What is pathological demand avoidance – and how is it different to ‘acting out’?
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“Charlie” is an eight-year-old child with autism. Her parents are worried because she often responds to requests with insults, aggression and refusal. Simple demands, such as being asked to get dressed, can trigger an intense need to control the situation, fights and meltdowns.
Charlie’s parents find themselves in a constant cycle of conflict, trying to manage her and their own reactions, often unsuccessfully. Their attempts to provide structure and consequences are met with more resistance.
What’s going on? What makes Charlie’s behaviour – that some are calling “pathological demand avoidance” – different to the defiance most children show their parents or carers from time-to-time?
What is pathological demand avoidance?
British developmental psychologist Elizabeth Newson coined the term “pathological demand avoidance” (commonly shortened to PDA) in the 1980s after studying groups of children in her practice.
A 2021 systematic review noted features of PDA include resistance to everyday requests and strong emotional and behavioural reactions.
Children with PDA might show obsessive behaviour, struggle with persistence, and seek to control situations. They may struggle with attention and impulsivity, alongside motor and coordination difficulties, language delay and a tendency to retreat into role play or fantasy worlds.
PDA is also known as “extreme demand avoidance” and is often described as a subtype of autism. Some people prefer the term persistent drive for autonomy or pervasive drive for autonomy.
What does the evidence say?
Every clinician working with children and families recognises the behavioural profile described by PDA. The challenging question is why these behaviours emerge.
PDA is not currently listed in the two diagnostic manuals used in psychiatry and psychology to diagnose mental health and developmental conditions, the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the World Health Organization’s International Classification of Diseases (ICD-11).
Researchers have reported concerns about the science behind PDA. There are no clear theories or explanations of why or how the profile of symptoms develop, and little inclusion of children or adults with lived experience of PDA symptoms in the studies. Environmental, family or other contextual factors that may contribute to behaviour have not been systematically studied.
A major limitation of existing PDA research and case studies is a lack of consideration of overlapping symptoms with other conditions, such as autism, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, anxiety disorder, selective mutism and other developmental disorders. Diagnostic labels can have positive and negative consequences and so need to be thoroughly investigated before they are used in practice.
Classifying a “new” condition requires consistency across seven clinical and research aspects: epidemiological data, long-term patient follow-up, family inheritance, laboratory findings, exclusion from other conditions, response to treatment, and distinct predictors of outcome. At this stage, these domains have not been established for PDA. It is not clear whether PDA is different from other formal diagnoses or developmental differences.
Finding the why
Debates over classification don’t relieve distress for a child or those close to them. If a child is “intentionally” engaged in antisocial behaviour, the question is then “why?”
Beneath the behaviour is almost always developmental difference, genuine distress and difficulty coping. A broad and deep understanding of developmental processes is required.
Interestingly, while girls are “under-represented” in autism research, they are equally represented in studies characterising PDA. But if a child’s behaviour is only understood through a “pathologising” or diagnostic lens, there is a risk their agency may be reduced. Underlying experiences of distress, sensory overload, social confusion and feelings of isolation may be missed.
So, what can be done to help?
There are no empirical studies to date regarding PDA treatment strategies or their effectiveness. Clinical advice and case studies suggest strategies that may help include:
- reducing demands
- giving multiple options
- minimising expectations to avoid triggering avoidance
- engaging with interests to support regulation.
Early intervention in the preschool and primary years benefits children with complex developmental differences. Clinical care that involves a range of medical and allied health clinicians and considers the whole person is needed to ensure children and families get the support they need.
It is important to recognise these children often feel as frustrated and helpless as their caregivers. Both find themselves stuck in a repetitive cycle of distress, frustration and lack of progress. A personalised approach can take into account the child’s unique social, sensory and cognitive sensitivities.
In the preschool and early primary years, children have limited ability to manage their impulses or learn techniques for managing their emotions, relationships or environments. Careful watching for potential triggers and then working on timetables and routines, sleep, environments, tasks, and relationships can help.
As children move into later primary school and adolescence, they are more likely to want to influence others and be able to have more self control. As their autonomy and ability to collaborate increases, the problematic behaviours tend to reduce.
