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Cheap zocor canada

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Samples of the drug sent to the Michigan State Police Laboratory found the drug has several components, including the synthetic opioid fentanyl, niacinamide (a form of vitamin B), acetaminophen (the key ingredient in Tylenol), flualprazolam (an illicit sedative similar to Xanax), buspirone (an anti-anxiety drug) and brorphine, a new non-fentanyl synthetic opioid.Officials said brorphine, like fentanyl, is lethal in even small doses and is cheap zocor canada 50 to 100 times more powerful than morphine. Officials also said it is unknown whether the drug is colored before or after its arrival in Michigan. Poison Center cheap zocor canada officials said brorphine is considered a recreational drug.

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The lawmakers argue that the FDA should cheap zocor canada provide additional context and data standardization regarding the oxycodone prescribing data. €œStandardizing data for comparison cheap zocor canada is important given that, while FDA believes it only intended to narrow the indication for OxyContin, the 2001 label change may have been used to help promote higher-dose, longer-term prescriptions, and thus could have facilitated prescriptions of Extended-Release and Long-Acting (ER/LA) oxycodone. Purdue internal documents indicate that the company may have viewed the effect of the label change effect as an opportunity to expand its market.

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Attendees were taught how to recognize and respond to an opioid overdose emergency. They also were informed about cheap zocor canada local treatment and support resources.“Amidst the COVID-19 pandemic, we can’t forget about the opioid epidemic. Addiction has its grip on our community, and with this event and others, we can make sure that Naloxone gets to individuals and families who may need it during an opioid overdose emergency,” Trinidad Navarro, the insurance commissioner, said.

€œWhile we continue to work to ensure that treatment for those with drug dependencies is affordable and accessible, events like these offer an opportunity to increase awareness and education life-saving techniques and tools.”Navarro hosted the event in collaboration with Public Health’s Kent County Community Response Team, cheap zocor canada the First Presbyterian Church of Smyrna, and the Smyrna-Clayton Ministerium. The event was outdoors and offered drive-through and walk-up options..

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On the HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels does zocor cause diabetes -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers. People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit.

Box 3 on page 1 is Spousal Impoverishment levels does zocor cause diabetes for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 C.F.R.

§ 435.4 does zocor cause diabetes. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <. Age 1, 154% FPL for children age 1 - 19.

CAUTION does zocor cause diabetes. What is counted as income may not be what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards.

However, for the MAGI population - which is virtually everyone under age 65 who does zocor cause diabetes is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes and bad changes. GOOD.

Veteran's benefits, Workers compensation, and gifts from family or others no longer does zocor cause diabetes count as income. BAD. There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules.

For all of the does zocor cause diabetes rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical.

There are different rules depending on does zocor cause diabetes the "category" of the person seeking Medicaid. Here are the 2 basic categories and the rules for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size.

These same rules apply to the Medicare Savings Program, with some exceptions explained does zocor cause diabetes in this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated.

New rule is explained in State's directive does zocor cause diabetes 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size. See slides 28-49.

Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 does zocor cause diabetes -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category. Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility.

See does zocor cause diabetes 18 NYCRR 360-4.2, MRG p. 573, NYS GIS 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits.

If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is does zocor cause diabetes determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI. The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL).

Medicaid for adults between ages does zocor cause diabetes 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits.

It did does zocor cause diabetes not allow "spend down" of excess income. This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL.

This has does zocor cause diabetes now been folded into the new MAGI adult group whose limit is 138% FPL. For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange. PAST INCOME &.

RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in does zocor cause diabetes chronological order. These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs in NYS. This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing.

One way New York State is trying to address that barrier is with the Special does zocor cause diabetes Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care. The special income standard for housing expenses helps pay for housing expenses to help certain nursing home or adult home residents to safely transition back to the community with MLTC. Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult homes.

GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer does zocor cause diabetes need to use a pooled trust. KNOW YOUR RIGHTS - FACT SHEET on THREE ways to Reduce Spend-down, including this Special Income Standard. September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below.

"How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" does zocor cause diabetes and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify. "Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC plan. Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard.

The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC does zocor cause diabetes plan, the month of discharge to the community. Questions regarding the special income standard may be directed to DOH at 518-474-8887. Who is eligible for this special income standard?.

must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC. How much is the allowance?. The rates vary by region and change yearly.

Region Counties Deduction (2020) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence, Tioga, Tompkins $436 Long Island Nassau, Suffolk $1,361 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,451 (up from 1,300 in 2019) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $483 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $930 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $444 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $386 Past rates published as follows, available on DOH website 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates. The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05.

2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS. 2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N. Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?.

Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo. Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!. HOW TO OBTAIN THE HOUSING DISREGARD.

When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard. See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it. The procedures in NYC are explained in this Troubleshooting guide.

NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest). NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III – OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02.

MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy. References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept.

28, 2018 - this finally implements the most recent Special Terms &. Conditions of the CMS 1115 Waiver that governs the MLTC program, dated Jan. 19, 2017.

The section on this income standard is at pages 26-27.

19 in school) 138% FPL*** cheap zocor canada Children < why not find out more. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $875 (up from $859 in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 in 2019) NO LIMIT** NO LIMIT SOURCE for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF). All of the attachments with the various levels are posted cheap zocor canada here. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?.

