How do you get lasix

This article appeared in the September/October 2021 issue of Discover how do you get lasix magazine as http://www.erada.com/how-to-buy-lasix-online/ "Frontline Fatigue." Become a subscriber for unlimited access to our archive.In February 1945, U.S. Navy nurse Dorothy Still was a prisoner of war in the Japanese-occupied Philippines. Along with 11 other Navy nurses, Nurse Still provided care for civilian inmates in a prison camp where food was scarce and how do you get lasix guards were brutal.

Few inmates weighed more than 100 pounds, and most were dying from malnutrition. On the night of Feb. 22, Nurse Still how do you get lasix and the other inmates watched as their captors set up guns around the perimeter of the camp and turned the barrels inward.

Other guards dug shallow graves. The inmates had long suspected the camp commander planned to massacre them all, and it seemed the rumors were coming true. Yet Nurse how do you get lasix Still and another Navy nurse reported to the infirmary for the night shift.

They had little medicine or food to offer their patients. Comfort and kindness were all they had left to give. Nurse Still heard gunfire the next morning at how do you get lasix dawn and assumed the massacre had begun.

She steeled herself to glance out the infirmary window and saw parachutes gliding to the ground. Liberation had come just in time!. U.S how do you get lasix.

And Filipino forces swiftly evacuated the 2,400 inmates to safety. But that wasn’t the end of Nurse Still’s journey. She was haunted by the horrors she witnessed in the prison camp, and the trauma stuck with her for the rest how do you get lasix of her life.

Now nursing leaders and advocates are saying the problem of not addressing nurses’ mental health needs has again reached a critical point. Nurses have been on the front lines of the hypertension medications crisis, but most aren’t receiving comprehensive mental health screening or treatment. Nursing advocacy groups and scholars who study PTSD in nursing warn that leaving nurses’ mental health needs untreated could lead to a nursing shortage, much as it did after World War II.Taken as prisoners of war in 1942, Dorothy Still and 11 other Navy nurses provided medical care how do you get lasix in the midst of brutal suffering at Los Baños Internment Camp.

(Credit. Courtesy of Bureau of Medicine and Surgery) Suffering in Silence Back in the States, Nurse Still was tasked with speaking at war bond drives about the three years she was a how do you get lasix prisoner of war. She found the experience troubling and requested a transfer to Panama, but her memories followed her to her new post.

At times, she was depressed. Other times, she couldn’t stop thinking about all she how do you get lasix had endured. She sometimes cried without provocation and struggled to stop crying once she had started.

On advice of her fiancé, she booked an appointment with a naval physician. During her appointment, Nurse Still told the physician how do you get lasix she had been a prisoner of war for more than three years, and asked for a medical discharge based on the trauma she was experiencing. The doctor asked when Nurse Still was liberated.

The date was the same as the raising of the flag at Iwo Jima. The physician said those men were heroes, but Nurse Still was a woman and a nurse, and therefore, did not suffer how do you get lasix. Denied treatment, Nurse Still left the appointment shaking.

She vowed she would keep her pain to herself. The Navy nurses weren’t the how do you get lasix only medical care providers taken prisoner during WWII. Sixty-six U.S.

Army nurses as well as hundreds of physicians, pharmacists, and medical assistants were also held captive in the South Pacific. But at the end of the war, how do you get lasix as the U.S. Prepared to welcome home millions of men and women who served their country, mental health treatment was limited — and reserved for men.

Nurses, it was assumed, did not suffer. At the time, how do you get lasix the U.S. Military was the largest employer of nurses, and it had established an expected code of silence regarding how nurses responded to their own trauma.

In 1947, an article in the American Journal of Psychiatry claimed a military hospital was a controlled environment that insulated nurses from the brutality of war. The study’s author claimed that nurses’ mental how do you get lasix health needs were “less complex,” and that nursing fulfilled women by catering to their natural instinct to care for men. €œThey were supplying a service which gratified the passive needs of men.

And which identified these women how do you get lasix with the mother, the wife, or the sweetheart back home.”Many nurses, including Nurse Still, responded to the lack of mental health treatment by leaving both the military and nursing. The late 1940s saw a shortage in nurses at time when hospital admissions rose by 26 percent. The shortage persisted until the late 1960s when wages began to increase.After three years as POWs, the Navy nurses were liberated in 1945.

Here, they how do you get lasix speak with Admiral Thomas C. Kinkaid after their release, and are shown next to the aircraft that brought them from the South Pacific to Hawaii. (Credit.

U.S. Navy Bureau of Medicine and Surgery)A Looming Crisis The hypertension medications lasix has meant that for the first time since WWII, the vast majority of U.S. Nurses are embroiled in fighting a common enemy.

It’s a demanding and emotional battle that advocates say adds a deeper stress to an already taxing job.Across the country, nurses have been caring for patients dying from hypertension medications who do not have the support of family at their bedside due to visitor restrictions. €œThe nurses are often the ones who are serving as the loved one and helping the patient navigate the end-of-life journey,” says Holly Carpenter, a senior policy advisor with the American Nurses Association. In addition to caring for dying hypertension medications patients, Carpenter says, many nurses were not properly equipped at the height of the lasix with the personal protection equipment needed to avoid .

These nurses lived in fear of being infected or transmitting the lasix to loved ones at home. And on top of these stressors, nurses are also still coping with the usual demands of the job. €œThere are the things that have always been there — long shifts, sometimes mandatory overtime, a workload that’s heavier than you’re comfortable with, having to work through breaks or lunchtime, having to come in early and stay late,” Carpenter says.

Prior to the lasix, studies estimated that as many as half of critical-care nurses experienced post-traumatic stress disorder (PTSD). Since the lasix began, researchers have found the crisis has amplified symptoms of mental health problems. A 2020 study in General Hospital Psychiatry found that 64 percent of nurses in a New York City medical center reported experiencing acute stress.

€œAcute stress included symptoms like nightmares, inability to stop thinking about hypertension medications, and feeling numb, detached, and on guard,” says study leader Marwah Abdalla, a clinical cardiologist and assistant professor of medicine at Columbia University Medical Center. €œThis is concerning. We know that if these symptoms persist for more than a month, it can lead to PTSD.” Some nurses experienced PTSD before hypertension medications, but the conditions of the lasix have amplified mental health problems.

(Credit. Eldar Nurkovic/Shutterstock)A person is diagnosed with PTSD if they meet criteria outlined by the DSM-5, the psychiatric profession’s official manual. Criteria include experiencing, witnessing or learning about a traumatic event (such as death, serious injury, or sexual violence).

Intrusive symptoms like dreams and flashbacks. Avoidance of reminders of the event. Negative changes in thoughts and moods.

And behavioral changes. A person can also develop PTSD if they are repeatedly exposed to details of a traumatic event. Suffering from undiagnosed or untreated PTSD is a life-altering condition with diverse ramifications, and may lead a nurse to leave health care.

€œWe’re potentially setting up an occupational health care crisis,” Abdalla says. €œThis has long-term implications for the health care industry and our ability to deliver adequate health care for our patients.” Carpenter says health care organizations must be proactive with screening nurses for symptoms related to anxiety, depression, and PTSD. Such screenings must be confidential and come with the assurance that a nurse’s license or job will not be compromised.

Organizations also need to work to destigmatize mental health diagnosis and treatment. €œHistorically, nurses are always looked upon as the healers and the helpers,” Carpenter says. €œThey feel they need to be strong for other people.

What do you do when the hero needs help?. €For Nurse Still, help never came. She left the Navy and nursing, married, and had three children.

She returned to nursing in the late 1950s after her husband died suddenly and she needed to support her family.Only in the 1990s did she begin speaking about her experiences in interviews with oral historians and documentary producers. She also wrote a memoir, but kept the story light and did not disclose her extensive suffering.The profession has advanced since Nurse Still’s 1940s appeal for mental health support was rejected. €œWe do recognize the full PTSD, compassion fatigue, and burnout of nurses.

It’s been chronicled now and we understand it,” Carpenter says. Now the challenge is encouraging each nurse to seek and receive help. Otherwise, advocates warn, their health and wellbeing will continue to decline, and history may repeat as stressed nurses leave a strained profession.

Emilie Le Beau Lucchesi is a journalist in the Chicago area and the author of This is Really War. The Incredible True Story of a Navy Nurse POW in the Occupied Philippines.It’s pretty obvious when a dog is sad. It might whine or whimper, knit its brow, or turn its big, imploring eyes upward at you.

But it would be another thing entirely to see a big tear rolling down your canine companion’s face.Animals simply don’t cry. Or at least, they don’t shed emotional tears. The only creatures who have evolved to do so, it turns out, are humans.

We snivel at sad movies, well up at weddings and blink away hot tears of frustration during arguments. €œWe appear to be the only animal that sheds tears for emotional reasons,” says Randolph Cornelius, a professor of psychological science at Vassar College in New York and an expert on human emotion.There are many theories on the evolution and purpose of emotional tears. Experts even have a few ideas why animals — who do experience emotions — don’t weep like we do.

But why we evolved to eject liquid out of our eyes as a signal of distress, rather than some other reaction, is still far from settled.The Biology of CryingFrom a biological perspective, there are three types of tears. One is basal tears, which our eyes create automatically to lubricate and clean our eyes. These come from our accessory lacrimal glands, located under the eyelids.

Then there are reflex tears, which you’re likely acquainted with if you’ve ever cut an onion or been poked in the eye. The third is emotional tears — the only variety that we can control, to some extent. These latter two types come from lacrimal glands on the upper outside of our eye sockets.“One argument is that [emotional crying] is almost like an emotional reflex as opposed to just a physical reflex,” says Marc Baker, a teaching fellow at the University of Portsmouth in England who researches adult emotional crying.Indeed, some have hypothesized that the purpose of crying is itself just another biological function.

For example, biochemist William Frey theorized in the 1980s that crying balances levels of hormones in our body to relieve stress. He also suggested that crying clears our body of toxins, though subsequent studies have largely disproven this. English naturalist Charles Darwin, the father of evolution, believed children cried to experience physical relief from negative emotions.In these theories, crying is something that restores us to equilibrium.

It is the idea of crying as catharsis, or a way to calm ourselves in times of distress. After all, it’s not unusual for people to report feeling better after “a good cry” — but that relief may be coming from unexpected places.The Psychology of CryingPerhaps the most compelling explanation for tearful crying is that it is driven by our social needs. Crying is a distinct visual signal that something is wrong.

In an instant, it communicates that someone might need help. When others attend to the crier, it contributes to a collaborative social environment that is highly complex in humans.Inquiries by Cornelius support this theory of tears as a quick and effective social signal. In a number of studies, he and colleagues showed photographs of faces to participants (under the guise of another purpose) and asked them to interpret the emotion.

In some of the photos, people were crying real tears. In others, they had been digitally removed.When shown the pictures with tears, almost every participant labelled the emotion as sadness or grief. Tear-free crying faces, on the other hand, were confusing.

€œWithout the tears, the emotion almost disappears,” Cornelius says. €œTheir judgments of the emotion don't tend to cluster around the ‘sad’ family of emotions — they're all over the place. And in fact, some people say there's no emotion there at all.”This indicated that crying is a strong signal to others of our immediate emotional state.

It’s hard to fake real tears. And as researchers of crying can attest, it’s hard to induce genuine emotional crying in a lab setting — one of the reasons it’s challenging to study.Solving an Evolutionary MysteryFrom an evolutionary perspective, some of our physiological reactions have a clear purpose. It makes sense that we sweat when overheated, raise our voices when angry or tense up in fear.

But at a distance, our tearful tendencies are just plain weird. Someone showing an alien around Earth would have to explain that when humans (and only humans) feel distress or even overwhelming happiness, their faces get slightly wet and puffy.Animals do have lacrimal glands, which they use for reflex tears. But in humans, something seems to have changed somewhere along the way.

What started as distress calls that many animals make became connected with the production of tears, and experts still aren’t sure why. €œThere’s no answer, sorry,” Baker says. But there are a few theories.Clinical psychologist Ad Vingerhoets has suggested that crying might have been more advantageous than other kinds of noises because it suggests submissiveness and harmlessness to would-be predators, who might then reduce their aggression.

But that still doesn’t explain the tears themselves or why animals wouldn’t benefit from them in the same way.For that, researchers point toward other, seemingly unrelated hallmarks of human physiology and development that could have led to tears. For one, we walk upright — unlike bears and wolves, who, in their position closer to the ground, rely mostly on smells to signal distress. Perhaps partially because of this, we rely heavily on visual cues to communicate in social situations.

€œFrom a kind of evolutionary perspective, it makes sense that lots of our signals become visual signals, because we are just quite visual animals,” Baker says. We also position ourselves forward. Our faces, then, developed to become the most complex in the animal kingdom — especially on the top half of our face.

€œOur kind of facial expressions far exceed almost every other animal, especially around the eyes,” he says. €œWe can do much more with the top half of our face.”An intricate facial musculature arose, and with it, machinery that could induce crying. Asmir Gračanin, a professor of psychology at the University of Rijeka in Croatia, and colleagues theorized that the orbicularis oculi muscle may have evolved along with our hyper-expressive faces.

This eye socket muscle could have squeezed the corneal sensory nerves that trigger the production of tears by the lacrimal gland and proved advantageous to human babies as a call for immediate help.This also fits in with the uniqueness of human babies, who are much more helpless than other baby animals that come out of the womb ready to walk and perform other basic functions. Human babies need more help, cry for assistance and comfort, and then (largely) grow out of crying as adults.But adults still do cry emotional tears — in sadness, happiness, awe or frustration. €œIt's kind of what makes us human, almost,” says Baker, “[our] ability to share emotions very silently, with a small drop of saline solution from the eye.”The introduction of the contraceptive pill in the 1960s spurred a landmark moment for women, liberating many from the home and propelling them into the world.

But this excitement overshadowed the side effects and hazards associated with the pill, which we now know may include a slightly increased risk of breast cancer.“A lot of women are unaware of the cancer risk associated with hormonal birth control because the advent of the pill freed up the lives of women to enter the workforce more effectively,” says Beverly Strassmann, a human evolutionary biologist at the University of Michigan. When radically altering the body with synthetic hormones, you can’t assume there won’t be side effects, she says. But the field hasn’t made significant progress, partly because contraceptives have provided women with tangible benefits.

Sixty years on, pharmaceutical companies are still “resting on their laurels” and need to better evaluate the association between hormonal birth control and cancer, she adds. Research has also linked the pill to depression, decreased sexual desire, anxiety and an altered ability to form emotional memories. Most physicians, however, still don’t closely follow research investigating the links between hormonal birth control and its psychological side effects, says evolutionary psychologist Sarah Hill, author of How the Pill Changes Everything.

Your Brain on Birth Control. €œMost medication doesn’t look at the full spectrum of side effects in the way people experience the world. It’s not even in physicians’ peripheral vision,” Hill says.

But women want the next birth control revolution. Younger women especially seek non-hormonal options, Hill says. €œA lot of women aren’t being served, and many are on the pill even though they don’t love it — their standards are low because there’s so few good options,” she says.

In recent years, contraception apps have attracted a rise in users, which may suggest that many women no longer tolerate the impacts of hormonal birth control on their bodies. But these apps have faced criticism over their efficacy. A New Kind of PillAnother possibility.

A non-hormonal pill. Now, University of Connecticut physiologist and geneticist Jianjun Sun is wading through the unknowns to formulate it.“We know that, in humans, the ovulation process is triggered by a hormone surge, but how the egg is released is very precise. The menstrual cycle is very tightly controlled and there are a lot of unknowns in this area,” he says.

Sun does know that when a person ovulates, an egg that’s contained within a follicle bursts out of the ovary and sets off down the fallopian tube, where it can be fertilized. He’s hoping to formulate a drug that stops the follicle from rupturing and releasing the egg. Shutting off ovulation isn’t a new concept — hormonal contraception does this by tricking the body into thinking users aren’t pregnant.

But he seeks a new way to halt egg release without the use of synthetic hormones. Crucially, Sun has devised a way to analyze different compounds without relying on human subjects (which would complicate the process). He realized that fruit flies ovulate in a similar way to people, and the fly’s ovulation process resembles that within mice.

As this research took off, the Gates Foundation had begun supporting scientists developing non-hormonal contraceptives. The organization has funded Sun to test compounds on flies. Now, Sun is screening up to 500 compounds daily to see which ones prevent follicles from rupturing and releasing eggs.

€œThe Gates are very excited now. They’re trying to get us to find the target, then we can study this target using genetic tools,” he says. Researchers could test the drug in humans eventually, Sun says.

Unlike hormonal pills, users wouldn’t need to take it daily. To inhibit ovulation, you only need to take it for a week or so before the process begins.While this sounds tempting, many people don’t know when exactly they ovulate — and only 10 to 15 percent of women experience 28-day cycles. And because the drug concept is so new, researchers aren’t sure what dosing might look like.

€œIt’s still hypothetical in terms of how to use contraceptives targeting ovulation, since there’s no products on the market,” Sun says. A Dearth of ResearchDespite the many unknowns, experts seem receptive to any new research in hormonal birth control alternatives. In recent years, few studies have taken on this challenge.Hormonal contraceptives dominate at a time when, researchers argue, scientific and technological advances bring unprecedented opportunities for new drugs across medical fields.

If Sun’s research is fruitful, it could attract more funding for other researchers working on these alternatives, says Bethan Swift, a PhD student at the University of Oxford who studies the epidemiology of women’s health. €œOne big barrier to developing new contraception is that existing options work,” Swift says, “So there’s little demand from the pharmaceutical industry to put money into creating new compounds.” This shortage of funds places significant pressure on Sun. The Gates Foundation hopes that at least one drug will hit the market by 2026, he says.

But the bar for birth control approval is uniquely high. Because it isn’t meant to alleviate an illness, possible side effects may not be worth the trade-off versus, for example, cancer treatments. It will probably take between five and 10 years before a new drug is available, Sun says.

“Developing new contraception isn’t easy because they’re going to healthy women, unlike other drugs, where it’s more accepted that there will be side effects,” Sun says. The final drug will likely cause some side effects, but fewer than hormone-based contraceptives, he notes. However, Hill is concerned that the end product could still affect the body’s natural hormone levels.Our bodies produce most sex hormones via ovulation, and high levels of estrogen propel monthly egg maturation.

After an egg is released, the empty follicle releases progesterone — so levels would fall fairly low if you prevent ovulation, she says. €œStopping ovulation sounds perfect, but if you understand that’s how the body makes hormones, you’d realize it’s not a panacea.”This article contains affiliate links to products. Discover may receive a commission for purchases made through these links.Did you know that sleeping in a zero-gravity position may help alleviate symptoms from improve sleep disorders, relieve neck and back pain, and allow for better circulation and heart health?.

An adjustable bed frame allows you to place your body in a zero-gravity position to enjoy all of these benefits and more as you sleep comfortably with optimal support throughout the night. If you’ve been considering getting an adjustable bed, you’re not alone. Many individuals are making the switch to enhance their comfort, improve their health, and, of course, to enjoy more restful sleep.