Strategies that build self-determination are crucial. They include opportunities for developing confidence, communication and more options to choose from when facing challenges. This therapeutic work with children and families takes time and needs to be revisited at different developmental stages. Support to engage in school and community activities is also needed. Each small step brings more capacity and more effective ways for a child to understand and manage themselves and their worlds.
What about Charlie?
The current scope to explain and manage PDA is limited. Future research must include the voices and views of children and adults with PDA symptoms.
Such emotional and behavioural difficulties are distressing and difficult for children and families. They need compassion and practical help.
For a child like Charlie, this could look like a series of sessions where she and her parents meet with clinicians to explore Charlie’s perspective, experiences and triggers. The family might come to understand that, in addition to autism, Charlie has complex developmental strengths and challenges, anxiety, and some difficulties with adjustment related to stress at home and school. This means Charlie experiences a fight, flight, freeze response that looks like aggression, avoidance or shutting down.
With carefully planned supports at home and school, Charlie’s options can broaden and her distress and avoidance can soften. Outside the clinic room, Charlie and her family can be supported to join an inclusive local community sporting or creative activity. Gradually she can spend more time engaged at home, school and in the community.
Nicole Rinehart, Professor, Child and Adolescent Psychology, Director, Krongold Clinic (Research), Monash University; David Moseley, Senior Research Fellow, Deputy Director (Clinical), Monash Krongold Clinic, Monash University, and Michael Gordon, Associate Professor, Psychiatry, Monash University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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Black Beans vs Fava Beans – Which is Healthier?
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Our Verdict
When comparing black beans to fava beans, we picked the black beans.
Why?
In terms of macros, black beans have more protein, carbs, and notably more fiber, the ratio of the latter two also being such that black beans enjoy the lower glycemic index (but both are still good). All in all, a clear win for black beans in this category.
In the category of vitamins, black beans have more of vitamins B1, B5, B6, E, K, and choline, while fava beans have more of vitamins A, B2, B3, B9, and C. That’s a marginal 6:5 win for black beans, before we take into account that they also have 43x as much vitamin E, which is quite a margin, while fava beans doesn’t have any similarly stand-out nutrient. So, another clear win for black beans.
When it comes to minerals, black beans have more calcium, copper, iron, magnesium, phosphorus, and potassium, while fava beans have more manganese, selenium, and zinc. Superficially this is a 6:3 win for black beans; it’s worth noting however that the margins aren’t high on either side in the case of any mineral, so this one’s closer than it looks. Still a win for black beans, though.
Adding up the sections makes for an easy overall win for black beans, but by all means, enjoy either or both—diversity is good!
Want to learn more?
You might like to read:
Eat More (Of This) For Lower Blood Pressure
Take care!
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Blood, urine and other bodily fluids: how your leftover pathology samples can be used for medical research
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A doctor’s visit often ends with you leaving with a pathology request form in hand. The request form soon has you filling a sample pot, having blood drawn, or perhaps even a tissue biopsy taken.
After that, your sample goes to a clinical pathology lab to be analysed, in whichever manner the doctor requested. All this is done with the goal of getting to the bottom of the health issue you’re experiencing.
But after all the tests are done, what happens with the leftover sample? In most cases, leftover samples go in the waste bin, destined for incineration. Sometimes though, they may be used again for other purposes, including research.
Kaboompics.com/Pexels Who can use my leftover samples?
The samples we’re talking about here cover the range of samples clinical labs receive in the normal course of their testing work. These include blood and its various components (including plasma and serum), urine, faeces, joint and spinal fluids, swabs (such as from the nose or a wound), and tissue samples from biopsies, among others.
Clinical pathology labs often use leftover samples to practise or check their testing methods and help ensure test accuracy. This type of use is a vital part of the quality assurance processes labs need to perform, and is not considered research.
Leftover samples can also be used by researchers from a range of agencies such as universities, research institutes or private companies.
They may use leftover samples for research activities such as trying out new ideas or conducting small-scale studies (more on this later). Companies that develop new or improved medical diagnostic tests can also use leftover samples to assess the efficacy of their test, generating data needed for regulatory approval.
What about informed consent?
If you’ve ever participated in a medical research project such as a clinical trial, you may be familiar with the concept of informed consent. In this process, you have the opportunity to learn about the study and what your participation involves, before you decide whether or not to participate.