Which household size applies?. The cheap zocor canada rules are complicated. See rules here. On the HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 cheap zocor canada are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers.

People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 cheap zocor canada or under 19 if in school. 42 C.F.R. § 435.4.

Certain populations have an even higher income limit - 224% FPL for pregnant cheap zocor canada women and babies <. Age 1, 154% FPL for children age 1 - 19. CAUTION. What is counted as income may not be what cheap zocor canada you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards.

However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good cheap zocor canada changes and bad changes. GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD cheap zocor canada.

There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules The income limits increase cheap zocor canada with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid.

Here cheap zocor canada are the 2 basic categories and the rules for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not cheap zocor canada yet on Medicare -- this is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated.

New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household cheap zocor canada Size. See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible cheap zocor canada for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category.

Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p. 573, NYS GIS cheap zocor canada 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI.

The following programs were available prior to cheap zocor canada 2014, but are now discontinued because they are folded into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles cheap zocor canada and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits.

It did not allow "spend down" of excess income. This category has now been subsumed cheap zocor canada under the new MAGI adult group whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL. For applicants between 138%-150% FPL, they will be eligible for a cheap zocor canada new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange.

PAST INCOME &. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order. These include Medicaid levels for MAGI cheap zocor canada and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs in NYS. This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care.

The special income standard for housing expenses helps pay for housing expenses to help certain nursing home or adult home residents to safely transition back cheap zocor canada to the community with MLTC. Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult homes. GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust. KNOW YOUR RIGHTS - FACT SHEET on THREE ways to Reduce Spend-down, including this Special Income cheap zocor canada Standard. September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below.

"How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify. "Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC cheap zocor canada health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC plan. Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community. Questions regarding cheap zocor canada the special income standard may be directed to DOH at 518-474-8887.

Who is eligible for this special income standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC. How much is cheap zocor canada the allowance?. The rates vary by region and change yearly. Region Counties Deduction (2020) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St.

Lawrence, Tioga, Tompkins $436 Long Island Nassau, Suffolk $1,361 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,451 (up from 1,300 in 2019) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington cheap zocor canada $483 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $930 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $444 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $386 Past rates published as follows, available on DOH website 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates. The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS. 2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N. Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?.

Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo. Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!. HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard. See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it.

The procedures in NYC are explained in this Troubleshooting guide. NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest). NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III – OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02. MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy.

References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept. 28, 2018 - this finally implements the most recent Special Terms &. Conditions of the CMS 1115 Waiver that governs the MLTC program, dated Jan.

Zocor maximum dosage

This story also ran on Fortune. This story can be republished for free (details). Donella Pogue has trouble finding dentists in her rural area willing to accommodate her 21-year-old son, Justin, who is 6 feet, 8 inches tall, is on the autism spectrum and has difficulty sitting still when touched.And zocor maximum dosage this summer, he had a cavity and his face swelled. Pogue, of Bristol, New York, reached out to the Eastman Institute zocor maximum dosage for Oral Health in Rochester, which offers teledentistry.Dr. Adela Planerova looked into his mouth from 28 miles away as Pogue pointed her laptop’s camera into her son’s mouth. Planerova determined they did not need to make an emergency one-hour zocor maximum dosage drive to her clinic.

Instead, the dentist prescribed antibiotics and anti-inflammatory drugs, and weeks later he had surgery.Teledentistry allows dental professionals like Planerova to remotely review records and diagnose patients over video. Some smile about its promise, seeing it zocor maximum dosage as a way to become more efficient, to reach the one-third of U.S. Adults who federal figures from 2017 estimate hadn’t seen a dentist in the previous year and to practice more safely during the pandemic.But others see it as lesser-quality care that’s cheaper for dental professionals to provide, allowing them to make more money. At the same time, widespread adoption is hindered by issues such as spotty internet zocor maximum dosage and insurance companies unwilling to reimburse for teledentistry procedures.

Don't Miss A Story Subscribe to KHN’s free Weekly Edition newsletter. Dr zocor maximum dosage. Christina Carter, an orthodontist in Morristown, New Jersey, said teledentistry has its place but shouldn’t replace time in the dental chair.“It cannot be used for a full diagnosis because we need other tools, like X-rays,” she said. €œWe have all tried to see things on our phone or even on a Zoom call, and there is still just a different feel.”Still, as the pandemic curbs in-person visits and reduces dentists’ zocor maximum dosage revenue, more dentists are seeking guidance from Dr.

Nathan Suter, a leading teledentistry advocate who owns the consulting company Access Teledentistry. Since March, he said, he’s done webinars for about 9,000 dental professionals, up from fewer than 1,000 in the three years before the pandemic.Teledentistry providers trace the practice to 1994, when the Army launched a pilot program in which health care providers used an intra-oral camera to take photos of a patient’s mouth at a fort in Georgia and then sent them over the internet to a dental clinic at zocor maximum dosage a fort 120 miles away.Over the next two decades, dentists in upstate New York and the San Francisco Bay Area led teledentistry pilot programs for underserved children, some of whom were in preschool and already had cavities. The number of children who completed the prescribed dental treatment rose significantly.Supporters say teledentistry can help reach the zocor maximum dosage 43% of rural Americans who lack access to dental care. Medicaid and the Children’s Health Insurance Program will pay for many dental procedures for those enrolled in those programs, but only 38% of dentists participate in those programs, according to the American Dental Association.

