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How to buy lasix

Patients Figure how to buy lasix https://www.andrees-angelreisen.de/cheap-lasix/ 1. Figure 1. Enrollment and how to buy lasix Randomization.

Of the 1107 patients who were assessed for eligibility, 1063 underwent randomization. 541 were assigned to the remdesivir group and 522 how to buy lasix to the placebo group (Figure 1). Of those assigned to receive remdesivir, 531 patients (98.2%) received the treatment as assigned.

Forty-nine patients had remdesivir treatment discontinued before day 10 because of an adverse event or a serious adverse event other than death (36 patients) or because the patient withdrew consent (13). Of those assigned to receive placebo, how to buy lasix 518 patients (99.2%) received placebo as assigned. Fifty-three patients discontinued placebo before day 10 because of an adverse event or a serious adverse event other than death (36 patients), because the patient withdrew consent (15), or because the patient was found to be ineligible for trial enrollment (2).

As of April 28, 2020, a total of 391 patients in the remdesivir group and 340 in the placebo group had completed the trial through day 29, recovered, or how to buy lasix died. Eight patients who received remdesivir and 9 who received placebo terminated their participation in the trial before day 29. There were 132 patients in the remdesivir group and 169 in the placebo group who had not recovered and had not completed the day 29 follow-up how to buy lasix visit.

The analysis population included 1059 patients for whom we have at least some postbaseline data available (538 in the remdesivir group and 521 in the placebo group). Four of the 1063 patients were not included in the primary analysis because no postbaseline data were available at the time of the database freeze. Table 1 how to buy lasix.

Table 1. Demographic and Clinical how to buy lasix Characteristics at Baseline. The mean age of patients was 58.9 years, and 64.3% were male (Table 1).

On the basis of the evolving epidemiology of Covid-19 during the trial, 79.8% of patients were enrolled at sites in North America, 15.3% how to buy lasix in Europe, and 4.9% in Asia (Table S1). Overall, 53.2% of the patients were white, 20.6% were black, 12.6% were Asian, and 13.6% were designated as other or not reported. 249 (23.4%) were Hispanic or Latino.

Most patients had either one (27.0%) or two or how to buy lasix more (52.1%) of the prespecified coexisting conditions at enrollment, most commonly hypertension (49.6%), obesity (37.0%), and type 2 diabetes mellitus (29.7%). The median number of days between symptom onset and randomization was 9 (interquartile range, 6 to 12). Nine hundred forty-three (88.7%) patients had severe disease how to buy lasix at enrollment as defined in the Supplementary Appendix.

272 (25.6%) patients met category 7 criteria on the ordinal scale, 197 (18.5%) category 6, 421 (39.6%) category 5, and 127 (11.9%) category 4. There were 46 (4.3%) patients who had missing ordinal scale data at enrollment how to buy lasix. No substantial imbalances in baseline characteristics were observed between the remdesivir group and the placebo group.

Primary Outcome Figure 2. Figure 2 how to buy lasix. Kaplan–Meier Estimates of Cumulative Recoveries.

Cumulative recovery estimates are shown in the overall population (Panel A), in patients with a baseline score of how to buy lasix 4 on the ordinal scale (not receiving oxygen. Panel B), in those with a baseline score of 5 (receiving oxygen. Panel C), in those with a baseline score of 6 how to buy lasix (receiving high-flow oxygen or noninvasive mechanical ventilation.

Panel D), and in those with a baseline score of 7 (receiving mechanical ventilation or ECMO. Panel E). Table 2 how to buy lasix.

Table 2. Outcomes Overall and According to Score on the Ordinal Scale in the how to buy lasix Intention-to-Treat Population. Figure 3.

Figure 3 how to buy lasix. Time to Recovery According to Subgroup. The widths of the confidence intervals have not been adjusted for multiplicity and therefore cannot be used to infer treatment effects.

Race and ethnic group were how to buy lasix reported by the patients. Patients in the remdesivir group had a shorter time to recovery than patients in the placebo group (median, 11 days, as compared with 15 days. Rate ratio for recovery, how to buy lasix 1.32.

95% confidence interval [CI], 1.12 to 1.55. P<0.001. 1059 patients (Figure 2 and Table 2).

Among patients with a baseline ordinal score of 5 (421 patients), the rate ratio for recovery was 1.47 (95% CI, 1.17 to 1.84). Among patients with a baseline score of 4 (127 patients) and those with a baseline score of 6 (197 patients), the rate ratio estimates for recovery were 1.38 (95% CI, 0.94 to 2.03) and 1.20 (95% CI, 0.79 to 1.81), respectively. For those receiving mechanical ventilation or ECMO at enrollment (baseline ordinal scores of 7.

272 patients), the rate ratio for recovery was 0.95 (95% CI, 0.64 to 1.42). A test of interaction of treatment with baseline score on the ordinal scale was not significant. An analysis adjusting for baseline ordinal score as a stratification variable was conducted to evaluate the overall effect (of the percentage of patients in each ordinal score category at baseline) on the primary outcome.

This adjusted analysis produced a similar treatment-effect estimate (rate ratio for recovery, 1.31. 95% CI, 1.12 to 1.54. 1017 patients).

Table S2 in the Supplementary Appendix shows results according to the baseline severity stratum of mild-to-moderate as compared with severe. Patients who underwent randomization during the first 10 days after the onset of symptoms had a rate ratio for recovery of 1.28 (95% CI, 1.05 to 1.57. 664 patients), whereas patients who underwent randomization more than 10 days after the onset of symptoms had a rate ratio for recovery of 1.38 (95% CI, 1.05 to 1.81.

380 patients) (Figure 3). Key Secondary Outcome The odds of improvement in the ordinal scale score were higher in the remdesivir group, as determined by a proportional odds model at the day 15 visit, than in the placebo group (odds ratio for improvement, 1.50. 95% CI, 1.18 to 1.91.

P=0.001. 844 patients) (Table 2 and Fig. S5).

Mortality was numerically lower in the remdesivir group than in the placebo group, but the difference was not significant (hazard ratio for death, 0.70. 95% CI, 0.47 to 1.04. 1059 patients).

The Kaplan–Meier estimates of mortality by 14 days were 7.1% and 11.9% in the remdesivir and placebo groups, respectively (Table 2). The Kaplan–Meier estimates of mortality by 28 days are not reported in this preliminary analysis, given the large number of patients that had yet to complete day 29 visits. An analysis with adjustment for baseline ordinal score as a stratification variable showed a hazard ratio for death of 0.74 (95% CI, 0.50 to 1.10).

Safety Outcomes Serious adverse events occurred in 114 patients (21.1%) in the remdesivir group and 141 patients (27.0%) in the placebo group (Table S3). 4 events (2 in each group) were judged by site investigators to be related to remdesivir or placebo. There were 28 serious respiratory failure adverse events in the remdesivir group (5.2% of patients) and 42 in the placebo group (8.0% of patients).

Acute respiratory failure, hypotension, viral pneumonia, and acute kidney injury were slightly more common among patients in the placebo group. No deaths were considered to be related to treatment assignment, as judged by the site investigators. Grade 3 or 4 adverse events occurred in 156 patients (28.8%) in the remdesivir group and in 172 in the placebo group (33.0%) (Table S4).

The most common adverse events in the remdesivir group were anemia or decreased hemoglobin (43 events [7.9%], as compared with 47 [9.0%] in the placebo group). Acute kidney injury, decreased estimated glomerular filtration rate or creatinine clearance, or increased blood creatinine (40 events [7.4%], as compared with 38 [7.3%]). Pyrexia (27 events [5.0%], as compared with 17 [3.3%]).

Hyperglycemia or increased blood glucose level (22 events [4.1%], as compared with 17 [3.3%]). And increased aminotransferase levels including alanine aminotransferase, aspartate aminotransferase, or both (22 events [4.1%], as compared with 31 [5.9%]). Otherwise, the incidence of adverse events was not found to be significantly different between the remdesivir group and the placebo group.Trial Design and Oversight The RECOVERY trial was designed to evaluate the effects of potential treatments in patients hospitalized with Covid-19 at 176 National Health Service organizations in the United Kingdom and was supported by the National Institute for Health Research Clinical Research Network.

(Details regarding this trial are provided in the Supplementary Appendix, available with the full text of this article at NEJM.org.) The trial is being coordinated by the Nuffield Department of Population Health at the University of Oxford, the trial sponsor. Although the randomization of patients to receive dexamethasone, hydroxychloroquine, or lopinavir–ritonavir has now been stopped, the trial continues randomization to groups receiving azithromycin, tocilizumab, or convalescent plasma. Hospitalized patients were eligible for the trial if they had clinically suspected or laboratory-confirmed SARS-CoV-2 infection and no medical history that might, in the opinion of the attending clinician, put patients at substantial risk if they were to participate in the trial.

Initially, recruitment was limited to patients who were at least 18 years of age, but the age limit was removed starting on May 9, 2020. Pregnant or breast-feeding women were eligible. Written informed consent was obtained from all the patients or from a legal representative if they were unable to provide consent.

The trial was conducted in accordance with the principles of the Good Clinical Practice guidelines of the International Conference on Harmonisation and was approved by the U.K. Medicines and Healthcare Products Regulatory Agency and the Cambridge East Research Ethics Committee. The protocol with its statistical analysis plan is available at NEJM.org and on the trial website at www.recoverytrial.net.

The initial version of the manuscript was drafted by the first and last authors, developed by the writing committee, and approved by all members of the trial steering committee. The funders had no role in the analysis of the data, in the preparation or approval of the manuscript, or in the decision to submit the manuscript for publication. The first and last members of the writing committee vouch for the completeness and accuracy of the data and for the fidelity of the trial to the protocol and statistical analysis plan.

Randomization We collected baseline data using a Web-based case-report form that included demographic data, the level of respiratory support, major coexisting illnesses, suitability of the trial treatment for a particular patient, and treatment availability at the trial site. Randomization was performed with the use of a Web-based system with concealment of the trial-group assignment. Eligible and consenting patients were assigned in a 2:1 ratio to receive either the usual standard of care alone or the usual standard of care plus oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days (or until hospital discharge if sooner) or to receive one of the other suitable and available treatments that were being evaluated in the trial.

For some patients, dexamethasone was unavailable at the hospital at the time of enrollment or was considered by the managing physician to be either definitely indicated or definitely contraindicated. These patients were excluded from entry in the randomized comparison between dexamethasone and usual care and hence were not included in this report. The randomly assigned treatment was prescribed by the treating clinician.

Patients and local members of the trial staff were aware of the assigned treatments. Procedures A single online follow-up form was to be completed when the patients were discharged or had died or at 28 days after randomization, whichever occurred first. Information was recorded regarding the patients’ adherence to the assigned treatment, receipt of other trial treatments, duration of admission, receipt of respiratory support (with duration and type), receipt of renal support, and vital status (including the cause of death).

In addition, we obtained routine health care and registry data, including information on vital status (with date and cause of death), discharge from the hospital, and respiratory and renal support therapy. Outcome Measures The primary outcome was all-cause mortality within 28 days after randomization. Further analyses were specified at 6 months.

Secondary outcomes were the time until discharge from the hospital and, among patients not receiving invasive mechanical ventilation at the time of randomization, subsequent receipt of invasive mechanical ventilation (including extracorporeal membrane oxygenation) or death. Other prespecified clinical outcomes included cause-specific mortality, receipt of renal hemodialysis or hemofiltration, major cardiac arrhythmia (recorded in a subgroup), and receipt and duration of ventilation. Statistical Analysis As stated in the protocol, appropriate sample sizes could not be estimated when the trial was being planned at the start of the Covid-19 pandemic.

As the trial progressed, the trial steering committee, whose members were unaware of the results of the trial comparisons, determined that if 28-day mortality was 20%, then the enrollment of at least 2000 patients in the dexamethasone group and 4000 in the usual care group would provide a power of at least 90% at a two-sided P value of 0.01 to detect a clinically relevant proportional reduction of 20% (an absolute difference of 4 percentage points) between the two groups. Consequently, on June 8, 2020, the steering committee closed recruitment to the dexamethasone group, since enrollment had exceeded 2000 patients. For the primary outcome of 28-day mortality, the hazard ratio from Cox regression was used to estimate the mortality rate ratio.

Among the few patients (0.1%) who had not been followed for 28 days by the time of the data cutoff on July 6, 2020, data were censored either on that date or on day 29 if the patient had already been discharged. That is, in the absence of any information to the contrary, these patients were assumed to have survived for 28 days. Kaplan–Meier survival curves were constructed to show cumulative mortality over the 28-day period.

Cox regression was used to analyze the secondary outcome of hospital discharge within 28 days, with censoring of data on day 29 for patients who had died during hospitalization. For the prespecified composite secondary outcome of invasive mechanical ventilation or death within 28 days (among patients who were not receiving invasive mechanical ventilation at randomization), the precise date of invasive mechanical ventilation was not available, so a log-binomial regression model was used to estimate the risk ratio. Table 1.

Table 1. Characteristics of the Patients at Baseline, According to Treatment Assignment and Level of Respiratory Support. Through the play of chance in the unstratified randomization, the mean age was 1.1 years older among patients in the dexamethasone group than among those in the usual care group (Table 1).

To account for this imbalance in an important prognostic factor, estimates of rate ratios were adjusted for the baseline age in three categories (<70 years, 70 to 79 years, and ≥80 years). This adjustment was not specified in the first version of the statistical analysis plan but was added once the imbalance in age became apparent. Results without age adjustment (corresponding to the first version of the analysis plan) are provided in the Supplementary Appendix.

Prespecified analyses of the primary outcome were performed in five subgroups, as defined by characteristics at randomization. Age, sex, level of respiratory support, days since symptom onset, and predicted 28-day mortality risk. (One further prespecified subgroup analysis regarding race will be conducted once the data collection has been completed.) In prespecified subgroups, we estimated rate ratios (or risk ratios in some analyses) and their confidence intervals using regression models that included an interaction term between the treatment assignment and the subgroup of interest.

Chi-square tests for linear trend across the subgroup-specific log estimates were then performed in accordance with the prespecified plan. All P values are two-sided and are shown without adjustment for multiple testing. All analyses were performed according to the intention-to-treat principle.

The full database is held by the trial team, which collected the data from trial sites and performed the analyses at the Nuffield Department of Population Health, University of Oxford.Trial Population Table 1. Table 1. Characteristics of the Participants in the mRNA-1273 Trial at Enrollment.

The 45 enrolled participants received their first vaccination between March 16 and April 14, 2020 (Fig. S1). Three participants did not receive the second vaccination, including one in the 25-μg group who had urticaria on both legs, with onset 5 days after the first vaccination, and two (one in the 25-μg group and one in the 250-μg group) who missed the second vaccination window owing to isolation for suspected Covid-19 while the test results, ultimately negative, were pending.

All continued to attend scheduled trial visits. The demographic characteristics of participants at enrollment are provided in Table 1. Vaccine Safety No serious adverse events were noted, and no prespecified trial halting rules were met.

As noted above, one participant in the 25-μg group was withdrawn because of an unsolicited adverse event, transient urticaria, judged to be related to the first vaccination. Figure 1. Figure 1.

Systemic and Local Adverse Events. The severity of solicited adverse events was graded as mild, moderate, or severe (see Table S1).After the first vaccination, solicited systemic adverse events were reported by 5 participants (33%) in the 25-μg group, 10 (67%) in the 100-μg group, and 8 (53%) in the 250-μg group. All were mild or moderate in severity (Figure 1 and Table S2).

