 48–50 Both teams need to exchange information optimally and should consider transition as a longitudinal process rather than a fixed moment in time.

Age-appropriate information is key at all ages, and an overview of topics to be discussed at each stage is described by Cools et al.15 Table 1 shows an example of how transition can be organised.View this table:Table 1 Example of transition table as used in the DSD clinic of the Erasmus Medical CenterPsychological support and the continued provision of information remains important for individuals with a DSD at all ages.15 22 In addition to the information given by the DSD team members, families and patients can benefit from resources such as support groups and information available on the internet.47 Information available online should be checked for accuracy and completeness when referring patients and parents to internet sites.Recommendations for future actionsMost guidelines and articles on the diagnosis and management of DSD are aimed at specialists and are only published in specialist journals or on websites for endocrinologists, urologists or geneticists. Yet there is a need for guidelines directed towards first-line and second-line healthcare workers that summarise the recommendations about the first crucial steps in the management of DSD. These should be published in widely available general medical journals and online, along with a national list of DSD centres. Furthermore, DSD (expert) centres should provide continuous education to all those who may be involved in the identification of individuals with a DSD in order to enable these healthcare professionals to recognise atypical genitalia, to promptly refer individuals who have a DSD and to inform the patient and parents about this and subsequent diagnostic procedures.As DSD continues to be a rare condition, it will take time to evaluate the effects of having such a guideline on the preparedness of first-line and second-line healthcare workers to recognise DSD conditions.

One way to evaluate this might be the development and use of questionnaires asking patients, carers and families and referring physicians how satisfied they were with the initial medical consultation and referral and what could be improved. A helpful addition to existing international databases that collect information on genetic variations would be a list of centres that offer suitable functional studies for certain genes, ideally covering the most frequently mutated genes (at minimum).Patient organisations can also play an important role in informing patients about newly available diagnostic or therapeutic strategies and options, and their influence and specific role has now been recognised and discussed in several publications.17 47 However, it should be kept in mind that these organisations do not represent all patients, as a substantial number of patients and parents are not member of such an organisation.Professionals have to provide optimal medical care based on well-established evidence, or at least on broad consensus. Yet not everything can be regulated by recommendations and guidelines. Options, ideas and wishes should be openly discussed between professionals, patients and families within their confidential relationship.

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

Guidelines can provide a framework within which individualised patient care should be discussed with all stakeholders.AcknowledgmentsThe authors would like to thank the colleagues of the DSD teams for their input in and critical reading of the Dutch-Flemish guideline. Amsterdam University Center (AMC and VU), Maastricht University Medical Center, Erasmus Medical Center Rotterdam, Radboud University Medical Center Nijmegen, University Medical Center Groningen, University Medical Center Utrecht, Ghent University Hospital. The authors would like to thank Kate McIntyre for editing the revised manuscript and Tom de Vries Lentsch for providing the figures as a PDF. Three of the authors of this publication are members of the European Reference Network for rare endocrine diseases—Project ID 739543.IntroductionEndometrial cancer is the most common gynaecological malignancy in the developed world.1 Its incidence has risen over the last two decades as a consequence of the ageing population, fewer hysterectomies for benign disease and the obesity epidemic.

In the USA, it is estimated that women have a 1 in 35 lifetime risk of endometrial cancer, and in contrast to cancers of most other sites, cancer-specific mortality has risen by approximately 2% every year since 2008 related to the rapidly rising incidence.2Endometrial cancer has traditionally been classified into type I and type II based on morphology.3 The more common subtype, type I, is mostly comprised of endometrioid tumours and is oestrogen-driven, arises from a hyperplastic endometrium, presents at an early stage and has an excellent 5 year survival rate.4 By contrast, type II includes non-endometrioid tumours, specifically serous, carcinosarcoma and clear cell subtypes, which are biologically aggressive tumours with a poor prognosis that are often diagnosed at an advanced stage.5 Recent efforts have focused on a molecular classification system for more accurate categorisation of endometrial tumours into four groups with distinct prognostic profiles.6 7The majority of endometrial cancers arise through the interplay of familial, genetic and lifestyle factors. Two inherited cancer predisposition syndromes, Lynch syndrome and the much rarer Cowden syndrome, substantially increase the lifetime risk of endometrial cancer, but these only account for around 3–5% of cases.8–10 Having first or second degree relative(s) with endometrial or colorectal cancer increases endometrial cancer risk, although a large European twin study failed to demonstrate a strong heritable link.11 The authors failed to show that there was greater concordance in monozygotic than dizygotic twins, but the study was based on relatively small numbers of endometrial cancers. Lu and colleagues reported an association between common single nucleotide polymorphisms (SNPs) and endometrial cancer risk, revealing the potential role of SNPs in explaining part of the risk in both the familial and general populations.12 Thus far, many SNPs have been reported to modify susceptibility to endometrial cancer. However, much of this work predated genome wide association studies and is of variable quality.

Understanding genetic predisposition to endometrial cancer could facilitate personalised risk assessment with a view to targeted prevention and screening interventions.13 This emerged as the most important unanswered research question in endometrial cancer according to patients, carers and healthcare professionals in our recently completed James Lind Womb Cancer Alliance Priority Setting Partnership.14 It would be particularly useful for non-endometrioid endometrial cancers, for which advancing age is so far the only predictor.15We therefore conducted a comprehensive systematic review of the literature to provide an overview of the relationship between SNPs and endometrial cancer risk. We compiled a list of the most robust endometrial cancer-associated SNPs. We assessed the applicability of this panel of SNPs with a theoretical polygenic risk score (PRS) calculation. We also critically appraised the meta-analyses investigating the most frequently reported SNPs in MDM2.

Finally, we described all SNPs reported within genes and pathways that are likely involved in endometrial carcinogenesis and metastasis.MethodsOur systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) collaboration 2009 recommendations. The registered protocol is available through PROSPERO (CRD42018091907).16Search strategyWe searched Embase, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases via the Healthcare Databases Advanced Search (HDAS) platform, from 2007 to 2018, to identify studies reporting associations between polymorphisms and endometrial cancer risk. Key words including MeSH (Medical Subject Heading) terms and free-text words were searched in both titles and abstracts. The following terms were used.

€œendomet*”,“uter*”, “womb”, “cancer(s)”, “neoplasm(s)”, “endometrium tumour”, “carcinoma”, “adenosarcoma”, “clear cell carcinoma”, “carcinosarcoma”, “SNP”, “single nucleotide polymorphism”, “GWAS”, and “genome-wide association study/ies”. No other restrictions were applied. The search was repeated with time restrictions between 2018 and June 2019 to capture any recent publications.Eligibility criteriaStudies were selected for full-text evaluation if they were primary articles investigating a relationship between endometrial cancer and SNPs. Study outcome was either the increased or decreased risk of endometrial cancer relative to controls reported as an odds ratio (OR) with corresponding 95% confidence intervals (95% CIs).Study selectionThree independent reviewers screened all articles uploaded to a screening spreadsheet developed by Helena VonVille.17 Disagreements were resolved by discussion.

Chronbach’s α score was calculated between reviewers and indicated high consistency at 0.92. Case–control, prospective and retrospective studies, genome-wide association studies (GWAS), and both discovery and validation studies were selected for full-text evaluation. Non-English articles, editorials, conference abstracts and proceedings, letters and correspondence, case reports and review articles were excluded.Candidate-gene studies with at least 100 women and GWAS with at least 1000 women in the case arm were selected to ensure reliability of the results, as explained by Spencer et al.18 To construct a panel of up to 30 SNPs with the strongest evidence of association, those with the strongest p values were selected. For the purpose of an SNP panel, articles utilising broad European or multi-ethnic cohorts were selected.

Where overlapping populations were identified, the most comprehensive study was included.Data extraction and synthesisFor each study, the following data were extracted. SNP ID, nearby gene(s)/chromosome location, OR (95% CI), p value, minor or effect allele frequency (MAF/EAF), EA (effect allele) and OA (other allele), adjustment, ethnicity and ancestry, number of cases and controls, endometrial cancer type, and study type including discovery or validation study and meta-analysis. For risk estimates, a preference towards most adjusted results was applied. For candidate-gene studies, a standard p value of<0.05 was applied and for GWAS a p value of <5×10-8, indicating genome-wide significance, was accepted as statistically significant.

However, due to the limited number of SNPs with p values reaching genome-wide significance, this threshold was then lowered to <1×10-5, allowing for marginally significant SNPs to be included. As shown by Mavaddat et al, for breast cancer, SNPs that fall below genome-wide significance may still be useful for generating a PRS and improving the models.19We estimated the potential value of a PRS based on the most significant SNPs by comparing the predicted risk for a woman with a risk score in the top 1% of the distribution to the mean predicted risk. Per-allele ORs and MAFs were taken from the publications and standard errors (SEs) for the lnORs were derived from published 95% CIs. The PRS was assumed to have a Normal distribution, with mean 2∑βipI and SE, σ, equal to √2∑βi2pI(1−pi), according to the binomial distribution, where the summation is over all SNPs in the risk score.

Hence the relative risk (RR) comparing the top 1% of the distribution to the mean is given by exp(Z0.01σ), where Z is the inverse of the standard normal cumulative distribution.ResultsThe flow chart of study selection is illustrated in figure 1. In total, 453 text articles were evaluated and, of those, 149 articles met our inclusion criteria. One study was excluded from table 1, for having an Asian-only population, as this would make it harder to compare with the rest of the results which were all either multi-ethnic or Caucasian cohorts, as stated in our inclusion criteria for the SNP panel.20 Any SNPs without 95% CIs were also excluded from any downstream analysis. Additionally, SNPs in linkage disequilibrium (r2 >0.2) with each other were examined, and of those in linkage disequilibrium, the SNP with strongest association was reported.

Per allele ORs were used unless stated otherwise.View this table:Table 1 List of top SNPs most likely to contribute to endometrial cancer risk identified through systematic review of recent literature21–25Study selection flow diagram. *Reasons. Irrelevant articles, articles focusing on other conditions, non-GWAS/candidate-gene study related articles, technical and duplicate articles. GWAS, genome-wide association study.

Adapted from. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement.

PLoS Med 6(6). E1000097. Doi:10.1371/journal.pmed1000097." data-icon-position data-hide-link-title="0">Figure 1 Study selection flow diagram. *Reasons.

Irrelevant articles, articles focusing on other conditions, non-GWAS/candidate-gene study related articles, technical and duplicate articles. GWAS, genome-wide association study. Adapted from. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009).

Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement. PLoS Med 6(6). E1000097.

Doi:10.1371/journal.pmed1000097.Top SNPs associated with endometrial cancer riskFollowing careful interpretation of the data, 24 independent SNPs with the lowest p values that showed the strongest association with endometrial cancer were obtained (table 1).21–25 These SNPs are located in or around genes coding for transcription factors, cell growth and apoptosis regulators, and enzymes involved in the steroidogenesis pathway. All the SNPs presented here were reported on the basis of a GWAS or in one case, an exome-wide association study, and hence no SNPs from candidate-gene studies made it to the list. This is partly due to the nature of larger GWAS providing more comprehensive and powered results as opposed to candidate gene studies. Additionally, a vast majority of SNPs reported by candidate-gene studies were later refuted by large-scale GWAS such as in the case of TERT and MDM2 variants.26 27 The exception to this is the CYP19 gene, where candidate-gene studies reported an association between variants in this gene with endometrial cancer in both Asian and broad European populations, and this association was more recently confirmed by large-scale GWAS.21 28–30 Moreover, a recent article authored by O’Mara and colleagues reviewed the GWAS that identified most of the currently known SNPs associated with endometrial cancer.31Most of the studies represented in table 1 are GWAS and the majority of these involved broad European populations.

Those having a multi-ethnic cohort also consisted primarily of broad European populations. Only four of the variants in table 1 are located in coding regions of a gene, or in regulatory flanking regions around the gene. Thus, most of these variants would not be expected to cause any functional effects on the gene or the resulting protein. An eQTL search using GTEx Portal showed that some of the SNPs are significantly associated (p<0.05) with modified transcription levels of the respective genes in various tissues such as prostate (rs11263761), thyroid (rs9668337), pituitary (rs2747716), breast mammary (rs882380) and testicular (rs2498794) tissue, as summarised in table 2.View this table:Table 2 List of eQTL hits for the selected panel of SNPsThe only variant for which there was an indication of a specific association with non-endometrioid endometrial cancer was rs148261157 near the BCL11A gene.

The A allele of this SNP had a moderately higher association in the non-endometrioid arm (OR 1.64, 95% CI 1.32 to 2.04. P=9.6×10-6) compared with the endometrioid arm (OR 1.25, 95% CI 1.14 to 1.38. P=4.7×10-6).21Oestrogen receptors α and β encoded by ESR1 and ESR2, respectively, have been extensively studied due to the assumed role of oestrogens in the development of endometrial cancer. O’Mara et al reported a lead SNP (rs79575945) in the ESR1 region that was associated with endometrial cancer (p=1.86×10-5).24 However, this SNP did not reach genome-wide significance in a more recent larger GWAS.21 No statistically significant associations have been reported between endometrial cancer and SNPs in the ESR2 gene region.AKT is an oncogene linked to endometrial carcinogenesis.

It is involved in the PI3K/AKT/mTOR pro-proliferative signalling pathway to inactivate apoptosis and allow cell survival. The A allele of rs2494737 and G allele of rs2498796 were reported to be associated with increased and decreased risk of endometrial cancer in 2016, respectively.22 30 However, this association was not replicated in a larger GWAS in 2018.21 Nevertheless, given the previous strong indications, and biological basis that could explain endometrial carcinogenesis, we decided to include an AKT1 variant (rs2498794) in our results.PTEN is a multi-functional tumour suppressor gene that regulates the AKT/PKB signalling pathway and is commonly mutated in many cancers including endometrial cancer.32 Loss-of-function germline mutations in PTEN are responsible for Cowden syndrome, which exerts a lifetime risk of endometrial cancer of up to 28%.9 Lacey and colleagues studied SNPs in the PTEN gene region. However, none showed significant differences in frequency between 447 endometrial cancer cases and 439 controls of European ancestry.33KRAS mutations are known to be present in endometrial cancer. These can be activated by high levels of KLF5 (transcriptional activator).

Three SNPs have been identified in or around KLF5 that are associated with endometrial cancer. The G allele of rs11841589 (OR 1.15, 95% CI 1.11 to 1.21. P=4.83×10-11), the A allele of rs9600103 (OR 1.23, 95% CI 1.16 to 1.30. P=3.76×10-12) and C allele of rs7981863 (OR 1.16, 95% CI 1.12 to 1.20.