One reason zocor maximum dosage. Medicaid typically reimburses at a significantly lower rate than those of private insurance plans.Teledentistry could help dentists treat more patients and make more money a number of ways. If dentists remotely zocor maximum dosage review data captured by hygienists, they can see more patients. Because video appointments save them time, dentists then have room for the people “who need the more expensive services” while also focusing on preventive care, said Kirill Zaydenman, vice president of innovation for DentaQuest, an administrator of dental insurance and oral health care provider.Donella Pogue says that teledentistry was the best option for her 21-year-old son, Justin, when he had a cavity this summer that caused his face to swell.

Justin has special needs and was able to see the dentist from zocor maximum dosage the comfort of home. (Donella Pogue)But dentists have not widely adopted teledentistry — mainly because they’ve had difficulty getting insurers to pay for it, said Dr. Dorota Kopycka-Kedzierawski, a Rochester zocor maximum dosage dentist. That’s partly because of insurers’ concerns about fraud.

Dr. Paul Glassman, who started the Virtual Dental Home project to reach underserved preschool children in the Bay Area, considers those fears “completely incorrect.”“If you want to bill for something you didn’t do,” he said, “you can do that just as easily in an in-person environment as you can using teledentistry.”Since March, as the pandemic descended, most, if not all, private dental plans have been reimbursing for teledentistry, said Tom Meyers, vice president of public policy for America’s Health Insurance Plans, a trade organization. And all state Medicaid programs now reimburse for teledentistry in some form, Glassman said, though policies differ by state and some practices may not be covered in some places.But teledentistry isn’t reimbursable under Medicare. (Most dentistry isn’t.) Another obstacle to widespread adoption.

Some dentists and lawmakers connect teledentistry to companies offering at-home teeth aligners with little or no in-person contact with a dentist. Glassman has promoted teledentistry throughout the United States and reviewed proposed legislation or regulations in states such as Idaho, Massachusetts and Texas. He said he hears concerns from dentists about the lack of an in-person exam during which X-rays are taken. Such concerns are reflected in some legislation.SmileDirectClub, an at-home teeth-aligner company, has argued in statehouse testimony that in-person care is not always needed.

The company opposed a 2019 bill in Texas that aimed to improve access to dentistry in rural areas because it included a number of restrictions on teledentistry, including one that would have required an in-person dentist’s examination if a teledentistry provider treated that patient for more than 12 months.SmileDirect’s attorney argued at a hearing the rule “could interrupt the course of a patient’s treatment.”The measure failed.Proponents argue teledentistry isn’t just about making more money. Pogue, the New York woman, said it was the best option for her son with special needs.“He is really afraid of dentistry, so when he goes to see someone, he is really tense and really jumpy, so that’s another reason the teledentistry was nice was because he was in my bedroom doing it, so he was really comfortable,” said Pogue, 53, whose son is covered by Medicaid.A few weeks later, Justin did have to have surgery, which went “perfect,” his mom said.Some dentists say teledentistry faces particular stumbling blocks in rural areas. Dr. Mack Taylor, 36, a dentist who grew up in the small town of Dexter, Missouri, now practices in a health center just down the road.

Twenty years ago, he said, Dexter had eight dentists. Now there are only three.Technology is a major obstacle for local residents, many of whom lack reliable internet service. Taylor recently applied for a U.S. Department of Agriculture grant that would give him $26,500 to buy equipment so that, for example, a hygienist can take photos inside the mouths of nursing home residents and send them to Taylor to review.“It’s not like medicine where you can discuss someone’s ailments and have a good idea what’s going on,” Taylor said.

€œMaybe all you can tell me is ‘I have a broken tooth,’ but I can’t physically see what’s going on and prescribe the right treatment.” Related Topics COVID-19 Dental Health Telemedicine.

This story also cheap zocor canada ran on Fortune. This story can be republished for free (details). Donella Pogue has trouble finding dentists in her rural area willing to accommodate her 21-year-old son, Justin, who is 6 feet, 8 inches tall, is on the autism spectrum and has difficulty sitting still when touched.And this summer, he had a cavity and his face swelled. Pogue, of Bristol, New York, reached out to the Eastman Institute for Oral Health in Rochester, which cheap zocor canada offers teledentistry.Dr. Adela Planerova looked into his mouth from 28 miles away as Pogue pointed her laptop’s camera into her son’s mouth. Planerova determined they did not need to make an emergency one-hour cheap zocor canada drive to her clinic.

Instead, the dentist prescribed antibiotics and anti-inflammatory drugs, and weeks later he had surgery.Teledentistry allows dental professionals like Planerova to remotely review records and diagnose patients over video. Some smile about its promise, seeing it as a way to become more cheap zocor canada efficient, to reach the one-third of U.S. Adults who federal figures from 2017 estimate hadn’t seen a dentist in the previous year and to practice more safely during the pandemic.But others see it as lesser-quality care that’s cheaper for dental professionals to provide, allowing them to make more money. At the same time, widespread adoption is hindered by issues such cheap zocor canada as spotty internet and insurance companies unwilling to reimburse for teledentistry procedures.