Deciding which adjustable bed frame is right for you can be challenging. The market is overflowing with options, and sorting through all these choices can be overwhelming. Fortunately, our best adjustable beds reviews below can help you focus your search, narrow down your choices, and select the right model to help you mitigate sleep disorders, to sleep more comfortably, and to wake up feeling more rested.

What is Zero Gravity?. Zero gravity refers to a specific position where the body is a state of weightlessness. NASA actually developed this term for astronauts to help them find the ideal position to keep their weight balanced and neutralized as they flew into space.

Being in a zero-gravity position prevents gravity from affecting your body, which means that nothing is pulling your body down. Your body is in a zero-gravity position when. When your body is in the zero-gravity position, it should look like a V shape.

This alignment helps ensure that your weight is distributed evenly. As you can imagine, sleeping in this V-shaped position on a standard bed frame isn’t possible. However, adjustable bed frames enable you to sleep in a zero-gravity position and prevent your body’s weight from placing pressure on your hips, spine, and other joints.

Sleeping in a zero-gravity position offers a myriad of benefits. We’ll explore these benefits in the next section. Benefits of Sleeping in a Zero-Gravity Position with an Adjustable Bed Frame Adjustable beds have been used in hospitals for over a century due to their ability to properly position patients to facilitate recovery and reduce complications from surgeries and other medical procedures.

If adjustable beds can protect the health of patients in a hospital, then it seems like a logical conclusion that they can also offer health benefits for individuals who use them at home. Indeed, there are many ways switching to an adjustable bed frame and sleeping in a zero-gravity position can benefit your health. These include.

While some individuals snore every night, others are more prone to it only when they are congested. Adjustable beds can also help reduce snoring caused by congestion because keeping the head elevated can allow the sinuses to drain. Reduced sleep apnea.

An adjustable bed may also reduce sleep apnea symptoms. Sleep apnea, which occurs when an individual stops breathing during sleep, is also sometimes the result of an obstructed airway. Elevating the head may open up the airway enough to prevent or lessen sleep apnea, allowing individuals get more restful sleep.

Relief from neck, back, and joint pain. Sleeping in a zero-gravity position can significantly increase your comfort and reduce your pain. The reason for this benefit is that when you’re in the zero-gravity position, your weight is evenly distributed.

This improved distribution of weight takes the pressure of your back, neck, and joints, which is often the main cause of pain. Laying on a flat mattress, on the other hand, does not allow your weight to be evenly distributed. This places unnecessary pressure on the spinal column and can result in a significant pain and discomfort.

Adjustable beds may provide relief from pain caused from sciatica, fibromyalgia, arthritis, scoliosis, and other conditions. Improved circulation. Sleeping in a zero-gravity position allows more blood to flow to the heart.

This increase of blood flow reaching the heart makes its muscles work harder to pump that blood throughout the body. Increased blood circulation can improve the overall health of your heart and other vital organs. Decreased swelling.

Another benefit of improved circulation is decreased swelling. When the body lays flat, blood and other fluids may accumulate the in the lower body since the heart isn’t able to keep blood flowing effectively. This can result in inflammation or swelling.

However, with the increased blood flow that results from sleeping in a zero-gravity position, fluids won’t accumulate in the extremities, and swelling may be reduced. Improved digestion. Digestion can also be improved by sleeping on an adjustable bed frame.

Sleeping flat can make it more difficult for the body to digest food properly. Sleeping flat can also aggravate acid reflux, heartburn, and GERD (gastroesophageal reflux disease. Elevating the head about six inches can reduce these symptoms.

This position removes pressure from the digestive track and makes it more difficult for stomach acids to go up into the throat. Better breathing. When you sleep in the zero-gravity position, the pressure placed on your lungs and airway is reduced.

As a result, your body can breathe more easily and can limit the impact asthma, allergies, and congestion can have on your sleep. Best Adjustable Bed Reviews Whether you’re looking for the best split king adjustable bed reviews or the best adjustable twin, queen, or full bed frames, we have you covered. We have selected some of the top models currently available that will help you stay comfortable while you sleep and will enable you to enjoy the benefits described above.

Read on to discover which adjustable bed frame is right for you. GhostBed Adjustable Base If you’re looking for an adjustable bed frame with luxury features for a budget-friendly price, consider the GhostBed Adjustable Base. This fully-adjustable frame allows you to customize your position for ultimate comfort.

The fully adjustable head and foot sections allow for an unlimited number of options, including a zero-gravity position. This bed frame also offers 15 head and foot massage modes to deliver additional comfort and relaxation. Furthermore, it is equipped with two USB ports on each side to allow for easy charging and convenient access to electronic devices.

Under-bed LED lights are also integrated into the design to provide soft lighting if you wake up in the middle of the night. The included backlit remote makes it easy to adjust the bed to the ideal position for sleeping or relaxing. Use the foot and head up/down buttons to move the frame to the exact position you desire.

The remote can also save your favorite position for sleeping and return you to it with just a press of a button. Additionally, the remote offers preset positions for zero-gravity, watching TV, and lounging. With the remote, you can even control the under-bed lighting and turn on the head or foot massage and adjust their intensity.

The GhostBed Adjustable Base features a sturdy steel frame. It also has a retainer bar and non-skid surface to ensure the mattress stays in place. This adjustable bed frame is available in twin XL, queen, and split king sizes.

Split king adjustable beds offer the added benefit of allowing each partner to customize their own position. All orders include free shipping and a limited lifetime warranty. Puffy Adjustable Base Premium The Adjustable Base Premium from Puffy Sleep is another top contender when you’re looking for the best adjustable bed frame.

The head on this model adjusts up to 60 degrees and the legs adjust up to 45 degrees to help each individual find their most comfortable sleeping position. The adjustable bed frame from Puffy Sleep is available in twin, twin XL, full, queen, king, and split-king sizes. Use the included remote to customize your position whether reading a book in bed, watching TV, or drifting off to dreamland.

The remote also has a memory feature that can save your favorite position. Some of the other remote settings include zero gravity, watching TV, and anti-snore. Puffy Sleep has some of the best split king adjustable beds reviews.

With the split king adjustable frame, you and a partner can each set the bed to the position that is most comfortable for you. This can help ensure that each of you get the restorative sleep that need. For a nominal additional fee, you can upgrade the Puffy Sleep Adjustable Base to include head and food massage features and dual USB ports for charging electronic devices.

This adjustable frame is constructed from coated metal for lasting durability. Each purchase is protected by a 10-year warranty and includes free shipping. Layla Adjustable Base Plus This motorized and fully adjustable base from Layla Sleep also has a lot to offer users.

It is available in twin XL, queen, king, and split king sizes. A wireless remote is included with the frame for easy operation. The remote includes preset buttons for moving the frame to zero-gravity, anti-snore, or flat positions.

You can also set the remote to remember up to three of your preferred positions. A mobile app is available for controlling the bed frame with a smartphone or tablet, and the frame is even compatible with Amazon’s Alexa and the Google Assistant for voice command operations. Layla Sleep incorporated some upgraded features into the design of this frame.

The frame features dual-zone vibrating massage motors at the head and foot of the frame. There are three massage intensities to choose from, as well as an auto-shutoff timer to stop the vibrations at a set time. Each side of the frame features two ports to keep your devices charged and within easy reach.

Some of the other notable features of this adjustable bed frame include the under-bed lighting and wall-hugging technology that keeps the head of the bed at the same distance from the wall regardless of the incline angle. Layla Sleep backs this bed frame with a 10-year warranty. They also offer free-shipping and a 30-night money-back guarantee.

Sweet Night Tranquil Adjustable Bed Frame Last, but certainly not least, we also think you’ll love the Tranquil Adjustable Bed Frame from Sweet Night. Available in twin XL, full, queen, and split California king sizes, this bed frame delivers the ability to tailor your position for enhanced comfort. Adjust the head incline between 0 and 60 degrees and the foot incline between 0 and 40 degrees for a nearly endless number of positioning options.

The Tranquil Adjustable Bed Frame from Sweet Night can be controlled using the included wireless remote or with an app on your smartphone or tablet. Use the remote or app to adjust the head and foot inclines or to select one of the preset positions including anti-snore, zero gravity, watching TV, or lying down flat. In addition to allowing you to adjust your position, this bed frame includes some other helpful and impressive features.

Each side of the frame offers dual USB ports for charging your phone, tablet, or other devices. There is also a pocket on each side to hold a smartphone and keep it within easy reach. Remote-controlled LED under-bed lights, provide low lighting if needed at night or in the morning.

The frame is made using a sturdy aluminum alloy that can support up to 705 pounds. All orders include free shipping and free returns. Adjustable Bed Frame Buying Guide If you’re interested in taking advantage of all the benefits associated with using an adjustable bed frame, it is imperative to note that each model is slightly different.

There are a number of important considerations to keep in mind as you shop for an adjustable bed frame. Read through our buying guide below to learn more about these considerations and choose the best adjustable bed frame to match your needs. Mattress Compatibility If you’re planning to use your existing mattress, the first thing you should do is to confirm compatibility.

Most adjustable bed frames are designed to be compatible with different mattress brands, but some manufacturers recommend only using their mattresses on their proprietary frames. Keep in mind that most innerspring mattresses are too inflexible to work well with an adjustable frame. Hybrid, foam, or latex mattresses are more flexible and will work best.

Size After determining if your current mattress is compatible with the bed frame or if you need to purchase a new mattress with your new bed frame, then you will need to evaluate if each model is available in your desired sire. Obviously, the bed frame must match the size of the mattress you are planning to use on it, so you won’t want to waste your time looking at a model that isn’t even available in your preferred size. Settings and Operation Before making a purchase, look at the range of motion of each bed frame.

Some adjustable bed frames offer more adjustability than others. This flexibility, or lack of it, could certainly make one model more appealing than another. The head can often be elevated between 60 and 80 degrees, while the range of motion for the lower portion of the mattress is typically between 30 and 40 degrees.

If there is a specific angle you’d prefer, then confirm it is possible with each bed frame you’re considering. Next, look at how easy it will be to adjust the bed frame. Does it include a remote control?.

Are there any preset positions or memory features?. Can you download an app to control the bed frame using a smart device?. Additional Features Some manufacturers include additional features to make their adjustable bed frames more user-friendly.

These features may include heat and massage functions, under-bed lighting, USB charging ports, and built-in speakers. If any of these features are important to you, look for a manufacturer that integrates them into their design of their adjustable bed frame. Frequently Asked Questions Can you use a regular mattress on an adjustable bed frame?.

Yes, most regular mattresses can be used on an adjustable bed frame. Many frames are compatible with latex, foam, and hybrid mattresses. Unfortunately, most innerspring mattresses are too rigid to move with an adjustable frame.

What is a split king adjustable bed?. Split king adjustable beds allow the right and left sides to adjust independently of one another. This means that each partner can elevate their head and feet to their exact comfort level without needing to make compromises with their partner.

Are adjustable beds worth the additional cost?. This is a personal question that will come down to your priorities and financial situation. Many people find that adjustable beds are worth the additional cost due to how much better they sleep and all the other health benefits they offer, such as reduced back and neck pain, better circulation, decreased swelling, and improved digestion.

Split king adjustable beds can be particularly beneficial for partners who prefer different sleeping positions or who are facing different health issues. With a split king adjustable bed, each partner can independently adjust their own side of the bed. How can you get into a zero-gravity position with an adjustable bed?.

You need to elevate your legs and feet to a higher level than your head and your heart to achieve a zero-gravity position. This position alleviates pressure placed on your joints to relieve back pain and is also beneficial for improving the body’s circulation. How do you keep sheets on an adjustable bed?.

When shopping for sheets for an adjustable bed, the first thing to do is to check the depth of the mattress and confirm that the pocket-depth of the fitted sheet is sufficient for a proper fit. Choosing a sheet that is not deep enough for your mattress will almost certainly cause the corners to slip off as the bed adjusts. When making the bed, tuck the edges of the flat sheet under the mattress.

You can also find some flat sheets that include corner straps. These corner straps grip on to the fitted sheet and will help ensure that the flat sheet stays in place. If these ideas still don’t work, sheet suspenders are another option.

A sheet suspender is a large band designed to ensure a flat sheet doesn’t slip off a mattress.This article appeared in the September/October 2021 issue of Discover magazine as "Heart Ache." Become a subscriber for unlimited access to the archive.Chloe looked miserable. She was curled up on the hospital bed, sweaty and shaking, wracked with waves of nausea, her heart racing. I gave her a cool washcloth and a basin as the nurse started her IV.

I had cared for her before. Though only 16, she’d been in the hospital a dozen times already.“I think it may be another heart valve ,” I told her. She nodded, familiar with the diagnosis, and the treatment that followed.

She was at particular risk for a type of called endocarditis, where bacteria invade and infect the valves of the heart.Chloe was born with an aortic valve that had only two parts, instead of its normal three, and was unusually small and stiff. As she grew older, her valve became thicker and less pliable. Unable to open properly, her heart had to work too hard to pump out blood.

When she was 14 years old, surgeons cut through her breastbone to her heart, delicately repairing the abnormal aortic valve. Though her valve was now working normally and heart pumping well, she was still dealing with the procedure’s unwelcome consequences.As before, we followed the same routine — strong antibiotics to kill the bacteria in her heart and bloodstream, fluids and medications to quell her nausea and dehydration. She settled into her hospital room with magazines and movies, expecting a long stay.The Night ShiftTwo days later, I stopped to check on Chloe at the beginning of my night shift.

Her thin frame was tangled in the sheets, shaking and agitated, unable to find a comfortable position. Her nurse told me Chloe seemed no better — and perhaps worse — than when she’d arrived. The usual medicines did not seem to relieve her nausea, and she had started having diarrhea.I wondered if something more was going on.

Could it be a more aggressive or resistant bacteria causing her endocarditis, or an entirely new intestinal caused by her antibiotics?. But blood tests showed the same common bacteria that had caused her previous heart s, and which her antibiotic should kill. Stool tests sent that day showed no dangerous bacteria.

Perhaps she just needed more time to improve on her current treatment.As I sat by her bedside, I noticed a few other odd symptoms. Her pupils were as wide as saucers, her nose was running, and her skin was damp with sweat and covered with goosebumps. This constellation of findings pointed in a surprising direction that I had seen before in my adult medicine rotations as a student — opiate withdrawal.I looked in Chloe’s chart, reviewing the medications she took routinely at home and those we had given her in the hospital.

While she had needed opiate pain medicines such as morphine, hydrocodone and fentanyl in the past, we had not given her any this time, nor did she have any recent prescriptions for them.Returning to her bedside with another cool washcloth, I approached Chloe gently. I asked her to be honest with me, explaining that I truly needed to know everything that was going on so I could help her out of this misery.Tearfully, she began to whisper about her struggle with opiates, which had started shortly after her surgery. Despite trying, she had been unable to wean off the pain medications, finding herself dependent on the high they provided.

She started buying oxycodone pills from a schoolmate at first, but when this got too expensive, she turned to a cheaper and riskier alternative. Heroin. At first, she snorted or smoked it, but in the last several months had turned to injecting it.

I realized this was likely what caused her endocarditis. The unclean needles introduced bacteria into the bloodstream, where they could nestle into her healing heart valve. Her days in the hospital restricted her access to opiates, sending her plummeting into withdrawal.(Credit.

Kellie Jaeger/Discover)While not fatal, opiate withdrawal feels awful. Taking opiates generally slows things down, making you sleepy, constipated and slowing your heart and breathing rates. But withdrawing from them speeds things up, making you more agitated, with a faster heart rate and overactive bowels.

For chronic opiate users, the first few hours without the drug are marked by cravings, anxiety and restlessness. Within a day, the body is wracked with tremors, insomnia, runny nose, profuse sweating, belly cramping, vomiting and diarrhea.Now we knew we didn’t just have to treat Chloe’s endocarditis, but address her opiate dependence, as well.An Ongoing EpidemicChloe was not alone. Teens in the United States are using opiates at concerning levels.

Between 2001 and 2014, opiate-use disorders among youth aged 13 to 25 soared nearly sixfold. Although their use has since started to decline, hundreds of thousands of adolescents still misused pain relievers each year between 2015 and 2019, according to a national survey from the U.S. Substance Abuse and Mental Health Services Administration.About a third of people over age 12 get their drugs from healthcare providers, at least initially.

Opiates such as morphine and fentanyl can be immensely helpful for the acute, severe pain caused by surgeries like Chloe’s heart valve repair. These medications take advantage of our body’s natural pain response system. Under stress, our body can create its own pain management hormones, commonly called endorphins, sending chemical messengers that connect with opiate receptors in organs all across the body.

The opiates we take as medications bind to these same receptors, mimicking endorphins. When bound to receptors in the brain and nerves, opiates quell pain signals, calm stress responses by dampening our “fight or flight” hormones and stimulate our brain’s reward and pleasure centers. These intoxicating effects on the brain are what give chronic opiate use the particular potential to develop into full-blown addiction.

Outside the nervous system, opiates can slow down the intestines, disrupt deep sleep and blunt the body’s immune response. They can also cause the lungs to breathe slowly and irregularly, which is often the cause of death from overdose.Studies show that 5 to 7 percent of adolescents and young adults prescribed an opioid will go on to develop an opioid-use disorder. Accordingly, all who care for teens must be wary of their potential to spark dependence.

They can even lead to a more dangerous road — now, more teens are transitioning from prescription opioids to heroin, which is often less expensive and easier to acquire.While adults are increasingly receiving care for opioid use disorders, for adolescents, the rate of treatment is actually declining, particularly among youth of color. It’s often harder for teens to get successful treatment because many care facilities are uncomfortable with or inexperienced in treating them. Those that do accept teens may find it difficult to keep them in treatment.

And many providers who care for adolescents are uncomfortable or unfamiliar with the use of effective medications such as naexone or buprenorphine.Thankfully, Chloe was open to treatment and had access to care from our hospital’s adolescent addiction team. She was given methadone during her hospitalization, which quickly quenched her withdrawal. Within weeks, her endocarditis was cured, and she left the hospital with a plan for tackling for her opioid-use disorder.

She started taking methadone daily to address her body’s cravings for opiates. To deal with the psychological effects of her dependence, she began attending weekly counseling and group therapy sessions. Tired of spending time in the hospital, Chloe was driven to put her surgery — and all its complications — behind her..

Best over the counter lasix

Specificity of best over the counter lasix hypertension Antibody Assays Both assays measuring pan-Ig antibodies had low numbers of false positives among samples collected in 2017. There were 0 and 1 false positives for the two assays among 472 samples, results that compared favorably with those obtained with the single IgM anti-N and IgG anti-N assays best over the counter lasix (Table S3). Because of the low prevalence of hypertension in Iceland, we required positive results from both pan-Ig antibody assays for a sample to be considered seropositive (see Supplementary Methods in Supplementary Appendix 1). None of the samples collected in early 2020 group were best over the counter lasix seropositive, which indicates that the lasix had not spread widely in Iceland before February 2020.

hypertension Antibodies among qPCR-Positive Persons Figure 2. Figure 2 best over the counter lasix. Antibody Prevalence and Titers among qPCR-Positive Cases as a Function of Time since Diagnosis by qPCR. Shown are the percentages of samples positive for both pan-Ig antibody assays and the antibody best over the counter lasix titers.