P=2.70×10-17) have all been found to be associated with an increased likelihood of endometrial cancer in large European cohorts.21 30 34 It is worth noting that these SNPs are not independent, and hence they quite possibly tag the same causal variant.The MYC family of proto-oncogenes encode transcription factors that regulate cell proliferation, which can contribute to cancer development if dysregulated. The recent GWAS by O’Mara et al reported three SNPs within the MYC region that reached genome-wide significance with conditional p values reaching at least 5×10–8.35To test the utility of these SNPs as predictive markers, we devised a theoretical PRS calculation using the log ORs and EAFs per SNP from the published data. The results were very encouraging with an RR of 3.16 for the top 1% versus the mean, using all the top SNPs presented in table 1 and 2.09 when using only the SNPs that reached genome-wide significance (including AKT1).Controversy surrounding MDM2 variant SNP309MDM2 negatively regulates tumour suppressor gene TP53, and as such, has been extensively studied in relation to its potential role in predisposition to endometrial cancer. Our search identified six original studies of the association between MDM2 SNP rs2279744 (also referred to as SNP309) and endometrial cancer, all of which found a statistically significant increased risk per copy of the G allele.

Two more original studies were identified through our full-text evaluation. However, these were not included here as they did not meet our inclusion criteria—one due to small sample size, the other due to studying rs2279744 status dependent on another SNP.36 37 Even so, the two studies were described in multiple meta-analyses that are listed in table 3. Different permutations of these eight original studies appear in at least eight published meta-analyses. However, even the largest meta-analysis contained <2000 cases (table 3)38View this table:Table 3 Characteristics of studies that examined MDM2 SNP rs2279744In comparison, a GWAS including nearly 13 000 cases found no evidence of an association with OR and corresponding 95% CI of 1.00 (0.97 to 1.03) and a p value of 0.93 (personal communication).21 Nevertheless, we cannot completely rule out a role for MDM2 variants in endometrial cancer predisposition as the candidate-gene studies reported larger effects in Asians, whereas the GWAS primarily contained participants of European ancestry.

There is also some suggestion that the SNP309 variant is in linkage disequilibrium with another variant, SNP285, which confers an opposite effect.It is worth noting that the SNP285C/SNP309G haplotype frequency was observed in up to 8% of Europeans, thus requiring correction for the confounding effect of SNP285C in European studies.39 However, aside from one study conducted by Knappskog et al, no other study including the meta-analyses corrected for the confounding effect of SNP285.40 Among the studies presented in table 3, Knappskog et al (2012) reported that after correcting for SNP285, the OR for association of this haplotype with endometrial cancer was much lower, though still significant. Unfortunately, the meta-analyses which synthesised Knappskog et al (2012), as part of their analysis, did not correct for SNP285C in the European-based studies they included.38 41 42 It is also concerning that two meta-analyses using the same primary articles failed to report the same result, in two instances.38 42–44DiscussionThis article represents the most comprehensive systematic review to date, regarding critical appraisal of the available evidence of common low-penetrance variants implicated in predisposition to endometrial cancer. We have identified the most robust SNPs in the context of endometrial cancer risk. Of those, only 19 were significant at genome-wide level and a further five were considered marginally significant.

The largest GWAS conducted in this field was the discovery- and meta-GWAS by O’Mara et al, which utilised 12 096 cases and 108 979 controls.21 Despite the inclusion of all published GWAS and around 5000 newly genotyped cases, the total number did not reach anywhere near what is currently available for other common cancers such as breast cancer. For instance, BCAC (Breast Cancer Association Consortium) stands at well over 200 000 individuals with more than half being cases, and resulted in identification of ~170 SNPs in relation to breast cancer.19 45 A total of 313 SNPs including imputations were then used to derive a PRS for breast cancer.19 Therefore, further efforts should be directed to recruit more patients, with deep phenotypic clinical data to allow for relevant adjustments and subgroup analyses to be conducted for better precision.A recent pre-print study by Zhang and colleagues examined the polygenicity and potential for SNP-based risk prediction for 14 common cancers, including endometrial cancer, using available summary-level data from European-ancestry datasets.46 They estimated that there are just over 1000 independent endometrial cancer susceptibility SNPs, and that a PRS comprising all such SNPs would have an area under the receiver-operator curve of 0.64, similar to that predicted for ovarian cancer, but lower than that for the other cancers in the study. The modelling in the paper suggests that an endometrial cancer GWAS double the size of the current largest study would be able to identify susceptibility SNPs together explaining 40% of the genetic variance, but that in order to explain 75% of the genetic variance it would be necessary to have a GWAS comprising close to 150 000 cases and controls, far in excess of what is currently feasible.We found that the literature consists mainly of candidate-gene studies with small sample sizes, meta-analyses reporting conflicting results despite using the same set of primary articles, and multiple reports of significant SNPs that have not been validated by any larger GWAS. The candidate-gene studies were indeed the most useful and cheaper technique available until the mid to late 2000s.

However, a lack of reproducibility (particularly due to population stratification and reporting bias), uncertainty of reported associations, and considerably high false discovery rates make these studies much less appropriate in the post-GWAS era. Unlike the candidate-gene approach, GWAS do not require prior knowledge, selection of genes or SNPs, and provide vast amounts of data. Furthermore, both the genotyping process and data analysis phases have become cheaper, the latter particularly due to faster and open-access pre-phasing and imputation tools being made available.It is clear from table 1 that some SNPs were reported with wide 95% CI, which can be directly attributed to small sample sizes particularly when restricting the cases to non-endometrioid histology only, low EAF or poor imputation quality. Thus, these should be interpreted with caution.

Additionally, most of the SNPs reported by candidate-gene studies were not detected by the largest GWAS to date conducted by O’Mara et al.21 However, this does not necessarily mean that the possibility of those SNPs being relevant should be completely dismissed. Moreover, meta-analyses were attempted for other variants. However, these showed no statistically significant association and many presented with high heterogeneity between the respective studies (data not shown). Furthermore, as many studies utilised the same set of cases and/or controls, conducting a meta-analysis was not possible for a good number of SNPs.

It is therefore unequivocal that the literature is crowded with numerous small candidate-gene studies and conflicting data. This makes it particularly hard to detect novel SNPs and conduct meaningful meta-analyses.We found convincing evidence for 19 variants that indicated the strongest association with endometrial cancer, as shown in table 1. The associations between endometrial cancer and variants in or around HNF1B, CYP19A1, SOX4, MYC, KLF and EIF2AK found in earlier GWAS were then replicated in the latest and largest GWAS. These SNPs showed promising potential in a theoretical PRS we devised based on published data.

Using all 24 or genome-wide significant SNPs only, women with a PRS in the top 1% of the distribution would be predicted to have a risk of endometrial cancer 3.16 and 2.09 times higher than the mean risk, respectively.However, the importance of these variants and relevance of the proximate genes in a functional or biological context is challenging to evaluate. Long distance promoter regulation by enhancers may disguise the genuine target gene. In addition, enhancers often do not loop to the nearest gene, further complicating the relevance of nearby gene(s) to a GWAS hit. In order to elucidate biologically relevant candidate target genes in endometrial cancer, O’Mara et al looked into promoter-associated chromatin looping using a modern HiChIP approach.47 The authors utilised normal and tumoural endometrial cell lines for this analysis which showed significant enrichment for endometrial cancer heritability, with 103 candidate target genes identified across the 13 risk loci identified by the largest ECAC GWAS.

Notable genes identified here were CDKN2A and WT1, and their antisense counterparts. The former was reported to be nearby of rs1679014 and the latter of rs10835920, as shown in table 1. Moreover, of the 36 candidate target genes, 17 were found to be downregulated while 19 were upregulated in endometrial tumours.The authors also investigated overlap between the 13 endometrial cancer risk loci and top eQTL variants for each target gene.47 In whole blood, of the two particular lead SNPs, rs8822380 at 17q21.32 was a top eQTL for SNX11 and HOXB2, whereas rs937213 at 15q15.1 was a top eQTL for SRP14. In endometrial tumour, rs7579014 at 2p16.1 was found to be a top eQTL for BCL11A.

This is particularly interesting because BCL11A was the only nearby/candidate gene that had a GWAS association reported in both endometrioid and non-endometrioid subtypes. The study looked at protein–protein interactions between endometrial cancer drivers and candidate target gene products. Significant interactions were observed with TP53 (most significant), AKT, PTEN, ESR1 and KRAS, among others. Finally, when 103 target candidate genes and 387 proteins were combined together, 462 pathways were found to be significantly enriched.

Many of these are related to gene regulation, cancer, obesity, insulinaemia and oestrogen exposure. This study clearly showed a potential biological relevance for some of the SNPs reported by ECAC GWAS in 2018.Most of the larger included studies used cohorts primarily composed of women of broad European descent. Hence, there are negligible data available for other ethnicities, particularly African women. This is compounded by the lack of reference genotype data available for comparative analysis, making it harder for research to be conducted in ethnicities other than Europeans.

This poses a problem for developing risk prediction models that are equally valuable and predictive across populations. Thus, our results also are of limited applicability to non-European populations.Furthermore, considering that non-endometrioid cases comprise a small proportion (~20%) of all endometrial cancer cases, much larger cohort sizes are needed to detect any genuine signals for non-endometrioid tumours. Most of the evaluated studies looked at either overall/mixed endometrial cancer subtypes or endometrioid histology, and those that looked at variant associations with non-endometrioid histology were unlikely to have enough power to detect any signal with statistical significance. This is particularly concerning because non-endometrioid subtypes are biologically aggressive tumours with a much poorer prognosis that contribute disproportionately to mortality from endometrial cancer.

It is particularly important that attempts to improve early detection and prevention of endometrial cancer focus primarily on improving outcomes from these subtypes. It is also worth noting that, despite the current shift towards a molecular classification of endometrial cancer, most studies used the overarching classical Bokhman’s classification system, type I versus type II, or no histological classification system at all. Therefore, it is important to create and follow a standardised and comprehensive classification system for reporting tumour subtypes for future studies.This study compiled and presented available information for an extensively studied, yet unproven in large datasets, SNP309 variant in MDM2. Currently, there is no convincing evidence for an association between this variant and endometrial cancer risk.

Additionally, of all the studies, only one accounted for the opposing effect of a nearby variant SNP285 in their analyses. Thus, we conclude that until confirmed by a sufficiently large GWAS, this variant should not be considered significant in influencing the risk of endometrial cancer and therefore not included in a PRS. This is also true for the majority of the SNPs reported in candidate-gene studies, as the numbers fall far short of being able to detect genuine signals.This systematic review presents the most up-to-date evidence for endometrial cancer susceptibility variants, emphasising the need for further large-scale studies to identify more variants of importance, and validation of these associations. Until data from larger and more diverse cohorts are available, the top 24 SNPs presented here are the most robust common genetic variants that affect endometrial cancer risk.

The multiplicative effects of these SNPs could be used in a PRS to allow personalised risk prediction models to be developed for targeted screening and prevention interventions for women at greatest risk of endometrial cancer..

Grapefruit juice and viagra

Shutterstock Robert Gebbia, American Foundation for Suicide Prevention (AFSP) CEO, released a statement grapefruit juice and viagra following Congress’ approval go of an omnibus appropriations package for fiscal year 2021. AFSP, the country’s grapefruit juice and viagra largest suicide prevention organization, supports the legislation that includes the Department of Defense and Labor, Health and Human Services, Education and Related Agencies appropriations bills. €œAs an organization dedicated to saving lives and bringing hope to those affected by suicide, we would like to thank Congress for their work on the latest funding they have awarded to suicide prevention, and we urge continued bipartisan support for addressing this leading cause of death,” Gebbia said.

The appropriations package increases funding for the National Suicide Prevention Lifeline from $19 million to $24 million, for the Suicide Prevention Resource Center from $7.9 million to $9 grapefruit juice and viagra million, and the Center for Disease Control and Prevention’s suicide efforts from $10 million to $12 million. It also increases funding for National Institute of Mental Health research. The bill also grapefruit juice and viagra includes suicide prevention as a priority research topic within the Peer-Reviewed Medical Research Program at the Department of Defense.

AFSP thanked the Appropriations Committees for including language in the package encouraging greater collaboration and partnership between health agencies to examine the relationship between substance use disorder and suicide.Shutterstock Nearly half of people who suffer from substance use disorders (SUD) are hesitant to take a erectile dysfunction treatment, according to an Addiction Policy Forum survey.Of those who are willing, most said they would take it as soon as possible, while the remainder said they prefer to wait.SUD patients who have a history of intravenous drug use said injections were a potential trigger that could hamper their recoveries. In contrast, nearly 25 percent of those surveyed said the number of required doses of a treatment would affect their decision to get vaccinated.The viagra caused the respondents to distrust health care providers more than they did before the grapefruit juice and viagra crisis. Still, health care providers are the grapefruit juice and viagra top source of health care information, followed by family members and television and newspapers.“Results from this study emphasize the vital role physicians play as an educator and messenger of information to inform patient healthcare decisions, especially among the SUD population.” Jessica Hulsey, Addiction Policy Forum president, said.

€œEducation is needed to deliver treatment information to patients, especially to individuals struggling with addiction or in recovery, who experience more severe effects and may be at a higher risk of contracting erectile dysfunction treatment.”The survey was conducted Sept. 14-Sept. 27.Sutterstock On Monday, Congress passed a sweeping $900 billion stimulus package that would not provide direct help to Americans during the erectile dysfunction treatment viagra but would also fund necessary mental health and substance abuse treatment services.

According to research from the Centers for Disease Control and Prevention, 25.5 percent of Americans surveyed in June had symptoms of anxiety, and 24.3 percent had symptoms of depression – a threefold and fourfold increase over the same time the year before. Additionally, a survey released in September by Recovery Village found that 55 percent of the 1,000 American adults surveyed reported an increase in their past-month alcohol consumption, with 18 percent reporting a significant increase. In New York, New Jersey, Massachusetts, Rhode Island, and Connecticut hit hardest by erectile dysfunction treatment, past month alcohol consumption was up by 67 percent, with 25 percent reporting a significant increase.

The survey also found that 36 percent of respondents had reported an increase in illicit drug use. More than half of the respondents said they were using substances to cope with stress, while 39 percent said they used substances to relieve boredom, and 32 percent said they were trying to cope with anxiety and depression. To address the growing mental health and substance abuse crisis stemming from the viagra, legislators included $4.25 billion in increased mental health and substance abuse services and support, including $1.6 billion for the Substance Abuse and Prevention Treatment Block Grants.

Other funding priorities included $1.65 billion for the Mental Health Services Block Grant. $600 million for Certified Community Behavioral Health Clinics. $50 million for suicide prevention programs.

$50 million for Project AWARE to support school-based mental health for children. $240 million for emergency grants to State. And $10 million for the National Child Traumatic Stress Network.The bill requires that not less than $125 million of the funds provided to SAMHSA has to go to tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes.Shutterstock U.S.

Sen. Rob Portman (R-OH) announced Monday that the final 2021 Fiscal Year funding agreement would include $782 million in grants for the Comprehensive Addiction and Recovery Act (CARA). Portman previously introduced the Comprehensive Addiction and Recovery Act (CARA) 2.0 that would increase the original law’s funding authorization levels for the original law enacted in 2016.