Don't Miss A Story Subscribe to KHN’s free Weekly Edition newsletter. Dr cheap zocor canada. Christina Carter, an orthodontist in Morristown, New Jersey, said teledentistry has its place but shouldn’t replace time in the dental chair.“It cannot be used for a full diagnosis because we need other tools, like X-rays,” she said. €œWe have all tried to see things cheap zocor canada on our phone or even on a Zoom call, and there is still just a different feel.”Still, as the pandemic curbs in-person visits and reduces dentists’ revenue, more dentists are seeking guidance from Dr.

Nathan Suter, a leading teledentistry advocate who owns the consulting company Access Teledentistry. Since March, he said, he’s done webinars for about 9,000 dental professionals, up from fewer than 1,000 in the three years before the pandemic.Teledentistry providers trace the practice to 1994, when the Army launched a pilot program in which health care providers used an intra-oral camera to take photos of a patient’s mouth at a fort in Georgia cheap zocor canada and then sent them over the internet to a dental clinic at a fort 120 miles away.Over the next two decades, dentists in upstate New York and the San Francisco Bay Area led teledentistry pilot programs for underserved children, some of whom were in preschool and already had cavities. The number of children cheap zocor canada who completed the prescribed dental treatment rose significantly.Supporters say teledentistry can help reach the 43% of rural Americans who lack access to dental care. Medicaid and the Children’s Health Insurance Program will pay for many dental procedures for those enrolled in those programs, but only 38% of dentists participate in those programs, according to the American Dental Association.

One reason cheap zocor canada. Medicaid typically reimburses at a significantly lower rate than those of private insurance plans.Teledentistry could help dentists treat more patients and make more money a number of ways. If dentists remotely review data captured by hygienists, they can see more cheap zocor canada patients. Because video appointments save them time, dentists then have room for the people “who need the more expensive services” while also focusing on preventive care, said Kirill Zaydenman, vice president of innovation for DentaQuest, an administrator of dental insurance and oral health care provider.Donella Pogue says that teledentistry was the best option for her 21-year-old son, Justin, when he had a cavity this summer that caused his face to swell.

Justin has special needs and was able to see the dentist from cheap zocor canada the comfort of home. (Donella Pogue)But dentists have not widely adopted teledentistry — mainly because they’ve had difficulty getting insurers to pay for it, said Dr. Dorota Kopycka-Kedzierawski, a Rochester cheap zocor canada dentist. That’s partly because of insurers’ concerns about fraud.

Dr. Paul Glassman, who started the Virtual Dental Home project to reach underserved preschool children in the Bay Area, considers those fears “completely incorrect.”“If you want to bill for something you didn’t do,” he said, “you can do that just as easily in an in-person environment as you can using teledentistry.”Since March, as the pandemic descended, most, if not all, private dental plans have been reimbursing for teledentistry, said Tom Meyers, vice president of public policy for America’s Health Insurance Plans, a trade organization. And all state Medicaid programs now reimburse for teledentistry in some form, Glassman said, though policies differ by state and some practices may not be covered in some places.But teledentistry isn’t reimbursable under Medicare. (Most dentistry isn’t.) Another obstacle to widespread adoption.

Some dentists and lawmakers connect teledentistry to companies offering at-home teeth aligners with little or no in-person contact with a dentist. Glassman has promoted teledentistry throughout the United States and reviewed proposed legislation or regulations in states such as Idaho, Massachusetts and Texas. He said he hears concerns from dentists about the lack of an in-person exam during which X-rays are taken. Such concerns are reflected in some legislation.SmileDirectClub, an at-home teeth-aligner company, has argued in statehouse testimony that in-person care is not always needed.

The company opposed a 2019 bill in Texas that aimed to improve access to dentistry in rural areas because it included a number of restrictions on teledentistry, including one that would have required an in-person dentist’s examination if a teledentistry provider treated that patient for more than 12 months.SmileDirect’s attorney argued at a hearing the rule “could interrupt the course of a patient’s treatment.”The measure failed.Proponents argue teledentistry isn’t just about making more money. Pogue, the New York woman, said it was the best option for her son with special needs.“He is really afraid of dentistry, so when he goes to see someone, he is really tense and really jumpy, so that’s another reason the teledentistry was nice was because he was in my bedroom doing it, so he was really comfortable,” said Pogue, 53, whose son is covered by Medicaid.A few weeks later, Justin did have to have surgery, which went “perfect,” his mom said.Some dentists say teledentistry faces particular stumbling blocks in rural areas. Dr. Mack Taylor, 36, a dentist who grew up in the small town of Dexter, Missouri, now practices in a health center just down the road.

Twenty years ago, he said, Dexter had eight dentists. Now there are only three.Technology is a major obstacle for local residents, many of whom lack reliable internet service. Taylor recently applied for a U.S. Department of Agriculture grant that would give him $26,500 to buy equipment so that, for example, a hygienist can take photos inside the mouths of nursing home residents and send them to Taylor to review.“It’s not like medicine where you can discuss someone’s ailments and have a good idea what’s going on,” Taylor said.

€œMaybe all you can tell me is ‘I have a broken tooth,’ but I can’t physically see what’s going on and prescribe the right treatment.” Related Topics COVID-19 Dental Health Telemedicine.