Red denotes the count or percentage of samples among persons during their hospitalization (249 samples from 48 persons), and blue denotes the count or percentage of samples among persons after they were declared recovered (1853 samples from 1215 persons). Vertical bars denote 95% best over the counter lasix confidence intervals. The dashed lines indicated the thresholds for a test to be declared positive. OD denotes optical density, best over the counter lasix and RBD receptor binding domain.Table 1.

Table 1. Prevalence of best over the counter lasix hypertension Antibodies by Sample Collection as Measured by Two Pan-Ig Antibody Assays. Twenty-five days after diagnosis by qPCR, best over the counter lasix more than 90% of samples from recovered persons tested positive with both pan-Ig antibody assays, and the percentage of persons testing positive remained stable thereafter (Figure 2 and Fig. S2).

Hospitalized persons seroconverted more frequently and quickly after qPCR diagnosis than did nonhospitalized persons (Figure best over the counter lasix 2 and Fig. S3). Of 1215 best over the counter lasix persons who had recovered (on the basis of results for the most recently obtained sample from persons for whom we had multiple samples), 1107 were seropositive (91.1%. 95% confidence interval [CI], 89.4 to 92.6) (Table 1 and Table S4).

Since some diagnoses may have been made on the basis of false positive qPCR results, we determined best over the counter lasix that 91.1% represents the lower bound of sensitivity of the combined pan-Ig tests for the detection of hypertension antibodies among recovered persons. Table 2. Table 2 best over the counter lasix. Results of Repeated Pan-Ig Antibody Tests among Recovered qPCR-Diagnosed Persons.

Among the 487 recovered persons with two or more samples, 19 (4%) had different pan-Ig antibody test results at different time points (Table 2 and Fig best over the counter lasix. S4). It is notable that of the 22 persons with an early sample that tested negative for both pan-Ig antibodies, 19 remained negative at the best over the counter lasix most recent test date (again, for both antibodies). One person tested positive for both pan-Ig antibodies in the first test and negative for both in the most recent test.

The longitudinal changes in antibody levels among recovered persons were consistent with best over the counter lasix the cross-sectional results (Fig. S5). Antibody levels were higher in the last sample than in the first sample when the antibodies were measured with the two pan-Ig assays, slightly lower than in the first sample when measured with IgG anti-N and IgG anti-S1 assays, and substantially lower than in the first sample when measured with IgM anti-N and IgA anti-S1 assays. IgG anti-N, IgM anti-N, IgG anti-S1, and IgA anti-S1 antibody levels were correlated among the qPCR-positive persons (Figs.

S5 and S6 and Table S5). Antibody levels measured with both pan-Ig antibody assays increased over the first 2 months after qPCR diagnosis and remained at a plateau over the next 2 months of the study. IgM anti-N antibody levels increased rapidly soon after diagnosis and then fell rapidly and were generally not detected after 2 months. IgA anti-S1 antibodies decreased 1 month after diagnosis and remained detectable thereafter.

IgG anti-N and anti-S1 antibody levels increased during the first 6 weeks after diagnosis and then decreased slightly. hypertension in Quarantine Table 3. Table 3. hypertension among Quarantined Persons According to Exposure Type and Presence of Symptoms.

Of the 1797 qPCR-positive Icelanders, 1088 (61%) were in quarantine when hypertension was diagnosed by qPCR. We tested for antibodies among 4222 quarantined persons who had not tested qPCR-positive (they had received a negative result by qPCR or had simply not been tested). Of those 4222 quarantined persons, 97 (2.3%. 95% CI, 1.9 to 2.8) were seropositive (Table 1).

Those with household exposure were 5.2 (95% CI, 3.3 to 8.0) times more likely to be seropositive than those with other types of exposure (Table 3). Similarly, a positive result by qPCR for those with household exposure was 5.2 (95% CI, 4.5 to 6.1) times more likely than for those with other types of exposure. When these two sets of results (qPCR-positive and seropositive) were combined, we calculated that 26.6% of quarantined persons with household exposure and 5.0% of quarantined persons without household exposure were infected. Those who had symptoms during quarantine were 3.2 (95% CI, 1.7 to 6.2) times more likely to be seropositive and 18.2 times (95% CI, 14.8 to 22.4) more likely to test positive with qPCR than those without symptoms.

We also tested persons in two regions of Iceland affected by cluster outbreaks. In a hypertension cluster in Vestfirdir, 1.4% of residents were qPCR-positive and 10% of residents were quarantined. We found that none of the 326 persons outside quarantine who had not been tested by qPCR (or who tested negative) were seropositive. In a cluster in Vestmannaeyjar, 2.3% of residents were qPCR-positive and 13% of residents were quarantined.

Of the 447 quarantined persons who had not received a qPCR-positive result, 4 were seropositive (0.9%. 95% CI, 0.3 to 2.1). Of the 663 outside quarantine in Vestmannaeyjar, 3 were seropositive (0.5%. 95% CI, 0.1 to 0.2%).

hypertension Seroprevalence in Iceland None of the serum samples collected from 470 healthy Icelanders between February 18 and March 9, 2020, tested positive for both pan-Ig antibodies, although four were positive for the pan-Ig anti-N assay (0.9%), a finding that suggests that the lasix had not spread widely in Iceland before March 9. Of the 18,609 persons tested for hypertension antibodies through contact with the Icelandic health care system for reasons other than hypertension medications, 39 were positive for both pan-Ig antibody assays (estimated seroprevalence by weighting the sample on the basis of residence, sex, and 10-year age category, 0.3%. 95% CI, 0.2 to 0.4). There were regional differences in the percentages of qPCR-positive persons across Iceland that were roughly proportional to the percentage of people quarantined (Table S6).

However, after exclusion of the qPCR-positive and quarantined persons, the percentage of persons who tested positive for hypertension antibodies did not correlate with the percentage of those who tested positive by qPCR. The estimated seroprevalence in the random sample collection from Reykjavik (0.4%. 95% CI, 0.3 to 0.6) was similar to that in the Health Care group (0.3%. 95% CI, 0.2 to 0.4) (Table S6).

We calculate that 0.5% of the residents of Iceland have tested positive with qPCR. The 2.3% with hypertension seroconversion among persons in quarantine extrapolates to 0.1% of Icelandic residents. On the basis of this finding and the seroprevalence from the Health Care group, we estimate that 0.9% (95% CI, 0.8 to 0.9) of the population of Iceland has been infected by hypertension. Approximately 56% of all hypertension s were therefore diagnosed by qPCR, 14% occurred in quarantine without having been diagnosed with qPCR, and the remaining 30% of s occurred outside quarantine and were not detected by qPCR.

Deaths from hypertension medications in Iceland In Iceland, 10 deaths have been attributed to hypertension medications, which corresponds to 3 deaths per 100,000 nationwide. Among the qPCR-positive cases, 0.6% (95% CI, 0.3 to 1.0) were fatal. Using the 0.9% prevalence of hypertension in Iceland as the denominator, however, we calculate an fatality risk of 0.3% (95% CI, 0.2 to 0.6). Stratified by age, the fatality risk was substantially lower in those 70 years old or younger (0.1%.

95% CI, 0.0 to 0.3) than in those over 70 years of age (4.4%. 95% CI, 1.9 to 8.4) (Table S7). Age, Sex, Clinical Characteristics, and Antibody Levels Table 4. Table 4.

Association of Existing Conditions and hypertension medications Severity with hypertension Antibody Levels among Recovered Persons. hypertension antibody levels were higher in older people and in those who were hospitalized (Table 4, and Table S8 [described in Supplementary Appendix 1 and available in Supplementary Appendix 2]). Pan-Ig anti–S1-RBD and IgA anti-S1 levels were lower in female persons. Of the preexisting conditions, and after adjustment for multiple testing, we found that body-mass index, smoking status, and use of antiinflammatory medication were associated with hypertension antibody levels.

Body-mass index correlated positively with antibody levels. Smokers and users of antiinflammatory medication had lower antibody levels. With respect to clinical characteristics, antibody levels were most strongly associated with hospitalization and clinical severity, followed by clinical symptoms such as fever, maximum temperature reading, cough, and loss of appetite. Severity of these individual symptoms, with the exception of loss of energy, was associated with higher antibody levels.To the Editor.

Rapid and accurate diagnostic tests are essential for controlling the ongoing hypertension medications lasix. Although the current standard involves testing of nasopharyngeal swab specimens by quantitative reverse-transcriptase polymerase chain reaction (RT-qPCR) to detect hypertension, saliva specimens may be an alternative diagnostic sample.1-4 Rigorous evaluation is needed to determine how saliva specimens compare with nasopharyngeal swab specimens with respect to sensitivity in detection of hypertension during the course of . A total of 70 inpatients with hypertension medications provided written informed consent to participate in our study (see the Methods section in Supplementary Appendix 1, available with the full text of this letter at NEJM.org). After hypertension medications was confirmed with a positive nasopharyngeal swab specimen at hospital admission, we obtained additional samples from the patients during hospitalization.

We tested saliva specimens collected by the patients themselves and nasopharyngeal swabs collected from the patients at the same time point by health care workers. Figure 1. Figure 1. hypertension RNA Titers in Saliva Specimens and Nasopharyngeal Swab Specimens.

Samples were obtained from 70 hospital inpatients who had a diagnosis of hypertension medications. Panel A shows hypertension RNA titers in the first available nasopharyngeal and saliva samples. The lines indicate samples from the same patient. Results were compared with the use of a Wilcoxon signed-rank test (P<0.001).

Panel B shows percentages of positivity for hypertension in tests of the first matched nasopharyngeal and saliva samples at 1 to 5 days, 6 to 10 days, and 11 or more days (maximum, 53 days) after the diagnosis of hypertension medications. Panel C shows longitudinal hypertension RNA copies per milliliter in 97 saliva samples, according to days since symptom onset. Each circle represents a separate sample. Dashed lines indicate additional samples from the same patient.

The red line indicates a negative saliva sample that was followed by a positive sample at the next collection of a specimen. Panel D shows longitudinal hypertension RNA copies per milliliter in 97 nasopharyngeal swab specimens, according to days since symptom onset. The red lines indicate negative nasopharyngeal swab specimens there were followed by a positive swab at the next collection of a specimen. The gray area in Panels C and D indicates samples that were below the lower limit of detection of 5610 lasix RNA copies per milliliter of sample, which is at cycle threshold 38 of our quantitative reverse-transcriptase polymerase chain reaction assay targeting the hypertension N1 sequence recommended by the Centers for Disease Control and Prevention.

To analyze these data, we used a linear mixed-effects regression model (see Supplementary Appendix 1) that accounts for the correlation between samples collected from the same person at a single time point (i.e., multivariate response) and the correlation between samples collected across time from the same patient (i.e., repeated measures). All the data used to generate this figure, including the raw cycle thresholds, are provided in Supplementary Data 1 in Supplementary Appendix 2.Using primer sequences from the Centers for Disease Control and Prevention, we detected more hypertension RNA copies in the saliva specimens (mean log copies per milliliter, 5.58. 95% confidence interval [CI], 5.09 to 6.07) than in the nasopharyngeal swab specimens (mean log copies per milliliter, 4.93. 95% CI, 4.53 to 5.33) (Figure 1A, and Fig.

S1 in Supplementary Appendix 1). In addition, a higher percentage of saliva samples than nasopharyngeal swab samples were positive up to 10 days after the hypertension medications diagnosis (Figure 1B). At 1 to 5 days after diagnosis, 81% (95% CI, 71 to 96) of the saliva samples were positive, as compared with 71% (95% CI, 67 to 94) of the nasopharyngeal swab specimens. These findings suggest that saliva specimens and nasopharyngeal swab specimens have at least similar sensitivity in the detection of hypertension during the course of hospitalization.

Because the results of testing of nasopharyngeal swab specimens to detect hypertension may vary with repeated sampling in individual patients,5 we evaluated viral detection in matched samples over time. The level of hypertension RNA decreased after symptom onset in both saliva specimens (estimated slope, −0.11. 95% credible interval, −0.15 to −0.06) (Figure 1C) and nasopharyngeal swab specimens (estimated slope, −0.09. 95% credible interval, −0.13 to −0.05) (Figure 1D).

In three instances, a negative nasopharyngeal swab specimen was followed by a positive swab at the next collection of a specimen (Figure 1D). This phenomenon occurred only once with the saliva specimens (Figure 1C). During the clinical course, we observed less variation in levels of hypertension RNA in the saliva specimens (standard deviation, 0.98 lasix RNA copies per milliliter. 95% credible interval, 0.08 to 1.98) than in the nasopharyngeal swab specimens (standard deviation, 2.01 lasix RNA copies per milliliter.

95% credible interval, 1.29 to 2.70) (see Supplementary Appendix 1). Recent studies have shown that hypertension can be detected in the saliva of asymptomatic persons and outpatients.1-3 We therefore screened 495 asymptomatic health care workers who provided written informed consent to participate in our prospective study, and we used RT-qPCR to test both saliva and nasopharyngeal samples obtained from these persons. We detected hypertension RNA in saliva specimens obtained from 13 persons who did not report any symptoms at or before the time of sample collection. Of these 13 health care workers, 9 had collected matched nasopharyngeal swab specimens by themselves on the same day, and 7 of these specimens tested negative (Fig.

S2). The diagnosis in the 13 health care workers with positive saliva specimens was later confirmed in diagnostic testing of additional nasopharyngeal samples by a CLIA (Clinical Laboratory Improvement Amendments of 1988)–certified laboratory. Variation in nasopharyngeal sampling may be an explanation for false negative results, so monitoring an internal control for proper sample collection may provide an alternative evaluation technique. In specimens collected from inpatients by health care workers, we found greater variation in human RNase P cycle threshold (Ct) values in nasopharyngeal swab specimens (standard deviation, 2.89 Ct.

95% CI, 26.53 to 27.69) than in saliva specimens (standard deviation, 2.49 Ct. 95% CI, 23.35 to 24.35). When health care workers collected their own specimens, we also found greater variation in RNase P Ct values in nasopharyngeal swab specimens (standard deviation, 2.26 Ct. 95% CI, 28.39 to 28.56) than in saliva specimens (standard deviation , 1.65 Ct.

95% CI, 24.14 to 24.26) (Fig. S3). Collection of saliva samples by patients themselves negates the need for direct interaction between health care workers and patients. This interaction is a source of major testing bottlenecks and presents a risk of nosocomial .

Collection of saliva samples by patients themselves also alleviates demands for supplies of swabs and personal protective equipment. Given the growing need for testing, our findings provide support for the potential of saliva specimens in the diagnosis of hypertension . Anne L. Wyllie, Ph.D.Yale School of Public Health, New Haven, CT [email protected]John Fournier, M.D.Yale School of Medicine, New Haven, CTArnau Casanovas-Massana, Ph.D.Yale School of Public Health, New Haven, CTMelissa Campbell, M.D.Maria Tokuyama, Ph.D.Pavithra Vijayakumar, B.A.Yale School of Medicine, New Haven, CTJoshua L.

Warren, Ph.D.Yale School of Public Health, New Haven, CTBertie Geng, M.D.Yale School of Medicine, New Haven, CTM. Catherine Muenker, M.S.Adam J. Moore, M.P.H.Chantal B.F. Vogels, Ph.D.Mary E.

Petrone, B.S.Isabel M. Ott, B.S.Yale School of Public Health, New Haven, CTPeiwen Lu, Ph.D.Arvind Venkataraman, B.S.Alice Lu-Culligan, B.S.Jonathan Klein, B.S.Yale School of Medicine, New Haven, CTRebecca Earnest, M.P.H.Yale School of Public Health, New Haven, CTMichael Simonov, M.D.Rupak Datta, M.D., Ph.D.Ryan Handoko, M.D.Nida Naushad, B.S.Lorenzo R. Sewanan, M.Phil.Jordan Valdez, B.S.Yale School of Medicine, New Haven, CTElizabeth B. White, A.B.Sarah Lapidus, M.S.Chaney C.

Kalinich, M.P.H.Yale School of Public Health, New Haven, CTXiaodong Jiang, M.D., Ph.D.Daniel J. Kim, A.B.Eriko Kudo, Ph.D.Melissa Linehan, M.S.Tianyang Mao, B.S.Miyu Moriyama, Ph.D.Ji E. Oh, M.D., Ph.D.Annsea Park, B.A.Julio Silva, B.S.Eric Song, M.S.Takehiro Takahashi, M.D., Ph.D.Manabu Taura, Ph.D.Orr-El Weizman, B.A.Patrick Wong, M.S.Yexin Yang, B.S.Santos Bermejo, B.S.Yale School of Medicine, New Haven, CTCamila D. Odio, M.D.Yale New Haven Health, New Haven, CTSaad B.

Omer, M.B., B.S., Ph.D.Yale Institute for Global Health, New Haven, CTCharles S. Dela Cruz, M.D., Ph.D.Shelli Farhadian, M.D., Ph.D.Richard A. Martinello, M.D.Akiko Iwasaki, Ph.D.Yale School of Medicine, New Haven, CTNathan D. Grubaugh, Ph.D.Albert I.

Ko, M.D.Yale School of Public Health, New Haven, CT [email protected], [email protected] Supported by the Huffman Family Donor Advised Fund, a Fast Grant from Emergent Ventures at the Mercatus Center at George Mason University, the Yale Institute for Global Health, the Yale School of Medicine, a grant (U19 AI08992, to Dr. Ko) from the National Institute of Allergy and Infectious Diseases, the Beatrice Kleinberg Neuwirth Fund, and a grant (Rubicon 019.181EN.004, to Dr. Vogel) from the Dutch Research Council (NWO). Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

This letter was published on August 28, 2020, at NEJM.org. Drs. Grubaugh and Ko contributed equally to this letter. 5 References1.

Kojima N, Turner F, Slepnev V, et al. Self-collected oral fluid and nasal swabs demonstrate comparable sensitivity to clinician collected nasopharyngeal swabs for hypertension medications detection. April 15, 2020 (https://www.medrxiv.org/content/10.1101/2020.04.11.20062372v1). Preprint.Google Scholar2.

Williams E, Bond K, Zhang B, Putland M, Williamson DA. Saliva as a non-invasive specimen for detection of hypertension. J Clin Microbiol 2020;58(8):e00776-20-e00776-20.3. Pasomsub E, Watcharananan SP, Boonyawat K, et al.

Saliva sample as a non-invasive specimen for the diagnosis of hypertension disease 2019. A cross-sectional study. Clin Microbiol Infect 2020 May 15 (Epub ahead of print).4. Vogels CBF, Brackney D, Wang J, et al.

SalivaDirect. Simple and sensitive molecular diagnostic test for hypertension surveillance. August 4, 2020 (https://www.medrxiv.org/content/10.1101/2020.08.03.20167791v1). Preprint.Google Scholar5.

Zou L, Ruan F, Huang M, et al. hypertension viral load in upper respiratory specimens of infected patients. N Engl J Med 2020;382:1177-1179.Trial Population Table 1. Table 1.

Demographic Characteristics of the Participants in the NVX-CoV2373 Trial at Enrollment. The trial was initiated on May 26, 2020. 134 participants underwent randomization between May 27 and June 6, 2020, including 3 participants who were to serve as backups for sentinel dosing and who immediately withdrew from the trial without being vaccinated (Fig. S1).