CARA 2.0 would also include additional policy reforms to help combat the opioid epidemic that has worsened during the erectile dysfunction treatment viagra, Portman’s office said. €œThe ongoing erectile dysfunction treatment viagra has resulted in a heartbreaking surge in overdose deaths, and that’s why I’m glad Congress has acted to increase CARA funding to help make a difference and save lives throughout Ohio. This $782 million will help state and local health officials, prevention experts, treatment providers, and law enforcement to work together to address this epidemic,” Portman said.

€œPrior to the impact of the erectile dysfunction treatment viagra, we had made significant progress in combating this epidemic thanks to CARA, and this funding will help us redouble our efforts. I will continue to work with my colleagues in the Senate to make sure those on the ground, our community leaders, first responders, and family members have the support and funding they need to continue their work fighting this epidemic. In the new Congress, we have a unique opportunity to work together in a bipartisan way, and I believe that CARA 2.0 can help us strengthen our efforts to combat this epidemic.”The bill would increase to $42 million the number of grants for providing Naloxone to first responders and would increase to $102 million the amount allocated for expanded drug treatment.

Additionally, CARA 2.0 would allocate $369 million – more than three times the original $103 million allocated in 2016 – to the Comprehensive Opioid Abuse Program. However, grants for co-prescribing Naloxone would stay at the original $1 million level passed in 2016. That funding level has remained constant throughout the life of the legislation.Shutterstock On Friday, White House Office of National Drug Control Policy (ONDCP) Director Jim Carroll said that while information on trends in youth substance misuse show drug use has not increased in the past year, trends could show an increase next year because of the erectile dysfunction treatment viagra.

Reacting to the 2020 Monitoring the Future study, which tracks youth substance misuse, Carroll said rates of illicit substance use among young people remained similar to those in 2019. In some cases, the rates of misuse, such as marijuana vaping among 10th graders, actually fell. €œThe Trump administration has dedicated a historic level of resources to ensuring the youth of our Nation are informed of the dangers of illicit substance use — information that remains critically important.

This year’s data indicates that youth substance misuse rates, collected prior to the proclamation of a state of emergency due to erectile dysfunction treatment, are similar to those in 2019. While we were fortunate not to see increases in use over the past year, we must not become complacent. As the United States emerges from the erectile dysfunction treatment viagra, we must be mindful of the impact of the viagra on youth and families, and the toll drug use takes on our country and especially on our next generation.”The study looks at tobacco, alcohol, marijuana, vaping, and other drug use in 8th, 10th, and 12th graders.

This year’s report found that while smoking in the past month dropped for eighth and tenth graders over 2019 levels, it rose in 12th graders from 5.7 percent to 7.5 percent. The study found that nearly 1 in 4 high school students – 3.65 million – currently used tobacco in some form, down about 25 percent from the 1 in 3 students in 2019. For middle school students, about 1 in 15 currently used tobacco, down nearly 50 percent from 1 in 8 in 2019.

Illicit drug use in the last month rose slightly for 8th graders, from 8.5 percent to 8.7 percent, but fell for 10th and 12th graders – 19.8 to 18.2 and 23.7 to 22.2, respectively. Daily alcohol use increased in all grade levels. In 8th graders, daily alcohol use doubled from .2 percent to .4, while the rate nearly doubled for 10th graders (.6 percent to 1 percent) and 12th graders (1.7 percent to 2.7 percent)..

Shutterstock Robert Gebbia, American Foundation for Suicide Prevention (AFSP) CEO, released a statement following Congress’ approval of how to get a viagra prescription from your doctor an omnibus appropriations package for fiscal year 2021. AFSP, the country’s largest suicide prevention organization, supports the legislation that includes the Department of Defense and Labor, Health and Human Services, Education and Related Agencies appropriations bills how to get a viagra prescription from your doctor. €œAs an organization dedicated to saving lives and bringing hope to those affected by suicide, we would like to thank Congress for their work on the latest funding they have awarded to suicide prevention, and we urge continued bipartisan support for addressing this leading cause of death,” Gebbia said. The appropriations package increases funding for the National Suicide Prevention Lifeline from $19 million to $24 million, for the Suicide how to get a viagra prescription from your doctor Prevention Resource Center from $7.9 million to $9 million, and the Center for Disease Control and Prevention’s suicide efforts from $10 million to $12 million.

It also increases funding for National Institute of Mental Health research. The bill also includes suicide prevention as a priority research topic within the Peer-Reviewed Medical Research Program at the Department of Defense how to get a viagra prescription from your doctor. AFSP thanked the Appropriations Committees for including language in the package encouraging greater collaboration and partnership between health agencies to examine the relationship between substance use disorder and suicide.Shutterstock Nearly half of people who suffer from substance use disorders (SUD) are hesitant to take a erectile dysfunction treatment, according to an Addiction Policy Forum survey.Of those who are willing, most said they would take it as soon as possible, while the remainder said they prefer to wait.SUD patients who have a history of intravenous drug use said injections were a potential trigger that could hamper their recoveries. In contrast, nearly 25 percent of those surveyed said the number of required doses of a treatment would affect their decision to get vaccinated.The viagra how to get a viagra prescription from your doctor caused the respondents to distrust health care providers more than they did before the crisis.

Still, health care providers are the top source of health care information, followed by family members and television and newspapers.“Results from this study emphasize the vital role physicians play as an educator and messenger of information to inform patient healthcare decisions, especially among the SUD population.” Jessica Hulsey, Addiction Policy how to get a viagra prescription from your doctor Forum president, said. €œEducation is needed to deliver treatment information to patients, especially to individuals struggling with addiction or in recovery, who experience more severe effects and may be at a higher risk of contracting erectile dysfunction treatment.”The survey was conducted Sept. 14-Sept. 27.Sutterstock On Monday, Congress passed a sweeping $900 billion stimulus package that would not provide direct help to Americans during the erectile dysfunction treatment viagra but would also fund necessary mental health and substance abuse treatment services.

According to research from the Centers for Disease Control and Prevention, 25.5 percent of Americans surveyed in June had symptoms of anxiety, and 24.3 percent had symptoms of depression – a threefold and fourfold increase over the same time the year before. Additionally, a survey released in September by Recovery Village found that 55 percent of the 1,000 American adults surveyed reported an increase in their past-month alcohol consumption, with 18 percent reporting a significant increase. In New York, New Jersey, Massachusetts, Rhode Island, and Connecticut hit hardest by erectile dysfunction treatment, past month alcohol consumption was up by 67 percent, with 25 percent reporting a significant increase. The survey also found that 36 percent of respondents had reported an increase in illicit drug use.

More than half of the respondents said they were using substances to cope with stress, while 39 percent said they used substances to relieve boredom, and 32 percent said they were trying to cope with anxiety and depression. To address the growing mental health and substance abuse crisis stemming from the viagra, legislators included $4.25 billion in increased mental health and substance abuse services and support, including $1.6 billion for the Substance Abuse and Prevention Treatment Block Grants. Other funding priorities included $1.65 billion for the Mental Health Services Block Grant. $600 million for Certified Community Behavioral Health Clinics.

$50 million for suicide prevention programs. $50 million for Project AWARE to support school-based mental health for children. $240 million for emergency grants to State. And $10 million for the National Child Traumatic Stress Network.The bill requires that not less than $125 million of the funds provided to SAMHSA has to go to tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes.Shutterstock U.S.

Sen. Rob Portman (R-OH) announced Monday that the final 2021 Fiscal Year funding agreement would include $782 million in grants for the Comprehensive Addiction and Recovery Act (CARA). Portman previously introduced the Comprehensive Addiction and Recovery Act (CARA) 2.0 that would increase the original law’s funding authorization levels for the original law enacted in 2016. CARA 2.0 would also include additional policy reforms to help combat the opioid epidemic that has worsened during the erectile dysfunction treatment viagra, Portman’s office said.

€œThe ongoing erectile dysfunction treatment viagra has resulted in a heartbreaking surge in overdose deaths, and that’s why I’m glad Congress has acted to increase CARA funding to help make a difference and save lives throughout Ohio. This $782 million will help state and local health officials, prevention experts, treatment providers, and law enforcement to work together to address this epidemic,” Portman said. €œPrior to the impact of the erectile dysfunction treatment viagra, we had made significant progress in combating this epidemic thanks to CARA, and this funding will help us redouble our efforts. I will continue to work with my colleagues in the Senate to make sure those on the ground, our community leaders, first responders, and family members have the support and funding they need to continue their work fighting this epidemic.

In the new Congress, we have a unique opportunity to work together in a bipartisan way, and I believe that CARA 2.0 can help us strengthen our efforts to combat this epidemic.”The bill would increase to $42 million the number of grants for providing Naloxone to first responders and would increase to $102 million the amount allocated for expanded drug treatment. Additionally, CARA 2.0 would allocate $369 million – more than three times the original $103 million allocated in 2016 – to the Comprehensive Opioid Abuse Program. However, grants for co-prescribing Naloxone would stay at the original $1 million level passed in 2016. That funding level has remained constant throughout the life of the legislation.Shutterstock On Friday, White House Office of National Drug Control Policy (ONDCP) Director Jim Carroll said that while information on trends in youth substance misuse show drug use has not increased in the past year, trends could show an increase next year because of the erectile dysfunction treatment viagra.

Reacting to the 2020 Monitoring the Future study, which tracks youth substance misuse, Carroll said rates of illicit substance use among young people remained similar to those in 2019. In some cases, the rates of misuse, such as marijuana vaping among 10th graders, actually fell. €œThe Trump administration has dedicated a historic level of resources to ensuring the youth of our Nation are informed of the dangers of illicit substance use — information that remains critically important. This year’s data indicates that youth substance misuse rates, collected prior to the proclamation of a state of emergency due to erectile dysfunction treatment, are similar to those in 2019.

While we were fortunate not to see increases in use over the past year, we must not become complacent. As the United States emerges from the erectile dysfunction treatment viagra, we must be mindful of the impact of the viagra on youth and families, and the toll drug use takes on our country and especially on our next generation.”The study looks at tobacco, alcohol, marijuana, vaping, and other drug use in 8th, 10th, and 12th graders. This year’s report found that while smoking in the past month dropped for eighth and tenth graders over 2019 levels, it rose in 12th graders from 5.7 percent to 7.5 percent. The study found that nearly 1 in 4 high school students – 3.65 million – currently used tobacco in some form, down about 25 percent from the 1 in 3 students in 2019.

For middle school students, about 1 in 15 currently used tobacco, down nearly 50 percent from 1 in 8 in 2019. Illicit drug use in the last month rose slightly for 8th graders, from 8.5 percent to 8.7 percent, but fell for 10th and 12th graders – 19.8 to 18.2 and 23.7 to 22.2, respectively. Daily alcohol use increased in all grade levels. In 8th graders, daily alcohol use doubled from .2 percent to .4, while the rate nearly doubled for 10th graders (.6 percent to 1 percent) and 12th graders (1.7 percent to 2.7 percent)..

Reddit viagra

Study Design We used two approaches to estimate the effect of you could look here vaccination on the delta variant reddit viagra. First, we used a test-negative case–control design to estimate treatment effectiveness against symptomatic disease caused by the delta variant, as compared with the alpha variant, over the period that the delta variant has been circulating. This approach has been described in detail elsewhere.10 In brief, we compared vaccination status in persons with symptomatic erectile dysfunction treatment with reddit viagra vaccination status in persons who reported symptoms but had a negative test. This approach helps to control for biases related to health-seeking behavior, access to testing, and case ascertainment. For the secondary analysis, the proportion of persons with cases caused by the delta variant relative to the main circulating viagra (the alpha variant) was reddit viagra estimated according to vaccination status.

The underlying assumption was that if the treatment had some efficacy and was equally effective against each variant, a similar proportion of cases with either variant would be expected in unvaccinated persons and in vaccinated persons. Conversely, if the treatment was less effective against the delta variant than against the alpha variant, then the delta variant would be expected to make up a higher proportion of cases occurring more than 3 weeks after vaccination than among unvaccinated persons. Details of this analysis are described in Section S1 in the Supplementary reddit viagra Appendix, available with the full text of this article at NEJM.org. The authors vouch for the accuracy and completeness of the data and for the fidelity of the trial to the protocol. Data Sources Vaccination Status Data on all persons in England who have been vaccinated with erectile dysfunction treatments are available in a national vaccination register (the National Immunisation reddit viagra Management System).

Data regarding vaccinations that had occurred up to May 16, 2021, including the date of receipt of each dose of treatment and the treatment type, were extracted on May 17, 2021. Vaccination status was categorized as receipt of one dose of treatment among persons who had symptom onset occurring 21 days or more after receipt of the first dose up to the day before the second dose was received, as receipt of the second dose among persons who had symptom onset occurring 14 days or more after receipt of the second dose, and as receipt of the first or second dose among persons with symptom onset reddit viagra occurring 21 days or more after the receipt of the first dose (including any period after the receipt of the second dose). erectile dysfunction Testing Polymerase-chain-reaction (PCR) testing for erectile dysfunction in the United Kingdom is undertaken by hospital and public health laboratories, as well as by community testing with the use of drive-through or at-home testing, which is available to anyone with symptoms consistent with erectile dysfunction treatment (high temperature, new continuous cough, or loss or change in sense of smell or taste). Data on all positive PCR tests between October 26, 2020, and May 16, 2021, were extracted. Data on all recorded negative community tests among persons who reported symptoms were also reddit viagra extracted for the test-negative case–control analysis.

Children younger than 16 years of age as of March 21, 2021, were excluded. Data were restricted to persons who had reported symptoms, and only persons who had undergone testing within 10 reddit viagra days after symptom onset were included, in order to account for reduced sensitivity of PCR testing beyond this period.25 Identification of Variant Whole-genome sequencing was used to identify the delta and alpha variants. The proportion of all positive samples that were sequenced increased from approximately 10% in February 2021 to approximately 60% in May 2021.4 Sequencing is undertaken at a network of laboratories, including the Wellcome Sanger Institute, where a high proportion of samples has been tested, and whole-genome sequences are assigned to Public Health England definitions of variants on the basis of mutations.26 Spike gene target status on PCR was used as a second approach for identifying each variant. Laboratories used the TaqPath assay (Thermo Fisher Scientific) to test for three gene targets. Spike (S), nucleocapsid (N), and reddit viagra open reading frame 1ab (ORF1ab).

In December 2020, the alpha variant was noted to be associated with negative testing on the S target, so S target–negative status was subsequently used as a proxy for identification of the variant. The alpha variant accounts for between 98% reddit viagra and 100% of S target–negative results in England. Among sequenced samples that tested positive for the S target, the delta variant was in 72.2% of the samples in April 2021 and in 93.0% in May (as of May 12, 2021).4 For the test-negative case–control analysis, only samples that had been tested at laboratories with the use of the TaqPath assay were included. Data Linkage The three reddit viagra data sources described above were linked with the use of the National Health Service number (a unique identifier for each person receiving medical care in the United Kingdom). These data sources were also linked with data on the patient’s date of birth, surname, first name, postal code, and specimen identifiers and sample dates.