Zocor dosage

Can’t see https://www.voiture-et-handicap.fr/cheap-generic-zocor/ the audio zocor dosage player?. Click zocor dosage here to listen on SoundCloud. Republicans appear to be on track to confirm Judge Amy Coney Barrett to the Supreme Court before Election Day, cementing a 6-3 conservative majority on the high court regardless of what happens Nov. 3.

Democrats, meanwhile, lacking the votes to block the nomination, used the high-profile hearings to batter Republicans for trying to overturn the Affordable Care Act.Meanwhile, a number of scientific journals that typically eschew politics, including the prestigious New England Journal of Medicine, threw their support to Democratic presidential candidate Joe Biden, citing what they call the Trump administration’s bungling of the coronavirus pandemic.This week’s panelists are Julie Rovner of Kaiser Health News, Mary Ellen McIntire of CQ Roll Call, Shefali Luthra of The 19th and Sarah Karlin-Smith of Pink Sheet.Among the takeaways from this week’s podcast:The lack of progress on a bipartisan coronavirus relief package is making both Democrats and Republicans nervous as they approach Election Day without something to help voters.During hearings on the nomination of Judge Amy Coney Barrett for the Supreme Court, Democrats were consistently on message, seeking to focus public attention before the election on the threat that Republicans pose to the Affordable Care Act as the law goes before the court next month. Four members of the Senate Judiciary Committee, which will vote on the nomination, are up for reelection. Also on the committee is Sen. Kamala Harris, the Democrats’ vice presidential candidate.The public health optics of the hearing were jarring for some viewers.

Although the committee chairman said the room was set up to meet federal health guidelines, Republican senators often did not wear masks, including Sens. Thom Tillis (N.C.) and Mike Lee (Utah), who both were diagnosed with COVID-19 after attending a White House celebration for Barrett.The lack of masks could add to confusion about public health messages. And voters sometimes find it insulting that politicians play down risks that the public is called upon to assume.Barrett’s testimony did not change many perceptions of her. Although she was extremely careful not to reveal her personal views on issues that could come before the court, including the ACA and abortion, both Democrats and Republicans highlighted her strong conservative credentials.Scientific American and the New England Journal of Medicine have published stinging critiques of the current administration’s policies on science and medicine.

Although it’s not clear what impact the editorials will have, they are a sign of the further politicization of public health.This week, Rovner also interviews Dr. Ashish Jha, dean of the Brown University School of Public Health. Jha talked about the challenges public health professionals have faced in trying to deal with the COVID-19 pandemic.Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:Julie Rovner. The Atlantic’s “How to Tell If Socializing Indoors Is Safe,” by Olga KhazanShefali Luthra.

The New York Times’ “A $52,112 Air Ambulance Ride. Coronavirus Patients Battle Surprise Bills,” by Sarah KliffMary Ellen McIntire. KHN’s “Making Money Off Masks, COVID-Spawned Chain Store Aims to Become Obsolete,” by Markian HawrylukSarah Karlin-Smith. Politico’s “Health Officials Scrambling to Produce Trump’s ‘Last-Minute’ Drug Cards by Election Day,” by Dan DiamondAlso mentioned in this week’s podcast:Bill of the Month update.

KHN’s “Moved by Plight of Young Heart Patient, Stranger Pays His Hospital Bill,” by Laura UngarScientific journal endorsements. The New England Journal of Medicine’s “Dying in a Leadership Vacuum”“Scientific American Endorses Joe Biden,” by The EditorsTo hear all our podcasts, click here.And subscribe to What the Health?. on iTunes, Stitcher, Google Play, Spotify, or Pocket Casts. Related Topics Courts Multimedia Public Health The Health Law COVID-19 KHN's 'What The Health?.

' PodcastsThis story also ran on NPR. This story can be republished for free (details). In late March, shortly after New York state closed nonessential businesses and asked people to stay home, Ashley Laderer began waking each morning with a throbbing headache.“The pressure was so intense it felt like my head was going to explode,” recalled the 27-year-old freelance writer from Long Island.She tried spending less time on the computer and taking over-the-counter pain medication, but the pounding kept breaking through — a constant drumbeat to accompany her equally incessant worries about COVID-19.After a month and a half with a pounding headache, Ashley Laderer decided to visit a neurologist, who ordered an MRI. But the doctor found no physical cause. The scan was clear.(Alissa Castleton)“Every day I lived in fear that I was going to get it and I was going to infect my whole family,” she said.After a month and a half, Laderer decided to visit a neurologist, who ordered an MRI. But the doctor found no physical cause.

The scan was clear.Then he asked. Are you under a lot of stress?. Throughout the pandemic, people who never had the coronavirus have been reporting a host of seemingly unrelated symptoms. Excruciating headaches, episodes of hair loss, upset stomach for weeks on end, sudden outbreaks of shingles and flare-ups of autoimmune disorders.

The disparate symptoms, often in otherwise healthy individuals, have puzzled doctors and patients alike, sometimes resulting in a series of visits to specialists with few answers. But it turns out there’s a common thread among many of these conditions, one that has been months in the making. Chronic stress.Although people often underestimate the influence of the mind on the body, a growing catalog of research shows that high levels of stress over an extended time can drastically alter physical function and affect nearly every organ system.Now, at least eight months into the pandemic, alongside a divisive election cycle and racial unrest, those effects are showing up in a variety of symptoms.“The mental health component of COVID is starting to come like a tsunami,” said Dr. Jennifer Love, a California-based psychiatrist and co-author of an upcoming book on how to heal from chronic stress.