So you may be surprised to learn using leftover samples for research purposes without your consent is permitted in most parts of Australia, and elsewhere. However, it’s only allowed under certain conditions.
In Australia, the National Health and Medical Research Council (NHMRC) offers guidance around the use of leftover pathology samples.
One of the conditions for using leftover samples without consent for research is that they were received and retained by an accredited pathology service. This helps ensure the samples were collected safely and properly, for a legitimate clinical reason, and that no additional burdens or risk of harm to the person who provided the sample will be created with their further use.
Another condition is anonymity: the leftover samples must be deidentified, and not easily able to be reidentified. This means they can only be used in research if the identity of the donor is not needed.
Leftover pathology samples are sometimes used in medical research. hedgehog94/Shutterstock The decision to allow a particular research project to use leftover pathology samples is made by an independent human research ethics committee which includes consumers and independent experts. The committee evaluates the project and weighs up the risks and potential benefits before permitting an exemption to the need for informed consent.
Similar frameworks exist in the United States, the United Kingdom, India and elsewhere.
What research might be done on my leftover samples?
You might wonder how useful leftover samples are, particularly when they’re not linked to a person and their medical history. But these samples can still be a valuable resource, particularly for early-stage “discovery” research.
Research using leftover samples has helped our understanding of antibiotic resistance in a bacterium that causes stomach ulcers, Helicobacter pylori. It has helped us understand how malaria parasites, Plasmodium falciparum, damage red blood cells.
Leftover samples are also helping researchers identify better, less invasive ways to detect chronic diseases such as pulmonary fibrosis. And they’re allowing scientists to assess the prevalence of a variant in haemoglobin that can interfere with widely used diagnostic blood tests.
All of this can be done without your permission. The kinds of tests researchers do on leftover samples will not harm the person they were taken from in any way. However, using what would otherwise be discarded allows researchers to test a new method or treatment and avoid burdening people with providing fresh samples specifically for the research.
When considering questions of ethics, it could be argued not using these samples to derive maximum benefit is in fact unethical, because their potential is wasted. Using leftover samples also minimises the cost of preliminary studies, which are often funded by taxpayers.
The use of leftover pathology samples in research has been subject to some debate. Andrey_Popov/Shutterstock Inconsistencies in policy
Despite NHMRC guidance, certain states and territories have their own legislation and guidelines which differ in important ways. For instance, in New South Wales, only pathology services may use leftover specimens for certain types of internal work. In all other cases consent must be obtained.
Ethical standards and their application in research are not static, and they evolve over time. As medical research continues to advance, so too will the frameworks that govern the use of leftover samples. Nonetheless, developing a nationally consistent approach on this issue would be ideal.
Striking a balance between ensuring ethical integrity and fostering scientific discovery is essential. With ongoing dialogue and oversight, leftover pathology samples will continue to play a crucial role in driving innovation and advances in health care, while respecting the privacy and rights of individuals.
Christine Carson, Senior Research Fellow, School of Medicine, The University of Western Australia and Nikolajs Zeps, Professor, School of Public Health and Preventive Medicine, Monash University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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What happens to your vagina as you age?
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The vagina is an internal organ with a complex ecosystem, influenced by circulating hormone levels which change during the menstrual cycle, pregnancy, breastfeeding and menopause.
Around and after menopause, there are normal changes in the growth and function of vaginal cells, as well as the vagina’s microbiome (groups of bacteria living in the vagina). Many women won’t notice these changes. They don’t usually cause symptoms or concern, but if they do, symptoms can usually be managed.
Here’s what happens to your vagina as you age, whether you notice or not.
Let’s clear up the terminology
We’re focusing on the vagina, the muscular tube that goes from the external genitalia (the vulva), past the cervix, to the womb (uterus). Sometimes the word “vagina” is used to include the external genitalia. However, these are different organs and play different roles in women’s health.
What happens to the vagina as you age?
Like many other organs in the body, the vagina is sensitive to female sex steroid hormones (hormones) that change around puberty, pregnancy and menopause.