Covariates Multiple covariates that may be associated with the likelihood of being offered or accepting a treatment and the risk of exposure to erectile dysfunction treatment or specifically to either of the variants analyzed were also extracted from the National Immunisation Management System and the testing data. These data included age (in 10-year age groups), sex, index of multiple deprivation (a national indication of reddit viagra level of deprivation that is based on small geographic areas of residence,27 assessed in quintiles), race or ethnic group, care home residence status, history of foreign travel (i.e., outside the United Kingdom or Ireland), geographic region, period (calendar week), health and social care worker status, and status of being in a clinically extremely vulnerable group.28 In addition, for the test-negative case–control analysis, history of erectile dysfunction before the start of the vaccination program was included. Persons were considered to have traveled if, at the point of requesting a test, they reported having traveled outside the United Kingdom and Ireland within the preceding 14 days or if they had been tested in a quarantine hotel or while quarantining at home. Postal codes were used to determine the index of multiple deprivation, and unique property-reference numbers were used to identify care homes.29 Statistical Analysis For the test-negative case–control analysis, logistic regression was used to estimate the reddit viagra odds of having a symptomatic, PCR-confirmed case of erectile dysfunction treatment among vaccinated persons as compared with unvaccinated persons (control). Cases were identified as having the delta variant by means of sequencing or if they were S target–positive on the TaqPath PCR assay.

Cases were identified as having the alpha variant by means of sequencing or if they were S target–negative on the TaqPath PCR assay. If a person had tested positive on multiple occasions within a 90-day reddit viagra period (which may represent a single illness episode), only the first positive test was included. A maximum of three randomly chosen negative test results were included for each person. Negative tests reddit viagra in which the sample had been obtained within 3 weeks before a positive result or after a positive result could have been false negatives. Therefore, these were excluded.

Tests that had been administered reddit viagra within 7 days after a previous negative result were also excluded. Persons who had previously tested positive before the analysis period were also excluded in order to estimate treatment effectiveness in fully susceptible persons. All the covariates were included in the model as had been done with previous test-negative case–control analyses, with calendar week included as a factor and without an interaction with region. With regard reddit viagra to S target–positive or –negative status, only persons who had tested positive on the other two PCR gene targets were included. Assignment to the delta variant on the basis of S target status was restricted to the week commencing April 12, 2021, and onward in order to aim for high specificity of S target–positive testing for the delta variant.4 treatment effectiveness for the first dose was estimated among persons with a symptom-onset date that was 21 days or more after receipt of the first dose of treatment, and treatment effects for the second dose were estimated among persons with a symptom-onset date that was 14 days or more after receipt of the second dose.

Comparison was made with unvaccinated persons and with persons reddit viagra who had symptom onset in the period of 4 to 13 days after vaccination in order to help account for differences in underlying risk of . The period from the day of treatment administration (day 0) to day 3 was excluded because reactogenicity to the treatment can cause an increase in testing that biases results, as previously described.10Breakthrough s Among 11,453 fully vaccinated health care workers, 1497 (13.1%) underwent RT-PCR testing during the study period. Of the tested workers, 39 breakthrough cases were detected. More than 38 persons were tested for every positive case that was detected, for a test positivity of 2.6% reddit viagra. Thus, this percentage was much lower than the test positivity rate in Israel at the time, since the ratio between positive results and the extensive number of tests that were administered in our study was much smaller than that in the national population.

Of the 39 breakthrough case patients, 18 (46%) reddit viagra were nursing staff members, 10 (26%) were administration or maintenance workers, 6 (15%) were allied health professionals, and 5 (13%) were physicians. The average age of the 39 infected workers was 42 years, and the majority were women (64%). The median interval from the second treatment dose to erectile dysfunction detection was 39 days (range, 11 to reddit viagra 102). Only one infected person (3%) had immunosuppression. Other coexisting illnesses are detailed in Table S1.

In all 37 case patients for reddit viagra whom data were available regarding the source of , the suspected source was an unvaccinated person. In 21 patients (57%), this person was a household member. Among these case patients were two married couples, in which both sets of spouses worked at Sheba Medical Center and had an unvaccinated child who had reddit viagra tested positive for erectile dysfunction treatment and was assumed to be the source. In 11 of 37 case patients (30%), the suspected source was an unvaccinated fellow health care worker or patient. In 7 of the 11 case patients, the was caused by a nosocomial outbreak of the B.1.1.7 (alpha) reddit viagra variant.

These 7 patients, who worked in different hospital sectors and wards, were all found to be linked to the same suspected unvaccinated index patient who had been receiving noninvasive positive-pressure ventilation before her had been detected. Of the 39 cases of , 27 occurred in workers who were tested solely because of exposure to a person with known erectile dysfunction . Of all the workers with breakthrough , 26 (67%) had mild symptoms at some stage, and reddit viagra none required hospitalization. The remaining 13 workers (33% of all cases) were asymptomatic during the duration of . Of these workers, 6 were defined as borderline cases, reddit viagra since they had an N gene Ct value of more than 35 on repeat testing.

The most common symptom that was reported was upper respiratory congestion (36% of all cases), followed by myalgia (28%) and loss of smell or taste (28%). Fever or rigors were reported in 21% (Table S1). On follow-up questioning, 31% of all infected workers reported having residual symptoms 14 days reddit viagra after their diagnosis. At 6 weeks after their diagnosis, 19% reported having “long erectile dysfunction treatment” symptoms, which included a prolonged loss of smell, persistent cough, fatigue, weakness, dyspnea, or myalgia. Nine workers (23%) reddit viagra took a leave of absence from work beyond the 10 days of required quarantine.

Of these workers, 4 returned to work within 2 weeks. One worker had not reddit viagra yet returned after 6 weeks. Verification Testing and Secondary s Repeat RT-PCR assays were performed on samples obtained from most of the infected workers and for all case patients with an initial N gene Ct value of more than 30 to verify that the initial test was not taken too early, before the worker had become infectious. A total of 29 case patients (74%) had a Ct value of less than 30 at some point during their . However, of these workers, only 17 (59%) reddit viagra had positive results on a concurrent Ag-RDT.

Ten workers (26%) had an N gene Ct value of more than 30 throughout the entire period. 6 of these workers had values of more than 35 reddit viagra and probably had never been infectious. Of the 33 isolates that were tested for a variant of concern, 28 (85%) were identified as the B.1.1.7 variant, by either multiplex PCR assay or genomic sequencing. At the time of this study, the B.1.1.7 variant was the most widespread variant in Israel and accounted for up to 94.5% of erectile dysfunction isolates.1,16 Since the end of the study, the country has had a surge of cases caused by the delta variant, as have many other countries worldwide. Thorough epidemiologic investigations reddit viagra of data regarding in-hospital contact tracing did not detect any cases of transmission from infected health care workers (secondary s) among the 39 primary s.

Among the 31 cases for whom data regarding household transmission (including symptoms and RT-PCR results) were available, no secondary s were detected, including 10 case patients and their 27 household members in whom the health care worker was the only index case patient. Data regarding post N-specific IgG antibodies were available for 22 of 39 case patients (56%) reddit viagra on days 8 to 72 after the first positive result on RT-PCR assay. Of these workers, 4 (18%) did not have an immune response, as detected by negative results on N-specific IgG antibody testing. Among these reddit viagra 4 workers were 2 who were asymptomatic (Ct values, 32 and 35), 1 who underwent serologic testing only on day 10 after diagnosis, and 1 who had immunosuppression. Case–Control Analysis The results of peri- neutralizing antibody tests were available for 22 breakthrough cases.

Included in this group were 3 health care workers who had participated in the serologic study and had a test performed in the week preceding detection. In 19 other workers, reddit viagra neutralizing and S-specific IgG antibodies were assessed on detection day. Of these 19 case patients, 12 were asymptomatic at the time of detection. For each case, 4 to 5 reddit viagra controls were matched as described (Fig. S1).

In total, 22 breakthrough cases and their 104 matched controls were included in the case–control analysis. Table 1 reddit viagra. Table 1. Population Characteristics and Outcomes in the reddit viagra Case–Control Study. Figure 2.

Figure 2 reddit viagra. Neutralizing Antibody and IgG Titers among Cases and Controls, According to Timing. Among the 39 fully vaccinated health care workers who had breakthrough with erectile dysfunction, shown are the neutralizing antibody titers during the peri- period (within a week before erectile dysfunction detection) (Panel A) and the peak titers within 1 month after the second dose (Panel B), as compared with matched controls. Also shown are IgG titers during the peri- period (Panel C) and peak titers (Panel D) in the reddit viagra two groups. Each case of breakthrough was matched with 4 to 5 controls according to sex, age, immunosuppression status, and timing of serologic testing after the second treatment dose.

In each reddit viagra panel, the horizontal bars indicate the mean geometric titers and the 𝙸 bars indicate 95% confidence intervals. Symptomatic cases, which were all mild and did not require hospitalization, are indicated in red.Figure 3. Figure 3 reddit viagra. Correlation between Neutralizing Antibody Titer and N Gene Cycle Threshold as Indication of Infectivity. The results of antigen-detecting (Ag) rapid diagnostic testing for the presence of erectile dysfunction are shown, along with neutralizing antibody titers and N gene cycle threshold (Ct) values in 22 fully vaccinated health care workers with breakthrough for whom data were available (slope of regression line, 171.2.

95% CI, 62.9 to 279.4).The predicted GMT of peri- neutralizing antibody titers was 192.8 (95% confidence interval [CI], 67.6 to 549.8) for cases and 533.7 (95% CI, 408.1 to 698.0) for controls, for a predicted case-to-control ratio of neutralizing antibody titers of 0.361 (95% CI, 0.165 to 0.787) reddit viagra (Table 1 and Figure 2A). In a subgroup analysis in which the borderline cases were excluded, the ratio was 0.353 (95% CI, 0.185 to 0.674). Peri- neutralizing reddit viagra antibody titers in the breakthrough cases were associated with higher N gene Ct values (i.e., a lower viral RNA copy number) (slope of regression line, 171.2. 95% CI, 62.9 to 279.4) (Figure 3). A peak neutralizing antibody titer within the first month after the second treatment dose was available for only 12 of the breakthrough cases.

The GEE predicted peak neutralizing antibody titer was 152.2 reddit viagra (95% CI, 30.5 to 759.3) in 12 cases and 1027.5 (95% CI, 761.6 to 1386.2) in 56 controls, for a ratio of 0.148 (95% CI, 0.040 to 0.548) (Figure 2B). In the subgroup analysis in which borderline cases were excluded, the ratio was 0.114 (95% CI, 0.042 to 0.309). The observed and predicted GMTs of peri- S-specific IgG antibody levels reddit viagra in breakthrough cases were lower than that in controls, with a predicted ratio of 0.514 (95% CI, 0.282 to 0.937) (Figure 2C). The observed and predicted peak IgG GMTs in cases were also somewhat lower than those in controls (0.507. 95% CI, 0.260 reddit viagra to 0.989) (Figure 2D).

To assess whether our practice of measuring antibodies on the day of diagnosis created bias by capturing anamnestic responses to the current , we plotted peak (first-month) IgG titers against peri- titers on the day of diagnosis in 13 case patients for whom both values were available. In all cases, peri- titers were lower than the previous peak titers, indicating that the titers that were obtained on the day of diagnosis were probably representative of peri- titers (Fig. S2).V-safe Surveillance reddit viagra. Local and Systemic Reactogenicity in Pregnant Persons Table 1. Table 1 reddit viagra.

Characteristics of Persons Who Identified as Pregnant in the V-safe Surveillance System and Received an mRNA erectile dysfunction treatment. Table 2. Table 2 reddit viagra. Frequency of Local and Systemic Reactions Reported on the Day after mRNA erectile dysfunction treatment Vaccination in Pregnant Persons. From December reddit viagra 14, 2020, to February 28, 2021, a total of 35,691 v-safe participants identified as pregnant.

Age distributions were similar among the participants who received the Pfizer–BioNTech treatment and those who received the Moderna treatment, with the majority of the participants being 25 to 34 years of age (61.9% and 60.6% for each treatment, respectively) and non-Hispanic White (76.2% and 75.4%, respectively). Most participants (85.8% and reddit viagra 87.4%, respectively) reported being pregnant at the time of vaccination (Table 1). Solicited reports of injection-site pain, fatigue, headache, and myalgia were the most frequent local and systemic reactions after either dose for both treatments (Table 2) and were reported more frequently after dose 2 for both treatments. Participant-measured temperature at or above 38°C was reported by less than 1% of the participants on day 1 after dose 1 and by 8.0% after dose 2 for both treatments. Figure 1 reddit viagra.

Figure 1. Most Frequent Local and Systemic Reactions Reported reddit viagra in the V-safe Surveillance System on the Day after mRNA erectile dysfunction treatment Vaccination. Shown are solicited reactions in pregnant persons and nonpregnant women 16 to 54 years of age who received a messenger RNA (mRNA) erectile dysfunction disease 2019 (erectile dysfunction treatment) treatment — BNT162b2 (Pfizer–BioNTech) or mRNA-1273 (Moderna) — from December 14, 2020, to February 28, 2021. The percentage of respondents was calculated among those who completed a day 1 survey, with the top events shown of injection-site pain (pain), fatigue or tiredness (fatigue), headache, muscle or body aches (myalgia), chills, and fever or felt feverish (fever).These patterns of reporting, with respect to both most frequently reported solicited reactions and the higher reporting of reactogenicity after dose 2, were similar to patterns observed among nonpregnant women (Figure 1). Small differences in reporting frequency between pregnant persons and nonpregnant women were observed for reddit viagra specific reactions (injection-site pain was reported more frequently among pregnant persons, and other systemic reactions were reported more frequently among nonpregnant women), but the overall reactogenicity profile was similar.

Pregnant persons did not report having severe reactions more frequently than nonpregnant women, except for nausea and vomiting, which were reported slightly more frequently only after dose 2 (Table S3). V-safe Pregnancy reddit viagra Registry. Pregnancy Outcomes and Neonatal Outcomes Table 3. Table 3 reddit viagra. Characteristics of V-safe Pregnancy Registry Participants.

As of March 30, 2021, the v-safe pregnancy registry call center attempted to contact 5230 persons who were vaccinated through February 28, 2021, and who identified during a v-safe survey as pregnant at or shortly after erectile dysfunction treatment vaccination. Of these, 912 were unreachable, 86 declined to participate, and 274 did not meet reddit viagra inclusion criteria (e.g., were never pregnant, were pregnant but received vaccination more than 30 days before the last menstrual period, or did not provide enough information to determine eligibility). The registry enrolled 3958 participants with vaccination from December 14, 2020, to February 28, 2021, of whom 3719 (94.0%) identified as health care personnel. Among enrolled participants, most were 25 to 44 years of age (98.8%), non-Hispanic White (79.0%), and, at the time of interview, did not report a erectile dysfunction treatment diagnosis during pregnancy (97.6%) (Table 3) reddit viagra. Receipt of a first dose of treatment meeting registry-eligibility criteria was reported by 92 participants (2.3%) during the periconception period, by 1132 (28.6%) in the first trimester of pregnancy, by 1714 (43.3%) in the second trimester, and by 1019 (25.7%) in the third trimester (1 participant was missing information to determine the timing of vaccination) (Table 3).