Of the 131 participants who received injections, 23 received placebo (group A), 25 received 25-μg doses of rhypertension (group B), 29 received 5-μg doses of rhypertension plus Matrix-M1, including three sentinels (group C), 28 received 25-μg doses of rhypertension plus Matrix-M1, including three sentinels (group D), and 26 received a single 25-μg dose of rhypertension plus Matrix-M1 followed by a single dose of placebo (group E). All 131 participants received their first vaccination on day 0, and all but 3 received their second vaccination at least 21 days later. Exceptions include 2 in the placebo group (group A) who withdrew consent (unrelated to any adverse event) and 1 in the 25-μg rhypertension + Matrix-M1 group (group D) who had an unsolicited adverse event (mild cellulitis. See below).

Demographic characteristics of the participants are presented in Table 1. Of note, missing data were infrequent. Safety Outcomes No serious adverse events or adverse events of special interest were reported, and vaccination pause rules were not implemented. As noted above, one participant did not receive a second vaccination owing to an unsolicited adverse event, mild cellulitis, that was associated with after an intravenous cannula placement to address an unrelated mild adverse event that occurred during the second week of follow-up.

Second vaccination was withheld because the participant was still recovering and receiving antibiotics. This participant remains in the trial. Figure 2. Figure 2.

Solicited Local and Systemic Adverse Events. The percentage of participants in each treatment group (groups A, B, C, D, and E) with adverse events according to the maximum FDA toxicity grade (mild, moderate, or severe) during the 7 days after each vaccination is plotted for solicited local (Panel A) and systemic (Panel B) adverse events. There were no grade 4 (life-threatening) events. Participants who reported 0 events make up the remainder of the 100% calculation (not displayed).

Excluded were the three sentinel participants in groups C (5 μg + Matrix-M1, 5 μg + Matrix-M1) and D (25 μg + Matrix-M1, 25 μg + Matrix-M1), who received the trial treatment in an open-label manner (see Table S7 for complete safety data on all participants).Overall reactogenicity was largely absent or mild, and second vaccinations were neither withheld nor delayed due to reactogenicity. After the first vaccination, local and systemic reactogenicity was absent or mild in the majority of participants (local. 100%, 96%, 89%, 84%, and 88% of participants in groups A, B, C, D, and E, respectively. Systemic.

91%, 92%, 96%, 68%, and 89%) who were unaware of treatment assignment (Figure 2 and Table S7). Two participants (2%), one each in groups D and E, had severe adverse events (headache, fatigue, and malaise). Two participants, one each in groups A and E, had reactogenicity events (fatigue, malaise, and tenderness) that extended 2 days after day 7. After the second vaccination, local and systemic reactogenicity were absent or mild in the majority of participants in the five groups (local.

100%, 100%, 65%, 67%, and 100% of participants, respectively. Systemic. 86%, 84%, 73%, 58%, and 96%) who were unaware of treatment assignment. One participant, in group D, had a severe local event (tenderness), and eight participants, one or two participants in each group, had severe systemic events.

The most common severe systemic events were joint pain and fatigue. Only one participant, in group D, had fever (temperature, 38.1°C) after the second vaccination, on day 1 only. No adverse event extended beyond 7 days after the second vaccination. Of note, the mean duration of reactogenicity events was 2 days or less for both the first vaccination and second vaccination periods.

Laboratory abnormalities of grade 2 or higher occurred in 13 participants (10%). 9 after the first vaccination and 4 after the second vaccination (Table S8). Abnormal laboratory values were not associated with any clinical manifestations and showed no worsening with repeat vaccination. Six participants (5%.

Five women and one man) had grade 2 or higher transient reductions in hemoglobin from baseline, with no evidence of hemolysis or microcytic anemia and with resolution within 7 to 21 days. Of the six, two had an absolute hemoglobin value (grade 2) that resolved or stabilized during the testing period. Four participants (3%), including one who had received placebo, had elevated liver enzymes that were noted after the first vaccination and resolved within 7 to 14 days (i.e., before the second vaccination). Vital signs remained stable immediately after vaccination and at all visits.

Unsolicited adverse events (Table S9) were predominantly mild in severity (in 71%, 91%, 83%, 90%, and 82% of participants in groups A, B, C, D, and E, respectively) and were similarly distributed across the groups receiving adjuvanted and unadjuvanted treatment. There were no reports of severe adverse events. Immunogenicity Outcomes Figure 3. Figure 3.

hypertension Anti-Spike IgG and Neutralizing Antibody Responses. Shown are geometric mean anti-spike IgG enzyme-linked immunosorbent assay (ELISA) unit responses to recombinant severe acute respiratory syndrome hypertension 2 (rhypertension) protein antigens (Panel A) and wild-type hypertension microneutralization assay at an inhibitory concentration greater than 99% (MN IC>99%) titer responses (Panel B) at baseline (day 0), 3 weeks after the first vaccination (day 21), and 2 weeks after the second vaccination (day 35) for the placebo group (group A), the 25-μg unadjuvanted group (group B), the 5-μg and 25-μg adjuvanted groups (groups C and D, respectively), and the 25-μg adjuvanted and placebo group (group E). Diamonds and whisker endpoints represent geometric mean titer values and 95% confidence intervals, respectively. The hypertension medications human convalescent serum panel includes specimens from PCR-confirmed hypertension medications participants, obtained from Baylor College of Medicine (29 specimens for ELISA and 32 specimens for MN IC>99%), with geometric mean titer values according to hypertension medications severity.

The severity of hypertension medications is indicated by the colors of the dots for hospitalized patients (including those in intensive care), symptomatic outpatients (with samples collected in the emergency department), and asymptomatic patients who had been exposed to hypertension medications (with samples collected during contact and exposure assessment). Mean values (in black) for human convalescent serum are depicted next to (and of same color as) the category of hypertension medications patients, with the overall mean shown above the scatter plot (in black). For each trial treatment group, the mean at day 35 is depicted above the scatterplot.ELISA anti-spike IgG geometric mean ELISA units (GMEUs) ranged from 105 to 116 at day 0. By day 21, responses had occurred for all adjuvanted regimens (1984, 2626, and 3317 GMEUs for groups C, D, and E, respectively), and geometric mean fold rises (GMFRs) exceeded those induced without adjuvant by a factor of at least 10 (Figure 3 and Table S10).

Within 7 days after the second vaccination with adjuvant (day 28. Groups C and D), GMEUs had further increased by a factor of 8 (to 15,319 and 20,429, respectively) over responses seen with the first vaccination, and within 14 days (day 35), responses had more than doubled yet again (to 63,160 and 47,521, respectively), achieving GMFRs that were approximately 100 times greater than those observed with rhypertension alone. A single vaccination with adjuvant achieved GMEU levels similar to those in asymptomatic (exposed) patients with hypertension medications (1661), and a second vaccination with adjuvant achieved GMEU levels that exceeded those in convalescent serum from symptomatic outpatients with hypertension medications (7420) by a factor of at least 6 and rose to levels similar to those in convalescent serum from patients hospitalized with hypertension medications (53,391). The responses in the two-dose 5-μg and 25-μg adjuvanted treatment regimens were similar, a finding that highlights the role of adjuvant dose sparing.

Neutralizing antibodies were undetectable before vaccination and had patterns of response similar to those of anti-spike antibodies after vaccination with adjuvant (Figure 3 and Table S11). After the first vaccination (day 21), GMFRs were approximately 5 times greater with adjuvant (5.2, 6.3, and 5.9 for groups C, D, and E, respectively) than without adjuvant (1.1). By day 35, second vaccinations with adjuvant induced an increase more than 100 times greater (195 and 165 for groups C and D, respectively) than single vaccinations without adjuvant. When compared with convalescent serum, second vaccinations with adjuvant resulted in GMT levels approximately 4 times greater (3906 and 3305 for groups C and D, respectively) than those in symptomatic outpatients with hypertension medications (837) and approached the magnitude of levels observed in hospitalized patients with hypertension medications (7457).

At day 35, ELISA anti-spike IgG GMEUs and neutralizing antibodies induced by the two-dose 5-μg and 25-μg adjuvanted treatment regimens were 4 to 6 times greater than the geometric mean convalescent serum measures (8344 and 983, respectively). Figure 4. Figure 4. Correlation of Anti-Spike IgG and Neutralizing Antibody Responses.

Shown are scatter plots of 100% wild-type neutralizing antibody responses and anti-spike IgG ELISA unit responses at 3 weeks after the first vaccination (day 21) and 2 weeks after the second vaccination (day 35) for the two-dose 25-μg unadjuvanted treatment (group B. Panel A), the combined two-dose 5-μg and 25-μg adjuvanted treatment (groups C and D, respectively. Panel B), and convalescent serum from patients with hypertension medications (Panel C). In Panel C, the severity of hypertension medications is indicated by the colors of the dots for hospitalized patients (including those in intensive care), symptomatic outpatients (with samples collected in the emergency department), and asymptomatic patients who had been exposed to hypertension medications (with samples collected during contact and exposure assessment).A strong correlation was observed between neutralizing antibody titers and anti-spike IgG GMEUs with adjuvanted treatment at day 35 (correlation, 0.95) (Figure 4), a finding that was not observed with unadjuvanted treatment (correlation, 0.76) but was similar to that of convalescent serum (correlation, 0.96).

Two-dose regimens of 5-μg and 25-μg rhypertension plus Matrix-M1 produced similar magnitudes of response, and every participant had seroconversion according to either assay measurement. Reverse cumulative-distribution curves for day 35 are presented in Figure S2. Figure 5. Figure 5.

Rhypertension CD4+ T-cell Responses with or without Matrix-M1 Adjuvant. Frequencies of antigen-specific CD4+ T cells producing T helper 1 (Th1) cytokines interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), and interleukin-2 and for T helper 2 (Th2) cytokines interleukin-5 and interleukin-13 indicated cytokines from four participants each in the placebo (group A), 25-μg unadjuvanted (group B), 5-μg adjuvanted (group C), and 25-μg adjuvanted (group D) groups at baseline (day 0) and 1 week after the second vaccination (day 28) after stimulation with the recombinant spike protein. €œAny 2Th1” indicates CD4+ T cells that can produce two types of Th1 cytokines at the same time. €œAll 3 Th1” indicates CD4+ T cells that produce IFN-γ, TNF-α, and interleukin-2 simultaneously.

€œBoth Th2” indicates CD4+ T cells that can produce Th2 cytokines interleukin-5 and interleukin-13 at the same time.T-cell responses in 16 participants who were randomly selected from groups A through D, 4 participants per group, showed that adjuvanted regimens induced antigen-specific polyfunctional CD4+ T-cell responses that were reflected in IFN-γ, IL-2, and TNF-α production on spike protein stimulation. A strong bias toward this Th1 phenotype was noted. Th2 responses (as measured by IL-5 and IL-13 cytokines) were minimal (Figure 5).Start Preamble Centers for Medicare &. Medicaid Services (CMS), HHS.

Extension of timeline for publication of final rule. This notice announces an extension of the timeline for publication of a Medicare final rule in accordance with the Social Security Act, which allows us to extend the timeline for publication of the final rule. As of August 26, 2020, the timeline for publication of the final rule to finalize the provisions of the October 17, 2019 proposed rule (84 FR 55766) is extended until August 31, 2021. Start Further Info Lisa O.

Wilson, (410) 786-8852. End Further Info End Preamble Start Supplemental Information In the October 17, 2019 Federal Register (84 FR 55766), we published a proposed rule that addressed undue regulatory impact and burden of the physician self-referral law. The proposed rule was issued in conjunction with the Centers for Medicare &. Medicaid Services' (CMS) Patients over Paperwork initiative and the Department of Health and Human Services' (the Department or HHS) Regulatory Sprint to Coordinated Care.

In the proposed rule, we proposed exceptions to the physician self-referral law for certain value-based compensation arrangements between or among physicians, providers, and suppliers. A new exception for certain arrangements under which a physician receives limited remuneration for items or services actually provided by the physician. A new exception for donations of cybersecurity technology and related services. And amendments to the existing exception for electronic health records (EHR) items and services.

The proposed rule also provides critically necessary guidance for physicians and health care providers and suppliers whose financial relationships are governed by the physician self-referral statute and regulations. This notice announces an extension of the timeline for publication of the final rule and the continuation of effectiveness of the proposed rule. Section 1871(a)(3)(A) of the Social Security Act (the Act) requires us to establish and publish a regular timeline for the publication of final regulations based on the previous publication of a proposed regulation. In accordance with section 1871(a)(3)(B) of the Act, the timeline may vary among different regulations based on differences in the complexity of the regulation, the number and scope of comments received, and other relevant factors, but may not be longer than 3 years except under exceptional circumstances.

In addition, in accordance with section 1871(a)(3)(B) of the Act, the Secretary may extend the initial targeted publication date of the final regulation if the Secretary, no later than the regulation's previously established proposed publication date, publishes a notice with the new target date, and such notice includes a brief explanation of the justification for the variation. We announced in the Spring 2020 Unified Agenda (June 30, 2020, www.reginfo.gov) that we would issue the final rule in August 2020. However, we are still working through the Start Printed Page 52941complexity of the issues raised by comments received on the proposed rule and therefore we are not able to meet the announced publication target date. This notice extends the timeline for publication of the final rule until August 31, 2021.

Start Signature Dated. August 24, 2020. Wilma M. Robinson, Deputy Executive Secretary to the Department, Department of Health and Human Services.

End Signature End Supplemental Information [FR Doc. 2020-18867 Filed 8-26-20. 8:45 am]BILLING CODE 4120-01-PStart Preamble Notice of amendment. The Secretary issues this amendment pursuant to section 319F-3 of the Public Health Service Act to add additional categories of Qualified Persons and amend the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures.

This amendment to the Declaration published on March 17, 2020 (85 FR 15198) is effective as of August 24, 2020. Start Further Info Robert P. Kadlec, MD, MTM&H, MS, Assistant Secretary for Preparedness and Response, Office of the Secretary, Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201. Telephone.

202-205-2882. End Further Info End Preamble Start Supplemental Information The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the Secretary of Health and Human Services (the Secretary) to issue a Declaration to provide liability immunity to certain individuals and entities (Covered Persons) against any claim of loss caused by, arising out of, relating to, or resulting from the manufacture, distribution, administration, or use of medical countermeasures (Covered Countermeasures), except for claims involving “willful misconduct” as defined in the PREP Act. Under the PREP Act, a Declaration may be amended as circumstances warrant. The PREP Act was enacted on December 30, 2005, as Public Law 109-148, Division C, § 2.

It amended the Public Health Service (PHS) Act, adding section 319F-3, which addresses liability immunity, and section 319F-4, which creates a compensation program. These sections are codified at 42 U.S.C. 247d-6d and 42 U.S.C. 247d-6e, respectively.

Section 319F-3 of the PHS Act has been amended by the lasix and All-Hazards Preparedness Reauthorization Act (PAHPRA), Public Law 113-5, enacted on March 13, 2013 and the hypertension Aid, Relief, and Economic Security (CARES) Act, Public Law 116-136, enacted on March 27, Start Printed Page 521372020, to expand Covered Countermeasures under the PREP Act. On January 31, 2020, the Secretary declared a public health emergency pursuant to section 319 of the PHS Act, 42 U.S.C. 247d, effective January 27, 2020, for the entire United States to aid in the response of the nation's health care community to the hypertension medications outbreak. Pursuant to section 319 of the PHS Act, the Secretary renewed that declaration on April 26, 2020, and July 25, 2020.

On March 10, 2020, the Secretary issued a Declaration under the PREP Act for medical countermeasures against hypertension medications (85 FR 15198, Mar. 17, 2020) (the Declaration). On April 10, the Secretary amended the Declaration under the PREP Act to extend liability immunity to covered countermeasures authorized under the CARES Act (85 FR 21012, Apr. 15, 2020).

On June 4, the Secretary amended the Declaration to clarify that covered countermeasures under the Declaration include qualified countermeasures that limit the harm hypertension medications might otherwise cause. The Secretary now amends section V of the Declaration to identify as qualified persons covered under the PREP Act, and thus authorizes, certain State-licensed pharmacists to order and administer, and pharmacy interns (who are licensed or registered by their State board of pharmacy and acting under the supervision of a State-licensed pharmacist) to administer, any treatment that the Advisory Committee on Immunization Practices (ACIP) recommends to persons ages three through 18 according to ACIP's standard immunization schedule (ACIP-recommended treatments).[] The Secretary also amends section VIII of the Declaration to clarify that the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures includes not only hypertension medications caused by hypertension or a lasix mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by hypertension medications, hypertension, or a lasix mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Description of This Amendment by Section Section V. Covered Persons Under the PREP Act and the Declaration, a “qualified person” is a “covered person.” Subject to certain limitations, a covered person is immune from suit and liability under Federal and State law with respect to all claims for loss caused by, arising out of, relating to, or resulting from the administration or use of a covered countermeasure if a declaration under subsection (b) has been issued with respect to such countermeasure.

€œQualified person” includes (A) a licensed health professional or other individual who is authorized to prescribe, administer, or dispense such countermeasures under the law of the State in which the countermeasure was prescribed, administered, or dispensed. Or (B) “a person within a category of persons so identified in a declaration by the Secretary” under subsection (b) of the PREP Act. 42 U.S.C. 247d-6d(i)(8).[] By this amendment to the Declaration, the Secretary identifies an additional category of persons who are qualified persons under section 247d-6d(i)(8)(B).[] On May 8, 2020, CDC reported, “The identified declines in routine pediatric treatment ordering and doses administered might indicate that U.S.

Children and their communities face increased risks for outbreaks of treatment-preventable diseases,” and suggested that a decrease in rates of routine childhood vaccinations were due to changes in healthcare access, social distancing, and other hypertension medications mitigation strategies.[] The report also stated that “[p]arental concerns about potentially exposing their children to hypertension medications during well child visits might contribute to the declines observed.” [] On July 10, 2020, CDC reported its findings of a May survey it conducted to assess the capacity of pediatric health care practices to provide immunization services to children during the hypertension medications lasix. The survey, which was limited to practices participating in the treatments for Children program, found that, as of mid-May, 15 percent of Northeast pediatric practices were closed, 12.5 percent of Midwest practices were closed, 6.2 percent of practices in the South were closed, and 10 percent of practices in the West were closed. Most practices had reduced office hours for in-person visits. When asked whether their practices would likely be able to accommodate new patients for immunization services through August, 418 practices (21.3 percent) either responded that this was not likely or the practice was permanently closed or not resuming immunization services for all patients, and 380 (19.6 percent) responded that they were unsure.

Urban practices and those in the Northeast were less likely to be able to accommodate new patients compared with rural practices and those in the South, Midwest, or West.[] In response to these troubling developments, CDC and the American Academy of Pediatrics have stressed, “Well-child visits and vaccinations are essential services and help make sure children are protected.” [] The Secretary re-emphasizes that important recommendation to parents and legal guardians here. If your child is due for a well-child visit, contact your pediatrician's or other primary-care provider's office and ask about ways that the office safely offers well-child visits and vaccinations. Many medical offices are taking extra steps to make sure that well-child visits can occur safely during the hypertension medications lasix, including. Scheduling sick visits and well-child visits during different times of the Start Printed Page 52138day or days of the week, or at different locations.