Solicited systemic adverse events were more common after the second vaccination and occurred in 7 of 13 participants (54%) in the 25-μg group, all 15 in the 100-μg group, and all 14 in the 250-μg group, with 3 of those participants (21%) reporting one or more severe events. None of the participants had fever after the first vaccination. After the second vaccination, no participants in the 25-μg group, 6 (40%) in the 100-μg group, and 8 (57%) in the 250-μg group reported fever.

One of the events (maximum temperature, 39.6°C) in the 250-μg group was graded severe. (Additional details regarding adverse events for that participant are provided in the Supplementary Appendix.) Local adverse events, when present, were nearly all mild or moderate, and pain at the injection site was common. Across both vaccinations, solicited systemic and local adverse events that occurred in more than half the participants included fatigue, chills, headache, myalgia, and pain at the injection site.

Evaluation of safety clinical laboratory values of grade 2 or higher and unsolicited adverse events revealed no patterns of concern (Supplementary Appendix and Table S3). SARS-CoV-2 Binding Antibody Responses Table 2. Table 2.

Geometric Mean Humoral Immunogenicity Assay Responses to mRNA-1273 in Participants and in Convalescent Serum Specimens. Figure 2. Figure 2.

SARS-CoV-2 Antibody and Neutralization Responses. Shown are geometric mean reciprocal end-point enzyme-linked immunosorbent assay (ELISA) IgG titers to S-2P (Panel A) and receptor-binding domain (Panel B), PsVNA ID50 responses (Panel C), and live virus PRNT80 responses (Panel D). In Panel A and Panel B, boxes and horizontal bars denote interquartile range (IQR) and median area under the curve (AUC), respectively.

Whisker endpoints are equal to the maximum and minimum values below or above the median ±1.5 times the IQR. The convalescent serum panel includes specimens from 41 participants. Red dots indicate the 3 specimens that were also tested in the PRNT assay.

The other 38 specimens were used to calculate summary statistics for the box plot in the convalescent serum panel. In Panel C, boxes and horizontal bars denote IQR and median ID50, respectively. Whisker end points are equal to the maximum and minimum values below or above the median ±1.5 times the IQR.

In the convalescent serum panel, red dots indicate the 3 specimens that were also tested in the PRNT assay. The other 38 specimens were used to calculate summary statistics for the box plot in the convalescent panel. In Panel D, boxes and horizontal bars denote IQR and median PRNT80, respectively.

Whisker end points are equal to the maximum and minimum values below or above the median ±1.5 times the IQR. The three convalescent serum specimens were also tested in ELISA and PsVNA assays. Because of the time-intensive nature of the PRNT assay, for this preliminary report, PRNT results were available only for the 25-μg and 100-μg dose groups.Binding antibody IgG geometric mean titers (GMTs) to S-2P increased rapidly after the first vaccination, with seroconversion in all participants by day 15 (Table 2 and Figure 2A).

Dose-dependent responses to the first and second vaccinations were evident. Receptor-binding domain–specific antibody responses were similar in pattern and magnitude (Figure 2B). For both assays, the median magnitude of antibody responses after the first vaccination in the 100-μg and 250-μg dose groups was similar to the median magnitude in convalescent serum specimens, and in all dose groups the median magnitude after the second vaccination was in the upper quartile of values in the convalescent serum specimens.

The S-2P ELISA GMTs at day 57 (299,751 [95% confidence interval {CI}, 206,071 to 436,020] in the 25-μg group, 782,719 [95% CI, 619,310 to 989,244] in the 100-μg group, and 1,192,154 [95% CI, 924,878 to 1,536,669] in the 250-μg group) exceeded that in the convalescent serum specimens (142,140 [95% CI, 81,543 to 247,768]). SARS-CoV-2 Neutralization Responses No participant had detectable PsVNA responses before vaccination. After the first vaccination, PsVNA responses were detected in less than half the participants, and a dose effect was seen (50% inhibitory dilution [ID50].

Figure 2C, Fig. S8, and Table 2. 80% inhibitory dilution [ID80].

Fig. S2 and Table S6). However, after the second vaccination, PsVNA responses were identified in serum samples from all participants.

The lowest responses were in the 25-μg dose group, with a geometric mean ID50 of 112.3 (95% CI, 71.2 to 177.1) at day 43. The higher responses in the 100-μg and 250-μg groups were similar in magnitude (geometric mean ID50, 343.8 [95% CI, 261.2 to 452.7] and 332.2 [95% CI, 266.3 to 414.5], respectively, at day 43). These responses were similar to values in the upper half of the distribution of values for convalescent serum specimens.

Before vaccination, no participant had detectable 80% live-virus neutralization at the highest serum concentration tested (1:8 dilution) in the PRNT assay. At day 43, wild-type virus–neutralizing activity capable of reducing SARS-CoV-2 infectivity by 80% or more (PRNT80) was detected in all participants, with geometric mean PRNT80 responses of 339.7 (95% CI, 184.0 to 627.1) in the 25-μg group and 654.3 (95% CI, 460.1 to 930.5) in the 100-μg group (Figure 2D). Neutralizing PRNT80 average responses were generally at or above the values of the three convalescent serum specimens tested in this assay.

Good agreement was noted within and between the values from binding assays for S-2P and receptor-binding domain and neutralizing activity measured by PsVNA and PRNT (Figs. S3 through S7), which provides orthogonal support for each assay in characterizing the humoral response induced by mRNA-1273. SARS-CoV-2 T-Cell Responses The 25-μg and 100-μg doses elicited CD4 T-cell responses (Figs.

S9 and S10) that on stimulation by S-specific peptide pools were strongly biased toward expression of Th1 cytokines (tumor necrosis factor α >. Interleukin 2 >. Interferon γ), with minimal type 2 helper T-cell (Th2) cytokine expression (interleukin 4 and interleukin 13).

CD8 T-cell responses to S-2P were detected at low levels after the second vaccination in the 100-μg dose group (Fig. S11).Trial Design and Oversight We conducted this three-group trial at 55 hospitals in Brazil. The trial was designed by the executive committee (see the Supplementary Appendix, available with the full text of this article at NEJM.org) and approved by the Brazilian National Commission for Research Ethics, the Brazilian Health Regulatory Agency (ANVISA), and ethics committees at the participating sites.

The trial was funded by the hospitals and research institutes participating in Coalition Covid-19 Brazil (see the Supplementary Appendix). EMS Pharma provided additional funding and logistic support for the trial and also donated and supplied the trial drugs. EMS Pharma had no role in the conduct of the trial, the analysis, or the decision to submit the manuscript for publication.

The trial was overseen by an independent international data and safety monitoring committee. The executive committee vouches for the completeness and accuracy of the data and for the fidelity of the trial to the protocol (available at NEJM.org). Participants The trial included consecutive patients who were 18 years of age or older and who had been hospitalized with suspected or confirmed Covid-19 with 14 or fewer days since symptom onset.

Among the reasons for exclusion from the trial were the use of supplemental oxygen at a rate of more than 4 liters per minute as administered by a nasal cannula or at a level of at least 40% as administered by a Venturi mask. The use of supplemental oxygen administered by a high-flow nasal cannula or invasive or noninvasive ventilation. Previous use of chloroquine, hydroxychloroquine, azithromycin, or any other macrolide for more than 24 hours before enrollment (and since the onset of symptoms).

And a history of severe ventricular tachycardia or electrocardiographic findings with a corrected QT interval (QTc) of at least 480 msec. Complete information on the inclusion and exclusion criteria is provided in the Supplementary Appendix. All the patients provided written or electronic informed consent before randomization.

Randomization, Interventions, and Follow-up Patients were randomly assigned in a 1:1:1 ratio to receive standard care (control group), standard care plus hydroxychloroquine at a dose of 400 mg twice daily for 7 days (hydroxychloroquine-alone group), or standard care plus hydroxychloroquine at a dose of 400 mg twice daily plus azithromycin at a dose of 500 mg once a day for 7 days. Randomization was performed in blocks of six and was stratified according to the use or nonuse of supplemental oxygen at the time of randomization. Randomization was performed centrally by means of an electronic case-report form system (RedCap) as described in the Supplementary Appendix.12 The current standard care for Covid-19 was at the discretion of the treating physicians.

The use of glucocorticoids, other immunomodulators, antibiotic agents, and antiviral agents was allowed (see the Supplementary Appendix). The administration of hydroxychloroquine or chloroquine was not allowed in the control group, and the use of macrolides was not allowed in the control group or the hydroxychloroquine-alone group. Guidance was provided to the investigators about how to adjust or interrupt treatment according to side effects and laboratory abnormalities.

Data were collected daily, from randomization until day 15, in the electronic case-report form. For patients who were discharged before day 15, a structured telephone call to the patient or the patient’s family was conducted on or after day 15 by an interviewer who was unaware of the assigned trial group in order to assess vital status and return to routine activities. Outcomes The primary outcome was clinical status at 15 days, evaluated with the use of a seven-level ordinal scale.

Scores on the scale were defined as follows. A score of 1 indicated not hospitalized with no limitations on activities. 2, not hospitalized but with limitations on activities.

3, hospitalized and not receiving supplemental oxygen. 4, hospitalized and receiving supplemental oxygen. 5, hospitalized and receiving oxygen supplementation administered by a high-flow nasal cannula or noninvasive ventilation.

6, hospitalized and receiving mechanical ventilation. And 7, death. Secondary outcomes included clinical status at 7 days, evaluated with the use of a six-level ordinal scale (see below and see the Supplementary Appendix).

An indication for intubation within 15 days. The receipt of supplemental oxygen administered by a high-flow nasal cannula or noninvasive ventilation between randomization and 15 days. Duration of hospital stay.

In-hospital death. Thromboembolic complications. Acute kidney injury.

And the number of days alive and free from respiratory support up to 15 days. A day alive and free from respiratory support was defined as any day in which the patient did not receive supplemental oxygen or invasive or noninvasive mechanical ventilation, from randomization to day 15. Patients who died during the 15-day window were assigned a value of 0 days alive and free from respiratory support in this assessment.

Safety outcomes are listed in the Supplementary Appendix. All the trial outcomes were assessed by the site investigators, who were aware of the trial-group assignments (except as noted above for patients who had been discharged before day 15 and who were assessed for the primary outcome by means of a blinded telephone interview). No formal adjudication of trial outcomes was performed.

Sample-Size Calculation and Protocol Changes We had originally planned for the trial to include 630 patients, using the intention-to-treat analysis population, with a six-level ordinal outcome as the primary outcome, as described in the Supplementary Appendix. However, before the first interim analysis was conducted, we changed the primary-outcome assessment to the seven-level ordinal scale and the main analysis population from the intention-to-treat population to a modified intention-to-treat population that included only patients with a diagnosis of Covid-19 that had been confirmed by reverse-transcriptase–polymerase-chain-reaction (RT-PCR) testing (using the test available at each site). The change to the use of the seven-level ordinal scale was adopted because on April 10, 2020 (before the first enrolled patient had reached 15 days of follow-up), we established the capability to obtain 15-day information on limitations on activities with the use of blinded telephone interviews.

We therefore added another level to the six-level ordinal outcome, dividing the first level (not hospitalized) into two levels (level 1, not hospitalized and with no limitations on activities. And level 2, not hospitalized but with limitations on activities). The change to the modified intention-to-treat population was adopted because, under the hypothesis that treatment would have beneficial effects on the primary outcome only for patients who had a confirmed diagnosis, the inclusion of unconfirmed cases would decrease the estimated effect size and power.

As a related change, we added external adjudication of unconfirmed cases, which were classified as probable, possible, or probably not Covid-19 (see the Supplementary Appendix). The sample size was revised with the use of the overall distribution of the seven-level ordinal outcome at day 15 observed among the first 120 patients, with the levels 1 through 7 having the following proportions of patients. 60%, 19%, 7%, 1%, 1%, 5%, and 7%, respectively.

With 630 patients who had undergone randomization and 510 patients included in the modified intention-to-treat analysis, we calculated that the trial would have 80% power to detect an odds ratio of 0.5 between groups (two-by-two comparisons), at a significance level of 5% and with Bonferroni adjustment for multiple comparisons (α=5%, divided by 3 for each comparison).13 Statistical Analysis The primary outcome was analyzed by mixed ordinal logistic regression with random intercept according to site, assuming proportional odds. We report all two-by-two comparisons. Binary outcomes were assessed with the use of a mixed logistic-regression model, except for in-hospital mortality, which was assessed with a Cox proportional-hazards model.

Continuous outcomes were evaluated by means of generalized linear regression or mixed models for repeated variables, as appropriate. All models were adjusted for age and the use of supplemental oxygen at admission. We also performed sensitivity analyses that included all the patients who had undergone randomization (intention-to-treat population) and sensitivity analyses for the primary outcome for the following groups.

Patients with definitive, probable, or possible Covid-19. And patients with definitive or probable Covid-19. Two additional populations were considered.

An efficacy population included patients with a confirmed diagnosis who received at least one dose of the assigned trial drug. The safety population included patients according to the medications received, regardless of the assigned trial group or the result of Covid-19 testing. We planned three interim analyses, to be conducted when 120 patients, 315 patients, and 504 patients had completed 15 days of follow-up.

However, only the first interim analysis was conducted. Owing to faster-than-expected enrollment, primary-outcome data for the second and third interim analyses were available only after trial recruitment was finished. After discussion with the data and safety monitoring committee, the second and third interim analyses were cancelled.

The data and safety monitoring committee used Haybittle–Peto14 stopping boundaries, with a P-value threshold of less than 0.001 to interrupt the trial for safety and a P-value threshold of less than 0.0001 to interrupt the trial for efficacy. We did not adjust the final values of the hypothesis test for sequential analyses. Analyses were performed with the use of R software (R Core Team).15 P values for the primary outcome were adjusted with the use of Bonferroni correction.

No P values are reported for secondary outcomes. The widths of the confidence intervals for the secondary outcomes have not been adjusted for multiple comparisons, so the intervals should not be used to infer definitive treatment effects. P values for the safety analyses were not adjusted given the importance of identifying potential signals of harm.

Additional details about the statistical analyses are provided in the Supplementary Appendix.Interactive GraphicThere is broad consensus that widespread SARS-CoV-2 testing is essential to safely reopening the United States. A big concern has been test availability, but test accuracy may prove a larger long-term problem.While debate has focused on the accuracy of antibody tests, which identify prior infection, diagnostic testing, which identifies current infection, has received less attention. But inaccurate diagnostic tests undermine efforts at containment of the pandemic.Diagnostic tests (typically involving a nasopharyngeal swab) can be inaccurate in two ways.

A false positive result erroneously labels a person infected, with consequences including unnecessary quarantine and contact tracing. False negative results are more consequential, because infected persons — who might be asymptomatic — may not be isolated and can infect others.Given the need to know how well diagnostic tests rule out infection, it’s important to review assessment of test accuracy by the Food and Drug Administration (FDA) and clinical researchers, as well as interpretation of test results in a pandemic.The FDA has granted Emergency Use Authorizations (EUAs) to commercial test manufacturers and issued guidance on test validation.1 The agency requires measurement of analytic and clinical test performance. Analytic sensitivity indicates the likelihood that the test will be positive for material containing any virus strains and the minimum concentration the test can detect.

Analytic specificity indicates the likelihood that the test will be negative for material containing pathogens other than the target virus.Clinical evaluations, assessing performance of a test on patient specimens, vary among manufacturers. The FDA prefers the use of “natural clinical specimens” but has permitted the use of “contrived specimens” produced by adding viral RNA or inactivated virus to leftover clinical material. Ordinarily, test-performance studies entail having patients undergo an index test and a “reference standard” test determining their true state.