Email Sign-Up Subscribe to KHN’s free Morning Briefing. Nationwide, surveys have found increasing rates of depression, anxiety and suicidal thoughts during the pandemic. But many medical experts said it’s too soon to measure the related physical symptoms, since they generally appear months after the stress begins.Still, some early research, such as a small Chinese study and an online survey of more than 500 people in Turkey, points to an uptick.In the U.S., data from FAIR Health, a nonprofit database that provides cost information to the health industry and consumers, showed slight to moderate increases in the percentage of medical claims related to conditions triggered or exacerbated by stress, like multiple sclerosis and shingles. The portion of claims for the autoimmune disease lupus, for example, showed one of the biggest increases — 12% this year — compared with the same period last year (January to August).Express Scripts, a major pharmacy benefit manager, reported that prescriptions for anti-insomnia medications increased 15% early in the pandemic.Perhaps the strongest indicator comes from doctors reporting a growing number of patients with physical symptoms for which they can’t determine a cause.Dr.

Shilpi Khetarpal, a dermatologist at the Cleveland Clinic, used to see about five patients a week with stress-related hair loss. Since mid-June, that number has jumped to 20 or 25. Mostly women, ages 20 to 80, are reporting hair coming out in fistfuls, Khetarpal said.In Houston, at least a dozen patients have told fertility specialist Dr. Rashmi Kudesia they’re having irregular menstrual cycles, changes in cervical discharge and breast tenderness, despite normal hormone levels.Stress is also the culprit dentists are pointing to for the rapid increase in patients with teeth grinding, teeth fractures and TMJ.“We, as humans, like to have the idea that we are in control of our minds and that stress isn’t a big deal,” Love said.

€œBut it’s simply not true.”How Mental Stress Becomes PhysicalStress causes physical changes in the body that can affect nearly every organ system.Although symptoms of chronic stress are often dismissed as being in one’s head, the pain is very real, said Kate Harkness, a professor of psychology and psychiatry at Queen’s University in Ontario.When the body feels unsafe — whether it’s a physical threat of attack or a psychological fear of losing a job or catching a disease — the brain signals adrenal glands to pump stress hormones. Adrenaline and cortisol flood the body, activating the fight-or-flight response. They also disrupt bodily functions that aren’t necessary for immediate survival, like digestion and reproduction.When the danger is over, the hormones return to normal levels. But during times of chronic stress, like a pandemic, the body keeps pumping out stress hormones until it tires itself out.

This leads to increased inflammation throughout the body and brain, and a poorly functioning immune system.Studies link chronic stress to heart disease, muscle tension, gastrointestinal issues and even physical shrinking of the hippocampus, an area of the brain associated with memory and learning. As the immune system acts up, some people can even develop new allergic reactions, Harkness said.The good news is that many of these symptoms are reversible. But it’s important to recognize them early, especially when it comes to the brain, said Barbara Sahakian, a professor of clinical neuropsychology at the University of Cambridge.“The brain is plastic, so we can to some extent modify it,” Sahakian said. €œBut we don’t know if there’s a cliff beyond which you can’t reverse a change.

So the sooner you catch something, the better.”The Day-to-Day ImpactIn some ways, mental health awareness has increased during the pandemic. TV shows are flush with ads for therapy and meditation apps, like Talkspace and Calm, and companies are announcing mental health days off for staff.For Alex Kostka, pandemic-related stress has brought on mood swings, nightmares and jaw pain.(Jordan Battiste)But those spurts of attention fail to reveal the full impact of poor mental health on people’s daily lives.For Alex Kostka, pandemic-related stress has brought on mood swings, nightmares and jaw pain.He’d been working at a Whole Foods coffee bar in New York City for only about a month before the pandemic hit, suddenly anointing him an essential worker. As deaths in the city soared, Kostka continued riding the subway to work, interacting with co-workers in the store and working longer hours for just a $2-per-hour wage increase. (Months later, he’d get a $500 bonus.) It left the 28-year-old feeling constantly unsafe and helpless.“It was hard not to break down on the subway the minute I got on it,” Kostka said.Soon he began waking in the middle of the night with pain from clenching his jaw so tightly.

Often his teeth grinding and chomping were loud enough to wake his girlfriend.Kostka tried Talkspace, but found texting about his troubles felt impersonal. By the end of the summer, he decided to start using the seven free counseling sessions offered by his employer. That’s helped, he said. But as the sessions run out, he worries the symptoms might return if he’s unable to find a new therapist covered by his insurance.“Eventually, I will be able to leave this behind me, but it will take time,” Kostka said.

€œI’m still very much a work in progress.”How to Mitigate Chronic StressWhen it comes to chronic stress, seeing a doctor for stomach pain, headaches or skin rashes may address those physical symptoms. But the root cause is mental, medical experts say.That means the solution will often involve stress-management techniques. And there’s plenty we can do to feel better:Exercise. Even low- to moderate-intensity physical activity can help counteract stress-induced inflammation in the body.