Asking patients to remain outside until it is time for their appointments to reduce the number of people in waiting rooms. Adhering to recommended social (physical) distancing and other -control practices, such as the use of masks. The decrease in childhood-vaccination rates is a public health threat and a collateral harm caused by hypertension medications. Together, the United States must turn to available medical professionals to limit the harm and public health threats that may result from decreased immunization rates.

We must quickly do so to avoid preventable s in children, additional strains on our healthcare system, and any further increase in avoidable adverse health consequences—particularly if such complications coincide with additional resurgence of hypertension medications. Together with pediatricians and other healthcare professionals, pharmacists are positioned to expand access to childhood vaccinations. Many States already allow pharmacists to administer treatments to children of any age.[] Other States permit pharmacists to administer treatments to children depending on the age—for example, 2, 3, 5, 6, 7, 9, 10, 11, or 12 years of age and older.[] Few States restrict pharmacist-administered vaccinations to only adults.[] Many States also allow properly trained individuals under the supervision of a trained pharmacist to administer those treatments.[] Pharmacists are well positioned to increase access to vaccinations, particularly in certain areas or for certain populations that have too few pediatricians and other primary-care providers, or that are otherwise medically underserved.[] As of 2018, nearly 90 percent of Americans lived within five miles of a community pharmacy.[] Pharmacies often offer extended hours and added convenience. What is more, pharmacists are trusted healthcare professionals with established relationships with their patients.

Pharmacists also have strong relationships with local medical providers and hospitals to refer patients as appropriate. For example, pharmacists already play a significant role in annual influenza vaccination. In the early 2018-19 season, they administered the influenza treatment to nearly a third of all adults who received the treatment.[] Given the potential danger of serious influenza and continuing hypertension medications outbreaks this autumn and the impact that such concurrent outbreaks may have on our population, our healthcare system, and our whole-of-nation response to the hypertension medications lasix, we must quickly expand access to influenza vaccinations. Allowing more qualified pharmacists to administer the influenza treatment to children will make vaccinations more accessible.

Therefore, the Secretary amends the Declaration to identify State-licensed pharmacists (and pharmacy interns acting under their supervision if the pharmacy intern is licensed or registered by his or her State board of pharmacy) as qualified persons under section 247d-6d(i)(8)(B) when the pharmacist orders and either the pharmacist or the supervised pharmacy intern administers treatments to individuals ages three through 18 pursuant to the following requirements. The treatment must be FDA-authorized or FDA-approved. The vaccination must be ordered and administered according to ACIP's standard immunization schedule.[] The licensed pharmacist must complete a practical training program of at least 20 hours that is approved by the Accreditation Council for Pharmacy Education (ACPE). This training Start Printed Page 52139program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments.[] The licensed or registered pharmacy intern must complete a practical training program that is approved by the ACPE.

This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments.[] The licensed pharmacist and licensed or registered pharmacy intern must have a current certificate in basic cardiopulmonary resuscitation.[] The licensed pharmacist must complete a minimum of two hours of ACPE-approved, immunization-related continuing pharmacy education during each State licensing period.[] The licensed pharmacist must comply with recordkeeping and reporting requirements of the jurisdiction in which he or she administers treatments, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (treatment registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a treatment must review the treatment registry or other vaccination records prior to administering a treatment.[] The licensed pharmacist must inform his or her childhood-vaccination patients and the adult caregivers accompanying the children of the importance of a well-child visit with a pediatrician or other licensed primary-care provider and refer patients as appropriate.[] These requirements are consistent with those in many States that permit licensed pharmacists to order and administer treatments to children and permit licensed or registered pharmacy interns acting under their supervision to administer treatments to children.[] Administering vaccinations to children age three and older is less complicated and requires less training and resources than administering vaccinations to younger children. That is because ACIP generally recommends administering intramuscular injections in the deltoid muscle for individuals age three and older.[] For individuals less than three years of age, ACIP generally recommends administering intramuscular injections in the anterolateral aspect of the thigh muscle.[] Administering injections in the thigh muscle often presents additional complexities and requires additional training and resources including additional personnel to safely position the child while another healthcare professional injects the treatment.[] Moreover, as of 2018, 40% of three-year-olds were enrolled in preprimary programs (i.e. Preschool or kindergarten programs).[] Preprimary programs are beginning in the coming weeks or months, so the Secretary has concluded that it is particularly important for individuals ages three through 18 to receive ACIP-recommended treatments according to ACIP's standard immunization schedule. All States require children to be vaccinated against certain communicable diseases as a condition of school attendance.

These laws often apply to both public and private schools with identical immunization and exemption provisions.[] As nurseries, preschools, kindergartens, and schools reopen, increased access to childhood vaccinations is essential to ensuring children can return. Notwithstanding any State or local scope-of-practice legal requirements, (1) qualified licensed pharmacists are identified as qualified persons to order and administer ACIP-recommended treatments and (2) qualified State-licensed or registered pharmacy interns are identified as qualified persons to administer the ACIP-recommended treatments ordered by their supervising qualified licensed pharmacist.[] Both the PREP Act and the June 4, 2020 Second Amendment to the Declaration define “covered countermeasures” to include qualified lasix and epidemic products that “limit the harm such lasix or epidemic might otherwise cause.” [] The troubling decrease in ACIP-recommended childhood vaccinations and the resulting increased risk of associated diseases, adverse health conditions, and other threats are categories of harms otherwise caused by Start Printed Page 52140hypertension medications as set forth in Sections VI and VIII of this Declaration.[] Hence, such vaccinations are “covered countermeasures” under the PREP Act and the June 4, 2020 Second Amendment to the Declaration. Nothing in this Declaration shall be construed to affect the National treatment Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National treatment Injury Compensation Program authorized under 42 U.S.C.

300aa-10 et seq. Are covered under this Declaration for the purposes of liability immunity and injury compensation only to the extent that injury compensation is not provided under that Program. All other terms and conditions of the Declaration apply to such covered countermeasures. Section VIII.

Category of Disease, Health Condition, or Threat As discussed, the troubling decrease in ACIP-recommended childhood vaccinations and the resulting increased risk of associated diseases, adverse health conditions, and other threats are categories of harms otherwise caused by hypertension medications. The Secretary therefore amends section VIII, which describes the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures, to clarify that the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures is not only hypertension medications caused by hypertension or a lasix mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by hypertension medications, hypertension, or a lasix mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Amendments to Declaration Amended Declaration for Public Readiness and Emergency Preparedness Act Coverage for medical countermeasures against hypertension medications. Sections V and VIII of the March 10, 2020 Declaration under the PREP Act for medical countermeasures against hypertension medications, as amended April 10, 2020 and June 4, 2020, are further amended pursuant to section 319F-3(b)(4) of the PHS Act as described below.

All other sections of the Declaration remain in effect as published at 85 FR 15198 (Mar. 17, 2020) and amended at 85 FR 21012 (Apr. 15, 2020) and 85 FR 35100 (June 8, 2020). 1.

Covered Persons, section V, delete in full and replace with. V. Covered Persons 42 U.S.C. 247d-6d(i)(2), (3), (4), (6), (8)(A) and (B) Covered Persons who are afforded liability immunity under this Declaration are “manufacturers,” “distributors,” “program planners,” “qualified persons,” and their officials, agents, and employees, as those terms are defined in the PREP Act, and the United States.

In addition, I have determined that the following additional persons are qualified persons. (a) Any person authorized in accordance with the public health and medical emergency response of the Authority Having Jurisdiction, as described in Section VII below, to prescribe, administer, deliver, distribute or dispense the Covered Countermeasures, and their officials, agents, employees, contractors and volunteers, following a Declaration of an emergency. (b) any person authorized to prescribe, administer, or dispense the Covered Countermeasures or who is otherwise authorized to perform an activity under an Emergency Use Authorization in accordance with Section 564 of the FD&C Act. (c) any person authorized to prescribe, administer, or dispense Covered Countermeasures in accordance with Section 564A of the FD&C Act.

And (d) a State-licensed pharmacist who orders and administers, and pharmacy interns who administer (if the pharmacy intern acts under the supervision of such pharmacist and the pharmacy intern is licensed or registered by his or her State board of pharmacy), treatments that the Advisory Committee on Immunization Practices (ACIP) recommends to persons ages three through 18 according to ACIP's standard immunization schedule. Such State-licensed pharmacists and the State-licensed or registered interns under their supervision are qualified persons only if the following requirements are met. The treatment must be FDA-authorized or FDA-approved. The vaccination must be ordered and administered according to ACIP's standard immunization schedule.

The licensed pharmacist must complete a practical training program of at least 20 hours that is approved by the Accreditation Council for Pharmacy Education (ACPE). This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments. The licensed or registered pharmacy intern must complete a practical training program that is approved by the ACPE. This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments.

The licensed pharmacist and licensed or registered pharmacy intern must have a current certificate in basic cardiopulmonary resuscitation. The licensed pharmacist must complete a minimum of two hours of ACPE-approved, immunization-related continuing pharmacy education during each State licensing period. The licensed pharmacist must comply with recordkeeping and reporting requirements of the jurisdiction in which he or she administers treatments, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (treatment registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a treatment must review the treatment registry or other vaccination records prior to administering a treatment. The licensed pharmacist must inform his or her childhood-vaccination patients and the adult caregiver accompanying the child of the importance of a well-child visit with a pediatrician or other licensed primary-care provider and refer patients as appropriate.

Nothing in this Declaration shall be construed to affect the National treatment Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National treatment Injury Compensation Program authorized under 42 U.S.C. 300aa-10 et seq. Are covered under this Declaration for the purposes of liability immunity and injury compensation only to the extent that injury compensation is not provided under that Program.

All other Start Printed Page 52141terms and conditions of the Declaration apply to such covered countermeasures. 2. Category of Disease, Health Condition, or Threat, section VIII, delete in full and replace with. VIII.

Category of Disease, Health Condition, or Threat 42 U.S.C. 247d-6d(b)(2)(A) The category of disease, health condition, or threat for which I recommend the administration or use of the Covered Countermeasures is not only hypertension medications caused by hypertension or a lasix mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by hypertension medications, hypertension, or a lasix mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Start Authority 42 U.S.C. 247d-6d.

End Authority Start Signature Dated. August 19, 2020. Alex M. Azar II, Secretary of Health and Human Services.

End Signature End Supplemental Information [FR Doc. 2020-18542 Filed 8-20-20. 4:15 pm]BILLING CODE 4150-03-P.

Specificity of hypertension Antibody Assays how do you get lasix Both assays measuring pan-Ig antibodies had low numbers of false positives among samples collected in 2017 Antabuse pills for sale. There were how do you get lasix 0 and 1 false positives for the two assays among 472 samples, results that compared favorably with those obtained with the single IgM anti-N and IgG anti-N assays (Table S3). Because of the low prevalence of hypertension in Iceland, we required positive results from both pan-Ig antibody assays for a sample to be considered seropositive (see Supplementary Methods in Supplementary Appendix 1). None of the samples collected in early 2020 group were seropositive, which indicates that the lasix had not spread widely in Iceland how do you get lasix before February 2020. hypertension Antibodies among qPCR-Positive Persons Figure 2.

Figure 2 how do you get lasix. Antibody Prevalence and Titers among qPCR-Positive Cases as a Function of Time since Diagnosis by qPCR. Shown are the percentages of samples positive for both pan-Ig antibody how do you get lasix assays and the antibody titers. Red denotes the count or percentage of samples among persons during their hospitalization (249 samples from 48 persons), and blue denotes the count or percentage of samples among persons after they were declared recovered (1853 samples from 1215 persons). Vertical bars denote 95% confidence how do you get lasix intervals.

The dashed lines indicated the thresholds for a test to be declared positive. OD denotes optical density, and how do you get lasix RBD receptor binding domain.Table 1. Table 1. Prevalence of hypertension Antibodies by Sample Collection as Measured how do you get lasix by Two Pan-Ig Antibody Assays. Twenty-five days after diagnosis by qPCR, more than 90% of samples from recovered persons how do you get lasix tested positive with both pan-Ig antibody assays, and the percentage of persons testing positive remained stable thereafter (Figure 2 and Fig.

S2). Hospitalized persons seroconverted more frequently and quickly after qPCR diagnosis than did how do you get lasix nonhospitalized persons (Figure 2 and Fig. S3). Of 1215 how do you get lasix persons who had recovered (on the basis of results for the most recently obtained sample from persons for whom we had multiple samples), 1107 were seropositive (91.1%. 95% confidence interval [CI], 89.4 to 92.6) (Table 1 and Table S4).

Since some diagnoses may have been made on the basis of false positive qPCR results, we determined that 91.1% represents the lower bound how do you get lasix of sensitivity of the combined pan-Ig tests for the detection of hypertension antibodies among recovered persons. Table 2. Table 2 how do you get lasix. Results of Repeated Pan-Ig Antibody Tests among Recovered qPCR-Diagnosed Persons. Among the 487 recovered persons with two or how do you get lasix more samples, 19 (4%) had different pan-Ig antibody test results at different time points (Table 2 and Fig.

S4). It is notable that of the 22 persons with an early sample that tested negative for both pan-Ig antibodies, 19 remained negative at how do you get lasix the most recent test date (again, for both antibodies). One person tested positive for both pan-Ig antibodies in the first test and negative for both in the most recent test. The longitudinal changes in antibody levels among recovered persons were consistent with the cross-sectional results how do you get lasix (Fig. S5).

Antibody levels were higher in the last sample than in the first sample when the antibodies were measured with the two pan-Ig assays, slightly lower than in the first sample when measured with IgG anti-N and IgG anti-S1 assays, and substantially lower than in the first sample when measured with IgM anti-N and IgA anti-S1 assays. IgG anti-N, IgM anti-N, IgG anti-S1, and IgA anti-S1 antibody levels were correlated among the qPCR-positive persons (Figs. S5 and S6 and Table S5). Antibody levels measured with both pan-Ig antibody assays increased over the first 2 months after qPCR diagnosis and remained at a plateau over the next 2 months of the study. IgM anti-N antibody levels increased rapidly soon after diagnosis and then fell rapidly and were generally not detected after 2 months.

IgA anti-S1 antibodies decreased 1 month after diagnosis and remained detectable thereafter. IgG anti-N and anti-S1 antibody levels increased during the first 6 weeks after diagnosis and then decreased slightly. hypertension in Quarantine Table 3. Table 3. hypertension among Quarantined Persons According to Exposure Type and Presence of Symptoms.

Of the 1797 qPCR-positive Icelanders, 1088 (61%) were in quarantine when hypertension was diagnosed by qPCR. We tested for antibodies among 4222 quarantined persons who had not tested qPCR-positive (they had received a negative result by qPCR or had simply not been tested). Of those 4222 quarantined persons, 97 (2.3%. 95% CI, 1.9 to 2.8) were seropositive (Table 1). Those with household exposure were 5.2 (95% CI, 3.3 to 8.0) times more likely to be seropositive than those with other types of exposure (Table 3).

Similarly, a positive result by qPCR for those with household exposure was 5.2 (95% CI, 4.5 to 6.1) times more likely than for those with other types of exposure. When these two sets of results (qPCR-positive and seropositive) were combined, we calculated that 26.6% of quarantined persons with household exposure and 5.0% of quarantined persons without household exposure were infected. Those who had symptoms during quarantine were 3.2 (95% CI, 1.7 to 6.2) times more likely to be seropositive and 18.2 times (95% CI, 14.8 to 22.4) more likely to test positive with qPCR than those without symptoms. We also tested persons in two regions of Iceland affected by cluster outbreaks. In a hypertension cluster in Vestfirdir, 1.4% of residents were qPCR-positive and 10% of residents were quarantined.

We found that none of the 326 persons outside quarantine who had not been tested by qPCR (or who tested negative) were seropositive. In a cluster in Vestmannaeyjar, 2.3% of residents were qPCR-positive and 13% of residents were quarantined. Of the 447 quarantined persons who had not received a qPCR-positive result, 4 were seropositive (0.9%. 95% CI, 0.3 to 2.1). Of the 663 outside quarantine in Vestmannaeyjar, 3 were seropositive (0.5%.

95% CI, 0.1 to 0.2%). hypertension Seroprevalence in Iceland None of the serum samples collected from 470 healthy Icelanders between February 18 and March 9, 2020, tested positive for both pan-Ig antibodies, although four were positive for the pan-Ig anti-N assay (0.9%), a finding that suggests that the lasix had not spread widely in Iceland before March 9. Of the 18,609 persons tested for hypertension antibodies through contact with the Icelandic health care system for reasons other than hypertension medications, 39 were positive for both pan-Ig antibody assays (estimated seroprevalence by weighting the sample on the basis of residence, sex, and 10-year age category, 0.3%. 95% CI, 0.2 to 0.4). There were regional differences in the percentages of qPCR-positive persons across Iceland that were roughly proportional to the percentage of people quarantined (Table S6).

However, after exclusion of the qPCR-positive and quarantined persons, the percentage of persons who tested positive for hypertension antibodies did not correlate with the percentage of those who tested positive by qPCR. The estimated seroprevalence in the random sample collection from Reykjavik (0.4%. 95% CI, 0.3 to 0.6) was similar to that in the Health Care group (0.3%. 95% CI, 0.2 to 0.4) (Table S6). We calculate that 0.5% of the residents of Iceland have tested positive with qPCR.

The 2.3% with hypertension seroconversion among persons in quarantine extrapolates to 0.1% of Icelandic residents. On the basis of this finding and the seroprevalence from the Health Care group, we estimate that 0.9% (95% CI, 0.8 to 0.9) of the population of Iceland has been infected by hypertension. Approximately 56% of all hypertension s were therefore diagnosed by qPCR, 14% occurred in quarantine without having been diagnosed with qPCR, and the remaining 30% of s occurred outside quarantine and were not detected by qPCR. Deaths from hypertension medications in Iceland In Iceland, 10 deaths have been attributed to hypertension medications, which corresponds to 3 deaths per 100,000 nationwide. Among the qPCR-positive cases, 0.6% (95% CI, 0.3 to 1.0) were fatal.

Using the 0.9% prevalence of hypertension in Iceland as the denominator, however, we calculate an fatality risk of 0.3% (95% CI, 0.2 to 0.6). Stratified by age, the fatality risk was substantially lower in those 70 years old or younger (0.1%. 95% CI, 0.0 to 0.3) than in those over 70 years of age (4.4%. 95% CI, 1.9 to 8.4) (Table S7). Age, Sex, Clinical Characteristics, and Antibody Levels Table 4.

Table 4. Association of Existing Conditions and hypertension medications Severity with hypertension Antibody Levels among Recovered Persons. hypertension antibody levels were higher in older people and in those who were hospitalized (Table 4, and Table S8 [described in Supplementary Appendix 1 and available in Supplementary Appendix 2]). Pan-Ig anti–S1-RBD and IgA anti-S1 levels were lower in female persons. Of the preexisting conditions, and after adjustment for multiple testing, we found that body-mass index, smoking status, and use of antiinflammatory medication were associated with hypertension antibody levels.