Clinical sensitivity is the proportion of positive index tests in patients who in fact have the disease in question. Sensitivity, and its measurement, may vary with the clinical setting. For a sick person, the reference-standard test is likely to be a clinical diagnosis, ideally established by an independent adjudication panel whose members are unaware of the index-test results.

For SARS-CoV-2, it is unclear whether the sensitivity of any FDA-authorized commercial test has been assessed in this way. Under the EUAs, the FDA does allow companies to demonstrate clinical test performance by establishing the new test’s agreement with an authorized reverse-transcriptase–polymerase-chain-reaction (RT-PCR) test in known positive material from symptomatic people or contrived specimens. Use of either known positive or contrived samples may lead to overestimates of test sensitivity, since swabs may miss infected material in practice.1Designing a reference standard for measuring the sensitivity of SARS-CoV-2 tests in asymptomatic people is an unsolved problem that needs urgent attention to increase confidence in test results for contact-tracing or screening purposes.

Simply following people for the subsequent development of symptoms may be inadequate, since they may remain asymptomatic yet be infectious. Assessment of clinical sensitivity in asymptomatic people had not been reported for any commercial test as of June 1, 2020.Two studies from Wuhan, China, arouse concern about false negative RT-PCR tests in patients with apparent Covid-19 illness. In a preprint, Yang et al.

Described 213 patients hospitalized with Covid-19, of whom 37 were critically ill.2 They collected 205 throat swabs, 490 nasal swabs, and 142 sputum samples (median, 3 per patient) and used an RT-PCR test approved by the Chinese regulator. In days 1 through 7 after onset of illness, 11% of sputum, 27% of nasal, and 40% of throat samples were deemed falsely negative. Zhao et al.

Studied 173 hospitalized patients with acute respiratory symptoms and a chest CT “typical” of Covid-19, or SARS-CoV-2 detected in at least one respiratory specimen. Antibody seroconversion was observed in 93%.3 RT-PCR testing of respiratory samples taken on days 1 through 7 of hospitalization were SARS-CoV-2–positive in at least one sample from 67% of patients. Neither study reported using an independent panel, unaware of index-test results, to establish a final diagnosis of Covid-19 illness, which may have biased the researchers toward overestimating sensitivity.In a preprint systematic review of five studies (not including the Yang and Zhao studies), involving 957 patients (“under suspicion of Covid-19” or with “confirmed cases”), false negatives ranged from 2 to 29%.4 However, the certainty of the evidence was considered very low because of the heterogeneity of sensitivity estimates among the studies, lack of blinding to index-test results in establishing diagnoses, and failure to report key RT-PCR characteristics.4 Taken as a whole, the evidence, while limited, raises concern about frequent false negative RT-PCR results.If SARS-CoV-2 diagnostic tests were perfect, a positive test would mean that someone carries the virus and a negative test that they do not.

With imperfect tests, a negative result means only that a person is less likely to be infected. To calculate how likely, one can use Bayes’ theorem, which incorporates information about both the person and the accuracy of the test (recently reviewed5). For a negative test, there are two key inputs.

Pretest probability — an estimate, before testing, of the person’s chance of being infected — and test sensitivity. Pretest probability might depend on local Covid-19 prevalence, SARS-CoV-2 exposure history, and symptoms. Ideally, clinical sensitivity and specificity of each test would be measured in various clinically relevant real-life situations (e.g., varied specimen sources, timing, and illness severity).Assume that an RT-PCR test was perfectly specific (always negative in people not infected with SARS-CoV-2) and that the pretest probability for someone who, say, was feeling sick after close contact with someone with Covid-19 was 20%.

If the test sensitivity were 95% (95% of infected people test positive), the post-test probability of infection with a negative test would be 1%, which might be low enough to consider someone uninfected and may provide them assurance in visiting high-risk relatives. The post-test probability would remain below 5% even if the pretest probability were as high as 50%, a more reasonable estimate for someone with recent exposure and early symptoms in a “hot spot” area.But sensitivity for many available tests appears to be substantially lower. The studies cited above suggest that 70% is probably a reasonable estimate.

At this sensitivity level, with a pretest probability of 50%, the post-test probability with a negative test would be 23% — far too high to safely assume someone is uninfected.Chance of SARS-CoV-2 Infection, Given a Negative Test Result, According to Pretest Probability. The blue line represents a test with sensitivity of 70% and specificity of 95%. The green line represents a test with sensitivity of 90% and specificity of 95%.

The shading is the threshold for considering a person not to be infected (asserted to be 5%). Arrow A indicates that with the lower-sensitivity test, this threshold cannot be reached if the pretest probability exceeds about 15%. Arrow B indicates that for the higher-sensitivity test, the threshold can be reached up to a pretest probability of about 33%.

An of this graph is available at NEJM.org.The graph shows how the post-test probability of infection varies with the pretest probability for tests with low (70%) and high (95%) sensitivity. The horizontal line indicates a probability threshold below which it would be reasonable to act as if the person were uninfected (e.g., allowing the person to visit an elderly grandmother). Where this threshold should be set — here, 5% — is a value judgment and will vary with context (e.g., lower for people visiting a high-risk relative).

The threshold highlights why very sensitive diagnostic tests are needed. With a negative result on the low-sensitivity test, the threshold is exceeded when the pretest probability exceeds 15%, but with a high-sensitivity test, one can have a pretest probability of up to 33% and still, assuming the 5% threshold, be considered safe to be in contact with others.The graph also highlights why efforts to reduce pretest probability (e.g., by social distancing, possibly wearing masks) matter. If the pretest probability gets too high (above 50%, for example), testing loses its value because negative results cannot lower the probability of infection enough to reach the threshold.We draw several conclusions.

First, diagnostic testing will help in safely opening the country, but only if the tests are highly sensitive and validated under realistic conditions against a clinically meaningful reference standard. Second, the FDA should ensure that manufacturers provide details of tests’ clinical sensitivity and specificity at the time of market authorization. Tests without such information will have less relevance to patient care.Third, measuring test sensitivity in asymptomatic people is an urgent priority.

It will also be important to develop methods (e.g., prediction rules) for estimating the pretest probability of infection (for asymptomatic and symptomatic people) to allow calculation of post-test probabilities after positive or negative results. Fourth, negative results even on a highly sensitive test cannot rule out infection if the pretest probability is high, so clinicians should not trust unexpected negative results (i.e., assume a negative result is a “false negative” in a person with typical symptoms and known exposure). It’s possible that performing several simultaneous or repeated tests could overcome an individual test’s limited sensitivity.

However, such strategies need validation.Finally, thresholds for ruling out infection need to be developed for a variety of clinical situations. Since defining these thresholds is a value judgement, public input will be crucial..

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The General Medical Council’s (GMC) motto of ‘Working with doctors, working for patients’ is at the heart of the work we carry out to ensure medical schools and postgraduate lasix and calcium medical training is of the high standard that patients demand, and rightly deserve. However, we know delivering world-class healthcare is taking its toll on doctors and carrying out research into how we can ease the burden and find how burnout can be prevented is becoming a key focus of our work.While still delivering our important statutory functions of controlling access to the register and investigating when things go wrong, we are actively supporting professionals to maintain and improve standards of good medical practice. Additionally, there is a vast amount of work taking place behind the scenes at the GMC to adapt to the ever-evolving environment we are training doctors to work in.SHAPING TRAINING TO MEET THE NEEDS OF WORKFORCE AND lasix and calcium PATIENTSThe UK population is continuously changing.

We have an ageing and consequently increasingly frail population with more people with complex and comorbid diseases. We have more patients with disabilities related to mental and physical health problems—which we lasix and calcium expect will continue to rise due to the COVID-19 pandemic. In addition, more young people tend to live in urban areas, whereas there are more older people generally residing in more rural areas.This in turn places a demand on services meaning we need to train more doctors with more generalist, flexible skills and have doctors located in the right geographical areas to treat patients.

The ongoing COVID-19 pandemic lasix and calcium has highlighted the importance of doctors working flexibly.The medical workforce is also ever-varying. Our most recent ‘The state of medical education and practice in the UK’1 report showed we are seeing more female doctors on the register. Increasingly, female doctors make up a higher proportion of the workforce as male ….

The General Medical Council’s (GMC) motto of ‘Working with doctors, working for patients’ is at the heart of the work we carry out to ensure medical schools and postgraduate medical training is of the high standard that patients how to buy lasix demand, and rightly deserve. However, we know delivering world-class healthcare is taking its toll on doctors and carrying out research into how we can ease the burden and find how burnout can be prevented is becoming a key focus of our work.While still delivering our important statutory functions of controlling access to the register and investigating when things go wrong, we are actively supporting professionals to maintain and improve standards of good medical practice. Additionally, there how to buy lasix is a vast amount of work taking place behind the scenes at the GMC to adapt to the ever-evolving environment we are training doctors to work in.SHAPING TRAINING TO MEET THE NEEDS OF WORKFORCE AND PATIENTSThe UK population is continuously changing.

We have an ageing and consequently increasingly frail population with more people with complex and comorbid diseases. We have more patients with disabilities how to buy lasix related to mental and physical health problems—which we expect will continue to rise due to the COVID-19 pandemic. In addition, more young people tend to live in urban areas, whereas there are more older people generally residing in more rural areas.This in turn places a demand on services meaning we need to train more doctors with more generalist, flexible skills and have doctors located in the right geographical areas to treat patients.

The ongoing COVID-19 pandemic has highlighted the importance of how to buy lasix doctors working flexibly.The medical workforce is also ever-varying. Our most recent ‘The state of medical education and practice in the UK’1 report showed we are seeing more female doctors on the register. Increasingly, female doctors make up a higher proportion of the workforce as male ….

What should I watch for while using Lasix?

Visit your doctor or health care professional for regular checks on your progress. Check your blood pressure regularly. Ask your doctor or health care professional what your blood pressure should be, and when you should contact him or her. If you are a diabetic, check your blood sugar as directed.

You may need to be on a special diet while taking Lasix. Check with your doctor. Also, ask how many glasses of fluid you need to drink a day. You must not get dehydrated.

You may get drowsy or dizzy. Do not drive, use machinery, or do anything that needs mental alertness until you know how this drug affects you. Do not stand or sit up quickly, especially if you are an older patient. This reduces the risk of dizzy or fainting spells. Alcohol can make you more drowsy and dizzy. Avoid alcoholic drinks.

Lasix can make you more sensitive to the sun. Keep out of the sun. If you cannot avoid being in the sun, wear protective clothing and use sunscreen. Do not use sun lamps or tanning beds/booths.

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Start Preamble Centers read here for lasix for horses Medicare &. Medicaid Services (CMS), HHS. Final rule lasix for horses. Correction.

In the August 4, 2020 issue of the Federal Register, we published a final rule entitled “FY 2021 Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Special Requirements for Psychiatric Hospitals for Fiscal Year Beginning October 1, 2020 (FY 2021)”. The August 4, 2020 final rule updates the prospective payment rates, the outlier threshold, and the wage index for Medicare inpatient hospital services provided by Inpatient Psychiatric Facilities (IPF), which include psychiatric hospitals and excluded psychiatric units of lasix for horses an Inpatient Prospective Payment System (IPPS) hospital or critical access hospital. In addition, we adopted more recent Office of Management and Budget (OMB) statistical area delineations, and applied a 2-year transition for all providers negatively impacted by wage index changes. This correction document corrects the statement lasix for horses of economic significance in the August 4, 2020 final rule.

This correction is effective October 1, 2020. Start Further Info The IPF Payment Policy mailbox at IPFPaymentPolicy@cms.hhs.gov for general information. Nicolas Brock, (410) 786-5148, for information regarding the statement of economic lasix for horses significance. End Further Info End Preamble Start Supplemental Information I.

Background In lasix for horses FR Doc. 2020-16990 (85 FR 47042), the final rule entitled “FY 2021 Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Special Requirements for Psychiatric Hospitals for Fiscal Year Beginning October 1, 2020 (FY 2021)” (hereinafter referred to as the FY 2021 IPF PPS final rule) there was an error in the statement of economic significance and status as major under the Congressional Review Act (5 U.S.C. 801 et seq.). Based on an estimated total impact of $95 million in increased transfers from the federal government to IPF providers, we previously stated that the final rule was not economically significant under Executive Order (E.O.) 12866, and that lasix for horses the rule was not a major rule under the Congressional Review Act.

However, the Office of Management and Budget designated this rule as economically significant under E.O. 12866 and major under the lasix for horses Congressional Review Act. We are correcting our previous statement in the August 4, 2020 final rule accordingly. This correction is effective October 1, 2020.

II. Summary of Errors On page 47064, in the third column, the third full paragraph under B. Overall Impact should be replaced entirely. The entire paragraph stating.

€œWe estimate that this rulemaking is not economically significant as measured by the $100 million threshold, and hence not a major rule under the Congressional Review Act. Accordingly, we have prepared a Regulatory Impact Analysis that to the best of our ability presents the costs and benefits of the rulemaking.” should be replaced with. €œWe estimate that the total impact of this final rule is close to the $100 million threshold. The Office of Management and Budget has designated this rule as economically significant under E.O.

12866 and a major rule under the Congressional Review Act (5 U.S.C. 801 et seq.). Accordingly, we have prepared a Regulatory Impact Analysis that to the best of our ability presents the costs and benefits of the rulemaking.” III. Waiver of Proposed Rulemaking and Delay in Effective Date We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a rule take effect in accordance with section 553(b) of the Administrative Procedure Act (APA) (5 U.S.C.

553(b)). However, we can waive this notice and comment procedure if the Secretary of the Department of Human Services finds, for good cause, that the notice and comment process is impracticable, unnecessary, or contrary to the public interest, and incorporates a statement of the finding and the reasons therefore in the notice. This correction document does not constitute a rulemaking that would be subject to these requirements because it corrects only the statement of economic significance included in the FY 2021 IPF PPS final rule. The corrections contained in this document are consistent with, and do not make substantive changes to, the policies and payment methodologies that were adopted and subjected to notice and comment procedures in the FY 2021 IPF PPS final rule.

Rather, the corrections made through this correction document are intended to ensure that the FY 2021 IPF PPS final rule accurately reflects OMB's determination about its economic significance and major status under the Congressional Review Act (CRA). Executive Order 12866 and CRA determinations are functions of the Office of Management and Budget, not the Department of Health and Human Services, and are not rules as defined by the Administrative Procedure Act (5 U.S. Code 551(4)). We ordinarily provide a 60-day delay in the effective date of final rules after the date they are issued, in accordance with the CRA (5 U.S.C.

801(a)(3)). However, section 808(2) of the CRA provides that, if an agency finds good cause that notice and public procedure are impracticable, unnecessary, or contrary to the public interest, the rule shall take effect at such time as the agency determines. Even if this were a rulemaking to which the delayed effective date requirement applied, we found, in the FY 2021 IPF PPS Final Rule (85 FR 47043), good cause to waive the 60-day delay in the effective date of the IPF PPS final rule. In the final rule, we explained that, due to CMS prioritizing efforts in support of containing and combatting the COVID-Start Printed Page 5292419 public health emergency by devoting significant resources to that end, the work needed on the IPF PPS final rule was not completed in accordance with our usual rulemaking schedule.