It can also increase neuronal connections in the brain.Meditation and mindfulness. Research shows this can lead to positive, structural and functional changes in the brain.Fostering social connections. Talking to family and friends, even virtually, or staring into a pet’s eyes can release a hormone that may counteract inflammation.Learning something new. Whether it’s a formal class or taking up a casual hobby, learning supports brain plasticity, the ability to change and adapt as a result of experience, which can be protective against depression and other mental illness.“We shouldn’t think of this stressful situation as a negative sentence for the brain,” said Harkness, the psychology professor in Ontario.

€œBecause stress changes try this web-site the brain, that means positive stuff can change the brain, too. And there is plenty we can do to help ourselves feel better in the face of adversity.” Aneri Pattani. apattani@kff.org, @aneripattani Related Topics Mental Health Public Health COVID-19About HealthBent KHN's chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years, offers insight and analysis of policies and politics in her regular HealthBent columns.Send questions to jrovner@kff.org. Use Our Content This story can be republished for free (details). Democrats on the Senate Judiciary Committee know that, barring something unexpected, they lack the votes to block President Donald Trump from installing his third justice in four years on the Supreme Court and creating a 6-3 conservative majority.They also know that, in a normal year, by mid-October Congress would be out of session and members home campaigning.

But 2020 is obviously no normal year. So, while the rest of Congress is home, Democratic Judiciary members are trying something very different in the hearings for nominee Amy Coney Barrett. Rather than prosecuting their case against Barrett, currently a federal appeals court judge, they are refighting the war that helped them pick up seats in 2018 — banging on Republicans for trying to eliminate the Affordable Care Act.Conveniently, the ACA is relevant to the Supreme Court debate because the justices are scheduled to hear a case that could invalidate the law on Nov. 10 — exactly a week after Election Day.As California Sen.

Kamala Harris, a member of the Judiciary Committee and the Democratic vice presidential candidate, put it to Barrett on Tuesday, “Republicans are scrambling to confirm this nominee as fast as possible because they need one more Trump judge on the bench before Nov. 10th to win and strike down the entire Affordable Care Act. This is not hyperbole. This is not hypothetical.

This is happening.”Said Sen. Richard Durbin (D-Ill.), also on Tuesday. €œWe really believe the Supreme Court’s consideration of that case is going — could literally change America for millions of people.” Email Sign-Up Subscribe to KHN’s free Morning Briefing. To be sure, Republicans too were playing to their electorate during the questioning of Barrett, as they expounded on her conservative credentials on issues such as gun rights.Nonetheless, Democrats were uniformly disciplined in their assault on her potential vote in the ACA case.

They chided both Barrett and the Republicans who are rushing her nomination to the floor literally days before a presidential election. In addition, Democrats criticized Republicans for spending time on a nonemergency nomination while continuing to ignore the need for financial and other relief for the COVID-19 pandemic.And they raised what in more normal times would be the featured talking point for Democrats. The threat to abortion and other reproductive rights from Barrett, who before her elevation to the federal bench publicly opposed abortion and taught law at Notre Dame, one of the nation’s preeminent Catholic universities.“For many people, and particularly for women, this is a fundamental question,” said Sen. Dianne Feinstein (D-Calif.), the committee’s top Democrat.Barrett, like every other Supreme Court nominee for the past three decades, declined to offer positions that could suggest which way she might rule on hot-button issues, including abortion and the ACA.She repeatedly cited what has come to be called the “Ginsburg rule” — after the justice she would replace, Ruth Bader Ginsburg — saying “no hints, no previews, no forecasts.”Still, Democrats suggested that she may have tipped her hand on the Affordable Care Act case.

In pointing out that the issues in the case, now known as California v. Texas, are different from the previous cases upholding the health law in 2012 and 2015, she said the current case will turn on “severability.”She was referring to the question of whether, if one portion of a law is found to be unconstitutional, the rest of the law can stand without it. In the current ACA case, a group of Republican attorneys general — and the Trump administration — are arguing that when Congress reduced the ACA’s penalty for not having insurance to zero, the requirement to be covered no longer had a tax attached, and therefore the law is now unconstitutional. They based their argument on Chief Justice John Roberts’ 2012 conclusion that the ACA was valid because that penalty was a constitutionally appropriate tax.The law’s opponents say the rest of the law cannot be “severed” and must therefore fall, too.

A federal district judge in Texas agreed with them.But merely saying the case turns on severability suggests that Barrett has already prejudged major parts of the case, Democrats said. Sen. Chris Coons (D-Del.) noted, “You don’t get to the question of severability if you haven’t already determined the question of constitutionality.”Barrett insisted repeatedly that despite an article she wrote in 2017 suggesting that the 2012 case upholding the law was wrongly decided, “I have no animus to nor agenda for the ACA,” as she told Sen. Amy Klobuchar (D-Minn.) on Wednesday.In their rare show of unity of message, Democrats made clear that their primary audience in these hearings was not their Senate colleagues, but the voting public.

While this battle looks lost, they hope to win the War of Nov. 3.HealthBent, a regular feature of KHN, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years. Julie Rovner. jrovner@kff.org, @jrovner Related Topics Courts Elections HealthBent The Health Law Abortion U.S.