Among 1040 participants (91.9%) who received a treatment in the first trimester and 1700 (99.2%) who reddit viagra received a treatment in the second trimester, initial data had been collected and follow-up scheduled at designated time points approximately 10 to 12 weeks apart. Limited follow-up calls had been made at the time of this analysis. Table 4. Table 4 reddit viagra. Pregnancy Loss and Neonatal Outcomes in Published Studies and V-safe Pregnancy Registry Participants.

Among 827 reddit viagra participants who had a completed pregnancy, the pregnancy resulted in a live birth in 712 (86.1%), in a spontaneous abortion in 104 (12.6%), in stillbirth in 1 (0.1%), and in other outcomes (induced abortion and ectopic pregnancy) in 10 (1.2%). A total of 96 of 104 spontaneous abortions (92.3%) occurred before 13 weeks of gestation (Table 4), and 700 of 712 pregnancies that resulted in a live birth (98.3%) were among persons who received their first eligible treatment dose in the third trimester. Adverse outcomes among 724 live-born infants — including 12 sets of multiple gestation — were preterm birth (60 of 636 among those vaccinated before 37 weeks [9.4%]), small size for gestational age (23 of 724 [3.2%]), and major congenital anomalies (16 of 724 [2.2%]). No neonatal reddit viagra deaths were reported at the time of interview. Among the participants with completed pregnancies who reported congenital anomalies, none had received erectile dysfunction treatment in the first trimester or periconception period, and no specific pattern of congenital anomalies was observed.

Calculated proportions of pregnancy and neonatal outcomes appeared similar to incidences published in the peer-reviewed literature (Table reddit viagra 4). Adverse-Event Findings on the VAERS During the analysis period, the VAERS received and processed 221 reports involving erectile dysfunction treatment vaccination among pregnant persons. 155 (70.1%) involved reddit viagra nonpregnancy-specific adverse events, and 66 (29.9%) involved pregnancy- or neonatal-specific adverse events (Table S4). The most frequently reported pregnancy-related adverse events were spontaneous abortion (46 cases. 37 in the first trimester, 2 in the second trimester, and 7 in which the trimester was unknown or not reported), followed by stillbirth, premature rupture of membranes, and vaginal bleeding, with 3 reports for each.

No congenital anomalies were reported to the VAERS, a requirement under the EUAs.Participants Figure reddit viagra 1. Figure 1. Enrollment and reddit viagra Randomization. The diagram represents all enrolled participants through November 14, 2020. The safety subset (those with a median of 2 months of follow-up, in accordance with application requirements for Emergency Use Authorization) is based on an October 9, 2020, data cut-off date.

The further procedures that one participant in the placebo group declined after dose 2 (lower right corner of the diagram) were those involving collection reddit viagra of blood and nasal swab samples.Table 1. Table 1. Demographic Characteristics of reddit viagra the Participants in the Main Safety Population. Between July 27, 2020, and November 14, 2020, a total of 44,820 persons were screened, and 43,548 persons 16 years of age or older underwent randomization at 152 sites worldwide (United States, 130 sites. Argentina, 1 reddit viagra.

Brazil, 2. South Africa, 4. Germany, 6 reddit viagra. And Turkey, 9) in the phase 2/3 portion of the trial. A total of reddit viagra 43,448 participants received injections.

21,720 received BNT162b2 and 21,728 received placebo (Figure 1). At the data cut-off date of October 9, a total of 37,706 participants had a median of at least 2 months of safety data available after the second dose and contributed to the main safety data set. Among these 37,706 participants, 49% were female, 83% were White, 9% were Black or African American, 28% were Hispanic reddit viagra or Latinx, 35% were obese (body mass index [the weight in kilograms divided by the square of the height in meters] of at least 30.0), and 21% had at least one coexisting condition. The median age was 52 years, and 42% of participants were older than 55 years of age (Table 1 and Table S2). Safety Local reddit viagra Reactogenicity Figure 2.

Figure 2. Local and Systemic Reactions Reported within 7 Days after Injection reddit viagra of BNT162b2 or Placebo, According to Age Group. Data on local and systemic reactions and use of medication were collected with electronic diaries from participants in the reactogenicity subset (8,183 participants) for 7 days after each vaccination. Solicited injection-site (local) reactions are shown in Panel A. Pain at the injection site reddit viagra was assessed according to the following scale.

Mild, does not interfere with activity. Moderate, interferes with activity reddit viagra. Severe, prevents daily activity. And grade 4, emergency department visit or hospitalization. Redness and swelling were measured according to reddit viagra the following scale.

Mild, 2.0 to 5.0 cm in diameter. Moderate, >5.0 to 10.0 cm reddit viagra in diameter. Severe, >10.0 cm in diameter. And grade 4, necrosis or exfoliative dermatitis (for redness) and reddit viagra necrosis (for swelling). Systemic events and medication use are shown in Panel B.

Fever categories are designated in the key. Medication use was not reddit viagra graded. Additional scales were as follows. Fatigue, headache, chills, new or worsened muscle pain, new or worsened joint pain (mild reddit viagra. Does not interfere with activity.

Moderate. Some interference with activity. Or severe. Prevents daily activity), vomiting (mild. 1 to 2 times in 24 hours.

Moderate. >2 times in 24 hours. Or severe. Requires intravenous hydration), and diarrhea (mild. 2 to 3 loose stools in 24 hours.

Moderate. 4 to 5 loose stools in 24 hours. Or severe. 6 or more loose stools in 24 hours). Grade 4 for all events indicated an emergency department visit or hospitalization.

Н™¸ bars represent 95% confidence intervals, and numbers above the 𝙸 bars are the percentage of participants who reported the specified reaction.The reactogenicity subset included 8183 participants. Overall, BNT162b2 recipients reported more local reactions than placebo recipients. Among BNT162b2 recipients, mild-to-moderate pain at the injection site within 7 days after an injection was the most commonly reported local reaction, with less than 1% of participants across all age groups reporting severe pain (Figure 2). Pain was reported less frequently among participants older than 55 years of age (71% reported pain after the first dose. 66% after the second dose) than among younger participants (83% after the first dose.

78% after the second dose). A noticeably lower percentage of participants reported injection-site redness or swelling. The proportion of participants reporting local reactions did not increase after the second dose (Figure 2A), and no participant reported a grade 4 local reaction. In general, local reactions were mostly mild-to-moderate in severity and resolved within 1 to 2 days. Systemic Reactogenicity Systemic events were reported more often by younger treatment recipients (16 to 55 years of age) than by older treatment recipients (more than 55 years of age) in the reactogenicity subset and more often after dose 2 than dose 1 (Figure 2B).

The most commonly reported systemic events were fatigue and headache (59% and 52%, respectively, after the second dose, among younger treatment recipients. 51% and 39% among older recipients), although fatigue and headache were also reported by many placebo recipients (23% and 24%, respectively, after the second dose, among younger treatment recipients. 17% and 14% among older recipients). The frequency of any severe systemic event after the first dose was 0.9% or less. Severe systemic events were reported in less than 2% of treatment recipients after either dose, except for fatigue (in 3.8%) and headache (in 2.0%) after the second dose.

Fever (temperature, ≥38°C) was reported after the second dose by 16% of younger treatment recipients and by 11% of older recipients. Only 0.2% of treatment recipients and 0.1% of placebo recipients reported fever (temperature, 38.9 to 40°C) after the first dose, as compared with 0.8% and 0.1%, respectively, after the second dose. Two participants each in the treatment and placebo groups reported temperatures above 40.0°C. Younger treatment recipients were more likely to use antipyretic or pain medication (28% after dose 1. 45% after dose 2) than older treatment recipients (20% after dose 1.

38% after dose 2), and placebo recipients were less likely (10 to 14%) than treatment recipients to use the medications, regardless of age or dose. Systemic events including fever and chills were observed within the first 1 to 2 days after vaccination and resolved shortly thereafter. Daily use of the electronic diary ranged from 90 to 93% for each day after the first dose and from 75 to 83% for each day after the second dose. No difference was noted between the BNT162b2 group and the placebo group. Adverse Events Adverse event analyses are provided for all enrolled 43,252 participants, with variable follow-up time after dose 1 (Table S3).

More BNT162b2 recipients than placebo recipients reported any adverse event (27% and 12%, respectively) or a related adverse event (21% and 5%). This distribution largely reflects the inclusion of transient reactogenicity events, which were reported as adverse events more commonly by treatment recipients than by placebo recipients. Sixty-four treatment recipients (0.3%) and 6 placebo recipients (<0.1%) reported lymphadenopathy. Few participants in either group had severe adverse events, serious adverse events, or adverse events leading to withdrawal from the trial. Four related serious adverse events were reported among BNT162b2 recipients (shoulder injury related to treatment administration, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia).

Two BNT162b2 recipients died (one from arteriosclerosis, one from cardiac arrest), as did four placebo recipients (two from unknown causes, one from hemorrhagic stroke, and one from myocardial infarction). No deaths were considered by the investigators to be related to the treatment or placebo. No erectile dysfunction treatment–associated deaths were observed. No stopping rules were met during the reporting period. Safety monitoring will continue for 2 years after administration of the second dose of treatment.

Efficacy Table 2. Table 2. treatment Efficacy against erectile dysfunction treatment at Least 7 days after the Second Dose. Table 3. Table 3.

treatment Efficacy Overall and by Subgroup in Participants without Evidence of before 7 Days after Dose 2. Figure 3. Figure 3. Efficacy of BNT162b2 against erectile dysfunction treatment after the First Dose. Shown is the cumulative incidence of erectile dysfunction treatment after the first dose (modified intention-to-treat population).

Each symbol represents erectile dysfunction treatment cases starting on a given day. Filled symbols represent severe erectile dysfunction treatment cases. Some symbols represent more than one case, owing to overlapping dates. The inset shows the same data on an enlarged y axis, through 21 days. Surveillance time is the total time in 1000 person-years for the given end point across all participants within each group at risk for the end point.

The time period for erectile dysfunction treatment case accrual is from the first dose to the end of the surveillance period. The confidence interval (CI) for treatment efficacy (VE) is derived according to the Clopper–Pearson method.Among 36,523 participants who had no evidence of existing or prior erectile dysfunction , 8 cases of erectile dysfunction treatment with onset at least 7 days after the second dose were observed among treatment recipients and 162 among placebo recipients. This case split corresponds to 95.0% treatment efficacy (95% confidence interval [CI], 90.3 to 97.6. Table 2). Among participants with and those without evidence of prior SARS CoV-2 , 9 cases of erectile dysfunction treatment at least 7 days after the second dose were observed among treatment recipients and 169 among placebo recipients, corresponding to 94.6% treatment efficacy (95% CI, 89.9 to 97.3).

Supplemental analyses indicated that treatment efficacy among subgroups defined by age, sex, race, ethnicity, obesity, and presence of a coexisting condition was generally consistent with that observed in the overall population (Table 3 and Table S4). treatment efficacy among participants with hypertension was analyzed separately but was consistent with the other subgroup analyses (treatment efficacy, 94.6%. 95% CI, 68.7 to 99.9. Case split. BNT162b2, 2 cases.

Placebo, 44 cases). Figure 3 shows cases of erectile dysfunction treatment or severe erectile dysfunction treatment with onset at any time after the first dose (mITT population) (additional data on severe erectile dysfunction treatment are available in Table S5). Between the first dose and the second dose, 39 cases in the BNT162b2 group and 82 cases in the placebo group were observed, resulting in a treatment efficacy of 52% (95% CI, 29.5 to 68.4) during this interval and indicating early protection by the treatment, starting as soon as 12 days after the first dose.Trial Design and Oversight In the Study of Tofacitinib in Hospitalized Patients with erectile dysfunction treatment Pneumonia (STOP-erectile dysfunction treatment), we compared tofacitinib with placebo in patients with erectile dysfunction treatment pneumonia. The trial protocol (available with the full text of this article at NEJM.org) was approved by the institutional ethics board at participating sites. The trial was conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki.

The trial was sponsored by Pfizer and was designed and led by a steering committee that included academic investigators and representatives from Pfizer. The trial operations and statistical analyses were conducted by the Academic Research Organization of the Hospital Israelita Albert Einstein in São Paulo. An independent data and safety monitoring board reviewed unblinded patient-level data for safety on an ongoing basis during the trial. Pfizer provided the entire trial budget, which covered all trial-related expenses including but not limited to investigator fees, costs related to investigational product suppliers and importation, insurance, applicable taxes and fees, and funding to support the activities of the data and safety monitoring board. All the authors vouch for the accuracy and completeness of the data and for the fidelity of the trial to the protocol.

The trial committee members and participating investigators are listed in the Supplementary Appendix, available at NEJM.org. Trial Population The trial included patients 18 years of age or older who had laboratory-confirmed erectile dysfunction as determined on reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay before randomization, who had evidence of erectile dysfunction treatment pneumonia on radiographic imaging (computed tomography or radiography of the chest), and who had been hospitalized for less than 72 hours. Information regarding the timing of the qualifying RT-PCR assay in relation to symptom onset is provided in Section S3.1 in the Supplementary Appendix. High-flow devices constituted the maximum oxygen support that was allowed for trial inclusion. The main exclusion criteria were the use of noninvasive or invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO) on the day of randomization, a history of thrombosis or current thrombosis, known immunosuppression, and any current cancer for which the patient was receiving active treatment.

Details of the eligibility criteria are provided in Section S3.2. Written informed consent was obtained from each patient or from the patient’s legally authorized representative if the patient was unable to provide informed consent. Randomization, Interventions, and Follow-up Eligible patients were randomly assigned in a 1:1 ratio to receive either tofacitinib or placebo. Randomization, with stratification according to site, was performed with the use of a central concealed, Web-based, automated randomization system. Patients received either oral tofacitinib at a dose of 10 mg or placebo twice daily for up to 14 days or until hospital discharge, whichever was earlier.

If a participant underwent intubation before the end of the 14-day treatment period (or before discharge), they continued to receive tofacitinib or placebo if it was considered to be clinically appropriate by the treating physicians. A reduced-dose regimen of 5 mg of tofacitinib (or matching placebo) twice daily was administered in patients with an estimated glomerular fiation rate of less than 50 ml per minute per 1.73 m2 of body-surface area, in those with moderate hepatic impairment, and in those with concomitant use of a strong CYP3A4 inhibitor or a combination of a moderate CYP3A4 inhibitor and a strong CYP2C19 inhibitor. The rationale for the tofacitinib dosage is provided in Section S3.3. All the patients were treated according to local standards of care for erectile dysfunction treatment, which could have included glucocorticoids, antibiotic agents, anticoagulants, and antiviral agents. Concomitant use of other JAK inhibitors, biologic agents, potent immunosuppressants, interleukin-1 inhibitors, interleukin-6 inhibitors, or potent CYP450 inducers was prohibited.