Body-mass index correlated positively with antibody levels. Smokers and users of antiinflammatory medication had lower antibody levels. With respect to clinical characteristics, antibody levels were most strongly associated with hospitalization and clinical severity, followed by clinical symptoms such as fever, maximum temperature reading, cough, and loss of appetite. Severity of these individual symptoms, with the exception of loss of energy, was associated with higher antibody levels.To the Editor. Rapid and accurate diagnostic tests are essential for controlling the ongoing hypertension medications lasix.

Although the current standard involves testing of nasopharyngeal swab specimens by quantitative reverse-transcriptase polymerase chain reaction (RT-qPCR) to detect hypertension, saliva specimens may be an alternative diagnostic sample.1-4 Rigorous evaluation is needed to determine how saliva specimens compare with nasopharyngeal swab specimens with respect to sensitivity in detection of hypertension during the course of . A total of 70 inpatients with hypertension medications provided written informed consent to participate in our study (see the Methods section in Supplementary Appendix 1, available with the full text of this letter at NEJM.org). After hypertension medications was confirmed with a positive nasopharyngeal swab specimen at hospital admission, we obtained additional samples from the patients during hospitalization. We tested saliva specimens collected by the patients themselves and nasopharyngeal swabs collected from the patients at the same time point by health care workers. Figure 1.

Figure 1. hypertension RNA Titers in Saliva Specimens and Nasopharyngeal Swab Specimens. Samples were obtained from 70 hospital inpatients who had a diagnosis of hypertension medications. Panel A shows hypertension RNA titers in the first available nasopharyngeal and saliva samples. The lines indicate samples from the same patient.

Results were compared with the use of a Wilcoxon signed-rank test (P<0.001). Panel B shows percentages of positivity for hypertension in tests of the first matched nasopharyngeal and saliva samples at 1 to 5 days, 6 to 10 days, and 11 or more days (maximum, 53 days) after the diagnosis of hypertension medications. Panel C shows longitudinal hypertension RNA copies per milliliter in 97 saliva samples, according to days since symptom onset. Each circle represents a separate sample. Dashed lines indicate additional samples from the same patient.

The red line indicates a negative saliva sample that was followed by a positive sample at the next collection of a specimen. Panel D shows longitudinal hypertension RNA copies per milliliter in 97 nasopharyngeal swab specimens, according to days since symptom onset. The red lines indicate negative nasopharyngeal swab specimens there were followed by a positive swab at the next collection of a specimen. The gray area in Panels C and D indicates samples that were below the lower limit of detection of 5610 lasix RNA copies per milliliter of sample, which is at cycle threshold 38 of our quantitative reverse-transcriptase polymerase chain reaction assay targeting the hypertension N1 sequence recommended by the Centers for Disease Control and Prevention. To analyze these data, we used a linear mixed-effects regression model (see Supplementary Appendix 1) that accounts for the correlation between samples collected from the same person at a single time point (i.e., multivariate response) and the correlation between samples collected across time from the same patient (i.e., repeated measures).

All the data used to generate this figure, including the raw cycle thresholds, are provided in Supplementary Data 1 in Supplementary Appendix 2.Using primer sequences from the Centers for Disease Control and Prevention, we detected more hypertension RNA copies in the saliva specimens (mean log copies per milliliter, 5.58. 95% confidence interval [CI], 5.09 to 6.07) than in the nasopharyngeal swab specimens (mean log copies per milliliter, 4.93. 95% CI, 4.53 to 5.33) (Figure 1A, and Fig. S1 in Supplementary Appendix 1). In addition, a higher percentage of saliva samples than nasopharyngeal swab samples were positive up to 10 days after the hypertension medications diagnosis (Figure 1B).

At 1 to 5 days after diagnosis, 81% (95% CI, 71 to 96) of the saliva samples were positive, as compared with 71% (95% CI, 67 to 94) of the nasopharyngeal swab specimens. These findings suggest that saliva specimens and nasopharyngeal swab specimens have at least similar sensitivity in the detection of hypertension during the course of hospitalization. Because the results of testing of nasopharyngeal swab specimens to detect hypertension may vary with repeated sampling in individual patients,5 we evaluated viral detection in matched samples over time. The level of hypertension RNA decreased after symptom onset in both saliva specimens (estimated slope, −0.11. 95% credible interval, −0.15 to −0.06) (Figure 1C) and nasopharyngeal swab specimens (estimated slope, −0.09.

95% credible interval, −0.13 to −0.05) (Figure 1D). In three instances, a negative nasopharyngeal swab specimen was followed by a positive swab at the next collection of a specimen (Figure 1D). This phenomenon occurred only once with the saliva specimens (Figure 1C). During the clinical course, we observed less variation in levels of hypertension RNA in the saliva specimens (standard deviation, 0.98 lasix RNA copies per milliliter. 95% credible interval, 0.08 to 1.98) than in the nasopharyngeal swab specimens (standard deviation, 2.01 lasix RNA copies per milliliter.

95% credible interval, 1.29 to 2.70) (see Supplementary Appendix 1). Recent studies have shown that hypertension can be detected in the saliva of asymptomatic persons and outpatients.1-3 We therefore screened 495 asymptomatic health care workers who provided written informed consent to participate in our prospective study, and we used RT-qPCR to test both saliva and nasopharyngeal samples obtained from these persons. We detected hypertension RNA in saliva specimens obtained from 13 persons who did not report any symptoms at or before the time of sample collection. Of these 13 health care workers, 9 had collected matched nasopharyngeal swab specimens by themselves on the same day, and 7 of these specimens tested negative (Fig. S2).

The diagnosis in the 13 health care workers with positive saliva specimens was later confirmed in diagnostic testing of additional nasopharyngeal samples by a CLIA (Clinical Laboratory Improvement Amendments of 1988)–certified laboratory. Variation in nasopharyngeal sampling may be an explanation for false negative results, so monitoring an internal control for proper sample collection may provide an alternative evaluation technique. In specimens collected from inpatients by health care workers, we found greater variation in human RNase P cycle threshold (Ct) values in nasopharyngeal swab specimens (standard deviation, 2.89 Ct. 95% CI, 26.53 to 27.69) than in saliva specimens (standard deviation, 2.49 Ct. 95% CI, 23.35 to 24.35).

When health care workers collected their own specimens, we also found greater variation in RNase P Ct values in nasopharyngeal swab specimens (standard deviation, 2.26 Ct. 95% CI, 28.39 to 28.56) than in saliva specimens (standard deviation , 1.65 Ct. 95% CI, 24.14 to 24.26) (Fig. S3). Collection of saliva samples by patients themselves negates the need for direct interaction between health care workers and patients.

This interaction is a source of major testing bottlenecks and presents a risk of nosocomial . Collection of saliva samples by patients themselves also alleviates demands for supplies of swabs and personal protective equipment. Given the growing need for testing, our findings provide support for the potential of saliva specimens in the diagnosis of hypertension . Anne L. Wyllie, Ph.D.Yale School of Public Health, New Haven, CT [email protected]John Fournier, M.D.Yale School of Medicine, New Haven, CTArnau Casanovas-Massana, Ph.D.Yale School of Public Health, New Haven, CTMelissa Campbell, M.D.Maria Tokuyama, Ph.D.Pavithra Vijayakumar, B.A.Yale School of Medicine, New Haven, CTJoshua L.

Warren, Ph.D.Yale School of Public Health, New Haven, CTBertie Geng, M.D.Yale School of Medicine, New Haven, CTM. Catherine Muenker, M.S.Adam J. Moore, M.P.H.Chantal B.F. Vogels, Ph.D.Mary E. Petrone, B.S.Isabel M.

Ott, B.S.Yale School of Public Health, New Haven, CTPeiwen Lu, Ph.D.Arvind Venkataraman, B.S.Alice Lu-Culligan, B.S.Jonathan Klein, B.S.Yale School of Medicine, New Haven, CTRebecca Earnest, M.P.H.Yale School of Public Health, New Haven, CTMichael Simonov, M.D.Rupak Datta, M.D., Ph.D.Ryan Handoko, M.D.Nida Naushad, B.S.Lorenzo R. Sewanan, M.Phil.Jordan Valdez, B.S.Yale School of Medicine, New Haven, CTElizabeth B. White, A.B.Sarah Lapidus, M.S.Chaney C. Kalinich, M.P.H.Yale School of Public Health, New Haven, CTXiaodong Jiang, M.D., Ph.D.Daniel J. Kim, A.B.Eriko Kudo, Ph.D.Melissa Linehan, M.S.Tianyang Mao, B.S.Miyu Moriyama, Ph.D.Ji E.

Oh, M.D., Ph.D.Annsea Park, B.A.Julio Silva, B.S.Eric Song, M.S.Takehiro Takahashi, M.D., Ph.D.Manabu Taura, Ph.D.Orr-El Weizman, B.A.Patrick Wong, M.S.Yexin Yang, B.S.Santos Bermejo, B.S.Yale School of Medicine, New Haven, CTCamila D. Odio, M.D.Yale New Haven Health, New Haven, CTSaad B. Omer, M.B., B.S., Ph.D.Yale Institute for Global Health, New Haven, CTCharles S. Dela Cruz, M.D., Ph.D.Shelli Farhadian, M.D., Ph.D.Richard A. Martinello, M.D.Akiko Iwasaki, Ph.D.Yale School of Medicine, New Haven, CTNathan D.

Grubaugh, Ph.D.Albert I. Ko, M.D.Yale School of Public Health, New Haven, CT [email protected], [email protected] Supported by the Huffman Family Donor Advised Fund, a Fast Grant from Emergent Ventures at the Mercatus Center at George Mason University, the Yale Institute for Global Health, the Yale School of Medicine, a grant (U19 AI08992, to Dr. Ko) from the National Institute of Allergy and Infectious Diseases, the Beatrice Kleinberg Neuwirth Fund, and a grant (Rubicon 019.181EN.004, to Dr. Vogel) from the Dutch Research Council (NWO). Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

This letter was published on August 28, 2020, at NEJM.org. Drs. Grubaugh and Ko contributed equally to this letter. 5 References1. Kojima N, Turner F, Slepnev V, et al.

Self-collected oral fluid and nasal swabs demonstrate comparable sensitivity to clinician collected nasopharyngeal swabs for hypertension medications detection. April 15, 2020 (https://www.medrxiv.org/content/10.1101/2020.04.11.20062372v1). Preprint.Google Scholar2. Williams E, Bond K, Zhang B, Putland M, Williamson DA. Saliva as a non-invasive specimen for detection of hypertension.

J Clin Microbiol 2020;58(8):e00776-20-e00776-20.3. Pasomsub E, Watcharananan SP, Boonyawat K, et al. Saliva sample as a non-invasive specimen for the diagnosis of hypertension disease 2019. A cross-sectional study. Clin Microbiol Infect 2020 May 15 (Epub ahead of print).4.

Vogels CBF, Brackney D, Wang J, et al. SalivaDirect. Simple and sensitive molecular diagnostic test for hypertension surveillance. August 4, 2020 (https://www.medrxiv.org/content/10.1101/2020.08.03.20167791v1). Preprint.Google Scholar5.

Zou L, Ruan F, Huang M, et al. hypertension viral load in upper respiratory specimens of infected patients. N Engl J Med 2020;382:1177-1179.Trial Population Table 1. Table 1. Demographic Characteristics of the Participants in the NVX-CoV2373 Trial at Enrollment.

The trial was initiated on May 26, 2020. 134 participants underwent randomization between May 27 and June 6, 2020, including 3 participants who were to serve as backups for sentinel dosing and who immediately withdrew from the trial without being vaccinated (Fig. S1). Of the 131 participants who received injections, 23 received placebo (group A), 25 received 25-μg doses of rhypertension (group B), 29 received 5-μg doses of rhypertension plus Matrix-M1, including three sentinels (group C), 28 received 25-μg doses of rhypertension plus Matrix-M1, including three sentinels (group D), and 26 received a single 25-μg dose of rhypertension plus Matrix-M1 followed by a single dose of placebo (group E). All 131 participants received their first vaccination on day 0, and all but 3 received their second vaccination at least 21 days later.

Exceptions include 2 in the placebo group (group A) who withdrew consent (unrelated to any adverse event) and 1 in the 25-μg rhypertension + Matrix-M1 group (group D) who had an unsolicited adverse event (mild cellulitis. See below). Demographic characteristics of the participants are presented in Table 1. Of note, missing data were infrequent. Safety Outcomes No serious adverse events or adverse events of special interest were reported, and vaccination pause rules were not implemented.

As noted above, one participant did not receive a second vaccination owing to an unsolicited adverse event, mild cellulitis, that was associated with after an intravenous cannula placement to address an unrelated mild adverse event that occurred during the second week of follow-up. Second vaccination was withheld because the participant was still recovering and receiving antibiotics. This participant remains in the trial. Figure 2. Figure 2.

Solicited Local and Systemic Adverse Events. The percentage of participants in each treatment group (groups A, B, C, D, and E) with adverse events according to the maximum FDA toxicity grade (mild, moderate, or severe) during the 7 days after each vaccination is plotted for solicited local (Panel A) and systemic (Panel B) adverse events. There were no grade 4 (life-threatening) events. Participants who reported 0 events make up the remainder of the 100% calculation (not displayed). Excluded were the three sentinel participants in groups C (5 μg + Matrix-M1, 5 μg + Matrix-M1) and D (25 μg + Matrix-M1, 25 μg + Matrix-M1), who received the trial treatment in an open-label manner (see Table S7 for complete safety data on all participants).Overall reactogenicity was largely absent or mild, and second vaccinations were neither withheld nor delayed due to reactogenicity.

After the first vaccination, local and systemic reactogenicity was absent or mild in the majority of participants (local. 100%, 96%, 89%, 84%, and 88% of participants in groups A, B, C, D, and E, respectively. Systemic. 91%, 92%, 96%, 68%, and 89%) who were unaware of treatment assignment (Figure 2 and Table S7). Two participants (2%), one each in groups D and E, had severe adverse events (headache, fatigue, and malaise).

Two participants, one each in groups A and E, had reactogenicity events (fatigue, malaise, and tenderness) that extended 2 days after day 7. After the second vaccination, local and systemic reactogenicity were absent or mild in the majority of participants in the five groups (local. 100%, 100%, 65%, 67%, and 100% of participants, respectively. Systemic. 86%, 84%, 73%, 58%, and 96%) who were unaware of treatment assignment.

One participant, in group D, had a severe local event (tenderness), and eight participants, one or two participants in each group, had severe systemic events. The most common severe systemic events were joint pain and fatigue. Only one participant, in group D, had fever (temperature, 38.1°C) after the second vaccination, on day 1 only. No adverse event extended beyond 7 days after the second vaccination. Of note, the mean duration of reactogenicity events was 2 days or less for both the first vaccination and second vaccination periods.

Laboratory abnormalities of grade 2 or higher occurred in 13 participants (10%). 9 after the first vaccination and 4 after the second vaccination (Table S8). Abnormal laboratory values were not associated with any clinical manifestations and showed no worsening with repeat vaccination. Six participants (5%. Five women and one man) had grade 2 or higher transient reductions in hemoglobin from baseline, with no evidence of hemolysis or microcytic anemia and with resolution within 7 to 21 days.

Of the six, two had an absolute hemoglobin value (grade 2) that resolved or stabilized during the testing period. Four participants (3%), including one who had received placebo, had elevated liver enzymes that were noted after the first vaccination and resolved within 7 to 14 days (i.e., before the second vaccination). Vital signs remained stable immediately after vaccination and at all visits. Unsolicited adverse events (Table S9) were predominantly mild in severity (in 71%, 91%, 83%, 90%, and 82% of participants in groups A, B, C, D, and E, respectively) and were similarly distributed across the groups receiving adjuvanted and unadjuvanted treatment. There were no reports of severe adverse events.

Immunogenicity Outcomes Figure 3. Figure 3. hypertension Anti-Spike IgG and Neutralizing Antibody Responses. Shown are geometric mean anti-spike IgG enzyme-linked immunosorbent assay (ELISA) unit responses to recombinant severe acute respiratory syndrome hypertension 2 (rhypertension) protein antigens (Panel A) and wild-type hypertension microneutralization assay at an inhibitory concentration greater than 99% (MN IC>99%) titer responses (Panel B) at baseline (day 0), 3 weeks after the first vaccination (day 21), and 2 weeks after the second vaccination (day 35) for the placebo group (group A), the 25-μg unadjuvanted group (group B), the 5-μg and 25-μg adjuvanted groups (groups C and D, respectively), and the 25-μg adjuvanted and placebo group (group E). Diamonds and whisker endpoints represent geometric mean titer values and 95% confidence intervals, respectively.

The hypertension medications human convalescent serum panel includes specimens from PCR-confirmed hypertension medications participants, obtained from Baylor College of Medicine (29 specimens for ELISA and 32 specimens for MN IC>99%), with geometric mean titer values according to hypertension medications severity. The severity of hypertension medications is indicated by the colors of the dots for hospitalized patients (including those in intensive care), symptomatic outpatients (with samples collected in the emergency department), and asymptomatic patients who had been exposed to hypertension medications (with samples collected during contact and exposure assessment). Mean values (in black) for human convalescent serum are depicted next to (and of same color as) the category of hypertension medications patients, with the overall mean shown above the scatter plot (in black). For each trial treatment group, the mean at day 35 is depicted above the scatterplot.ELISA anti-spike IgG geometric mean ELISA units (GMEUs) ranged from 105 to 116 at day 0. By day 21, responses had occurred for all adjuvanted regimens (1984, 2626, and 3317 GMEUs for groups C, D, and E, respectively), and geometric mean fold rises (GMFRs) exceeded those induced without adjuvant by a factor of at least 10 (Figure 3 and Table S10).

Within 7 days after the second vaccination with adjuvant (day 28. Groups C and D), GMEUs had further increased by a factor of 8 (to 15,319 and 20,429, respectively) over responses seen with the first vaccination, and within 14 days (day 35), responses had more than doubled yet again (to 63,160 and 47,521, respectively), achieving GMFRs that were approximately 100 times greater than those observed with rhypertension alone. A single vaccination with adjuvant achieved GMEU levels similar to those in asymptomatic (exposed) patients with hypertension medications (1661), and a second vaccination with adjuvant achieved GMEU levels that exceeded those in convalescent serum from symptomatic outpatients with hypertension medications (7420) by a factor of at least 6 and rose to levels similar to those in convalescent serum from patients hospitalized with hypertension medications (53,391). The responses in the two-dose 5-μg and 25-μg adjuvanted treatment regimens were similar, a finding that highlights the role of adjuvant dose sparing. Neutralizing antibodies were undetectable before vaccination and had patterns of response similar to those of anti-spike antibodies after vaccination with adjuvant (Figure 3 and Table S11).