Menopause is associated with a drop in circulating oestrogen concentrations and the hormone progesterone is no longer produced. The changes in hormones affect the vagina and its ecosystem. Effects may include:
- less vaginal secretions, potentially leading to dryness
- less growth of vagina surface cells resulting in a thinned lining
- alteration to the support structure (connective tissue) around the vagina leading to less elasticity and more narrowing
- fewer blood vessels around the vagina, which may explain less blood flow after menopause
- a shift in the type and balance of bacteria, which can change vaginal acidity, from more acidic to more alkaline.
What symptoms can I expect?
Many women do not notice any bothersome vaginal changes as they age. There’s also little evidence many of these changes cause vaginal symptoms. For example, there is no direct evidence these changes cause vaginal infection or bleeding in menopausal women.
Some women notice vaginal dryness after menopause, which may be linked to less vaginal secretions. This may lead to pain and discomfort during sex. But it’s not clear how much of this dryness is due to menopause, as younger women also commonly report it. In one study, 47% of sexually active postmenopausal women reported vaginal dryness, as did around 20% of premenopausal women.
Other organs close to the vagina, such as the bladder and urethra, are also affected by the change in hormone levels after menopause. Some women experience recurrent urinary tract infections, which may cause pain (including pain to the side of the body) and irritation. So their symptoms are in fact not coming from the vagina itself but relate to changes in the urinary tract.
Not everyone has the same experience
Women vary in whether they notice vaginal changes and whether they are bothered by these to the same extent. For example, women with vaginal dryness who are not sexually active may not notice the change in vaginal secretions after menopause. However, some women notice severe dryness that affects their daily function and activities.
In fact, researchers globally are taking more notice of women’s experiences of menopause to inform future research. This includes prioritising symptoms that matter to women the most, such as vaginal dryness, discomfort, irritation and pain during sex.
If symptoms bother you
Symptoms such as dryness, irritation, or pain during sex can usually be effectively managed. Lubricants may reduce pain during sex. Vaginal moisturisers may reduce dryness. Both are available over-the-counter at your local pharmacy.
While there are many small clinical trials of individual products, these studies lack the power to demonstrate if they are really effective in improving vaginal symptoms.
In contrast, there is robust evidence that vaginal oestrogen is effective in treating vaginal dryness and reducing pain during sex. It also reduces your chance of recurrent urinary tract infections. You can talk to your doctor about a prescription.
Vaginal oestrogen is usually inserted using an applicator, two to three times a week. Very little is absorbed into the blood stream, it is generally safe but longer-term trials are required to confirm safety in long-term use beyond a year.
Women with a history of breast cancer should see their oncologist to discuss using oestrogen as it may not be suitable for them.
Are there other treatments?
New treatments for vaginal dryness are under investigation. One avenue relates to our growing understanding of how the vaginal microbiome adapts and modifies around changes in circulating and local concentrations of hormones.
For example, a small number of reports show that combining vaginal probiotics with low-dose vaginal oestrogen can improve vaginal symptoms. But more evidence is needed before this is recommended.
Where to from here?
The normal ageing process, as well as menopause, both affect the vagina as we age.
Most women do not have troublesome vaginal symptoms during and after menopause, but for some, these may cause discomfort or distress.
While hormonal treatments such as vaginal oestrogen are available, there is a pressing need for more non-hormonal treatments.
Dr Sianan Healy, from Women’s Health Victoria, contributed to this article.
Louie Ye, Clinical Fellow, Department of Obstetrics and Gynecology, The University of Melbourne and Martha Hickey, Professor of Obstetrics and Gynaecology, The University of Melbourne
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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Black Olives vs Green Olives – Which is Healthier
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Our Verdict
When comparing black olives to green olives, we picked the black olives.
Why?
First know this: they are the same plant, just at different stages of ripening (green olives are, as you might expect, less ripe).
Next: the nutritional values of both, from macros down to the phytochemicals, are mostly very similar, but there are a few things that stand out:
• Black olives usually have more calories per serving, average about 25% more. But these are from healthy fats, so unless you’re on a calorie-restricted diet, this is probably not a consideration.
• Green olives are almost always “cured” for longer, which results in a much higher sodium content often around 200% that of black olives. Black olives are often not “cured” at all.Hence, we chose the black olives!
You may be wondering: do green olives have anything going for them that black olives don’t?