Patients were assessed daily (up to day 28) while hospitalized. Follow-up visits occurred on day 14 and on day 28 for participants who were discharged before day 14 or 28. Prespecified reasons for permanent discontinuation of the trial intervention are described in Section S3.4. Outcomes The primary outcome was death or respiratory failure during the 28 days of follow-up. Death or respiratory failure was determined to occur if participants met the criteria for category 6 (status of being hospitalized while receiving noninvasive ventilation or ventilation through high-flow oxygen devices), 7 (status of being hospitalized while receiving invasive mechanical ventilation or ECMO), or 8 (death) on the eight-level National Institute of Allergy and Infectious Diseases (NIAID) ordinal scale of disease severity (on a scale from 1 to 8, with higher scores indicating a worse condition) (Table S1 in the Supplementary Appendix).

Patients who were enrolled in the trial while they were receiving oxygen through high-flow devices (category 6) were considered to have met the criteria for the primary outcome if they presented with clinical worsening to category 7 or 8. The occurrence of the primary outcome was adjudicated by an independent clinical-events classification committee, whose members were unaware of the group assignments. The protocol and statistical analysis plan used an inverted ordinal scale, which was reversed in this report to be consistent with previous studies. Secondary efficacy outcomes were the cumulative incidence of death through day 28, the scores on the NIAID ordinal scale of disease severity at day 14 and at day 28, the status of being alive and not using mechanical ventilation or ECMO at day 14 and day 28, the status of being alive and not hospitalized at day 14 and day 28, cure (defined as resolution of fever and cough and no use of ventilatory or oxygen support), the duration of stay in the hospital, and the duration of stay in the intensive care unit (ICU). The occurrence and severity of adverse events were evaluated and coded according to the Medical Dictionary for Regulatory Activities, version 23.1.

Details of adverse event reporting, including the reporting of prespecified adverse events of special interest, are described in Section S3.5. Statistical Analysis We estimated that the assignment of 260 patients, with randomization performed in a 1:1 ratio, would provide the trial with 80% power to detect a between-group difference of 15 percentage points in the incidence of the primary outcome, assuming that 15% of the participants in the tofacitinib group and 30% of those in the placebo group would have an event (death or respiratory failure through day 28). The hypothesis of superiority was tested at a two-tailed alpha level of 5%. The efficacy analyses included all the participants who underwent randomization. Safety analyses included all the participants who underwent randomization and took at least one dose of tofacitinib or placebo.

The results for the primary efficacy outcome were analyzed by means of binary regression with Firth correction, with trial group and antiviral therapy for erectile dysfunction treatment as covariates, and are expressed as a risk ratio. The antiviral treatments on day 1 were used in the statistical model. Dichotomous secondary outcomes were analyzed in a manner similar to that used for the primary outcome. The effect of the intervention on death through day 28 is expressed as a hazard ratio derived from Cox regression. For ordinal data, a proportional-odds model with adjustment for baseline antiviral therapy was used.

An odds ratio of less than 1.0 represents a clinical improvement as assessed on the ordinal scale. Odds proportionality was assessed with the use of the method of Pulkstenis–Robinson.9 We created Kaplan–Meier survival curves to express the time until the occurrence of the primary outcome, both overall and stratified according to the use of supplemental oxygen at baseline, and the occurrence of death through 28 days. As a sensitivity analysis, results for the primary outcome were analyzed by means of binary regression with Firth correction, with use of glucocorticoids and antiviral agents at baseline as covariates. In addition, results for the primary outcome were analyzed by means of logistic regression with Firth correction, with adjustment for baseline antiviral therapy. Prespecified subgroup analyses were performed according to age, sex, concomitant use of antiviral therapy, concomitant use of glucocorticoids, and time from symptom onset to randomization.

For the primary outcome, a two-sided P value of less than 0.05 was considered to indicate statistical significance. The 95% confidence intervals were estimated for all effect measures. The widths of the 95% confidence intervals for the secondary outcomes were not adjusted for multiple comparisons, so the intervals should not be used to infer definitive treatment effects. All the analyses were performed with the use of SAS software, version 9.4 (SAS Institute), and R software, version 3.6.3 (R Foundation for Statistical Computing). Additional details about the statistical analysis are provided in Section S3.6..

Study Design We used two approaches to estimate the effect of vaccination on the delta variant how to get a viagra prescription from your doctor. First, we used a test-negative case–control design to estimate treatment effectiveness against symptomatic disease caused by the delta variant, as compared with the alpha variant, over the period that the delta variant has been circulating. This approach has been described in detail elsewhere.10 In brief, we compared vaccination status in persons with symptomatic erectile dysfunction treatment with vaccination status in persons who reported symptoms but had a how to get a viagra prescription from your doctor negative test. This approach helps to control for biases related to health-seeking behavior, access to testing, and case ascertainment. For the secondary analysis, the proportion of persons with cases caused by the delta variant relative to the main circulating viagra (the how to get a viagra prescription from your doctor alpha variant) was estimated according to vaccination status.

The underlying assumption was that if the treatment had some efficacy and was equally effective against each variant, a similar proportion of cases with either variant would be expected in unvaccinated persons and in vaccinated persons. Conversely, if the treatment was less effective against the delta variant than against the alpha variant, then the delta variant would be expected to make up a higher proportion of cases occurring more than 3 weeks after vaccination than among unvaccinated persons. Details of this analysis are described in Section S1 how to get a viagra prescription from your doctor in the Supplementary Appendix, available with the full text of this article at NEJM.org. The authors vouch for the accuracy and completeness of the data and for the fidelity of the trial to the protocol. Data Sources Vaccination Status Data on all how to get a viagra prescription from your doctor persons in England who have been vaccinated with erectile dysfunction treatments are available in a national vaccination register (the National Immunisation Management System).

Data regarding vaccinations that had occurred up to May 16, 2021, including the date of receipt of each dose of treatment and the treatment type, were extracted on May 17, 2021. Vaccination status was categorized as receipt of one dose of treatment among persons who had symptom onset occurring 21 days or more after receipt of the first dose up to the day before the second dose was received, as receipt of the second dose among persons who had symptom onset occurring 14 days or more after receipt of the second dose, and as receipt of the first or second dose among persons with symptom onset occurring 21 days or more after the receipt of the first dose (including any period after the receipt of the how to get a viagra prescription from your doctor second dose). erectile dysfunction Testing Polymerase-chain-reaction (PCR) testing for erectile dysfunction in the United Kingdom is undertaken by hospital and public health laboratories, as well as by community testing with the use of drive-through or at-home testing, which is available to anyone with symptoms consistent with erectile dysfunction treatment (high temperature, new continuous cough, or loss or change in sense of smell or taste). Data on all positive PCR tests between October 26, 2020, and May 16, 2021, were extracted. Data on all recorded negative community tests among persons who reported symptoms were also extracted how to get a viagra prescription from your doctor for the test-negative case–control analysis.

Children younger than 16 years of age as of March 21, 2021, were excluded. Data were restricted to persons who had reported symptoms, and only persons who had undergone testing within 10 days after symptom onset were included, in order to account for reduced sensitivity of PCR testing beyond this period.25 Identification of Variant Whole-genome sequencing how to get a viagra prescription from your doctor was used to identify the delta and alpha variants. The proportion of all positive samples that were sequenced increased from approximately 10% in February 2021 to approximately 60% in May 2021.4 Sequencing is undertaken at a network of laboratories, including the Wellcome Sanger Institute, where a high proportion of samples has been tested, and whole-genome sequences are assigned to Public Health England definitions of variants on the basis of mutations.26 Spike gene target status on PCR was used as a second approach for identifying each variant. Laboratories used the TaqPath assay (Thermo Fisher Scientific) to test for three gene targets. Spike (S), nucleocapsid (N), and open how to get a viagra prescription from your doctor reading frame 1ab (ORF1ab).

In December 2020, the alpha variant was noted to be associated with negative testing on the S target, so S target–negative status was subsequently used as a proxy for identification of the variant. The alpha variant accounts for between 98% and how to get a viagra prescription from your doctor 100% of S target–negative results in England. Among sequenced samples that tested positive for the S target, the delta variant was in 72.2% of the samples in April 2021 and in 93.0% in May (as of May 12, 2021).4 For the test-negative case–control analysis, only samples that had been tested at laboratories with the use of the TaqPath assay were included. Data Linkage The three data sources described above were linked with the use of the National Health Service number (a unique identifier for each how to get a viagra prescription from your doctor person receiving medical care in the United Kingdom). These data sources were also linked with data on the patient’s date of birth, surname, first name, postal code, and specimen identifiers and sample dates.

Covariates Multiple covariates that may be associated with the likelihood of being offered or accepting a treatment and the risk of exposure to erectile dysfunction treatment or specifically to either of the variants analyzed were also extracted from the National Immunisation Management System and the testing data. These data included age (in 10-year age groups), sex, index of multiple deprivation (a national indication of level of deprivation that is based on small geographic areas of residence,27 assessed in quintiles), race or ethnic group, care home residence status, history of foreign travel (i.e., outside the United Kingdom or Ireland), geographic region, period (calendar week), health and social care worker status, and status of how to get a viagra prescription from your doctor being in a clinically extremely vulnerable group.28 In addition, for the test-negative case–control analysis, history of erectile dysfunction before the start of the vaccination program was included. Persons were considered to have traveled if, at the point of requesting a test, they reported having traveled outside the United Kingdom and Ireland within the preceding 14 days or if they had been tested in a quarantine hotel or while quarantining at home. Postal codes were used to determine the index of multiple deprivation, and unique property-reference numbers were used to identify care homes.29 Statistical Analysis For the test-negative case–control analysis, logistic regression was used to estimate the odds of having a symptomatic, PCR-confirmed case of erectile dysfunction treatment among vaccinated persons as compared with unvaccinated persons how to get a viagra prescription from your doctor (control). Cases were identified as having the delta variant by means of sequencing or if they were S target–positive on the TaqPath PCR assay.

Cases were identified as having the alpha variant by means of sequencing or if they were S target–negative on the TaqPath PCR assay. If a how to get a viagra prescription from your doctor person had tested positive on multiple occasions within a 90-day period (which may represent a single illness episode), only the first positive test was included. A maximum of three randomly chosen negative test results were included for each person. Negative tests in which the sample had been obtained within 3 weeks before a positive result or after a positive result could have been false how to get a viagra prescription from your doctor negatives. Therefore, these were excluded.

Tests that had been administered within how to get a viagra prescription from your doctor 7 days after a previous negative result were also excluded. Persons who had previously tested positive before the analysis period were also excluded in order to estimate treatment effectiveness in fully susceptible persons. All the covariates were included in the model as had been done with previous test-negative case–control analyses, with calendar week included as a factor and without an interaction with region. With regard to S target–positive or –negative status, only persons who had tested positive on the how to get a viagra prescription from your doctor other two PCR gene targets were included. Assignment to the delta variant on the basis of S target status was restricted to the week commencing April 12, 2021, and onward in order to aim for high specificity of S target–positive testing for the delta variant.4 treatment effectiveness for the first dose was estimated among persons with a symptom-onset date that was 21 days or more after receipt of the first dose of treatment, and treatment effects for the second dose were estimated among persons with a symptom-onset date that was 14 days or more after receipt of the second dose.

Comparison was made with unvaccinated persons and with persons who had symptom onset in the period of 4 to 13 days after vaccination in order to help account for differences in underlying how to get a viagra prescription from your doctor risk of . The period from the day of treatment administration (day 0) to day 3 was excluded because reactogenicity to the treatment can cause an increase in testing that biases results, as previously described.10Breakthrough s Among 11,453 fully vaccinated health care workers, 1497 (13.1%) underwent RT-PCR testing during the study period. Of the tested workers, 39 breakthrough cases were detected. More than 38 persons were tested for every positive case that was detected, for a test positivity how to get a viagra prescription from your doctor of 2.6%. Thus, this percentage was much lower than the test positivity rate in Israel at the time, since the ratio between positive results and the extensive number of tests that were administered in our study was much smaller than that in the national population.

Of the 39 breakthrough case patients, 18 (46%) were nursing staff members, 10 (26%) were administration or maintenance how to get a viagra prescription from your doctor workers, 6 (15%) were allied health professionals, and 5 (13%) were physicians. The average age of the 39 infected workers was 42 years, and the majority were women (64%). The median interval how to get a viagra prescription from your doctor from the second treatment dose to erectile dysfunction detection was 39 days (range, 11 to 102). Only one infected person (3%) had immunosuppression. Other coexisting illnesses are detailed in Table S1.

In all 37 case patients for whom data were available regarding the source how to get a viagra prescription from your doctor of , the suspected source was an unvaccinated person. In 21 patients (57%), this person was a household member. Among these case patients were two married couples, in which both sets of spouses worked at Sheba Medical Center and had an unvaccinated child who had tested positive for erectile dysfunction treatment and was assumed how to get a viagra prescription from your doctor to be the source. In 11 of 37 case patients (30%), the suspected source was an unvaccinated fellow health care worker or patient. In 7 of the 11 case patients, the was caused by a nosocomial outbreak of the B.1.1.7 (alpha) variant how to get a viagra prescription from your doctor.

These 7 patients, who worked in different hospital sectors and wards, were all found to be linked to the same suspected unvaccinated index patient who had been receiving noninvasive positive-pressure ventilation before her had been detected. Of the 39 cases of , 27 occurred in workers who were tested solely because of exposure to a person with known erectile dysfunction . Of all the workers with breakthrough , 26 (67%) had mild symptoms at how to get a viagra prescription from your doctor some stage, and none required hospitalization. The remaining 13 workers (33% of all cases) were asymptomatic during the duration of . Of these workers, 6 were defined as borderline cases, since they had an N gene Ct how to get a viagra prescription from your doctor value of more than 35 on repeat testing.

The most common symptom that was reported was upper respiratory congestion (36% of all cases), followed by myalgia (28%) and loss of smell or taste (28%). Fever or rigors were reported in 21% (Table S1). On follow-up questioning, 31% of all how to get a viagra prescription from your doctor infected workers reported having residual symptoms 14 days after their diagnosis. At 6 weeks after their diagnosis, 19% reported having “long erectile dysfunction treatment” symptoms, which included a prolonged loss of smell, persistent cough, fatigue, weakness, dyspnea, or myalgia. Nine workers (23%) took a leave of absence from work beyond the how to get a viagra prescription from your doctor 10 days of required quarantine.