We noted that it is critical, however, to ensure that the IPF PPS payment policies are effective on the first day of the fiscal year to which they are intended to apply and therefore, it would be contrary to the public interest to not waive the 60-day delay in the effective date. Undertaking further notice and comment procedures to incorporate the corrections in this document into the FY 2021 IPF PPS final rule or delaying the effective date would be contrary to the public interest because it is in the public's interest to ensure that the policies finalized in the FY 2021 IPF PPS are effective as of the first day of the fiscal year to ensure providers and suppliers receive timely and appropriate payments. Further, such procedures would be unnecessary, because we are not altering the payment methodologies or policies. Rather, the correction we are making is only to indicate that the FY 2021 IPF PPS final rule is economically significant and a major rule under the CRA.

For these reasons, we find we have good cause to waive the notice and comment and effective date requirements. IV. Correction of Errors in the Preamble In FR Doc. 2020-16990, appearing on page 47042 in the Federal Register of Tuesday, August 4, 2020, the following correction is made.

1. On page 47064, in the 3rd column, under B. Overall Impact, https://www.andrees-angelreisen.de/lasix-cost/ correct the third full paragraph to read as follows. We estimate that the total impact of this final rule is very close to the $100 million threshold.

The Office of Management and Budget has designated this rule as economically significant under E.O. 12866 and a major rule under the Congressional Review Act (5 U.S.C. 801 et seq.). Accordingly, we have prepared a Regulatory Impact Analysis that to the best of our ability presents the costs and benefits of the rulemaking.

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. 2020-18902 Filed 8-26-20. 8:45 am]BILLING CODE 4120-01-PBy Cyndie Shearing @CyndieShearing Americans from all walks of life are struggling to cope with an array of issues related to the COVID-19 pandemic. Fear and anxiety about this new disease and what could happen is sometimes overwhelming and can cause strong emotions in adults and children.

But long before the pandemic hit the U.S., farmers and ranchers were struggling. Years of falling commodity prices, natural disasters, declining farm income and trade disputes with China hit rural America hard, and not just financially. Farmers’ mental health is at risk, too. Long before the pandemic hit the U.S., farmers and ranchers were struggling.

Fortunately, America’s food producers have proven to be a resilient bunch. Across the country, they continue to adopt new ways to manage stress and cope with the difficult situations they’re facing. A few examples are below. In Oklahoma, Bryan Vincent and Gary Williams are part of an informal group that meets on a regular basis to share their burdens.

“It’s way past farming,” said Vincent, a local crop consultant. €œIt’s a chance to meet with like-minded people. It’s a chance for us to let some things out. We laugh, we may cry together, we may be disgusted together.

We share our emotions, whether good, bad.” Gathering with trusted friends has given them the chance to talk about what’s happening in their lives, both good and bad. €œI would encourage anybody – any group of farmers, friends, whatever – to form a group” to meet regularly, said Williams, a farmer. €œNot just in bad times. I think you should do that regardless, even in good times.

Share your victories and triumphs with one another, support one another.” James Young Credit. Nocole Zema/Virginia Farm Bureau In Michigan, dairy farmer Ashley Messing Kennedy battled postpartum depression and anxiety while also grieving over a close friend and farm employee who died by suicide. At first she coped by staying busy, fixing farm problems on her own and rarely asking for help. But six months later, she knew something wasn’t right.

Finding a meaningful activity to do away from the farm was a positive step forward. €œRunning’s been a game-changer for me,” Kennedy said. €œIt’s so important to interact with people, face-to-face, that you don’t normally engage with. Whatever that is for you, do it — take time to get off the farm and walk away for a while.

It will be there tomorrow.” Rich Baker also farms in Michigan and has found talking with others to be his stress management tactic of choice. €œYou can’t just bottle things up,” Baker said. €œIf you don’t have a built-in network of farmers, go talk to a professional. In some cases that may be even more beneficial because their opinions may be more impartial.” James Young, a beef cattle farmer in Virginia, has found that mental health issues are less stigmatized as a whole today compared to the recent past.

But there are farmers “who would throw you under the bus pretty fast” if they found out someone was seeking professional mental health, he said. €œIt’s still stigmatized here.” RFD-TV Special on Farm Stress and Farmer Mental HealthAs part of the American Farm Bureau Federation’s ongoing effort to raise awareness, reduce stigma and share resources related to mental health, the organization partnered with RFD-TV to produce a one-hour episode of “Rural America Live” on farm stress and farmer mental health. The episode features AFBF President Zippy Duvall, Farm Credit Council President Todd Van Hoose and National Farmers Union President Rob Larew, as well as two university Extension specialists, a rural pastor and the author of “Stress-Free You!. € The program aired Thursday, Aug.

27, and will be re-broadcast on Saturday, Aug. 29, at 6 a.m. Eastern/5 a.m. Central.

Cyndie Shearing is director of communications at the American Farm Bureau Federation. Quotes in this column originally appeared in state Farm Bureau publications and are reprinted with permission. Vincent, Williams (Oklahoma). Kennedy, Baker (Michigan) and Young (Virginia)..

Start Preamble how to buy lasix lasix renal scan results Centers for Medicare &. Medicaid Services (CMS), HHS. Final rule how to buy lasix. Correction.

In the August 4, 2020 issue of the Federal Register, we published a final rule entitled “FY 2021 Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Special Requirements for Psychiatric Hospitals for Fiscal Year Beginning October 1, 2020 (FY 2021)”. The August 4, 2020 final rule updates the prospective payment rates, the outlier threshold, and the wage index for Medicare inpatient hospital services provided how to buy lasix by Inpatient Psychiatric Facilities (IPF), which include psychiatric hospitals and excluded psychiatric units of an Inpatient Prospective Payment System (IPPS) hospital or critical access hospital. In addition, we adopted more recent Office of Management and Budget (OMB) statistical area delineations, and applied a 2-year transition for all providers negatively impacted by wage index changes. This correction document corrects the how to buy lasix statement of economic significance in the August 4, 2020 final rule.

This correction is effective October 1, 2020. Start Further Info The IPF Payment Policy mailbox at IPFPaymentPolicy@cms.hhs.gov for general information. Nicolas Brock, (410) 786-5148, how to buy lasix for information regarding the statement of economic significance. End Further Info End Preamble Start Supplemental Information I.

Background In how to buy lasix FR Doc. 2020-16990 (85 FR 47042), the final rule entitled “FY 2021 Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Special Requirements for Psychiatric Hospitals for Fiscal Year Beginning October 1, 2020 (FY 2021)” (hereinafter referred to as the FY 2021 IPF PPS final rule) there was an error in the statement of economic significance and status as major under the Congressional Review Act (5 U.S.C. 801 et seq.). Based on an estimated how to buy lasix total impact of $95 million in increased transfers from the federal government to IPF providers, we previously stated that the final rule was not economically significant under Executive Order (E.O.) 12866, and that the rule was not a major rule under the Congressional Review Act.

However, the Office of Management and Budget designated this rule as economically significant under E.O. 12866 and major under the Congressional how to buy lasix Review Act. We are correcting our previous statement in the August 4, 2020 final rule accordingly. This correction is effective October 1, 2020.

II. Summary of Errors On page 47064, in the third column, the third full paragraph under B. Overall Impact should be replaced entirely. The entire paragraph stating.

€œWe estimate that this rulemaking is not economically significant as measured by the $100 million threshold, and hence not a major rule under the Congressional Review Act. Accordingly, we have prepared a Regulatory Impact Analysis that to the best of our ability presents the costs and benefits of the rulemaking.” should be replaced with. €œWe estimate that the total impact of this final rule is close to the $100 million threshold. The Office of Management and Budget has designated this rule as economically significant under E.O.

12866 and a major rule under the Congressional Review Act (5 U.S.C. 801 et seq.). Accordingly, we have prepared a Regulatory Impact Analysis that to the best of our ability presents the costs and benefits of the rulemaking.” III. Waiver of Proposed Rulemaking and Delay in Effective Date We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a rule take effect in accordance with section 553(b) of the Administrative Procedure Act (APA) (5 U.S.C.

553(b)). However, we can waive this notice and comment procedure if the Secretary of the Department of Human Services finds, for good cause, that the notice and comment process is impracticable, unnecessary, or contrary to the public interest, and incorporates a statement of the finding and the reasons therefore in the notice. This correction document does not constitute a rulemaking that would be subject to these requirements because it corrects only the statement of economic significance included in the FY 2021 IPF PPS final rule. The corrections contained in this document are consistent with, and do not make substantive changes to, the policies and payment methodologies that were adopted and subjected to notice and comment procedures in the FY 2021 IPF PPS final rule.

Rather, the corrections made through this correction document are intended to ensure that the FY 2021 IPF PPS final rule accurately reflects OMB's determination about its economic significance and major status under the Congressional Review Act (CRA). Executive Order 12866 and CRA determinations are functions of the Office of Management and Budget, not the Department of Health and Human Services, and are not rules as defined by the Administrative Procedure Act (5 U.S. Code 551(4)). We ordinarily provide a 60-day delay in the effective date of final rules after the date they are issued, in accordance with the CRA (5 U.S.C.

801(a)(3)). However, section 808(2) of the CRA provides that, if an agency finds good cause that notice and public procedure are impracticable, unnecessary, or contrary to the public interest, the rule shall take effect at such time as the agency determines. Even if this were a rulemaking to which the delayed effective date requirement applied, we found, in the FY 2021 IPF PPS Final Rule (85 FR 47043), good cause to waive the 60-day delay in the effective date of the IPF PPS final rule. In the final rule, we explained that, due to CMS prioritizing efforts in support of containing and combatting the COVID-Start Printed Page 5292419 public health emergency by devoting significant resources to that end, the work needed on the IPF PPS final rule was not completed in accordance with our usual rulemaking schedule.

We noted that it is critical, however, to ensure that the IPF PPS payment policies are effective on the first day of the fiscal year to which they are intended to apply and therefore, it would be contrary to the public interest to not waive the 60-day delay in the effective date. Undertaking further notice and comment procedures to incorporate the corrections in this document into the FY 2021 IPF PPS final rule or delaying the effective date would be contrary to the public interest because it is in the public's interest to ensure that the policies finalized in the FY 2021 IPF PPS are effective as of the first day of the fiscal year to ensure providers and suppliers receive timely and appropriate payments. Further, such procedures would be unnecessary, because we are not altering the payment methodologies or policies. Rather, the correction we are making is only to indicate that the FY 2021 IPF PPS final rule is economically significant and a major rule under the CRA.

For these reasons, we find we have good cause to waive the notice and comment and effective date requirements. IV. Correction of Errors in the Preamble In FR Doc. 2020-16990, appearing on page 47042 in the Federal Register of Tuesday, August 4, 2020, the following correction is made.

1. On page 47064, in the 3rd column, under B. Overall Impact, correct the third full paragraph to read as follows. We estimate that the total impact of this final rule is very close to the $100 million threshold.

The Office of Management and Budget has designated this rule as economically significant under E.O. 12866 and a major rule under the Congressional Review Act (5 U.S.C. 801 et seq.). Accordingly, we have prepared a Regulatory Impact Analysis that to the best of our ability presents the costs and benefits of the rulemaking.

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. 2020-18902 Filed 8-26-20. 8:45 am]BILLING CODE 4120-01-PBy Cyndie Shearing @CyndieShearing Americans from all walks of life are struggling to cope with an array of issues related to the COVID-19 pandemic. Fear and anxiety about this new disease and what could happen is sometimes overwhelming and can cause strong emotions in adults and children.

But long before the pandemic hit the U.S., farmers and ranchers were struggling. Years of falling commodity prices, natural disasters, declining farm income and trade disputes with China hit rural America hard, and not just financially. Farmers’ mental health is at risk, too. Long before the pandemic hit the U.S., farmers and ranchers were struggling.

Fortunately, America’s food producers have proven to be a resilient bunch. Across the country, they continue to adopt new ways to manage stress and cope with the difficult situations they’re facing. A few examples are below. In Oklahoma, Bryan Vincent and Gary Williams are part of an informal group that meets on a regular basis to share their burdens.

“It’s way past farming,” said Vincent, a local crop consultant. €œIt’s a chance to meet with like-minded people. It’s a chance for us to let some things out. We laugh, we may cry together, we may be disgusted together.

We share our emotions, whether good, bad.” Gathering with trusted friends has given them the chance to talk about what’s happening in their lives, both good and bad. €œI would encourage anybody – any group of farmers, friends, whatever – to form a group” to meet regularly, said Williams, a farmer. €œNot just in bad times. I think you should do that regardless, even in good times.

Share your victories and triumphs with one another, support one another.” James Young Credit. Nocole Zema/Virginia Farm Bureau In Michigan, dairy farmer Ashley Messing Kennedy battled postpartum depression and anxiety while also grieving over a close friend and farm employee who died by suicide. At first she coped by staying busy, fixing farm problems on her own and rarely asking for help. But six months later, she knew something wasn’t right.

Finding a meaningful activity to do away from the farm was a positive step forward. €œRunning’s been a game-changer for me,” Kennedy said. €œIt’s so important to interact with people, face-to-face, that you don’t normally engage with. Whatever that is for you, do it — take time to get off the farm and walk away for a while.

It will be there tomorrow.” Rich Baker also farms in Michigan and has found talking with others to be his stress management tactic of choice. €œYou can’t just bottle things up,” Baker said. €œIf you don’t have a built-in network of farmers, go talk to a professional. In some cases that may be even more beneficial because their opinions may be more impartial.” James Young, a beef cattle farmer in Virginia, has found that mental health issues are less stigmatized as a whole today compared to the recent past.

But there are farmers “who would throw you under the bus pretty fast” if they found out someone was seeking professional mental health, he said. €œIt’s still stigmatized here.” RFD-TV Special on Farm Stress and Farmer Mental HealthAs part of the American Farm Bureau Federation’s ongoing effort to raise awareness, reduce stigma and share resources related to mental health, the organization partnered with RFD-TV to produce a one-hour episode of “Rural America Live” on farm stress and farmer mental health. The episode features AFBF President Zippy Duvall, Farm Credit Council President Todd Van Hoose and National Farmers Union President Rob Larew, as well as two university Extension specialists, a rural pastor and the author of “Stress-Free You!. € The program aired Thursday, Aug.

27, and will be re-broadcast on Saturday, Aug. 29, at 6 a.m. Eastern/5 a.m. Central.

Cyndie Shearing is director of communications at the American Farm Bureau Federation. Quotes in this column originally appeared in state Farm Bureau publications and are reprinted with permission. Vincent, Williams (Oklahoma). Kennedy, Baker (Michigan) and Young (Virginia)..

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Start Preamble Notice diuretic drugs lasix of amendment pop over to this web-site. 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 diuretic drugs lasix 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 diuretic drugs lasix 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 Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA), Public Law 113-5, enacted on March 13, 2013 and the Coronavirus 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 COVID-19 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 COVID-19 (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 COVID-19 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 vaccine that the Advisory Committee on Immunization Practices (ACIP) recommends to persons ages three through 18 according to ACIP's standard immunization schedule (ACIP-recommended vaccines).[] 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 COVID-19 caused by SARS-CoV-2 or a virus mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by COVID-19, SARS-CoV-2, or a virus 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 vaccine ordering and doses administered might indicate that U.S. Children and their communities face increased risks for outbreaks of vaccine-preventable diseases,” and suggested that a decrease in rates of routine childhood vaccinations were due to changes in healthcare access, social distancing, and other COVID-19 mitigation strategies.[] The report also stated that “[p]arental concerns about potentially exposing their children to COVID-19 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 COVID-19 pandemic. The survey, which was limited to practices participating in the Vaccines 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 COVID-19 pandemic, 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 infection-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 COVID-19. 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 infections 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 COVID-19. Together with pediatricians and other healthcare professionals, pharmacists are positioned to expand access to childhood vaccinations.