And the answer has a clue in the taste: green olives generally have a stronger, more bitter/pungent taste. And remember what we said about things that have a stronger, more bitter/pungent taste:
Tasty Polyphenols: Enjoy Bitter Foods For Your Heart & Brain
That’s right, green olives are a little higher in polyphenols than black olives.
But! If you want to enjoy the polyphenol content of green olives without the sodium content, the best way to do that is not olives, but olive oil—which is usually made from green olives.
For more about olive oil, check out:
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What Would a Second Trump Presidency Look Like for Health Care?
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On the presidential campaign trail, former President Donald Trump is, once again, promising to repeal and replace the Affordable Care Act — a nebulous goal that became one of his administration’s splashiest policy failures.
“We’re going to fight for much better health care than Obamacare. Obamacare is a catastrophe,” Trump said at a campaign stop in Iowa on Jan. 6.
The perplexing revival of one of Trump’s most politically damaging crusades comes at a time when the Obama-era health law is even more popular and widely used than it was in 2017, when Trump and congressional Republicans proved unable to pass their own plan to replace it. That failed effort was a big part of why Republicans lost control of the House of Representatives in the 2018 midterms.
Despite repeated promises, Trump never presented his own Obamacare replacement. And much of what Trump’s administration actually accomplished in health care has been reversed by the Biden administration.
Still, Trump secured some significant policy changes that remain in place today, including efforts to bring more transparency to prices charged by hospitals and paid by health insurers.
Trying to predict Trump’s priorities in a second term is even more difficult given that he frequently changes his positions on issues, sometimes multiple times.
The Trump campaign did not respond to a request for comment.
Perhaps Trump’s biggest achievement is something he rarely talks about on the campaign trail. His administration’s “Operation Warp Speed” managed to create, test, and bring to market a covid-19 vaccine in less than a year, far faster than even the most optimistic predictions.
Many of Trump’s supporters, though, don’t support — and some even vehemently oppose — covid vaccines.
Here is a recap of Trump’s health care record:
Public Health
Trump’s pandemic response dominates his overall record on health care.
More than 400,000 Americans died from covid over Trump’s last year in office. His travel bans and other efforts to prevent the global spread of the virus were ineffective, his administration was slower than other countries’ governments to develop a diagnostic test, and he publicly clashed with his own government’s health officials over the response.
Ahead of the 2020 election, Trump resumed large rallies and other public campaign events that many public health experts regarded as reckless in the face of a highly contagious, deadly virus. He personally flouted public health guidance after contracting covid himself and ending up hospitalized.
At the same time, despite what many saw as a politicization of public health by the White House, Trump signed a massive covid relief bill (after first threatening to veto it). He also presided over some of the largest boosts for the National Institutes of Health’s budget since the turn of the century. And the mRNA-based vaccines Operation Warp Speed helped develop were an astounding scientific breakthrough credited with helping save millions of lives while laying the groundwork for future shots to fight other diseases including cancer.
Abortion
Trump’s biggest contribution to abortion policy was indirect: He appointed three Supreme Court justices, who were instrumental in overturning the constitutional right to an abortion.
During his 2024 campaign, Trump has been all over the place on the red-hot issue. Since the Supreme Court overturned Roe v. Wade in 2022, Trump has bemoaned the issue as politically bad for Republicans; criticized one of his rivals, Florida Gov. Ron DeSantis, for signing a six-week abortion ban; and vowed to broker a compromise with “both sides” on abortion, promising that “for the first time in 52 years, you’ll have an issue that we can put behind us.”
He has so far avoided spelling out how he’d do that, or whether he’d support a national abortion ban after any number of weeks.
More recently, however, Trump appears to have mended fences over his criticism of Florida’s six-week ban and more with key abortion opponents, whose support helped him get elected in 2016 — and whom he repaid with a long list of policy changes during his presidency.
Among the anti-abortion actions taken by the Trump administration were a reinstatement of the “Mexico City Policy” that bars giving federal funds to international organizations that support abortion rights; a regulation to bar Planned Parenthood and other organizations that provide abortions from the federal family planning program, Title X; regulatory changes designed to make it easier for health care providers and employers to decline to participate in activities that violate their religious and moral beliefs; and other changes that made it harder for NIH scientists to conduct research using fetal tissue from elective abortions.
All of those policies have since been overturned by the Biden administration.