Of these workers, 4 returned to work within 2 weeks. One worker how to get a viagra prescription from your doctor had not yet returned after 6 weeks. Verification Testing and Secondary s Repeat RT-PCR assays were performed on samples obtained from most of the infected workers and for all case patients with an initial N gene Ct value of more than 30 to verify that the initial test was not taken too early, before the worker had become infectious. A total of 29 case patients (74%) had a Ct value of less than 30 at some point during their . However, of how to get a viagra prescription from your doctor these workers, only 17 (59%) had positive results on a concurrent Ag-RDT.

Ten workers (26%) had an N gene Ct value of more than 30 throughout the entire period. 6 of these workers had values how to get a viagra prescription from your doctor of more than 35 and probably had never been infectious. Of the 33 isolates that were tested for a variant of concern, 28 (85%) were identified as the B.1.1.7 variant, by either multiplex PCR assay or genomic sequencing. At the time of this study, the B.1.1.7 variant was the most widespread variant in Israel and accounted for up to 94.5% of erectile dysfunction isolates.1,16 Since the end of the study, the country has had a surge of cases caused by the delta variant, as have many other countries worldwide. Thorough epidemiologic investigations of data regarding in-hospital contact tracing did not detect any cases of transmission from infected health care workers (secondary how to get a viagra prescription from your doctor s) among the 39 primary s.

Among the 31 cases for whom data regarding household transmission (including symptoms and RT-PCR results) were available, no secondary s were detected, including 10 case patients and their 27 household members in whom the health care worker was the only index case patient. Data regarding post N-specific IgG antibodies were available for 22 of 39 case patients (56%) on days 8 to 72 how to get a viagra prescription from your doctor after the first positive result on RT-PCR assay. Of these workers, 4 (18%) did not have an immune response, as detected by negative results on N-specific IgG antibody testing. Among these 4 workers were 2 who were asymptomatic (Ct values, 32 how to get a viagra prescription from your doctor and 35), 1 who underwent serologic testing only on day 10 after diagnosis, and 1 who had immunosuppression. Case–Control Analysis The results of peri- neutralizing antibody tests were available for 22 breakthrough cases.

Included in this group were 3 health care workers who had participated in the serologic study and had a test performed in the week preceding detection. In 19 other workers, neutralizing and S-specific IgG antibodies were how to get a viagra prescription from your doctor assessed on detection day. Of these 19 case patients, 12 were asymptomatic at the time of detection. For each case, 4 to how to get a viagra prescription from your doctor 5 controls were matched as described (Fig. S1).

In total, 22 breakthrough cases and their 104 matched controls were included in the case–control analysis. Table 1 how to get a viagra prescription from your doctor. Table 1. Population Characteristics and Outcomes in how to get a viagra prescription from your doctor the Case–Control Study. Figure 2.

Figure 2 how to get a viagra prescription from your doctor. Neutralizing Antibody and IgG Titers among Cases and Controls, According to Timing. Among the 39 fully vaccinated health care workers who had breakthrough with erectile dysfunction, shown are the neutralizing antibody titers during the peri- period (within a week before erectile dysfunction detection) (Panel A) and the peak titers within 1 month after the second dose (Panel B), as compared with matched controls. Also shown are IgG titers during how to get a viagra prescription from your doctor the peri- period (Panel C) and peak titers (Panel D) in the two groups. Each case of breakthrough was matched with 4 to 5 controls according to sex, age, immunosuppression status, and timing of serologic testing after the second treatment dose.

In each panel, how to get a viagra prescription from your doctor the horizontal bars indicate the mean geometric titers and the 𝙸 bars indicate 95% confidence intervals. Symptomatic cases, which were all mild and did not require hospitalization, are indicated in red.Figure 3. Figure 3 how to get a viagra prescription from your doctor. Correlation between Neutralizing Antibody Titer and N Gene Cycle Threshold as Indication of Infectivity. The results of antigen-detecting (Ag) rapid diagnostic testing for the presence of erectile dysfunction are shown, along with neutralizing antibody titers and N gene cycle threshold (Ct) values in 22 fully vaccinated health care workers with breakthrough for whom data were available (slope of regression line, 171.2.

95% CI, 62.9 to 279.4).The predicted GMT of peri- neutralizing antibody titers was 192.8 (95% confidence interval [CI], 67.6 how to get a viagra prescription from your doctor to 549.8) for cases and 533.7 (95% CI, 408.1 to 698.0) for controls, for a predicted case-to-control ratio of neutralizing antibody titers of 0.361 (95% CI, 0.165 to 0.787) (Table 1 and Figure 2A). In a subgroup analysis in which the borderline cases were excluded, the ratio was 0.353 (95% CI, 0.185 to 0.674). Peri- neutralizing antibody titers in the breakthrough cases were associated with higher N gene Ct how to get a viagra prescription from your doctor values (i.e., a lower viral RNA copy number) (slope of regression line, 171.2. 95% CI, 62.9 to 279.4) (Figure 3). A peak neutralizing antibody titer within the first month after the second treatment dose was available for only 12 of the breakthrough cases.

The GEE predicted peak neutralizing antibody titer was 152.2 (95% CI, 30.5 to 759.3) in 12 cases how to get a viagra prescription from your doctor and 1027.5 (95% CI, 761.6 to 1386.2) in 56 controls, for a ratio of 0.148 (95% CI, 0.040 to 0.548) (Figure 2B). In the subgroup analysis in which borderline cases were excluded, the ratio was 0.114 (95% CI, 0.042 to 0.309). The observed and predicted GMTs of peri- S-specific how to get a viagra prescription from your doctor IgG antibody levels in breakthrough cases were lower than that in controls, with a predicted ratio of 0.514 (95% CI, 0.282 to 0.937) (Figure 2C). The observed and predicted peak IgG GMTs in cases were also somewhat lower than those in controls (0.507. 95% CI, 0.260 to how to get a viagra prescription from your doctor 0.989) (Figure 2D).

To assess whether our practice of measuring antibodies on the day of diagnosis created bias by capturing anamnestic responses to the current , we plotted peak (first-month) IgG titers against peri- titers on the day of diagnosis in 13 case patients for whom both values were available. In all cases, peri- titers were lower than the previous peak titers, indicating that the titers that were obtained on the day of diagnosis were probably representative of peri- titers (Fig. S2).V-safe Surveillance how to get a viagra prescription from your doctor. Local and Systemic Reactogenicity in Pregnant Persons Table 1. Table 1 how to get a viagra prescription from your doctor.

Characteristics of Persons Who Identified as Pregnant in the V-safe Surveillance System and Received an mRNA erectile dysfunction treatment. Table 2. Table 2 how to get a viagra prescription from your doctor. Frequency of Local and Systemic Reactions Reported on the Day after mRNA erectile dysfunction treatment Vaccination in Pregnant Persons. From December 14, 2020, to February how to get a viagra prescription from your doctor 28, 2021, a total of 35,691 v-safe participants identified as pregnant.

Age distributions were similar among the participants who received the Pfizer–BioNTech treatment and those who received the Moderna treatment, with the majority of the participants being 25 to 34 years of age (61.9% and 60.6% for each treatment, respectively) and non-Hispanic White (76.2% and 75.4%, respectively). Most participants (85.8% and 87.4%, respectively) reported being pregnant at the time of vaccination how to get a viagra prescription from your doctor (Table 1). Solicited reports of injection-site pain, fatigue, headache, and myalgia were the most frequent local and systemic reactions after either dose for both treatments (Table 2) and were reported more frequently after dose 2 for both treatments. Participant-measured temperature at or above 38°C was reported by less than 1% of the participants on day 1 after dose 1 and by 8.0% after dose 2 for both treatments. Figure 1 how to get a viagra prescription from your doctor.

Figure 1. Most Frequent Local and Systemic Reactions Reported in the V-safe Surveillance System on how to get a viagra prescription from your doctor the Day after mRNA erectile dysfunction treatment Vaccination. Shown are solicited reactions in pregnant persons and nonpregnant women 16 to 54 years of age who received a messenger RNA (mRNA) erectile dysfunction disease 2019 (erectile dysfunction treatment) treatment — BNT162b2 (Pfizer–BioNTech) or mRNA-1273 (Moderna) — from December 14, 2020, to February 28, 2021. The percentage of respondents was calculated among those who completed a day 1 survey, with the top events shown of injection-site pain (pain), fatigue or tiredness (fatigue), headache, muscle or body aches (myalgia), chills, and fever or felt feverish (fever).These patterns of reporting, with respect to both most frequently reported solicited reactions and the higher reporting of reactogenicity after dose 2, were similar to patterns observed among nonpregnant women (Figure 1). Small differences in reporting frequency between pregnant persons and nonpregnant women were observed for specific reactions (injection-site pain was reported more how to get a viagra prescription from your doctor frequently among pregnant persons, and other systemic reactions were reported more frequently among nonpregnant women), but the overall reactogenicity profile was similar.

Pregnant persons did not report having severe reactions more frequently than nonpregnant women, except for nausea and vomiting, which were reported slightly more frequently only after dose 2 (Table S3). V-safe Pregnancy how to get a viagra prescription from your doctor Registry. Pregnancy Outcomes and Neonatal Outcomes Table 3. Table 3 how to get a viagra prescription from your doctor. Characteristics of V-safe Pregnancy Registry Participants.

As of March 30, 2021, the v-safe pregnancy registry call center attempted to contact 5230 persons who were vaccinated through February 28, 2021, and who identified during a v-safe survey as pregnant at or shortly after erectile dysfunction treatment vaccination. Of these, 912 were unreachable, 86 declined to participate, and 274 did not meet inclusion criteria (e.g., were never pregnant, were pregnant but received vaccination more than 30 days before the last menstrual period, or how to get a viagra prescription from your doctor did not provide enough information to determine eligibility). The registry enrolled 3958 participants with vaccination from December 14, 2020, to February 28, 2021, of whom 3719 (94.0%) identified as health care personnel. Among enrolled participants, most were 25 to 44 years of age how to get a viagra prescription from your doctor (98.8%), non-Hispanic White (79.0%), and, at the time of interview, did not report a erectile dysfunction treatment diagnosis during pregnancy (97.6%) (Table 3). Receipt of a first dose of treatment meeting registry-eligibility criteria was reported by 92 participants (2.3%) during the periconception period, by 1132 (28.6%) in the first trimester of pregnancy, by 1714 (43.3%) in the second trimester, and by 1019 (25.7%) in the third trimester (1 participant was missing information to determine the timing of vaccination) (Table 3).

Among 1040 participants (91.9%) who received a treatment in the first trimester and 1700 (99.2%) who received a treatment in the how to get a viagra prescription from your doctor second trimester, initial data had been collected and follow-up scheduled at designated time points approximately 10 to 12 weeks apart. Limited follow-up calls had been made at the time of this analysis. Table 4. Table 4 how to get a viagra prescription from your doctor. Pregnancy Loss and Neonatal Outcomes in Published Studies and V-safe Pregnancy Registry Participants.

Among 827 participants who had a completed pregnancy, the pregnancy resulted in a live birth in 712 (86.1%), in a spontaneous abortion in 104 (12.6%), in stillbirth in 1 how to get a viagra prescription from your doctor (0.1%), and in other outcomes (induced abortion and ectopic pregnancy) in 10 (1.2%). A total of 96 of 104 spontaneous abortions (92.3%) occurred before 13 weeks of gestation (Table 4), and 700 of 712 pregnancies that resulted in a live birth (98.3%) were among persons who received their first eligible treatment dose in the third trimester. Adverse outcomes among 724 live-born infants — including 12 sets of multiple gestation — were preterm birth (60 of 636 among those vaccinated before 37 weeks [9.4%]), small size for gestational age (23 of 724 [3.2%]), and major congenital anomalies (16 of 724 [2.2%]). No neonatal deaths how to get a viagra prescription from your doctor were reported at the time of interview. Among the participants with completed pregnancies who reported congenital anomalies, none had received erectile dysfunction treatment in the first trimester or periconception period, and no specific pattern of congenital anomalies was observed.

Calculated proportions of pregnancy and neonatal outcomes appeared similar to how to get a viagra prescription from your doctor incidences published in the peer-reviewed literature (Table 4). Adverse-Event Findings on the VAERS During the analysis period, the VAERS received and processed 221 reports involving erectile dysfunction treatment vaccination among pregnant persons. 155 (70.1%) how to get a viagra prescription from your doctor involved nonpregnancy-specific adverse events, and 66 (29.9%) involved pregnancy- or neonatal-specific adverse events (Table S4). The most frequently reported pregnancy-related adverse events were spontaneous abortion (46 cases. 37 in the first trimester, 2 in the second trimester, and 7 in which the trimester was unknown or not reported), followed by stillbirth, premature rupture of membranes, and vaginal bleeding, with 3 reports for each.

No congenital anomalies were reported to the VAERS, a requirement under the EUAs.Participants Figure 1 how to get a viagra prescription from your doctor. Figure 1. Enrollment and Randomization how to get a viagra prescription from your doctor. The diagram represents all enrolled participants through November 14, 2020. The safety subset (those with a median of 2 months of follow-up, in accordance with application requirements for Emergency Use Authorization) is based on an October 9, 2020, data cut-off date.

The further procedures that one participant in the placebo how to get a viagra prescription from your doctor group declined after dose 2 (lower right corner of the diagram) were those involving collection of blood and nasal swab samples.Table 1. Table 1. Demographic Characteristics of the Participants how to get a viagra prescription from your doctor in the Main Safety Population. Between July 27, 2020, and November 14, 2020, a total of 44,820 persons were screened, and 43,548 persons 16 years of age or older underwent randomization at 152 sites worldwide (United States, 130 sites. Argentina, 1 how to get a viagra prescription from your doctor.

Brazil, 2. South Africa, 4. Germany, 6 how to get a viagra prescription from your doctor. And Turkey, 9) in the phase 2/3 portion of the trial. A total of 43,448 participants how to get a viagra prescription from your doctor received injections.

21,720 received BNT162b2 and 21,728 received placebo (Figure 1). At the data cut-off date of October 9, a total of 37,706 participants had a median of at least 2 months of safety data available after the second dose and contributed to the main safety data set. Among these 37,706 participants, 49% were female, 83% were White, 9% were Black or African American, 28% were Hispanic or Latinx, 35% were obese (body mass how to get a viagra prescription from your doctor index [the weight in kilograms divided by the square of the height in meters] of at least 30.0), and 21% had at least one coexisting condition. The median age was 52 years, and 42% of participants were older than 55 years of age (Table 1 and Table S2). Safety Local Reactogenicity Figure 2 how to get a viagra prescription from your doctor.

Figure 2. Local and Systemic how to get a viagra prescription from your doctor Reactions Reported within 7 Days after Injection of BNT162b2 or Placebo, According to Age Group. Data on local and systemic reactions and use of medication were collected with electronic diaries from participants in the reactogenicity subset (8,183 participants) for 7 days after each vaccination. Solicited injection-site (local) reactions are shown in Panel A. Pain at the injection site was assessed according to the following scale how to get a viagra prescription from your doctor.