Many States already allow pharmacists to administer vaccines to children of any age.[] Other States permit pharmacists to administer vaccines 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 vaccines.[] 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 vaccine to nearly a third of all adults who received the vaccine.[] Given the potential danger of serious influenza and continuing COVID-19 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 COVID-19 pandemic, we must quickly expand access to influenza vaccinations. Allowing more qualified pharmacists to administer the influenza vaccine 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 vaccines to individuals ages three through 18 pursuant to the following requirements. The vaccine 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 vaccines, and the recognition and treatment of emergency reactions to vaccines.[] 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 vaccines, and the recognition and treatment of emergency reactions to vaccines.[] 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 vaccines, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (vaccine registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a vaccine must review the vaccine registry or other vaccination records prior to administering a vaccine.[] 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 vaccines to children and permit licensed or registered pharmacy interns acting under their supervision to administer vaccines 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 vaccine.[] 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 vaccines 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 vaccines and (2) qualified State-licensed or registered pharmacy interns are identified as qualified persons to administer the ACIP-recommended vaccines 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 pandemic and epidemic products that “limit the harm such pandemic 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 52140COVID-19 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 Vaccine Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National Vaccine 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 COVID-19. 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 COVID-19 caused by SARS-CoV-2 or a virus mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by COVID-19, SARS-CoV-2, or a virus 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 COVID-19. Sections V and VIII of the March 10, 2020 Declaration under the PREP Act for medical countermeasures against COVID-19, 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), vaccines 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 vaccine 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 vaccines, and the recognition and treatment of emergency reactions to vaccines.

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 vaccines, and the recognition and treatment of emergency reactions to vaccines. 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 vaccines, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (vaccine registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a vaccine must review the vaccine registry or other vaccination records prior to administering a vaccine. 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 Vaccine Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National Vaccine 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 COVID-19 caused by SARS-CoV-2 or a virus mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by COVID-19, SARS-CoV-2, or a virus 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-PToday, the U.S. Department of Health and Human Services released Healthy People 2030, the nation's 10-year plan for addressing our most critical public health priorities and challenges. Since 1980, HHS's Office of Disease Prevention and Health Promotion has set measurable objectives and targets to improve the health and well-being of the nation.This decade, Healthy People 2030 features 355 core – or measurable – objectives with 10-year targets, new objectives related to opioid use disorder and youth e-cigarette use, and resources for adapting Healthy People 2030 to emerging public health threats like COVID-19. For the first time, Healthy People 2030 also sets 10-year targets for objectives related to social determinants of health."Healthy People was the first national effort to lay out a set of data-driven priorities for health improvement," said HHS Secretary Alex Azar.

"Healthy People 2030 adopts a more focused set of objectives and more rigorous data standards to help the federal government and all of our partners deliver results on these important goals over the next decade."Healthy People has led the nation with its focus on social determinants of health, and continues to prioritize economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context as factors that influence health. Healthy People 2030 also continues to prioritize health disparities, health equity, and health literacy."Now more than ever, we need programs like Healthy People that set a shared vision for a healthier nation, where all people can achieve their full potential for health and well-being across the lifespan," said ADM Brett P. Giroir, MD, Assistant Secretary for Health. "COVID-19 has brought the importance of public health to the forefront of our national dialogue.

Achieving Healthy People 2030's vision would help the United States become more resilient to public health threats like COVID-19."Healthy People 2030 emphasizes collaboration, with objectives and targets that span multiple sectors. A federal advisory committee of 13 external thought leaders and a workgroup of subject matter experts from more than 20 federal agencies contributed to Healthy People 2030, along with public comments received throughout the development process.The HHS Office of Disease Prevention and Health Promotion leads Healthy People in partnership with the National Center for Health Statistics at the Centers for Disease Control and Prevention, which oversees data in support of the initiative.HHS Secretary Alex M. Azar II, ADM Brett P. Giroir, MD, Assistant Secretary for Health, and U.S.

Surgeon General Jerome M. Adams, MD, MPH, and others from HHS and CDC will launch Healthy People 2030 during a webcast on August 18 at 1 pm (EDT) at https://www.hhs.gov/live. No registration is necessary. For more information about Healthy People 2030, visit https://healthypeople.gov..

Start Preamble how to buy lasix check out here 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 how to buy lasix 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 how to buy lasix 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 Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA), Public Law 113-5, enacted on March 13, 2013 and the Coronavirus 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 COVID-19 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 COVID-19 (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 COVID-19 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 vaccine that the Advisory Committee on Immunization Practices (ACIP) recommends to persons ages three through 18 according to ACIP's standard immunization schedule (ACIP-recommended vaccines).[] 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 COVID-19 caused by SARS-CoV-2 or a virus mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by COVID-19, SARS-CoV-2, or a virus 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 vaccine ordering and doses administered might indicate that U.S.

Children and their communities face increased risks for outbreaks of vaccine-preventable diseases,” and suggested that a decrease in rates of routine childhood vaccinations were due to changes in healthcare access, social distancing, and other COVID-19 mitigation strategies.[] The report also stated that “[p]arental concerns about potentially exposing their children to COVID-19 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 COVID-19 pandemic. The survey, which was limited to practices participating in the Vaccines 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 COVID-19 pandemic, 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 infection-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 COVID-19. 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 infections 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 COVID-19. Together with pediatricians and other healthcare professionals, pharmacists are positioned to expand access to childhood vaccinations. Many States already allow pharmacists to administer vaccines to children of any age.[] Other States permit pharmacists to administer vaccines 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 vaccines.[] 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 vaccine to nearly a third of all adults who received the vaccine.[] Given the potential danger of serious influenza and continuing COVID-19 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 COVID-19 pandemic, we must quickly expand access to influenza vaccinations. Allowing more qualified pharmacists to administer the influenza vaccine 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 vaccines to individuals ages three through 18 pursuant to the following requirements.

The vaccine 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 vaccines, and the recognition and treatment of emergency reactions to vaccines.[] 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 vaccines, and the recognition and treatment of emergency reactions to vaccines.[] 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 vaccines, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (vaccine registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a vaccine must review the vaccine registry or other vaccination records prior to administering a vaccine.[] 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 vaccines to children and permit licensed or registered pharmacy interns acting under their supervision to administer vaccines 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 vaccine.[] 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 vaccines 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 vaccines and (2) qualified State-licensed or registered pharmacy interns are identified as qualified persons to administer the ACIP-recommended vaccines 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 pandemic and epidemic products that “limit the harm such pandemic 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 52140COVID-19 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 Vaccine Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National Vaccine 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 how do you spell lasix 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 COVID-19. 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 COVID-19 caused by SARS-CoV-2 or a virus mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by COVID-19, SARS-CoV-2, or a virus 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 COVID-19.

Sections V and VIII of the March 10, 2020 Declaration under the PREP Act for medical countermeasures against COVID-19, 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), vaccines 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 vaccine 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 vaccines, and the recognition and treatment of emergency reactions to vaccines. 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 vaccines, and the recognition and treatment of emergency reactions to vaccines.

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 vaccines, including informing the patient's primary-care provider when available, submitting the required immunization information to the State or local immunization information system (vaccine registry), complying with requirements with respect to reporting adverse events, and complying with requirements whereby the person administering a vaccine must review the vaccine registry or other vaccination records prior to administering a vaccine.

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 Vaccine Injury Compensation Program, including an injured party's ability to obtain compensation under that program. Covered countermeasures that are subject to the National Vaccine 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 COVID-19 caused by SARS-CoV-2 or a virus mutating therefrom, but also other diseases, health conditions, or threats that may have been caused by COVID-19, SARS-CoV-2, or a virus 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-PToday, the U.S. Department of Health and Human Services released Healthy People 2030, the nation's 10-year plan for addressing our most critical public health priorities and challenges.

Since 1980, HHS's Office of Disease Prevention and Health Promotion has set measurable objectives and targets to improve the health and well-being of the nation.This decade, Healthy People 2030 features 355 core – or measurable – objectives with 10-year targets, new objectives related to opioid use disorder and youth e-cigarette use, and resources for adapting Healthy People 2030 to emerging public health threats like COVID-19. For the first time, Healthy People 2030 also sets 10-year targets for objectives related to social determinants of health."Healthy People was the first national effort to lay out a set of data-driven priorities for health improvement," said HHS Secretary Alex Azar. "Healthy People 2030 adopts a more focused set of objectives and more rigorous data standards to help the federal government and all of our partners deliver results on these important goals over the next decade."Healthy People has led the nation with its focus on social determinants of health, and continues to prioritize economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context as factors that influence health.

Healthy People 2030 also continues to prioritize health disparities, health equity, and health literacy."Now more than ever, we need programs like Healthy People that set a shared vision for a healthier nation, where all people can achieve their full potential for health and well-being across the lifespan," said ADM Brett P. Giroir, MD, Assistant Secretary for Health. "COVID-19 has brought the importance of public health to the forefront of our national dialogue.

Achieving Healthy People 2030's vision would help the United States become more resilient to public health threats like COVID-19."Healthy People 2030 emphasizes collaboration, with objectives and targets that span multiple sectors. A federal advisory committee of 13 external thought leaders and a workgroup of subject matter experts from more than 20 federal agencies contributed to Healthy People 2030, along with public comments received throughout the development process.The HHS Office of Disease Prevention and Health Promotion leads Healthy People in partnership with the National Center for Health Statistics at the Centers for Disease Control and Prevention, which oversees data in support of the initiative.HHS Secretary Alex M. Azar II, ADM Brett P.

Giroir, MD, Assistant Secretary for Health, and U.S. Surgeon General Jerome M. Adams, MD, MPH, and others from HHS and CDC will launch Healthy People 2030 during a webcast on August 18 at 1 pm (EDT) at https://www.hhs.gov/live.

No registration is necessary. For more information about Healthy People 2030, visit https://healthypeople.gov..

Lasix for pulmonary hypertension

lasix for pulmonary hypertension

In 1945, as World lasix for pulmonary hypertension War II came to a close, scientists logged a record drop in carbon dioxide emissions click resources. They reckoned that global CO2 emissions fell by some 790 million metric tons—a record that stood for more than 70 years. Then 2020 rolled lasix for pulmonary hypertension around. Global emissions fell 1,550 million metric tons in the first half of 2020, according to a study published yesterday in Nature Communications, obliterating the 1945 record and underlining the depths of the economic damage wrought by the coronavirus pandemic this year. The study, conducted by a team of 43 scientists from across the world, confirms earlier research on the emissions impact of the pandemic (Climatewire, May 20).

It at once lasix for pulmonary hypertension highlighted how much emissions have fallen as a result of the virus and the difficult road facing the world as it seeks to meet the targets of the Paris climate agreement. The world essentially would need to replicate 2020’s emission reductions every year for the next decade to have any chance of limiting warming to 1.5 degrees Celsius by century’s end, according to the United Nations’ Intergovernmental Panel on Climate Change. €œConsidering how disruptive the pandemic has been in all our lives, it seems like a small number,” said Steven Davis, a professor at the University of California, Irvine, who contributed to the study. €œThe task of decarbonizing our planet will not mean just changes in personal behavior but changes in the energy structure.” In the immediate term, the lasix for pulmonary hypertension study’s largest impact may be on emissions monitoring itself. Researchers compiled a lengthy list of real-time energy and emissions statistics from countries around the world.

The authors described the effort as a major step forward for a field that has traditionally relied on previous lasix for pulmonary hypertension years’ data to develop emissions estimates. €œThe pandemic has really forced our hand to do better and find these data sources where they are,” Davis said, noting that researchers plan to continue the emissions monitoring efforts. €œWhat is critical is we need to shorten the feedback cycle from the policymaker putting some policy in place to the scientific community telling the policymaker whether that has had an effect on emissions.” The data sources allowed researchers to pinpoint the locations of emission reductions as the pandemic rolled across the world. The year began with deep reductions in emissions in China, where the lasix for pulmonary hypertension shutdown of heavy industry and resulting drop in power demand led to big decreases in CO2. Emissions from the Chinese cement industry, about 22% of the country’s industrial emissions, fell by a combined 30% in January and February compared to 2019 levels.

But cement emissions began to surge as the Chinese economy jolted back to life. By April, Chinese cement emissions lasix for pulmonary hypertension were up 3.8% over the same month last year. The rebound in Chinese economic activity, and cement in particular, helps explain the relatively modest 3.7% reduction, or 187 million tons, in overall Chinese emissions over the first half of 2020. By the spring, the pandemic had the United States and Europe lasix for pulmonary hypertension in its grasp. There, the emissions reduction story was largely about transportation.

American transportation emissions, the largest source of CO2 emissions in the U.S., were down 24% over the first seven months of 2020. Overall U.S lasix for pulmonary hypertension. Emissions fell 13.8% compared to 2019 levels or by 338 million tons, the largest absolute drop in the world. Still, the study suggests the pandemic has not altered the worldwide energy system in a fundamental way. Emissions across the lasix for pulmonary hypertension globe were rebounding quickly as large parts of the world began to shake off the virus over the summer.

The research team has continued to monitor emissions beyond the time period in the Nature Communications study. By August, they showed that world emissions had fallen 1,481 million tons since the start of the year, suggesting that some of the reductions from earlier in the year already have been offset. Reprinted from Climatewire with permission lasix for pulmonary hypertension from E&E News. E&E provides daily coverage of essential energy and environmental news at www.eenews.net.The human eye is a limited organ. The portion of the electromagnetic spectrum that we can see is about 0.0035 percent of the total lasix for pulmonary hypertension light in the universe.

Without any aid, a normal human eye with 20/20 vision can clearly view up to only about five kilometers (about three miles) in the distance and can distinguish an object as small as about 0.1 millimeter. Just as spyglasses and telescopes extended our range of sight across Earth and into the cosmos, light microscopes allow us to peer at scales hundreds of times smaller than we would otherwise be able to detect. Such technology has bred innumerable discoveries in medicine, biology, geology and plant lasix for pulmonary hypertension science. For 46 years, camera company Nikon has run its Small World contest, which prizes excellence in photography at the tiniest scales—achieved with the aid of the light microscope. Scientists make up a substantial proportion of contest entrants because their work naturally lends itself to stunning visualization.

Below is this lasix for pulmonary hypertension year’s first-place winner and our editors’ picks for the best images. As entrant Jason Kirk of the Baylor College of Medicine says, the contest is a “unique opportunity to celebrate the convergence of art and science. Images like the ones showcased here are a [wonderful] bridge between lasix for pulmonary hypertension the scientific community and the general public.” This year’s winning image of a juvenile zebra fish was captured as part of research by a team at the National Institutes of Health. They discovered that zebra fish have lymphatic vessels inside their skull—a feature previously thought to only occur in mammals. Such a discovery could expedite and revolutionize research related to neurological diseases such as Alzheimer’s.

The researchers stitched together more lasix for pulmonary hypertension than 350 individual images to create this single one. Radula, or “tongue,” of a freshwater snail, stained and captured as a stack of images. The realm of tiny animals is replete with bizarre and sometimes alien forms, says the image’s creator, Igor Siwanowicz of Howard Hughes Medical Institute, who obtained the snail from his lab mate’s aquarium. €œIt's a lasix for pulmonary hypertension snail's tongue, looking like a decadent rococo chandelier,” he adds. The image won third place.