After the first vaccination (day 21), GMFRs were approximately 5 times greater with adjuvant (5.2, 6.3, and 5.9 for groups C, D, and E, respectively) than without adjuvant (1.1). By day 35, second vaccinations with adjuvant induced an increase more than 100 times greater (195 and 165 for groups C and D, respectively) than single vaccinations without adjuvant. When compared with convalescent serum, second vaccinations with adjuvant resulted in GMT levels approximately 4 times greater (3906 and 3305 for groups C and D, respectively) than those in symptomatic outpatients with hypertension medications (837) and approached the magnitude of levels observed in hospitalized patients with hypertension medications (7457). At day 35, ELISA anti-spike IgG GMEUs and neutralizing antibodies induced by the two-dose 5-μg and 25-μg adjuvanted treatment regimens were 4 to 6 times greater than the geometric mean convalescent serum measures (8344 and 983, respectively). Figure 4.

Figure 4. Correlation of Anti-Spike IgG and Neutralizing Antibody Responses. Shown are scatter plots of 100% wild-type neutralizing antibody responses and anti-spike IgG ELISA unit responses at 3 weeks after the first vaccination (day 21) and 2 weeks after the second vaccination (day 35) for the two-dose 25-μg unadjuvanted treatment (group B. Panel A), the combined two-dose 5-μg and 25-μg adjuvanted treatment (groups C and D, respectively. Panel B), and convalescent serum from patients with hypertension medications (Panel C).

In Panel C, the severity of hypertension medications is indicated by the colors of the dots for hospitalized patients (including those in intensive care), symptomatic outpatients (with samples collected in the emergency department), and asymptomatic patients who had been exposed to hypertension medications (with samples collected during contact and exposure assessment).A strong correlation was observed between neutralizing antibody titers and anti-spike IgG GMEUs with adjuvanted treatment at day 35 (correlation, 0.95) (Figure 4), a finding that was not observed with unadjuvanted treatment (correlation, 0.76) but was similar to that of convalescent serum (correlation, 0.96). Two-dose regimens of 5-μg and 25-μg rhypertension plus Matrix-M1 produced similar magnitudes of response, and every participant had seroconversion according to either assay measurement. Reverse cumulative-distribution curves for day 35 are presented in Figure S2. Figure 5. Figure 5.

Rhypertension CD4+ T-cell Responses with or without Matrix-M1 Adjuvant. Frequencies of antigen-specific CD4+ T cells producing T helper 1 (Th1) cytokines interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), and interleukin-2 and for T helper 2 (Th2) cytokines interleukin-5 and interleukin-13 indicated cytokines from four participants each in the placebo (group A), 25-μg unadjuvanted (group B), 5-μg adjuvanted (group C), and 25-μg adjuvanted (group D) groups at baseline (day 0) and 1 week after the second vaccination (day 28) after stimulation with the recombinant spike protein. €œAny 2Th1” indicates CD4+ T cells that can produce two types of Th1 cytokines at the same time. €œAll 3 Th1” indicates CD4+ T cells that produce IFN-γ, TNF-α, and interleukin-2 simultaneously. €œBoth Th2” indicates CD4+ T cells that can produce Th2 cytokines interleukin-5 and interleukin-13 at the same time.T-cell responses in 16 participants who were randomly selected from groups A through D, 4 participants per group, showed that adjuvanted regimens induced antigen-specific polyfunctional CD4+ T-cell responses that were reflected in IFN-γ, IL-2, and TNF-α production on spike protein stimulation.

A strong bias toward this Th1 phenotype was noted. Th2 responses (as measured by IL-5 and IL-13 cytokines) were minimal (Figure 5).Start Preamble Centers for Medicare &. Medicaid Services (CMS), HHS. Extension of timeline for publication of final rule. This notice announces an extension of the timeline for publication of a Medicare final rule in accordance with the Social Security Act, which allows us to extend the timeline for publication of the final rule.

As of August 26, 2020, the timeline for publication of the final rule to finalize the provisions of the October 17, 2019 proposed rule (84 FR 55766) is extended until August 31, 2021. Start Further Info Lisa O. Wilson, (410) 786-8852. End Further Info End Preamble Start Supplemental Information In the October 17, 2019 Federal Register (84 FR 55766), we published a proposed rule that addressed undue regulatory impact and burden of the physician self-referral law. The proposed rule was issued in conjunction with the Centers for Medicare &.

Medicaid Services' (CMS) Patients over Paperwork initiative and the Department of Health and Human Services' (the Department or HHS) Regulatory Sprint to Coordinated Care. In the proposed rule, we proposed exceptions to the physician self-referral law for certain value-based compensation arrangements between or among physicians, providers, and suppliers. A new exception for certain arrangements under which a physician receives limited remuneration for items or services actually provided by the physician. A new exception for donations of cybersecurity technology and related services. And amendments to the existing exception for electronic health records (EHR) items and services.

The proposed rule also provides critically necessary guidance for physicians and health care providers and suppliers whose financial relationships are governed by the physician self-referral statute and regulations. This notice announces an extension of the timeline for publication of the final rule and the continuation of effectiveness of the proposed rule. Section 1871(a)(3)(A) of the Social Security Act (the Act) requires us to establish and publish a regular timeline for the publication of final regulations based on the previous publication of a proposed regulation. In accordance with section 1871(a)(3)(B) of the Act, the timeline may vary among different regulations based on differences in the complexity of the regulation, the number and scope of comments received, and other relevant factors, but may not be longer than 3 years except under exceptional circumstances. In addition, in accordance with section 1871(a)(3)(B) of the Act, the Secretary may extend the initial targeted publication date of the final regulation if the Secretary, no later than the regulation's previously established proposed publication date, publishes a notice with the new target date, and such notice includes a brief explanation of the justification for the variation.

We announced in the Spring 2020 Unified Agenda (June 30, 2020, www.reginfo.gov) that we would issue the final rule in August 2020. However, we are still working through the Start Printed Page 52941complexity of the issues raised by comments received on the proposed rule and therefore we are not able to meet the announced publication target date. This notice extends the timeline for publication of the final rule until August 31, 2021. Start Signature Dated. August 24, 2020.

Wilma M. Robinson, Deputy Executive Secretary to the Department, Department of Health and Human Services. End Signature End Supplemental Information [FR Doc. 2020-18867 Filed 8-26-20. 8:45 am]BILLING CODE 4120-01-PStart Preamble Notice of amendment.

The Secretary issues this amendment pursuant to section 319F-3 of the Public Health Service Act to add additional categories of Qualified Persons and amend the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures. This amendment to the Declaration published on March 17, 2020 (85 FR 15198) is effective as of August 24, 2020. Start Further Info Robert P. Kadlec, MD, MTM&H, MS, Assistant Secretary for Preparedness and Response, Office of the Secretary, Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201. Telephone.

202-205-2882. End Further Info End Preamble Start Supplemental Information The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the Secretary of Health and Human Services (the Secretary) to issue a Declaration to provide liability immunity to certain individuals and entities (Covered Persons) against any claim of loss caused by, arising out of, relating to, or resulting from the manufacture, distribution, administration, or use of medical countermeasures (Covered Countermeasures), except for claims involving “willful misconduct” as defined in the PREP Act. Under the PREP Act, a Declaration may be amended as circumstances warrant. The PREP Act was enacted on December 30, 2005, as Public Law 109-148, Division C, § 2. It amended the Public Health Service (PHS) Act, adding section 319F-3, which addresses liability immunity, and section 319F-4, which creates a compensation program.

These sections are codified at 42 U.S.C. 247d-6d and 42 U.S.C. 247d-6e, respectively. Section 319F-3 of the PHS Act has been amended by the lasix and All-Hazards Preparedness Reauthorization Act (PAHPRA), Public Law 113-5, enacted on March 13, 2013 and the hypertension Aid, Relief, and Economic Security (CARES) Act, Public Law 116-136, enacted on March 27, Start Printed Page 521372020, to expand Covered Countermeasures under the PREP Act. On January 31, 2020, the Secretary declared a public health emergency pursuant to section 319 of the PHS Act, 42 U.S.C.

247d, effective January 27, 2020, for the entire United States to aid in the response of the nation's health care community to the hypertension medications outbreak. Pursuant to section 319 of the PHS Act, the Secretary renewed that declaration on April 26, 2020, and July 25, 2020. On March 10, 2020, the Secretary issued a Declaration under the PREP Act for medical countermeasures against hypertension medications (85 FR 15198, Mar. 17, 2020) (the Declaration). On April 10, the Secretary amended the Declaration under the PREP Act to extend liability immunity to covered countermeasures authorized under the CARES Act (85 FR 21012, Apr.

15, 2020). On June 4, the Secretary amended the Declaration to clarify that covered countermeasures under the Declaration include qualified countermeasures that limit the harm hypertension medications might otherwise cause. The Secretary now amends section V of the Declaration to identify as qualified persons covered under the PREP Act, and thus authorizes, certain State-licensed pharmacists to order and administer, and pharmacy interns (who are licensed or registered by their State board of pharmacy and acting under the supervision of a State-licensed pharmacist) to administer, any treatment that the Advisory Committee on Immunization Practices (ACIP) recommends to persons ages three through 18 according to ACIP's standard immunization schedule (ACIP-recommended treatments).[] The Secretary also amends section VIII of the Declaration to clarify that the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures includes not only hypertension medications caused by hypertension or a lasix mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by hypertension medications, hypertension, or a lasix mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Description of This Amendment by Section Section V. Covered Persons Under the PREP Act and the Declaration, a “qualified person” is a “covered person.” Subject to certain limitations, a covered person is immune from suit and liability under Federal and State law with respect to all claims for loss caused by, arising out of, relating to, or resulting from the administration or use of a covered countermeasure if a declaration under subsection (b) has been issued with respect to such countermeasure.

€œQualified person” includes (A) a licensed health professional or other individual who is authorized to prescribe, administer, or dispense such countermeasures under the law of the State in which the countermeasure was prescribed, administered, or dispensed. Or (B) “a person within a category of persons so identified in a declaration by the Secretary” under subsection (b) of the PREP Act. 42 U.S.C. 247d-6d(i)(8).[] By this amendment to the Declaration, the Secretary identifies an additional category of persons who are qualified persons under section 247d-6d(i)(8)(B).[] On May 8, 2020, CDC reported, “The identified declines in routine pediatric treatment ordering and doses administered might indicate that U.S. Children and their communities face increased risks for outbreaks of treatment-preventable diseases,” and suggested that a decrease in rates of routine childhood vaccinations were due to changes in healthcare access, social distancing, and other hypertension medications mitigation strategies.[] The report also stated that “[p]arental concerns about potentially exposing their children to hypertension medications during well child visits might contribute to the declines observed.” [] On July 10, 2020, CDC reported its findings of a May survey it conducted to assess the capacity of pediatric health care practices to provide immunization services to children during the hypertension medications lasix.

The survey, which was limited to practices participating in the treatments for Children program, found that, as of mid-May, 15 percent of Northeast pediatric practices were closed, 12.5 percent of Midwest practices were closed, 6.2 percent of practices in the South were closed, and 10 percent of practices in the West were closed. Most practices had reduced office hours for in-person visits. When asked whether their practices would likely be able to accommodate new patients for immunization services through August, 418 practices (21.3 percent) either responded that this was not likely or the practice was permanently closed or not resuming immunization services for all patients, and 380 (19.6 percent) responded that they were unsure. Urban practices and those in the Northeast were less likely to be able to accommodate new patients compared with rural practices and those in the South, Midwest, or West.[] In response to these troubling developments, CDC and the American Academy of Pediatrics have stressed, “Well-child visits and vaccinations are essential services and help make sure children are protected.” [] The Secretary re-emphasizes that important recommendation to parents and legal guardians here. If your child is due for a well-child visit, contact your pediatrician's or other primary-care provider's office and ask about ways that the office safely offers well-child visits and vaccinations.

Many medical offices are taking extra steps to make sure that well-child visits can occur safely during the hypertension medications lasix, including. Scheduling sick visits and well-child visits during different times of the Start Printed Page 52138day or days of the week, or at different locations. Asking patients to remain outside until it is time for their appointments to reduce the number of people in waiting rooms. Adhering to recommended social (physical) distancing and other -control practices, such as the use of masks. The decrease in childhood-vaccination rates is a public health threat and a collateral harm caused by hypertension medications.

Together, the United States must turn to available medical professionals to limit the harm and public health threats that may result from decreased immunization rates. We must quickly do so to avoid preventable s in children, additional strains on our healthcare system, and any further increase in avoidable adverse health consequences—particularly if such complications coincide with additional resurgence of hypertension medications. Together with pediatricians and other healthcare professionals, pharmacists are positioned to expand access to childhood vaccinations. Many States already allow pharmacists to administer treatments to children of any age.[] Other States permit pharmacists to administer treatments to children depending on the age—for example, 2, 3, 5, 6, 7, 9, 10, 11, or 12 years of age and older.[] Few States restrict pharmacist-administered vaccinations to only adults.[] Many States also allow properly trained individuals under the supervision of a trained pharmacist to administer those treatments.[] Pharmacists are well positioned to increase access to vaccinations, particularly in certain areas or for certain populations that have too few pediatricians and other primary-care providers, or that are otherwise medically underserved.[] As of 2018, nearly 90 percent of Americans lived within five miles of a community pharmacy.[] Pharmacies often offer extended hours and added convenience. What is more, pharmacists are trusted healthcare professionals with established relationships with their patients.

Pharmacists also have strong relationships with local medical providers and hospitals to refer patients as appropriate. For example, pharmacists already play a significant role in annual influenza vaccination. In the early 2018-19 season, they administered the influenza treatment to nearly a third of all adults who received the treatment.[] Given the potential danger of serious influenza and continuing hypertension medications outbreaks this autumn and the impact that such concurrent outbreaks may have on our population, our healthcare system, and our whole-of-nation response to the hypertension medications lasix, we must quickly expand access to influenza vaccinations. Allowing more qualified pharmacists to administer the influenza treatment to children will make vaccinations more accessible. Therefore, the Secretary amends the Declaration to identify State-licensed pharmacists (and pharmacy interns acting under their supervision if the pharmacy intern is licensed or registered by his or her State board of pharmacy) as qualified persons under section 247d-6d(i)(8)(B) when the pharmacist orders and either the pharmacist or the supervised pharmacy intern administers treatments to individuals ages three through 18 pursuant to the following requirements.

The treatment must be FDA-authorized or FDA-approved. The vaccination must be ordered and administered according to ACIP's standard immunization schedule.[] The licensed pharmacist must complete a practical training program of at least 20 hours that is approved by the Accreditation Council for Pharmacy Education (ACPE). This training Start Printed Page 52139program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments.[] The licensed or registered pharmacy intern must complete a practical training program that is approved by the ACPE. This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments.[] The licensed pharmacist and licensed or registered pharmacy intern must have a current certificate in basic cardiopulmonary resuscitation.[] The licensed pharmacist must complete a minimum of two hours of ACPE-approved, immunization-related continuing pharmacy education during each State licensing period.[] The licensed pharmacist must comply with recordkeeping and reporting requirements of the jurisdiction in which he or she administers treatments, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (treatment registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a treatment must review the treatment registry or other vaccination records prior to administering a treatment.[] The licensed pharmacist must inform his or her childhood-vaccination patients and the adult caregivers accompanying the children of the importance of a well-child visit with a pediatrician or other licensed primary-care provider and refer patients as appropriate.[] These requirements are consistent with those in many States that permit licensed pharmacists to order and administer treatments to children and permit licensed or registered pharmacy interns acting under their supervision to administer treatments to children.[] Administering vaccinations to children age three and older is less complicated and requires less training and resources than administering vaccinations to younger children. That is because ACIP generally recommends administering intramuscular injections in the deltoid muscle for individuals age three and older.[] For individuals less than three years of age, ACIP generally recommends administering intramuscular injections in the anterolateral aspect of the thigh muscle.[] Administering injections in the thigh muscle often presents additional complexities and requires additional training and resources including additional personnel to safely position the child while another healthcare professional injects the treatment.[] Moreover, as of 2018, 40% of three-year-olds were enrolled in preprimary programs (i.e.

Preschool or kindergarten programs).[] Preprimary programs are beginning in the coming weeks or months, so the Secretary has concluded that it is particularly important for individuals ages three through 18 to receive ACIP-recommended treatments according to ACIP's standard immunization schedule. All States require children to be vaccinated against certain communicable diseases as a condition of school attendance. These laws often apply to both public and private schools with identical immunization and exemption provisions.[] As nurseries, preschools, kindergartens, and schools reopen, increased access to childhood vaccinations is essential to ensuring children can return. Notwithstanding any State or local scope-of-practice legal requirements, (1) qualified licensed pharmacists are identified as qualified persons to order and administer ACIP-recommended treatments and (2) qualified State-licensed or registered pharmacy interns are identified as qualified persons to administer the ACIP-recommended treatments ordered by their supervising qualified licensed pharmacist.[] Both the PREP Act and the June 4, 2020 Second Amendment to the Declaration define “covered countermeasures” to include qualified lasix and epidemic products that “limit the harm such lasix or epidemic might otherwise cause.” [] The troubling decrease in ACIP-recommended childhood vaccinations and the resulting increased risk of associated diseases, adverse health conditions, and other threats are categories of harms otherwise caused by Start Printed Page 52140hypertension medications as set forth in Sections VI and VIII of this Declaration.[] Hence, such vaccinations are “covered countermeasures” under the PREP Act and the June 4, 2020 Second Amendment to the Declaration. Nothing in this Declaration shall be construed to affect the National treatment Injury Compensation Program, including an injured party's ability to obtain compensation under that program.

Covered countermeasures that are subject to the National treatment Injury Compensation Program authorized under 42 U.S.C. 300aa-10 et seq. Are covered under this Declaration for the purposes of liability immunity and injury compensation only to the extent that injury compensation is not provided under that Program. All other terms and conditions of the Declaration apply to such covered countermeasures. Section VIII.

Category of Disease, Health Condition, or Threat As discussed, the troubling decrease in ACIP-recommended childhood vaccinations and the resulting increased risk of associated diseases, adverse health conditions, and other threats are categories of harms otherwise caused by hypertension medications. The Secretary therefore amends section VIII, which describes the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures, to clarify that the category of disease, health condition, or threat for which he recommends the administration or use of the Covered Countermeasures is not only hypertension medications caused by hypertension or a lasix mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by hypertension medications, hypertension, or a lasix mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Amendments to Declaration Amended Declaration for Public Readiness and Emergency Preparedness Act Coverage for medical countermeasures against hypertension medications. Sections V and VIII of the March 10, 2020 Declaration under the PREP Act for medical countermeasures against hypertension medications, as amended April 10, 2020 and June 4, 2020, are further amended pursuant to section 319F-3(b)(4) of the PHS Act as described below. All other sections of the Declaration remain in effect as published at 85 FR 15198 (Mar.

17, 2020) and amended at 85 FR 21012 (Apr. 15, 2020) and 85 FR 35100 (June 8, 2020). 1. Covered Persons, section V, delete in full and replace with. V.