Health Insurance
Unlike Trump’s policies on reproductive health, many of his administration’s moves related to health insurance still stand.
For example, in 2020, Trump signed into law the No Surprises Act, a bipartisan measure aimed at protecting patients from unexpected medical bills stemming from payment disputes between health care providers and insurers. The bill was included in the $900 billion covid relief package he opposed before signing, though Trump had expressed support for ending surprise medical bills.
His administration also pushed — over the vehement objections of health industry officials — price transparency regulations that require hospitals to post prices and insurers to provide estimated costs for procedures. Those requirements also remain in place, although hospitals in particular have been slow to comply.
Medicaid
While first-time candidate Trump vowed not to cut popular entitlement programs like Medicare, Medicaid, and Social Security, his administration did not stick to that promise. The Affordable Care Act repeal legislation Trump supported in 2017 would have imposed major cuts to Medicaid, and his Department of Health and Human Services later encouraged states to require Medicaid recipients to prove they work in order to receive health insurance.
Drug Prices
One of the issues the Trump administration was most active on was reducing the price of prescription drugs for consumers — a top priority for both Democratic and Republican voters. But many of those proposals were blocked by the courts.
One Trump-era plan that never took effect would have pegged the price of some expensive drugs covered by Medicare to prices in other countries. Another would have required drug companies to include prices in their television advertisements.
A regulation allowing states to import cheaper drugs from Canada did take effect, in November 2020. However, it took until January 2024 for the FDA, under Trump’s successor, to approve the first importation plan, from Florida. Canada has said it won’t allow exports that risk causing drug shortages in that country, leaving unclear whether the policy is workable.
Trump also signed into law measures allowing pharmacists to disclose to patients when the cash price of a drug is lower than the cost using their insurance. Previously pharmacists could be barred from doing so under their contracts with insurers and pharmacy benefit managers.
Veterans’ Health
Trump is credited by some advocates for overhauling Department of Veterans Affairs health care. However, while he did sign a major bill allowing veterans to obtain care outside VA facilities, White House officials also tried to scuttle passage of the spending needed to pay for the initiative.
Medical Freedom
Trump scored a big win for the libertarian wing of the Republican Party when he signed into law the “Right to Try Act,” intended to make it easier for patients with terminal diseases to access drugs or treatments not yet approved by the FDA.
But it is not clear how many patients have managed to obtain treatment using the law because it is aimed at the FDA, which has traditionally granted requests for “compassionate use” of not-yet-approved drugs anyway. The stumbling block, which the law does not address, is getting drug companies to release doses of medicines that are still being tested and may be in short supply.
Trump said in a Jan. 10 Fox News town hall that the law had “saved thousands and thousands” of lives. There’s no evidence for the claim.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
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Built from Broken – by Scott Hogan, CPT, COES
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So many exercise programs come with the caveat “consult your doctor before engaging in any new activity”, and the safe-but-simple “do not try to train through an injury”.
Which is all very well and good for someone in fabulous health who sprained an ankle while running and can just wait a bit, but what about those of us carrying…
- long-term injuries
- recurring injuries
- or just plain unfixable physical disabilities?
That’s where physiotherapist Scott Hogan comes in. The subtitle line goes:
❝A Science-Based Guide to Healing Painful Joints, Preventing Injuries, and Rebuilding Your Body❞
…but he does also recognize that there are some things that won’t bounce back.
On the other hand… There are a lot of things that get written off by doctors as “here’s some ibuprofen” that, with consistent mindful training, could actually be fixed.
Hogan delivers again and again in this latter category! You’ll see on Amazon that the book has thousands of 4- and 5-star ratings and many glowing reviews, and it’s for a reason or three:
- The book first lays a foundational knowledge of the most common injuries likely to impede us from training
- It goes on to give step-by-step corrective exercises to guide your body through healing itself. Your body is trying to heal itself anyway; you might as well help it accomplish that!
- It finishes up with a comprehensive (and essential) guide to train for the strength and mobility that will help you avoid future problems.
In short: a potentially life-changing book if you have some (likely back- or joint-related) problem that needs overcoming!
And if you don’t? An excellent pre-emptive guide all the same. This is definitely one of those “an ounce of prevention is better than a pound of cure” things.
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