Scale from the wing of a blue emperor butterfly lasix for pulmonary hypertension (Papilio ulysses). Photographer Yousef Al Habshi, says the challenge in creating this image was finding the correct focal balance between the camera and the scales to capture the light, avoiding overexposure or underexposure. Daphnia, a water microorganism. To create lasix for pulmonary hypertension this image, photographer Paweł Błachowicz used the reflected-light technique. Light bounces off the subject and is captured by the camera.

This method is usually reserved for opaque objects, Błachowicz says, so he was surprised at this striking outcome. €œDaphnia is a transparent organism, and despite this, lasix for pulmonary hypertension with the reflected-light technique, it looks astonishing,” he adds. Crystals formed after heating an ethanol-and-water solution containing L-glutamine and beta-alanine. The proportions of both amino acids must be precisely balanced in order to form such striking crystal structures, says photographer Justin Zoll. He used lasix for pulmonary hypertension a polarized-light filter to capture this image, which won 13th place.

Lateral view of a leaf-roller weevil (Byctiscus betulae). The hard exoskeleton is highly reflective and therefore challenging to capture, says photographer Özgür Kerem Bulur, who had to balance the lasix for pulmonary hypertension light properly in order to capture these rainbow colors. This image won 14th place. Head of a tapeworm (Taenia pisiformis) from the gut of a rabbit. The angle of this photograph lasix for pulmonary hypertension shows the “teeth” on the edge of the parasite’s head that help it embed itself in its host’s digestive tract.

€œI love the image's geometrical beauty, its sculptural qualities and its ambiguity,” says image creator David Maitland. €œIs it a fossil or something embedded in sandstone?. What lasix for pulmonary hypertension is it?. € Credit. Jason Kirk Baylor College of Medicine Microtubules (orange) lasix for pulmonary hypertension inside a bovine pulmonary artery endothelial cell.

The nucleus is shown in cyan. In his work, Jason Kirk of the Baylor College of Medicine uses such cells to benchmark the performance of his microscopy equipment. But the end result, which lasix for pulmonary hypertension won seventh place, deserves acknowledgement for its artistic value. Science in Images is a new category of articles featuring photographs and videos from all the disciplines of science. Click on the button below to see the full collection.

Science in Images“Clow-dia,” lasix for pulmonary hypertension I say once. Twice. A third time lasix for pulmonary hypertension. Defeated, I say the Americanized version of my name. €œClaw-dee-ah.” Finally, Siri recognizes it.

Having to adapt lasix for pulmonary hypertension our way of speaking to interact with speech-recognition technologies is a familiar experience for people whose first language is not English or who do not have conventionally American-sounding names. I have now stopped using Siri, Apple's voice-based virtual assistant, because of it. The growth of this tech in the past decade—not just Siri but Alexa and Cortana and others—has unveiled a problem in it. Racial bias lasix for pulmonary hypertension. One recent study, published in the Proceedings of the National Academy of Sciences USA, showed that speech-recognition programs are biased against Black speakers.

On average, the authors found, all five programs from leading technology companies, including Apple and Microsoft, showed significant race disparities. They were roughly twice as lasix for pulmonary hypertension likely to incorrectly transcribe audio from Black speakers compared with white speakers. This effectively censors voices that are not part of the “standard” languages or accents used to create these technologies. €œI don't get to negotiate with these devices unless I adapt my language patterns,” lasix for pulmonary hypertension says Halcyon Lawrence, an assistant professor of technical communication and information design at Towson University, who was not part of the study. €œThat is problematic.” For Lawrence, who has a Trinidad and Tobagonian accent, or for me as a Puerto Rican, part of our identity comes from speaking a particular language, having an accent or using a set of speech forms such as African American Vernacular English (AAVE).

Having to change such an integral part of an identity to be able to be recognized is inherently cruel. The inability to be understood impacts other marginalized communities, such as people with visual or movement disabilities who rely on voice recognition and speech-to-text tools, says Allison Koenecke, a computational graduate student lasix for pulmonary hypertension and first author of the PNAS study. For someone with a disability who is dependent on these technologies, being misunderstood could have serious consequences. There are probably many culprits for these disparities, but Koenecke points to the most likely. The data used for training, which are predominantly from white, native speakers of American English lasix for pulmonary hypertension.

By using databases that are narrow both in the words that are used and how they are said, training systems exclude accents and other ways of speaking that have unique linguistic features. Humans, presumably including those who create these lasix for pulmonary hypertension technologies, have accent and language biases. For example, research shows that the presence of an accent affects whether jurors find people guilty and whether patients find their doctors competent. Recognizing these biases would be an important way to avoid implementing them in technologies. But developing more inclusive technology takes time, effort and money, lasix for pulmonary hypertension and often the decision to invest these are market-driven.

(In response to several queries, only a Google spokesperson responded in time for publication, saying, in part, “We've been working on the challenge of accurately recognizing variations of speech for several years and will continue to do so.”) Safiya Noble, an associate professor of information studies at the University of California, Los Angeles, admits that it's a tricky challenge. €œLanguage is contextual,” says Noble, who was not involved in the study. €œBut that doesn't mean that companies shouldn't strive to decrease bias and disparities.” To do this, they need the input of lasix for pulmonary hypertension humanists and social scientists who understand how language actually works. From the tech side, feeding more diverse training data into the programs could close this gap, Koenecke says. Noble adds that tech companies should also lasix for pulmonary hypertension test their products more widely and have more diverse workforces so people from different backgrounds and perspectives can directly influence the design of speech technologies.

Koenecke suggests that automated speech-recognition companies use the PNAS study as a preliminary benchmark and keep using it to assess their systems over time. In the meantime, many of us will continue to struggle between identity and being understood when interacting with Alexa, Cortana or Siri. But Lawrence lasix for pulmonary hypertension chooses identity every time. €œI'm not switching,” she says. €œI'm not doing it.”Hiral Tipirneni spent nearly a decade working in emergency medicine in Arizona.

She started out 23 lasix for pulmonary hypertension years ago at Banner Good Samaritan Hospital in downtown Phoenix, treating patients with broken bones, failing hearts and a lot of other problems. Then some health tragedies hit home. €œOur family suffered a great loss to cancer. My mom and nephew,” she says lasix for pulmonary hypertension. Tipirneni felt she should do something to combat the illness that took her loved ones.

In 2010 she accepted a position as a scientific review officer for the Society of Research Administrators International, a global research lasix for pulmonary hypertension management group overseeing cancer studies. But when Donald Trump was elected U.S. President in 2016, “I was terrified of the threats of ‘repeal and replace’ of the Affordable Care Act,” she recalls. €œAfter years spent in the ER seeing thousands of families come through with lasix for pulmonary hypertension no access to health care..., it was too much to stand by. That prompted me to throw my hat into the ring.” Following a failed bid for a seat in the House of Representatives during a 2018 special election, Tipirneni, a Democrat, is running for the state’s sixth congressional district in the November 3 election.

The district includes part of Maricopa county and some Phoenix suburbs. She is challenging Republican incumbent David Schweikert, a former businessman now serving his fourth lasix for pulmonary hypertension consecutive term in that seat and his fifth overall in the House. Republicans have held this seat since 1995. But in the middle of a pandemic that has killed more than 5,700 Arizonans—more than 3,400 of them in Maricopa County—Tipirneni is hoping her medical lasix for pulmonary hypertension background will carry weight with voters. €œWe see decision after decision being made not based on data, not based on science, but rather on political expediency, partisanship—or based on the election calendar,” she says.

€œThat’s blasphemy for a scientist or physician.” Tipirneni is one of several candidates with a scientific background running for federal office this fall. The election will serve as the political climax to a year that saw raging wildfires fueled by climate change, devastating hurricanes and the COVID pandemic, which has claimed the lives of more than 216,000 Americans—a death toll medical experts say has been driven high by politicians who have ignored public health lasix for pulmonary hypertension guidelines. Given these catastrophic outcomes, Tipirneni and another physician-politician, Barbara Bollier, who is running for an open U.S. Senate seat in Kansas, hope voters will be swayed by candidates who tout respect for science when making policy decisions. Both races lasix for pulmonary hypertension are incredibly close, with recent polls showing Tipirneni and Bollier either ahead or behind their opponents by only a few percentage points.

The stakes are high. If Democrats manage to flip a Senate seat in Kansas, along with achieving lasix for pulmonary hypertension a few other wins, they will gain control of the Senate. And Tipirneni winning in Arizona could help them hold onto their majority in the House. Both outcomes would put Democrats in charge of the two houses of Congress, ending the current split with Republicans. €œAfter a big military conflict, you often see a surge in military veterans running for office,” says Eitan lasix for pulmonary hypertension Hersh, a political scientist at Tufts University.

€œFollowing the 2016 election, more women ran than ever before [in the midterms.] And after COVID-19, it’s not surprising that some physicians would run for office, feeling like their voices need to be heard. If there’s a big surge in doctors running, some will get in.” Grand Battle in the Grand Canyon State In Arizona, Tipirneni has raised more than $1 million more in campaign funding than Schweikert. Generally, a September poll by the Arizona Policy Lab found that science-based approaches to lasix for pulmonary hypertension fighting COVID, including mask mandates, were popular among Arizonan voters in both parties. €œThere is really strong disapproval for how Donald Trump and how Republican governor Doug Ducey have handled COVID-19,” says Samara Klar, a political scientist at the University of Arizona. Ducey, for instance, pushed hard for the resumption of activities with few restrictions in the spring, only to see a surge in COVID cases that forced another shutdown.

Klar adds that polls show that “at the same time, there’s been strong support for how local mayors lasix for pulmonary hypertension have dealt with it.” This, she says, could hurt the Republicans’ chances in Arizona. Schweikert did not respond to requests for comment from Scientific American. He has been a vocal supporter of the use of lasix for pulmonary hypertension masks, however. In a July tweet, he encouraged his constituents to “continue wearing our face coverings when out in public, or when in close proximity to others.” He also advocated for increased access to federal resources to purchase items such as personal protective equipment (PPE). €œWe ...

Ask the U.S lasix for pulmonary hypertension. Department of Health and Human Resources (HHS) and the Federal Emergency Management Agency (FEMA) for an immediate influx of federal resources to combat the virus, through increased testing, contact tracing, personal protective equipment (PPE), staffing support, and emergency funding for local initiatives to respond to and mitigate further spread,” he and four other Arizonan congresspeople wrote in a letter in August. But despite Schweikert’s support for public health practices, his messages may be tainted by the president’s handling of the pandemic. Recent polls show that Republicans have begun to drift away from lasix for pulmonary hypertension Trump. Biden currently leads Trump, 49 percent to 41 percent, in Arizona.

On energy policy, Schweikert and Tipirneni’s messaging diverges lasix for pulmonary hypertension. €œArizona should be leading the charge on a renewable energy economy,” Tipirneni says, adding that those energy sources are key to reducing the impacts of climate change. €œBut we have leaders like my opponent, who has stood at every opportunity to block those kinds of initiatives because he is someone who still takes money from fossil fuels and is driven by party leadership to invest in other forms of energy.” Schweikert’s platform promotes an “‘all of the above’ energy solution,” tapping into “traditional energy reserves” but also expanding renewable energy resources. In his time in the House, however, he has lasix for pulmonary hypertension taken dozens of antienvironmental positions, including voting against protecting Chaco Canyon from oil and gas drilling, banning offshore drilling in the Atlantic and Pacific Ocean, and implementing methane pollution safeguards. The Kansas Contest Democrats have not cornered the market on physician candidates.

In Kansas, Roger Marshall, a Republican representative in the House and an ob-gyn, is running against Bollier, a Democratic former anesthesiologist, creating a rare doctor-doctor duel. But despite sharing a lasix for pulmonary hypertension medical background, the two appear diametrically opposed on issues pertaining to science. Barbara Bollier (left) and Roger Marshall (right). Credit. Barbara Bollier Flickr (Bollier).

Eric Connolly U.S. House Office of Photography (Marshall) Bollier had been a Republican until she switched parties in 2018, and has served in the state’s legislature for a decade. She acknowledges that climate change is caused by people and has committed to greatly expand wind energy in the state. In contrast, Marshall has rejected the scientific consensus on climate, stating, “I’m not sure that there is even climate change” in 2017. His campaign Web site makes no mention of the issue.

Bollier “is a scientist and data nerd at heart,” says her communications director Alexandra De Luca. €œBarbara follows science. She always listens to the experts. Roger Marshall does not. If Roger Marshall followed science, he wouldn’t be holding events indoors, shaking hands with vulnerable Kansans.” Bollier’s campaign, De Luca says, held more than 40 virtual town halls on Zoom this summer.

And Bollier only began in-person campaigning in late August—always outdoors and physically distanced. Marshall did push for additional coronavirus testing kits for Kansas in April, saying that more testing could keep workers at large meat processing plants on the job—processors in Kansas had already had big outbreaks of the virus. But Marshall differed from much medical research in May, when he told the Wall Street Journal he was taking the antimalarial drug hydroxychloroquine as a preventive measure against COVID-19. Though touted by President Trump as a possible cure, the data supporting the medication was always sparse, and emergency authorization for it was revoked by the U.S. Food and Drug Administration in June.

In the May article, Marshall added that he “would encourage any person over the age of 65 or with an underlying medical condition to talk to their own physician about taking hydroxychloroquine.” In September, Marshall wrote a Facebook post suggesting that most COVID-19 deaths were from other ailments. Facebook deleted the post. His campaign did not respond to Scientific American’s requests for an interview. Marshall regularly plays up his medical credentials. He has given himself the nickname “Doc,” and his Twitter username is @RogerMarshallMD.

He also has used his medical skills to help in the pandemic, he says. In late April, Marshall tweeted, “Today, I began treating COVID-19 patients on a volunteer basis in Wyandotte County, KS. I began the process of onboarding several days ago, and have started in the clinic today.” Thus far, polls show the race between Bollier and Marshall “as surprisingly close for a Republican state,” with all of them falling within the margin of error, says Don Haider-Markel, a political scientist at the University of Kansas. Despite electing a Democratic governor in 2018, he says, the state still leans conservative, and to have a competitive Democrat in the running is “not typical, to say the least.” After the economy and jobs, Haider-Markel observes, Kansans care most about the handling of the pandemic in this election cycle—ranking that issue ahead of education and civil unrest. In the final days of campaigning, Democrats are trying to focus attention on health care, he adds, but “it’s not clear that voters are prioritizing that more than last month.” Bollier is likely succeeding at picking up moderate Republican and independent voters, Haider-Markel says.

Trump’s election alienated many Republican women in the suburbs in eastern Kansas and around Wichita who have likely switched to supporting the Democratic candidate, he explains. €œI think Bollier’s messaging on evidence-based policy will resonate with them—but they were already going to be more attracted to her to begin with.” Patti Doll, a 67-year-old former social worker who lives in Wichita, has been following the Senate race closely. She is a Democrat and says the pandemic has made her pay greater attention to candidates’ adherence to scientific guidelines. Marshall, she notes with dissatisfaction, is still campaigning without a mask in October. €œIt’s his job to lead and show people that this is important,” she says.

€œIf it was switched, and it was Bollier who was a Republican, and Marshall was a Democrat, I would vote across party lines in this situation. It doesn’t matter to me. Follow the science.”Every time I log onto Facebook, I brace myself. My newsfeed—like everyone else’s I know—is filled with friends, relatives and acquaintances arguing about COVID-19, masks and Trump. Facebook has become a battleground among partisan “echo chambers.” But what is it about social media that makes people so polarized?.