Mild, does not interfere with activity. Moderate, interferes how to get a viagra prescription from your doctor with activity. Severe, prevents daily activity. And grade 4, emergency department visit or hospitalization. Redness and swelling were measured according to how to get a viagra prescription from your doctor the following scale.

Mild, 2.0 to 5.0 cm in diameter. Moderate, >5.0 to 10.0 how to get a viagra prescription from your doctor cm in diameter. Severe, >10.0 cm in diameter. And grade 4, necrosis or how to get a viagra prescription from your doctor exfoliative dermatitis (for redness) and necrosis (for swelling). Systemic events and medication use are shown in Panel B.

Fever categories are designated in the key. Medication use was not how to get a viagra prescription from your doctor graded. Additional scales were as follows. Fatigue, headache, chills, new or worsened muscle pain, new or worsened joint how to get a viagra prescription from your doctor pain (mild. Does not interfere with activity.

Moderate. Some interference with activity. Or severe. Prevents daily activity), vomiting (mild. 1 to 2 times in 24 hours.

Moderate. >2 times in 24 hours. Or severe. Requires intravenous hydration), and diarrhea (mild. 2 to 3 loose stools in 24 hours.

Moderate. 4 to 5 loose stools in 24 hours. Or severe. 6 or more loose stools in 24 hours). Grade 4 for all events indicated an emergency department visit or hospitalization.

Н™¸ bars represent 95% confidence intervals, and numbers above the 𝙸 bars are the percentage of participants who reported the specified reaction.The reactogenicity subset included 8183 participants. Overall, BNT162b2 recipients reported more local reactions than placebo recipients. Among BNT162b2 recipients, mild-to-moderate pain at the injection site within 7 days after an injection was the most commonly reported local reaction, with less than 1% of participants across all age groups reporting severe pain (Figure 2). Pain was reported less frequently among participants older than 55 years of age (71% reported pain after the first dose. 66% after the second dose) than among younger participants (83% after the first dose.

78% after the second dose). A noticeably lower percentage of participants reported injection-site redness or swelling. The proportion of participants reporting local reactions did not increase after the second dose (Figure 2A), and no participant reported a grade 4 local reaction. In general, local reactions were mostly mild-to-moderate in severity and resolved within 1 to 2 days. Systemic Reactogenicity Systemic events were reported more often by younger treatment recipients (16 to 55 years of age) than by older treatment recipients (more than 55 years of age) in the reactogenicity subset and more often after dose 2 than dose 1 (Figure 2B).

The most commonly reported systemic events were fatigue and headache (59% and 52%, respectively, after the second dose, among younger treatment recipients. 51% and 39% among older recipients), although fatigue and headache were also reported by many placebo recipients (23% and 24%, respectively, after the second dose, among younger treatment recipients. 17% and 14% among older recipients). The frequency of any severe systemic event after the first dose was 0.9% or less. Severe systemic events were reported in less than 2% of treatment recipients after either dose, except for fatigue (in 3.8%) and headache (in 2.0%) after the second dose.

Fever (temperature, ≥38°C) was reported after the second dose by 16% of younger treatment recipients and by 11% of older recipients. Only 0.2% of treatment recipients and 0.1% of placebo recipients reported fever (temperature, 38.9 to 40°C) after the first dose, as compared with 0.8% and 0.1%, respectively, after the second dose. Two participants each in the treatment and placebo groups reported temperatures above 40.0°C. Younger treatment recipients were more likely to use antipyretic or pain medication (28% after dose 1. 45% after dose 2) than older treatment recipients (20% after dose 1.

38% after dose 2), and placebo recipients were less likely (10 to 14%) than treatment recipients to use the medications, regardless of age or dose. Systemic events including fever and chills were observed within the first 1 to 2 days after vaccination and resolved shortly thereafter. Daily use of the electronic diary ranged from 90 to 93% for each day after the first dose and from 75 to 83% for each day after the second dose. No difference was noted between the BNT162b2 group and the placebo group. Adverse Events Adverse event analyses are provided for all enrolled 43,252 participants, with variable follow-up time after dose 1 (Table S3).

More BNT162b2 recipients than placebo recipients reported any adverse event (27% and 12%, respectively) or a related adverse event (21% and 5%). This distribution largely reflects the inclusion of transient reactogenicity events, which were reported as adverse events more commonly by treatment recipients than by placebo recipients. Sixty-four treatment recipients (0.3%) and 6 placebo recipients (<0.1%) reported lymphadenopathy. Few participants in either group had severe adverse events, serious adverse events, or adverse events leading to withdrawal from the trial. Four related serious adverse events were reported among BNT162b2 recipients (shoulder injury related to treatment administration, right axillary lymphadenopathy, paroxysmal ventricular arrhythmia, and right leg paresthesia).

Two BNT162b2 recipients died (one from arteriosclerosis, one from cardiac arrest), as did four placebo recipients (two from unknown causes, one from hemorrhagic stroke, and one from myocardial infarction). No deaths were considered by the investigators to be related to the treatment or placebo. No erectile dysfunction treatment–associated deaths were observed. No stopping rules were met during the reporting period. Safety monitoring will continue for 2 years after administration of the second dose of treatment.

Efficacy Table 2. Table 2. treatment Efficacy against erectile dysfunction treatment at Least 7 days after the Second Dose. Table 3. Table 3.

treatment Efficacy Overall and by Subgroup in Participants without Evidence of before 7 Days after Dose 2. Figure 3. Figure 3. Efficacy of BNT162b2 against erectile dysfunction treatment after the First Dose. Shown is the cumulative incidence of erectile dysfunction treatment after the first dose (modified intention-to-treat population).

Each symbol represents erectile dysfunction treatment cases starting on a given day. Filled symbols represent severe erectile dysfunction treatment cases. Some symbols represent more than one case, owing to overlapping dates. The inset shows the same data on an enlarged y axis, through 21 days. Surveillance time is the total time in 1000 person-years for the given end point across all participants within each group at risk for the end point.

The time period for erectile dysfunction treatment case accrual is from the first dose to the end of the surveillance period. The confidence interval (CI) for treatment efficacy (VE) is derived according to the Clopper–Pearson method.Among 36,523 participants who had no evidence of existing or prior erectile dysfunction , 8 cases of erectile dysfunction treatment with onset at least 7 days after the second dose were observed among treatment recipients and 162 among placebo recipients. This case split corresponds to 95.0% treatment efficacy (95% confidence interval [CI], 90.3 to 97.6. Table 2). Among participants with and those without evidence of prior SARS CoV-2 , 9 cases of erectile dysfunction treatment at least 7 days after the second dose were observed among treatment recipients and 169 among placebo recipients, corresponding to 94.6% treatment efficacy (95% CI, 89.9 to 97.3).

Supplemental analyses indicated that treatment efficacy among subgroups defined by age, sex, race, ethnicity, obesity, and presence of a coexisting condition was generally consistent with that observed in the overall population (Table 3 and Table S4). treatment efficacy among participants with hypertension was analyzed separately but was consistent with the other subgroup analyses (treatment efficacy, 94.6%. 95% CI, 68.7 to 99.9. Case split. BNT162b2, 2 cases.

Placebo, 44 cases). Figure 3 shows cases of erectile dysfunction treatment or severe erectile dysfunction treatment with onset at any time after the first dose (mITT population) (additional data on severe erectile dysfunction treatment are available in Table S5). Between the first dose and the second dose, 39 cases in the BNT162b2 group and 82 cases in the placebo group were observed, resulting in a treatment efficacy of 52% (95% CI, 29.5 to 68.4) during this interval and indicating early protection by the treatment, starting as soon as 12 days after the first dose.Trial Design and Oversight In the Study of Tofacitinib in Hospitalized Patients with erectile dysfunction treatment Pneumonia (STOP-erectile dysfunction treatment), we compared tofacitinib with placebo in patients with erectile dysfunction treatment pneumonia. The trial protocol (available with the full text of this article at NEJM.org) was approved by the institutional ethics board at participating sites. The trial was conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki.

The trial was sponsored by Pfizer and was designed and led by a steering committee that included academic investigators and representatives from Pfizer. The trial operations and statistical analyses were conducted by the Academic Research Organization of the Hospital Israelita Albert Einstein in São Paulo. An independent data and safety monitoring board reviewed unblinded patient-level data for safety on an ongoing basis during the trial. Pfizer provided the entire trial budget, which covered all trial-related expenses including but not limited to investigator fees, costs related to investigational product suppliers and importation, insurance, applicable taxes and fees, and funding to support the activities of the data and safety monitoring board. All the authors vouch for the accuracy and completeness of the data and for the fidelity of the trial to the protocol.

The trial committee members and participating investigators are listed in the Supplementary Appendix, available at NEJM.org. Trial Population The trial included patients 18 years of age or older who had laboratory-confirmed erectile dysfunction as determined on reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay before randomization, who had evidence of erectile dysfunction treatment pneumonia on radiographic imaging (computed tomography or radiography of the chest), and who had been hospitalized for less than 72 hours. Information regarding the timing of the qualifying RT-PCR assay in relation to symptom onset is provided in Section S3.1 in the Supplementary Appendix. High-flow devices constituted the maximum oxygen support that was allowed for trial inclusion. The main exclusion criteria were the use of noninvasive or invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO) on the day of randomization, a history of thrombosis or current thrombosis, known immunosuppression, and any current cancer for which the patient was receiving active treatment.

Details of the eligibility criteria are provided in Section S3.2. Written informed consent was obtained from each patient or from the patient’s legally authorized representative if the patient was unable to provide informed consent. Randomization, Interventions, and Follow-up Eligible patients were randomly assigned in a 1:1 ratio to receive either tofacitinib or placebo. Randomization, with stratification according to site, was performed with the use of a central concealed, Web-based, automated randomization system. Patients received either oral tofacitinib at a dose of 10 mg or placebo twice daily for up to 14 days or until hospital discharge, whichever was earlier.

If a participant underwent intubation before the end of the 14-day treatment period (or before discharge), they continued to receive tofacitinib or placebo if it was considered to be clinically appropriate by the treating physicians. A reduced-dose regimen of 5 mg of tofacitinib (or matching placebo) twice daily was administered in patients with an estimated glomerular fiation rate of less than 50 ml per minute per 1.73 m2 of body-surface area, in those with moderate hepatic impairment, and in those with concomitant use of a strong CYP3A4 inhibitor or a combination of a moderate CYP3A4 inhibitor and a strong CYP2C19 inhibitor. The rationale for the tofacitinib dosage is provided in Section S3.3. All the patients were treated according to local standards of care for erectile dysfunction treatment, which could have included glucocorticoids, antibiotic agents, anticoagulants, and antiviral agents. Concomitant use of other JAK inhibitors, biologic agents, potent immunosuppressants, interleukin-1 inhibitors, interleukin-6 inhibitors, or potent CYP450 inducers was prohibited.

Patients were assessed daily (up to day 28) while hospitalized. Follow-up visits occurred on day 14 and on day 28 for participants who were discharged before day 14 or 28. Prespecified reasons for permanent discontinuation of the trial intervention are described in Section S3.4. Outcomes The primary outcome was death or respiratory failure during the 28 days of follow-up. Death or respiratory failure was determined to occur if participants met the criteria for category 6 (status of being hospitalized while receiving noninvasive ventilation or ventilation through high-flow oxygen devices), 7 (status of being hospitalized while receiving invasive mechanical ventilation or ECMO), or 8 (death) on the eight-level National Institute of Allergy and Infectious Diseases (NIAID) ordinal scale of disease severity (on a scale from 1 to 8, with higher scores indicating a worse condition) (Table S1 in the Supplementary Appendix).

Patients who were enrolled in the trial while they were receiving oxygen through high-flow devices (category 6) were considered to have met the criteria for the primary outcome if they presented with clinical worsening to category 7 or 8. The occurrence of the primary outcome was adjudicated by an independent clinical-events classification committee, whose members were unaware of the group assignments. The protocol and statistical analysis plan used an inverted ordinal scale, which was reversed in this report to be consistent with previous studies. Secondary efficacy outcomes were the cumulative incidence of death through day 28, the scores on the NIAID ordinal scale of disease severity at day 14 and at day 28, the status of being alive and not using mechanical ventilation or ECMO at day 14 and day 28, the status of being alive and not hospitalized at day 14 and day 28, cure (defined as resolution of fever and cough and no use of ventilatory or oxygen support), the duration of stay in the hospital, and the duration of stay in the intensive care unit (ICU). The occurrence and severity of adverse events were evaluated and coded according to the Medical Dictionary for Regulatory Activities, version 23.1.

Details of adverse event reporting, including the reporting of prespecified adverse events of special interest, are described in Section S3.5. Statistical Analysis We estimated that the assignment of 260 patients, with randomization performed in a 1:1 ratio, would provide the trial with 80% power to detect a between-group difference of 15 percentage points in the incidence of the primary outcome, assuming that 15% of the participants in the tofacitinib group and 30% of those in the placebo group would have an event (death or respiratory failure through day 28). The hypothesis of superiority was tested at a two-tailed alpha level of 5%. The efficacy analyses included all the participants who underwent randomization. Safety analyses included all the participants who underwent randomization and took at least one dose of tofacitinib or placebo.

The results for the primary efficacy outcome were analyzed by means of binary regression with Firth correction, with trial group and antiviral therapy for erectile dysfunction treatment as covariates, and are expressed as a risk ratio. The antiviral treatments on day 1 were used in the statistical model. Dichotomous secondary outcomes were analyzed in a manner similar to that used for the primary outcome. The effect of the intervention on death through day 28 is expressed as a hazard ratio derived from Cox regression. For ordinal data, a proportional-odds model with adjustment for baseline antiviral therapy was used.

An odds ratio of less than 1.0 represents a clinical improvement as assessed on the ordinal scale. Odds proportionality was assessed with the use of the method of Pulkstenis–Robinson.9 We created Kaplan–Meier survival curves to express the time until the occurrence of the primary outcome, both overall and stratified according to the use of supplemental oxygen at baseline, and the occurrence of death through 28 days. As a sensitivity analysis, results for the primary outcome were analyzed by means of binary regression with Firth correction, with use of glucocorticoids and antiviral agents at baseline as covariates. In addition, results for the primary outcome were analyzed by means of logistic regression with Firth correction, with adjustment for baseline antiviral therapy. Prespecified subgroup analyses were performed according to age, sex, concomitant use of antiviral therapy, concomitant use of glucocorticoids, and time from symptom onset to randomization.

For the primary outcome, a two-sided P value of less than 0.05 was considered to indicate statistical significance. The 95% confidence intervals were estimated for all effect measures. The widths of the 95% confidence intervals for the secondary outcomes were not adjusted for multiple comparisons, so the intervals should not be used to infer definitive treatment effects. All the analyses were performed with the use of SAS software, version 9.4 (SAS Institute), and R software, version 3.6.3 (R Foundation for Statistical Computing). Additional details about the statistical analysis are provided in Section S3.6..