Covered Persons 42 U.S.C. 247d-6d(i)(2), (3), (4), (6), (8)(A) and (B) Covered Persons who are afforded liability immunity under this Declaration are “manufacturers,” “distributors,” “program planners,” “qualified persons,” and their officials, agents, and employees, as those terms are defined in the PREP Act, and the United States. In addition, I have determined that the following additional persons are qualified persons. (a) Any person authorized in accordance with the public health and medical emergency response of the Authority Having Jurisdiction, as described in Section VII below, to prescribe, administer, deliver, distribute or dispense the Covered Countermeasures, and their officials, agents, employees, contractors and volunteers, following a Declaration of an emergency. (b) any person authorized to prescribe, administer, or dispense the Covered Countermeasures or who is otherwise authorized to perform an activity under an Emergency Use Authorization in accordance with Section 564 of the FD&C Act.

(c) any person authorized to prescribe, administer, or dispense Covered Countermeasures in accordance with Section 564A of the FD&C Act. And (d) a State-licensed pharmacist who orders and administers, and pharmacy interns who administer (if the pharmacy intern acts under the supervision of such pharmacist and the pharmacy intern is licensed or registered by his or her State board of pharmacy), treatments that the Advisory Committee on Immunization Practices (ACIP) recommends to persons ages three through 18 according to ACIP's standard immunization schedule. Such State-licensed pharmacists and the State-licensed or registered interns under their supervision are qualified persons only if the following requirements are met. The treatment must be FDA-authorized or FDA-approved. The vaccination must be ordered and administered according to ACIP's standard immunization schedule.

The licensed pharmacist must complete a practical training program of at least 20 hours that is approved by the Accreditation Council for Pharmacy Education (ACPE). This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments. The licensed or registered pharmacy intern must complete a practical training program that is approved by the ACPE. This training program must include hands-on injection technique, clinical evaluation of indications and contraindications of treatments, and the recognition and treatment of emergency reactions to treatments. The licensed pharmacist and licensed or registered pharmacy intern must have a current certificate in basic cardiopulmonary resuscitation.

The licensed pharmacist must complete a minimum of two hours of ACPE-approved, immunization-related continuing pharmacy education during each State licensing period. The licensed pharmacist must comply with recordkeeping and reporting requirements of the jurisdiction in which he or she administers treatments, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (treatment registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a treatment must review the treatment registry or other vaccination records prior to administering a treatment. The licensed pharmacist must inform his or her childhood-vaccination patients and the adult caregiver accompanying the child of the importance of a well-child visit with a pediatrician or other licensed primary-care provider and refer patients as appropriate. Nothing in this Declaration shall be construed to affect the National treatment Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National treatment Injury Compensation Program authorized under 42 U.S.C.

300aa-10 et seq. Are covered under this Declaration for the purposes of liability immunity and injury compensation only to the extent that injury compensation is not provided under that Program. All other Start Printed Page 52141terms and conditions of the Declaration apply to such covered countermeasures. 2. Category of Disease, Health Condition, or Threat, section VIII, delete in full and replace with.

VIII. Category of Disease, Health Condition, or Threat 42 U.S.C. 247d-6d(b)(2)(A) The category of disease, health condition, or threat for which I recommend the administration or use of the Covered Countermeasures is not only hypertension medications caused by hypertension or a lasix mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by hypertension medications, hypertension, or a lasix mutating therefrom, including the decrease in the rate of childhood immunizations, which will lead to an increase in the rate of infectious diseases. Start Authority 42 U.S.C. 247d-6d.

End Authority Start Signature Dated. August 19, 2020. Alex M. Azar II, Secretary of Health and Human Services. End Signature End Supplemental Information [FR Doc.

2020-18542 Filed 8-20-20. 4:15 pm]BILLING CODE 4150-03-P.

What if I miss a dose?

If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses.

Does lasix cause hyponatremia

Protecting the does lasix cause hyponatremia safety and health of essential workers who support America’s food security—including the meat, poultry, and pork processing industries—is How to buy cheap ventolin a top priority for the Occupational Safety and Health Administration (OSHA). OSHA and the Centers for Disease Control and Prevention issued additional guidance to reduce the risk of exposure to the hypertension and keep workers safe and healthy in the meatpacking and meat processing industries —including those involved in beef, pork, and poultry operations. This new guidance provides specific does lasix cause hyponatremia recommendations for employers to meet their obligations to protect workers in these facilities, where people normally work closely together and share workspaces and equipment. Here are eight ways to help minimize meat processing workers’ exposure to the hypertension.

Screen workers before they enter the workplace. If a worker becomes sick, send them home does lasix cause hyponatremia and disinfect their workstation and any tools they used. Move workstations farther apart. Install partitions between workstations using strip curtains, plexiglass, or similar materials.

To limit spread between groups, assign the does lasix cause hyponatremia same workers to the same shifts with the same coworkers. Prevent workers from using other workers’ equipment. Allow workers to wear face coverings when entering, inside, and exiting the facility. Encourage workers to report does lasix cause hyponatremia any safety and health concerns to their supervisors.

OSHA is committed to ensuring that workers and employers in essential industries have clear guidance to keep workers safe and healthy from the hypertension—including guidance for essential workers in construction, manufacturing, package delivery, and retail. Workers and employers who have questions or concerns about workplace safety can contact OSHA online or by phone at 1-800-321-6742 (OSHA). You can find additional resources and learn more does lasix cause hyponatremia about OSHA’s response to the hypertension at www.osha.gov/hypertension. Loren Sweatt is the Principal Deputy Assistant Secretary for the U.S.

Department of Labor’s Occupation Safety and Health Administration Editor’s Note. It is important to does lasix cause hyponatremia note that information and guidance about hypertension medications continually evolve as conditions change. Workers and employers are encouraged to regularly refer to the resources below for updates:This October is the 75th anniversary of National Disability Employment Awareness Month (NDEAM), which happens to fall in the same year as we’re celebrating the 30th anniversary of the Americans with Disabilities Act, or ADA. To celebrate, the U.S.

Department of Labor’s Office of Disability Employment Policy (ODEP) held a does lasix cause hyponatremia virtual event this week focused on increasing access and opportunity through accessible technology.Accessible technology is key to advancing the employment success of people with disabilities and delivering on the promise inherent in the ADA. As our workplaces continue to evolve and advance, we know that new, emerging technologies will play an increasingly central role in how we get to work and how we perform on the job. During the event, we explored some of those exciting innovations does lasix cause hyponatremia with technology thought leaders, disability advocates, and experts in accessibility, transportation, and emerging technologies. Watch the full program.

[embedded content] Some key takeaways from the event include. Having an “accessibility for all” mindset in technology development does lasix cause hyponatremia – known as universal design – is essential and is increasingly starting to take hold. It’s important to have accessibility baked into a product right from the beginning. For example, I used to use an external microphone to power my computer’s voice-to-text capability, but now, that software is built right into my laptop and my smartphone.

Artificial intelligence has the potential to increase access to the workplace by eliminating potential bias in does lasix cause hyponatremia traditional job screening tools and methods, which have often been inaccessible for individuals with certain disabilities. Autonomous vehicles will be a game-changer for people with disabilities who cannot drive – but only if they are accessible. More employers are recognizing the skills of neurodiverse individuals and putting in place proactive hiring practices and electronic tools designed to tap into this talent pool. Through ODEP’s Partnership on Employment and Accessible Technology and related does lasix cause hyponatremia efforts, we help employers understand the importance of implementing workplace technology that works for everyone, and teach companies how to build and buy accessible products.

Because viewed in a certain light, all technologies are assistive. We’re at a moment of imagining possibilities to improve workplace inclusion for people with disabilities — for example, to cease designing around the idea of the “average” person to instead focus on usability by all. In this milestone year, the does lasix cause hyponatremia discussion this week was a great reminder of why increasing access and opportunity will be so critical over the next few decades. Success will take ongoing collaboration between tech industry leaders, entrepreneurs, academics, advocates, government leaders, and others.

By working together, we can build a future that works for all Americans. To learn more about ODEP’s accessible technology does lasix cause hyponatremia efforts, please visit https://peatworks.org. Jennifer Sheehy is the Deputy Assistant Secretary of Labor for Disability Employment Policy in the U.S. Department of Labor’s Office of Disability Employment Policy..

Protecting the safety and health of essential workers who support America’s food security—including the meat, poultry, and pork http://quietlions.co.uk/how-to-buy-cheap-ventolin/ processing industries—is a how do you get lasix top priority for the Occupational Safety and Health Administration (OSHA). OSHA and the Centers for Disease Control and Prevention issued additional guidance to reduce the risk of exposure to the hypertension and keep workers safe and healthy in the meatpacking and meat processing industries —including those involved in beef, pork, and poultry operations. This new guidance provides specific recommendations for employers to meet their obligations to protect workers in these facilities, where people normally work closely how do you get lasix together and share workspaces and equipment. Here are eight ways to help minimize meat processing workers’ exposure to the hypertension.

Screen workers before they enter the workplace. If a worker becomes sick, send them home and disinfect how do you get lasix their workstation and any tools they used. Move workstations farther apart. Install partitions between workstations using strip curtains, plexiglass, or similar materials.

To limit spread how do you get lasix between groups, assign the same workers to the same shifts with the same coworkers. Prevent workers from using other workers’ equipment. Allow workers to wear face coverings when entering, inside, and exiting the facility. Encourage workers to report how do you get lasix any safety and health concerns to their supervisors.

OSHA is committed to ensuring that workers and employers in essential industries have clear guidance to keep workers safe and healthy from the hypertension—including guidance for essential workers in construction, manufacturing, package delivery, and retail. Workers and employers who have questions or concerns about workplace safety can contact OSHA online or by phone at 1-800-321-6742 (OSHA). You can how do you get lasix find additional resources and learn more about OSHA’s response to the hypertension at www.osha.gov/hypertension. Loren Sweatt is the Principal Deputy Assistant Secretary for the U.S.

Department of Labor’s Occupation Safety and Health Administration Editor’s Note. It is important to note that information and guidance about hypertension medications continually evolve as conditions how do you get lasix change. Workers and employers are encouraged to regularly refer to the resources below for updates:This October is the 75th anniversary of National Disability Employment Awareness Month (NDEAM), which happens to fall in the same year as we’re celebrating the 30th anniversary of the Americans with Disabilities Act, or ADA. To celebrate, the U.S.

Department of Labor’s Office of Disability Employment Policy (ODEP) held a virtual event this week focused on how do you get lasix increasing access and opportunity through accessible technology.Accessible technology is key to advancing the employment success of people with disabilities and delivering on the promise inherent in the ADA. As our workplaces continue to evolve and advance, we know that new, emerging technologies will play an increasingly central role in how we get to work and how we perform on the job. During the event, we explored some of those exciting innovations with technology thought leaders, disability advocates, and experts in accessibility, transportation, and emerging technologies how do you get lasix. Watch the full program.

[embedded content] Some key takeaways from the event include. Having an “accessibility for all” mindset in technology development – known as universal design – is essential and is increasingly starting to how do you get lasix take hold. It’s important to have accessibility baked into a product right from the beginning. For example, I used to use an external microphone to power my computer’s voice-to-text capability, but now, that software is built right into my laptop and my smartphone.

Artificial intelligence has the potential to increase access to the workplace by eliminating potential bias in traditional job screening tools and methods, which have often been inaccessible for individuals with certain how do you get lasix disabilities. Autonomous vehicles will be a game-changer for people with disabilities who cannot drive – but only if they are accessible. More employers are recognizing the skills of neurodiverse individuals and putting in place proactive hiring practices and electronic tools designed to tap into this talent pool. Through ODEP’s Partnership on Employment and Accessible Technology and related efforts, we help employers understand the importance how do you get lasix of implementing workplace technology that works for everyone, and teach companies how to build and buy accessible products.

Because viewed in a certain light, all technologies are assistive. We’re at a moment of imagining possibilities to improve workplace inclusion for people with disabilities — for example, to cease designing around the idea of the “average” person to instead focus on usability by all. In this milestone year, the discussion this week was a great how do you get lasix reminder of why increasing access and opportunity will be so critical over the next few decades. Success will take ongoing collaboration between tech industry leaders, entrepreneurs, academics, advocates, government leaders, and others.

By working together, we can build a future that works for all Americans. To learn more about how do you get lasix ODEP’s accessible technology efforts, please visit https://peatworks.org. Jennifer Sheehy is the Deputy Assistant Secretary of Labor for Disability Employment Policy in the U.S. Department of Labor’s Office of Disability Employment Policy..

Lasix toxicity

Download Article lasix toxicity http://826la.org/event/echo-park-living-with-monsters/. Download (PDF 40.8 kb) No AbstractNo Reference information available - sign in for access. No Supplementary Data.No Article MediaNo MetricsDocument Type.

EditorialAffiliations:1. Department of Pneumology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova, Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany 2. Treatment Action Campaign, Cape Town, Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa 3.

Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USAPublication date:01 September 2021More about this publication?. The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on TB, TB-HIV and respiratory diseases such as hypertension medications, asthma, COPD, child lung health and the hazards of tobacco and air pollution. Individuals and institutes can subscribe to the IJTLD see online or in print – simply email us at [email protected] for details.

The IJTLD is dedicated to understanding lung disease and to the dissemination of knowledge leading to better lung health. To allow us to share scientific research as rapidly as possible, the IJTLD is fast-tracking the publication of certain articles as preprints prior to their publication. Read fast-track articles.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 websitesNo AbstractNo Reference information available - sign in for access.

No Supplementary Data.No Article MediaNo MetricsDocument Type. EditorialAffiliations:1. Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico, Tradate 2.

Paediatric Clinic, Pietro Barilla Children´s Hospital, Department of Medicine and Surgery, University of Parma, Parma, ItalyPublication date:01 September 2021More about this publication?.

Download (PDF 40.8 kb) No AbstractNo Reference information available how do you get lasix - sign in for access. No Supplementary Data.No Article MediaNo MetricsDocument Type. EditorialAffiliations:1.

Department of Pneumology and Allergology, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova, Division of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Borstel, Germany how do you get lasix 2. Treatment Action Campaign, Cape Town, Médecins Sans Frontières, Khayelitsha, Cape Town, South Africa 3. Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USAPublication date:01 September 2021More about this publication?.

The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on how do you get lasix TB, TB-HIV and respiratory diseases such as hypertension medications, asthma, COPD, child lung health and the hazards of tobacco and air pollution. Individuals and institutes can subscribe to the IJTLD online or in print – simply email us at [email protected] for details. The IJTLD is dedicated to understanding lung disease and to the dissemination of knowledge leading to better lung health.

To allow us to share scientific research as rapidly as possible, the IJTLD is fast-tracking the publication of certain articles as preprints prior to their publication. Read fast-track articles.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 websitesNo AbstractNo Reference information available - sign in for access. No Supplementary Data.No Article MediaNo MetricsDocument Type.

EditorialAffiliations:1. Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico, Tradate 2. Paediatric Clinic, Pietro Barilla Children´s Hospital, Department of Medicine and Surgery, University of Parma, Parma, ItalyPublication date:01 September 2021More about this publication?.

The International Journal of Tuberculosis and Lung Disease (IJTLD) is for clinical research and epidemiological studies on lung health, including articles on TB, TB-HIV and respiratory diseases such as hypertension medications, asthma, COPD, child lung health and the hazards of tobacco and air pollution.

Lasix incontinence

GOLDEN VALLEY, MN – Low-wage workers lasix incontinence often do much of the essential work in our communities, and women, immigrants and people of color often hold those jobs. The healthcare industry employs many of the nation’s low-wage workers, which underscores the importance of a federal court action and a U.S. Department of Labor Wage and Hour Division investigation related to a Golden Valley home healthcare provider.On Aug.

5, 2021, lasix incontinence U.S. District Court Judge Wilhelmina M. Wright for the District of Minnesota approved a settlement agreement between the department and Alliance HHC &.

Nursing Service LLC to resolve Fair Labor Standards lasix incontinence Act violations the department found in an investigation. The agreement requires Alliance to pay $241,582 in back wages and $241,582 in liquidated damages to 82 home healthcare workers it employs. The investigation determined Alliance HHC &.

Nursing Service LLC and its owner Robin Nyangena failed to pay workers overtime when they worked more than 40 hours in lasix incontinence a workweek, as the law requires. Instead, the employer continued to pay workers straight-time rates, regardless of the number of hours they worked each week. The home healthcare workers provide skilled nursing, private duty, personal aide and therapy services.

€œThe essential care that home healthcare workers lasix incontinence provide helps their clients maintain their dignity and remain in their homes,” said Acting Wage and Hour Division District Director Kristin Tout in Minneapolis. €œThe Wage and Hour Division is committed to ensuring essential employees receive every dollar of their hard-earned wages and that employers abide by the federal wage laws. Other employers should use the outcome of this investigation as an opportunity to review their own pay practices to ensure they comply with the law.” The division recently launched the Essential Workers, Essential Protections initiative to ensure that workers know about the workplace laws that protect them – and how to contact the division to get the help they need.

Learn more about wage rules lasix incontinence for healthcare workers. For more information about the FLSA and other laws enforced by the division, contact the agency’s toll-free helpline at 866-4US-WAGE (487-9243). Learn more about the Wage and Hour Division and use its search tool if you think you may be owed back wages collected by the division.

COURT NO lasix incontinence. Walsh v. Alliance HHC &.

Nursing Service LLC, Robin Nyangena 0:20-cv-01259 WMW-KMM.

GOLDEN VALLEY, MN – Low-wage workers how do you get lasix often do much of the official website essential work in our communities, and women, immigrants and people of color often hold those jobs. The healthcare industry employs many of the nation’s low-wage workers, which underscores the importance of a federal court action and a U.S. Department of Labor Wage and Hour Division investigation related to a Golden Valley home healthcare provider.On Aug. 5, 2021, how do you get lasix U.S. District Court Judge Wilhelmina M.

Wright for the District of Minnesota approved a settlement agreement between the department and Alliance HHC &. Nursing Service LLC to resolve how do you get lasix Fair Labor Standards Act violations the department found in an investigation. The agreement requires Alliance to pay $241,582 in back wages and $241,582 in liquidated damages to 82 home healthcare workers it employs. The investigation determined Alliance HHC &. Nursing Service LLC and its owner Robin Nyangena failed to pay workers overtime when how do you get lasix they worked more than 40 hours in a workweek, as the law requires.

Instead, the employer continued to pay workers straight-time rates, regardless of the number of hours they worked each week. The home healthcare workers informative post provide skilled nursing, private duty, personal aide and therapy services. €œThe essential care that how do you get lasix home healthcare workers provide helps their clients maintain their dignity and remain in their homes,” said Acting Wage and Hour Division District Director Kristin Tout in Minneapolis. €œThe Wage and Hour Division is committed to ensuring essential employees receive every dollar of their hard-earned wages and that employers abide by the federal wage laws. Other employers should use the outcome of this investigation as an opportunity to review their own pay practices to ensure they comply with the law.” The division recently launched the Essential Workers, Essential Protections initiative to ensure that workers know about the workplace laws that protect them – and how to contact the division to get the help they need.

Learn more about wage rules how do you get lasix for healthcare workers. For more information about the FLSA and other laws enforced by the division, contact the agency’s toll-free helpline at 866-4US-WAGE (487-9243). Learn more about the Wage and Hour Division and use its search tool if you think you may be owed back wages collected by the division. COURT NO how do you get lasix. Walsh v.

Alliance HHC &. Nursing Service LLC, Robin Nyangena 0:20-cv-01259 WMW-KMM.