To find out, my colleagues and I ran a social media experiment in which we divided Democrats and Republicans into “echo chambers,” or small groups whose members affiliate with just one political party. Next, we picked the most polarizing issues we could think of. Immigration, gun control and unemployment. We asked each participant what they thought of those issues, then let people talk to each other and revise their opinions. After several rounds of discussion and revision, we evaluated each group’s viewpoint.

To our surprise, the echo chambers did not make people more polarized, but less. After interacting in social networks with likeminded peers, each echo chamber—Republican and Democrat—had adopted a more moderate opinion. All groups independently moved toward opinions that were closer to the opinions on the “opposite” side of the political spectrum. As a scientist who studies networks, I’m used to being surprised by the results of my experiments. Technology has allowed us to access more information and data about people’s social networks, debunking many of our assumptions about human behavior.

But even my team at the Network Dynamics Group was surprised. Why did our social media experiment find the opposite of what happens all the time in the real world of social media?. The answer lies in something social media has amplified. €œinfluencers.” By now, most of us have a fairly specific understanding of what an “influencer” is. The word conjures up a young, wealthy person whose lifestyle is sponsored by brands like Instagram, TikTok or YouTube.

But the word has a very specific network science meaning. In social media, networks tend to be centralized. A small number of people, or perhaps just one person, at the “center” of the network is connected to lots of other people in the “periphery.” The multitudes in the periphery of the social network have only a modest number of connections, while the few—the so-called “influencers”—at the center of the network are connected to nearly everyone. This puts these people into the powerful position of being able to exert a disproportionate level of “influence” over the group. By contrast, the networks used in our study were “egalitarian”—the opposite of centralized.

In an egalitarian network, everyone has an equal number of contacts, and therefore influence, throughout the network. The key feature of an egalitarian network is that new ideas and opinions can emerge from anywhere in the community and spread to everyone. But in centralized networks—like many social media sites—ideas are filtered through, or sometimes even blocked, by a powerful social influencer. As I show in my upcoming book Change. The Power in the Periphery to Make Big Things Happen, centralized and egalitarian networks have very different effects on partisan bias and the acceptance of new ideas.

In a centralized echo chamber, if the influencer at the middle shows even a small amount of partisan bias, it can become amplified throughout the entire group. But in egalitarian networks, ideas spread based on their quality, and not the person touting them. There is a lot of wisdom in network peripheries, in regular people with good ideas. When the social network enables those people to talk with each other, new thinking that challenge a group’s biases can take hold and spread. To see how egalitarian networks might affect other kinds of contentious issues, we conducted another experiment with smokers and nonsmokers discussing the risks of cigarette smoking.

The effects were the same as with the partisan study. Both groups moved toward a more accurate understanding of smoking risks. Moreover, when participants were interviewed after the study, they reported having developed higher opinions of the other. Both smokers and nonsmokers had come to view the other group as more reasonable and trustworthy about the risks of smoking. But the exchange of ideas and eradication of bias only works when networks are egalitarian.

The problem of partisan bias is exacerbated on social media because online networks are often organized around a few key influencers. This feature of social media is one of the main reasons why misinformation and fake news has become so pervasive. In centralized networks, biased influencers have a disproportionate impact on their community—enabling small rumors and suppositions to become amplified into widespread misconceptions and false beliefs. Our country has been struggling with bias and polarization a long time. But the issue is about to get much more urgent.

As the debate over COVID-19 vaccination heats up, biased viewpoints will undoubtedly become entrenched in communities with powerful influencers at their center. If we want to eradicate, or at least lessen the impacts of the coronavirus, we should rethink how our online communities operate. The solution to the problem of vaccine hesitancy is not to eliminate echo chambers. Rather, it is to be intentional about the social networks in those echo chambers. The more equity in people’s social networks, the less biased and more informed groups will become—even when those groups start off with highly partisan opinions..

In 1945, as World War II came to a close, how to buy lasix scientists logged a record drop in carbon dioxide emissions. They reckoned that global CO2 emissions fell by some 790 million metric tons—a record that stood for more than 70 years. Then 2020 how to buy lasix rolled around. Global emissions fell 1,550 million metric tons in the first half of 2020, according to a study published yesterday in Nature Communications, obliterating the 1945 record and underlining the depths of the economic damage wrought by the coronavirus pandemic this year. The study, conducted by a team of 43 scientists from across the world, confirms earlier research on the emissions impact of the pandemic (Climatewire, May 20).

It at once highlighted how much emissions have fallen as a result of the virus and the difficult road facing the world as it how to buy lasix seeks to meet the targets of the Paris climate agreement. The world essentially would need to replicate 2020’s emission reductions every year for the next decade to have any chance of limiting warming to 1.5 degrees Celsius by century’s end, according to the United Nations’ Intergovernmental Panel on Climate Change. €œConsidering how disruptive the pandemic has been in all our lives, it seems like a small number,” said Steven Davis, a professor at the University of California, Irvine, who contributed to the study. €œThe task of decarbonizing our planet will not mean just changes in personal behavior but changes in the energy structure.” In the immediate term, the study’s largest impact may be how to buy lasix on emissions monitoring itself. Researchers compiled a lengthy list of real-time energy and emissions statistics from countries around the world.

The authors described the effort as a major step forward for a field that has traditionally relied on previous years’ data to how to buy lasix develop emissions estimates. €œThe pandemic has really forced our hand to do better and find these data sources where they are,” Davis said, noting that researchers plan to continue the emissions monitoring efforts. €œWhat is critical is we need to shorten the feedback cycle from the policymaker putting some policy in place to the scientific community telling the policymaker whether that has had an effect on emissions.” The data sources allowed researchers to pinpoint the locations of emission reductions as the pandemic rolled across the world. The year began with deep how to buy lasix reductions in emissions in China, where the shutdown of heavy industry and resulting drop in power demand led to big decreases in CO2. Emissions from the Chinese cement industry, about 22% of the country’s industrial emissions, fell by a combined 30% in January and February compared to 2019 levels.

But cement emissions began to surge as the Chinese economy jolted back to life. By April, Chinese cement emissions were up how to buy lasix 3.8% over the same month last year. The rebound in Chinese economic activity, and cement in particular, helps explain the relatively modest 3.7% reduction, or 187 million tons, in overall Chinese emissions over the first half of 2020. By the spring, the pandemic had the United States how to buy lasix and Europe in its grasp. There, the emissions reduction story was largely about transportation.

American transportation emissions, the largest source of CO2 emissions in the U.S., were down 24% over the first seven months of 2020. Overall U.S how to buy lasix. Emissions fell 13.8% compared to 2019 levels or by 338 million tons, the largest absolute drop in the world. Still, the study suggests the pandemic has not altered the worldwide energy system in a fundamental way. Emissions across the globe were rebounding quickly as large parts of the world began to shake off the how to buy lasix virus over the summer.

The research team has continued to monitor emissions beyond the time period in the Nature Communications study. By August, they showed that world emissions had fallen 1,481 million tons since the start of the year, suggesting that some of the reductions from earlier in the year already have been offset. Reprinted from Climatewire how to buy lasix with permission from E&E News. E&E provides daily coverage of essential energy and environmental news at www.eenews.net.The human eye is a limited organ. The portion of the how to buy lasix electromagnetic spectrum that we can see is about 0.0035 percent of the total light in the universe.

Without any aid, a normal human eye with 20/20 vision can clearly view up to only about five kilometers (about three miles) in the distance and can distinguish an object as small as about 0.1 millimeter. Just as spyglasses and telescopes extended our range of sight across Earth and into the cosmos, light microscopes allow us to peer at scales hundreds of times smaller than we would otherwise be able to detect. Such technology how to buy lasix has bred innumerable discoveries in medicine, biology, geology and plant science. For 46 years, camera company Nikon has run its Small World contest, which prizes excellence in photography at the tiniest scales—achieved with the aid of the light microscope. Scientists make up a substantial proportion of contest entrants because their work naturally lends itself to stunning visualization.

Below is this year’s how to buy lasix first-place winner and our editors’ picks for the best images. As entrant Jason Kirk of the Baylor College of Medicine says, the contest is a “unique opportunity to celebrate the convergence of art and science. Images like the ones showcased here are a [wonderful] bridge between the scientific community and the general public.” This year’s winning image of a juvenile zebra fish was captured as part of research by a team at the National how to buy lasix Institutes of Health. They discovered that zebra fish have lymphatic vessels inside their skull—a feature previously thought to only occur in mammals. Such a discovery could expedite and revolutionize research related to neurological diseases such as Alzheimer’s.

The researchers stitched how to buy lasix together more than 350 individual images to create this single one. Radula, or “tongue,” of a freshwater snail, stained and captured as a stack of images. The realm of tiny animals is replete with bizarre and sometimes alien forms, says the image’s creator, Igor Siwanowicz of Howard Hughes Medical Institute, who obtained the snail from his lab mate’s aquarium. €œIt's a snail's tongue, looking like a decadent how to buy lasix rococo chandelier,” he adds. The image won third place.

Scale from the wing of a blue emperor butterfly how to buy lasix (Papilio ulysses). Photographer Yousef Al Habshi, says the challenge in creating this image was finding the correct focal balance between the camera and the scales to capture the light, avoiding overexposure or underexposure. Daphnia, a water microorganism. To create this image, photographer Paweł Błachowicz used the reflected-light technique how to buy lasix. Light bounces off the subject and is captured by the camera.

This method is usually reserved for opaque objects, Błachowicz says, so he was surprised at this striking outcome. €œDaphnia is a transparent organism, and despite this, how to buy lasix with the reflected-light technique, it looks astonishing,” he adds. Crystals formed after heating an ethanol-and-water solution containing L-glutamine and beta-alanine. The proportions of both amino acids must be precisely balanced in order to form such striking crystal structures, says photographer Justin Zoll. He used a polarized-light filter to capture this image, which how to buy lasix won 13th place.

Lateral view of a leaf-roller weevil (Byctiscus betulae). The hard exoskeleton is highly reflective and therefore challenging to capture, says photographer Özgür Kerem Bulur, who had to balance the light properly in order to capture how to buy lasix these rainbow colors. This image won 14th place. Head of a tapeworm (Taenia pisiformis) from the gut of a rabbit. The angle of this photograph shows the “teeth” on the edge of the parasite’s head that help how to buy lasix it embed itself in its host’s digestive tract.

€œI love the image's geometrical beauty, its sculptural qualities and its ambiguity,” says image creator David Maitland. €œIs it a fossil or something embedded in sandstone?. What is how to buy lasix it?. € Credit. Jason Kirk Baylor College of Medicine Microtubules (orange) inside a bovine pulmonary how to buy lasix artery endothelial cell.

The nucleus is shown in cyan. In his work, Jason Kirk of the Baylor College of Medicine uses such cells to benchmark the performance of his microscopy equipment. But the end result, which won seventh place, deserves acknowledgement for its artistic how to buy lasix value. Science in Images is a new category of articles featuring photographs and videos from all the disciplines of science. Click on the button below to see the full collection.

Science in Images“Clow-dia,” I say once how to buy lasix. Twice. A third time how to buy lasix. Defeated, I say the Americanized version of my name. €œClaw-dee-ah.” Finally, Siri recognizes it.

Having to adapt our way of speaking how to buy lasix to interact with speech-recognition technologies is a familiar experience for people whose first language is not English or who do not have conventionally American-sounding names. I have now stopped using Siri, Apple's voice-based virtual assistant, because of it. The growth of this tech in the past decade—not just Siri but Alexa and Cortana and others—has unveiled a problem in it. Racial bias how to buy lasix. One recent study, published in the Proceedings of the National Academy of Sciences USA, showed that speech-recognition programs are biased against Black speakers.

On average, the authors found, all five programs from leading technology companies, including Apple and Microsoft, showed significant race disparities. They were roughly twice as likely to incorrectly transcribe how to buy lasix audio from Black speakers compared with white speakers. This effectively censors voices that are not part of the “standard” languages or accents used to create these technologies. €œI don't get to how to buy lasix negotiate with these devices unless I adapt my language patterns,” says Halcyon Lawrence, an assistant professor of technical communication and information design at Towson University, who was not part of the study. €œThat is problematic.” For Lawrence, who has a Trinidad and Tobagonian accent, or for me as a Puerto Rican, part of our identity comes from speaking a particular language, having an accent or using a set of speech forms such as African American Vernacular English (AAVE).

Having to change such an integral part of an identity to be able to be recognized is inherently cruel. The inability to be understood impacts other marginalized communities, such as people with visual or movement disabilities who rely on voice how to buy lasix recognition and speech-to-text tools, says Allison Koenecke, a computational graduate student and first author of the PNAS study. For someone with a disability who is dependent on these technologies, being misunderstood could have serious consequences. There are probably many culprits for these disparities, but Koenecke points to the most likely. The data used for training, how to buy lasix which are predominantly from white, native speakers of American English.

By using databases that are narrow both in the words that are used and how they are said, training systems exclude accents and other ways of speaking that have unique linguistic features. Humans, presumably including those who create how to buy lasix these technologies, have accent and language biases. For example, research shows that the presence of an accent affects whether jurors find people guilty and whether patients find their doctors competent. Recognizing these biases would be an important way to avoid implementing them in technologies. But developing more how to buy lasix inclusive technology takes time, effort and money, and often the decision to invest these are market-driven.

(In response to several queries, only a Google spokesperson responded in time for publication, saying, in part, “We've been working on the challenge of accurately recognizing variations of speech for several years and will continue to do so.”) Safiya Noble, an associate professor of information studies at the University of California, Los Angeles, admits that it's a tricky challenge. €œLanguage is contextual,” says Noble, who was not involved in the study. €œBut that doesn't mean that companies shouldn't strive to decrease bias and disparities.” To do this, they need the input of humanists and social scientists who understand how to buy lasix how language actually works. From the tech side, feeding more diverse training data into the programs could close this gap, Koenecke says. Noble adds that tech companies should also test their products more widely and have more diverse workforces so people from different backgrounds how to buy lasix and perspectives can directly influence the design of speech technologies.

Koenecke suggests that automated speech-recognition companies use the PNAS study as a preliminary benchmark and keep using it to assess their systems over time. In the meantime, many of us will continue to struggle between identity and being understood when interacting with Alexa, Cortana or Siri. But Lawrence chooses identity every time how to buy lasix. €œI'm not switching,” she says. €œI'm not doing it.”Hiral Tipirneni spent nearly a decade working in emergency medicine in Arizona.

She started out 23 years ago at Banner Good Samaritan Hospital in downtown Phoenix, treating how to buy lasix patients with broken bones, failing hearts and a lot of other problems. Then some health tragedies hit home. €œOur family suffered a great loss to cancer. My mom and nephew,” she how to buy lasix says. Tipirneni felt she should do something to combat the illness that took her loved ones.

In 2010 she accepted a position as a scientific review officer for the Society of Research Administrators International, a global research management group overseeing cancer how to buy lasix studies. But when Donald Trump was elected U.S. President in 2016, “I was terrified of the threats of ‘repeal and replace’ of the Affordable Care Act,” she recalls. €œAfter years spent in the ER seeing thousands of families come through with no access to health how to buy lasix care..., it was too much to stand by. That prompted me to throw my hat into the ring.” Following a failed bid for a seat in the House of Representatives during a 2018 special election, Tipirneni, a Democrat, is running for the state’s sixth congressional district in the November 3 election.

The district includes part of Maricopa county and some Phoenix suburbs. She is challenging Republican incumbent David Schweikert, a former businessman now serving his fourth consecutive term in that how to buy lasix seat and his fifth overall in the House. Republicans have held this seat since 1995. But in the middle of a pandemic that has killed more than how to buy lasix 5,700 Arizonans—more than 3,400 of them in Maricopa County—Tipirneni is hoping her medical background will carry weight with voters. €œWe see decision after decision being made not based on data, not based on science, but rather on political expediency, partisanship—or based on the election calendar,” she says.

€œThat’s blasphemy for a scientist or physician.” Tipirneni is one of several candidates with a scientific background running for federal office this fall. The election will serve as the political climax to a year that saw raging wildfires fueled by climate change, devastating how to buy lasix hurricanes and the COVID pandemic, which has claimed the lives of more than 216,000 Americans—a death toll medical experts say has been driven high by politicians who have ignored public health guidelines. Given these catastrophic outcomes, Tipirneni and another physician-politician, Barbara Bollier, who is running for an open U.S. Senate seat in Kansas, hope voters will be swayed by candidates who tout respect for science when making policy decisions. Both races are incredibly close, with recent polls showing Tipirneni and Bollier how to buy lasix either ahead or behind their opponents by only a few percentage points.

The stakes are high. If Democrats manage to flip a Senate seat in Kansas, along with achieving a few other wins, they will gain control of the Senate how to buy lasix. And Tipirneni winning in Arizona could help them hold onto their majority in the House. Both outcomes would put Democrats in charge of the two houses of Congress, ending the current split with Republicans. €œAfter a big military conflict, you often how to buy lasix see a surge in military veterans running for office,” says Eitan Hersh, a political scientist at Tufts University.

€œFollowing the 2016 election, more women ran than ever before [in the midterms.] And after COVID-19, it’s not surprising that some physicians would run for office, feeling like their voices need to be heard. If there’s a big surge in doctors running, some will get in.” Grand Battle in the Grand Canyon State In Arizona, Tipirneni has raised more than $1 million more in campaign funding than Schweikert. Generally, a September poll by the Arizona Policy Lab found that science-based approaches to fighting COVID, including mask mandates, were popular among Arizonan voters in both how to buy lasix parties. €œThere is really strong disapproval for how Donald Trump and how Republican governor Doug Ducey have handled COVID-19,” says Samara Klar, a political scientist at the University of Arizona. Ducey, for instance, pushed hard for the resumption of activities with few restrictions in the spring, only to see a surge in COVID cases that forced another shutdown.

Klar adds that polls show that “at the same time, there’s been strong support for how how to buy lasix local mayors have dealt with it.” This, she says, could hurt the Republicans’ chances in Arizona. Schweikert did not respond to requests for comment from Scientific American. He has been a vocal supporter of the use of masks, however how to buy lasix. In a July tweet, he encouraged his constituents to “continue wearing our face coverings when out in public, or when in close proximity to others.” He also advocated for increased access to federal resources to purchase items such as personal protective equipment (PPE). €œWe ...

Ask the how to buy lasix U.S. Department of Health and Human Resources (HHS) and the Federal Emergency Management Agency (FEMA) for an immediate influx of federal resources to combat the virus, through increased testing, contact tracing, personal protective equipment (PPE), staffing support, and emergency funding for local initiatives to respond to and mitigate further spread,” he and four other Arizonan congresspeople wrote in a letter in August. But despite Schweikert’s support for public health practices, his messages may be tainted by the president’s handling of the pandemic. Recent polls how to buy lasix show that Republicans have begun to drift away from Trump. Biden currently leads Trump, 49 percent to 41 percent, in Arizona.

On energy policy, Schweikert and Tipirneni’s messaging diverges how to buy lasix. €œArizona should be leading the charge on a renewable energy economy,” Tipirneni says, adding that those energy sources are key to reducing the impacts of climate change. €œBut we have leaders like my opponent, who has stood at every opportunity to block those kinds of initiatives because he is someone who still takes money from fossil fuels and is driven by party leadership to invest in other forms of energy.” Schweikert’s platform promotes an “‘all of the above’ energy solution,” tapping into “traditional energy reserves” but also expanding renewable energy resources. In his time in the House, however, he has taken dozens of antienvironmental how to buy lasix positions, including voting against protecting Chaco Canyon from oil and gas drilling, banning offshore drilling in the Atlantic and Pacific Ocean, and implementing methane pollution safeguards. The Kansas Contest Democrats have not cornered the market on physician candidates.

In Kansas, Roger Marshall, a Republican representative in the House and an ob-gyn, is running against Bollier, a Democratic former anesthesiologist, creating a rare doctor-doctor duel. But despite sharing a medical background, the two appear diametrically opposed on issues pertaining to how to buy lasix science. Barbara Bollier (left) and Roger Marshall (right). Credit. Barbara Bollier Flickr (Bollier).

Eric Connolly U.S. House Office of Photography (Marshall) Bollier had been a Republican until she switched parties in 2018, and has served in the state’s legislature for a decade. She acknowledges that climate change is caused by people and has committed to greatly expand wind energy in the state. In contrast, Marshall has rejected the scientific consensus on climate, stating, “I’m not sure that there is even climate change” in 2017. His campaign Web site makes no mention of the issue.

Bollier “is a scientist and data nerd at heart,” says her communications director Alexandra De Luca. €œBarbara follows science. She always listens to the experts. Roger Marshall does not. If Roger Marshall followed science, he wouldn’t be holding events indoors, shaking hands with vulnerable Kansans.” Bollier’s campaign, De Luca says, held more than 40 virtual town halls on Zoom this summer.

And Bollier only began in-person campaigning in late August—always outdoors and physically distanced. Marshall did push for additional coronavirus testing kits for Kansas in April, saying that more testing could keep workers at large meat processing plants on the job—processors in Kansas had already had big outbreaks of the virus. But Marshall differed from much medical research in May, when he told the Wall Street Journal he was taking the antimalarial drug hydroxychloroquine as a preventive measure against COVID-19. Though touted by President Trump as a possible cure, the data supporting the medication was always sparse, and emergency authorization for it was revoked by the U.S. Food and Drug Administration in June.

In the May article, Marshall added that he “would encourage any person over the age of 65 or with an underlying medical condition to talk to their own physician about taking hydroxychloroquine.” In September, Marshall wrote a Facebook post suggesting that most COVID-19 deaths were from other ailments. Facebook deleted the post. His campaign did not respond to Scientific American’s requests for an interview. Marshall regularly plays up his medical credentials. He has given himself the nickname “Doc,” and his Twitter username is @RogerMarshallMD.

He also has used his medical skills to help in the pandemic, he says. In late April, Marshall tweeted, “Today, I began treating COVID-19 patients on a volunteer basis in Wyandotte County, KS. I began the process of onboarding several days ago, and have started in the clinic today.” Thus far, polls show the race between Bollier and Marshall “as surprisingly close for a Republican state,” with all of them falling within the margin of error, says Don Haider-Markel, a political scientist at the University of Kansas. Despite electing a Democratic governor in 2018, he says, the state still leans conservative, and to have a competitive Democrat in the running is “not typical, to say the least.” After the economy and jobs, Haider-Markel observes, Kansans care most about the handling of the pandemic in this election cycle—ranking that issue ahead of education and civil unrest. In the final days of campaigning, Democrats are trying to focus attention on health care, he adds, but “it’s not clear that voters are prioritizing that more than last month.” Bollier is likely succeeding at picking up moderate Republican and independent voters, Haider-Markel says.

Trump’s election alienated many Republican women in the suburbs in eastern Kansas and around Wichita who have likely switched to supporting the Democratic candidate, he explains. €œI think Bollier’s messaging on evidence-based policy will resonate with them—but they were already going to be more attracted to her to begin with.” Patti Doll, a 67-year-old former social worker who lives in Wichita, has been following the Senate race closely. She is a Democrat and says the pandemic has made her pay greater attention to candidates’ adherence to scientific guidelines. Marshall, she notes with dissatisfaction, is still campaigning without a mask in October. €œIt’s his job to lead and show people that this is important,” she says.

€œIf it was switched, and it was Bollier who was a Republican, and Marshall was a Democrat, I would vote across party lines in this situation. It doesn’t matter to me. Follow the science.”Every time I log onto Facebook, I brace myself. My newsfeed—like everyone else’s I know—is filled with friends, relatives and acquaintances arguing about COVID-19, masks and Trump. Facebook has become a battleground among partisan “echo chambers.” But what is it about social media that makes people so polarized?.

To find out, my colleagues and I ran a social media experiment in which we divided Democrats and Republicans into “echo chambers,” or small groups whose members affiliate with just one political party. Next, we picked the most polarizing issues we could think of. Immigration, gun control and unemployment. We asked each participant what they thought of those issues, then let people talk to each other and revise their opinions. After several rounds of discussion and revision, we evaluated each group’s viewpoint.

To our surprise, the echo chambers did not make people more polarized, but less. After interacting in social networks with likeminded peers, each echo chamber—Republican and Democrat—had adopted a more moderate opinion. All groups independently moved toward opinions that were closer to the opinions on the “opposite” side of the political spectrum. As a scientist who studies networks, I’m used to being surprised by the results of my experiments. Technology has allowed us to access more information and data about people’s social networks, debunking many of our assumptions about human behavior.

But even my team at the Network Dynamics Group was surprised. Why did our social media experiment find the opposite of what happens all the time in the real world of social media?. The answer lies in something social media has amplified. €œinfluencers.” By now, most of us have a fairly specific understanding of what an “influencer” is. The word conjures up a young, wealthy person whose lifestyle is sponsored by brands like Instagram, TikTok or YouTube.

But the word has a very specific network science meaning. In social media, networks tend to be centralized. A small number of people, or perhaps just one person, at the “center” of the network is connected to lots of other people in the “periphery.” The multitudes in the periphery of the social network have only a modest number of connections, while the few—the so-called “influencers”—at the center of the network are connected to nearly everyone. This puts these people into the powerful position of being able to exert a disproportionate level of “influence” over the group. By contrast, the networks used in our study were “egalitarian”—the opposite of centralized.

In an egalitarian network, everyone has an equal number of contacts, and therefore influence, throughout the network. The key feature of an egalitarian network is that new ideas and opinions can emerge from anywhere in the community and spread to everyone. But in centralized networks—like many social media sites—ideas are filtered through, or sometimes even blocked, by a powerful social influencer. As I show in my upcoming book Change. The Power in the Periphery to Make Big Things Happen, centralized and egalitarian networks have very different effects on partisan bias and the acceptance of new ideas.

In a centralized echo chamber, if the influencer at the middle shows even a small amount of partisan bias, it can become amplified throughout the entire group. But in egalitarian networks, ideas spread based on their quality, and not the person touting them. There is a lot of wisdom in network peripheries, in regular people with good ideas. When the social network enables those people to talk with each other, new thinking that challenge a group’s biases can take hold and spread. To see how egalitarian networks might affect other kinds of contentious issues, we conducted another experiment with smokers and nonsmokers discussing the risks of cigarette smoking.

The effects were the same as with the partisan study. Both groups moved toward a more accurate understanding of smoking risks. Moreover, when participants were interviewed after the study, they reported having developed higher opinions of the other. Both smokers and nonsmokers had come to view the other group as more reasonable and trustworthy about the risks of smoking. But the exchange of ideas and eradication of bias only works when networks are egalitarian.

The problem of partisan bias is exacerbated on social media because online networks are often organized around a few key influencers. This feature of social media is one of the main reasons why misinformation and fake news has become so pervasive. In centralized networks, biased influencers have a disproportionate impact on their community—enabling small rumors and suppositions to become amplified into widespread misconceptions and false beliefs. Our country has been struggling with bias and polarization a long time. But the issue is about to get much more urgent.

As the debate over COVID-19 vaccination heats up, biased viewpoints will undoubtedly become entrenched in communities with powerful influencers at their center. If we want to eradicate, or at least lessen the impacts of the coronavirus, we should rethink how our online communities operate. The solution to the problem of vaccine hesitancy is not to eliminate echo chambers. Rather, it is to be intentional about the social networks in those echo chambers. The more equity in people’s social networks, the less biased and more informed groups will become—even when those groups start off with highly partisan opinions..

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In some cases, a drug maker walks away from a product, claiming it is no longer profitable, leaving an insufficient number of alternate suppliers. At times, some manufacturers complain that regulatory requirements are too costly to pursue and choose to withdraw from a particular market.Last year, lasix for pulmonary edema however, the U.S. Saw 186 new shortages, 82% of which were classified as due to “unknown” reasons largely because of “the intentional opacity and secrecy of the upstream supply chain,” the CIDRAP researchers wrote. In a report issued last year, the FDA noted that the number of ongoing shortages has been steadily rising — reaching about 110 — after peaking in 2011 lasix for pulmonary edema and then declining until 2018. The agency examined a sample of 163 drugs for which shortages first occurred between 2013 and 2017, and found 63% of the shortages arose after supply disruptions associated with product quality or manufacturing problems lasix for pulmonary edema.

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€œIf they’re all having a surge at the same time, we how to buy lasix don’t have the ability to shift supplies around as we tried to do in the spring.” The concerns arise after years in which the U.S. Pharmaceutical supply chain has been regularly hindered by shortages. And this occurs at how to buy lasix great, according to the report. Overall, U.S. Health systems spend more than $500 million a how to buy lasix year on estimated costs related to drug shortages, with approximately $200 million in direct costs and up to $360 million on indirect costs.The reasons buy generic lasix for shortages often vary.

In some cases, a drug maker walks away from a product, claiming it is no longer profitable, leaving an insufficient number of alternate suppliers. At times, some manufacturers complain that regulatory requirements are too costly to pursue and choose to withdraw how to buy lasix from a particular market.Last year, however, the U.S. Saw 186 new shortages, 82% of which were classified as due to “unknown” reasons largely because of “the intentional opacity and secrecy of the upstream supply chain,” the CIDRAP researchers wrote. In a report issued last year, the FDA how to buy lasix noted that the number of ongoing shortages has been steadily rising — reaching about 110 — after peaking in 2011 and then declining until 2018. The agency examined a sample of 163 drugs how to buy lasix for which shortages first occurred between 2013 and 2017, and found 63% of the shortages arose after supply disruptions associated with product quality or manufacturing problems.

Another 18% occurred for unknown reasons, 12% were due to unanticipated increases in demand, 5% followed natural disasters, and 3% were attributed to product discontinuations.The FDA has responded by approving more generics, but a recent study found that the proportion of approvals for drugs that could address those concerns has actually remained steady. Last year, the agency also considered creating a how to buy lasix system to rate manufacturing facilities run by drug makers, but the idea has not gained traction.As noted previously, however, the pandemic has highlighted concerns that the U.S. Remains vulnerable to shortages of numerous medicines — but especially antibiotics — if geopolitical disputes arise with China. Consequently, there has been increasing talk in the how to buy lasix U.S. Of creating an America First program to find ways to spur domestic production of APIs and finished medicines.InMay, the federal government awarded a $354 million contract to a new company to make generics that are in short supply during the pandemic.

But achieving this goal may be easier said than how to buy lasix done, if only because it can take time to build a sufficient number of facilities before domestic production could meet demand for key medicines or ingredients. For that to happen, pharmaceutical companies will likely demand incentives, since production is generally cheaper in other countries.“America First is not something that’s going to happen overnight,” said Osterholm. €œWe have to start looking at this from a national security standpoint, because we don’t want to be totally dependent on supplies from another country how to buy lasix. But we’re not having the discussion in this country.”.

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