CongressThis story also ran on LAist. This story can be republished for free (details). Los Angeles County officials attribute a dramatic decline in COVID-19 death and case rates among Blacks and Latinos over the past two months to aggressive workplace health enforcement and the opening of tip lines to report violations.Now, officials intend to cement those gains by creating workplace councils among employees trained to look for COVID-19 prevention violations and correct or report them — without fear of being fired or punished.Cal/OSHA, the state’s workplace safety and health authority, is overwhelmed with complaints and tips about COVID-19 violations, and the county’s health investigators — there were officially 346 of them as of last Friday — can’t possibly keep tabs on all of Los Angeles’ more than 240,000 businesses, labor advocates say.The councils could help keep Los Angeles from backsliding on its progress in mitigating cases and racial disparities in the fall as more businesses are likely to reopen, said Tia Koonse, a researcher with the UCLA Labor Center and co-author of an assessment of the workplace council proposal. The L.A. County Board of Supervisors is expected to approve an ordinance this month requiring businesses to permit employees to form the councils, which would troubleshoot compliance issues and report to the health department when necessary. Email Sign-Up Subscribe to KHN’s free Morning Briefing.

Critics, including many business leaders, say the measure will create more red tape at the worst possible time for the economy. But labor groups and some businesses say it is crucial to fighting the pandemic. Workers around the country have been sacked or reprimanded for complaining about COVID-related safety violations, and laws protecting them are spotty.“Workers have a right to be in a safe space and shouldn’t face any retaliation” for noting poor practices, said Barbara Ferrer, director of the L.A. County Public Health Department.

Low-wage workers have been “tremendously disadvantaged” by having to work outside the home in contact with other people, often without sufficient protection, she said.During the upsurge of COVID cases that followed Memorial Day weekend family gatherings and business openings, Latinos in Los Angeles were dying at a rate more than four times higher than that of whites, while Blacks were twice as likely as whites to die of the disease. Two months later, death rates among Blacks and Latinos had fallen by more than half and were approaching the rate for whites, according to age-adjusted data from the county health department. While four times as many Latinos as whites were reported COVID-positive in late July, the Latino case rates were only 64% higher by mid-September. The positivity rate among Blacks was 60% higher than that of whites in late July, but the disparity had waned by mid-September.Experts can’t be certain that any one policy is responsible for the decline in deaths among Blacks and Latinos in Los Angeles — and state and county rates have declined for the entire population in recent weeks.

But Ferrer attributed the progress to her department’s focus on workplace enforcement of health orders, which include rules about physical distancing, providing face coverings for workers and requiring face coverings for customers.“If you’re in violation, at this point we can either issue citations, or there are cases where we just close the place down because the violations are egregious,” she said.The sharp racial disparities that characterized the pandemic from the beginning are under even more scrutiny now that California has become the first state to make “health equity” a factor in its decisions to allow expanded reopening.Large counties may not advance toward full reopening until their most disadvantaged neighborhoods, and not just the county as a whole, meet or are lower than the targeted levels of disease. The criteria prod local governments to invest more in testing, contact tracing and education in poor neighborhoods with high levels of the disease.Ferrer’s focus on workplaces crystallized during a crackdown on Los Angeles Apparel, a clothing factory that had pivoted to face mask manufacturing during the pandemic. Despite the ready inventory of masks, an outbreak at the factory resulted in at least 300 cases — and four deaths.The health department, acting on a tip from community health centers flooded with sick Los Angeles Apparel workers, shut down the factory on June 27. That action highlighted the need to bring the government and labor unions together to fight the pandemic, said Jim Mangia, CEO of St.

John’s Well Child &. Family Center, a chain of community health centers in South L.A.“At St. John’s, almost all of our patients are the working poor,” Mangia said. €œThey were getting infected at work and bringing it home to their families, and I think intervening at the workplace is what really made all the difference.”Early in the pandemic, Ferrer had also set up an anonymous complaint line for employees who want to report workplace violations.

It gets about 2,000 calls a week, she said. As of Oct. 10, the department’s website lists 132 workplaces that have had three or more confirmed COVID-19 cases, with a total of 2,191 positives. Another table dated Oct.

7 lists 124 citations — mostly to gyms and places of worship — for failing to comply with a health officer order.“Fortunately, we’re not like Cal/OSHA, in the sense that it doesn’t take us months to complete an investigation,” Ferrer said. €œWe’re able to move more swiftly under the health officer orders to actually make sure that we’re protecting workers.”Public health councils are the next phase in Ferrer’s plan to keep workers safe. The plan stemmed from the response of Overhill Farms, a frozen-food factory in Vernon, California, after an outbreak of more than 20 cases and one death. The factory and its temporary job agency were hit with more than $200,000 in proposed penalties from Cal/OSHA in September, but before the fines landed, the factory leadership was already responding by beginning to hold meetings with workers to improve safety there.“They found that the workers helped them bring down infection rates and helped solve problems,” said Roxana Tynan, executive director of the Los Angeles Alliance for a New Economy, a worker advocacy organization.While it’s not exactly a feel-good story about corporate beneficence, the turnaround at Overhill Farms added credence to the benefits of workplace councils, said Koonse of UCLA.No company would have to spend more than 0.44% of its payroll cost on the health councils, she estimated.Still, the idea has gotten a mixed reception from businesses.

In an Aug. 24 statement, CEO Tracy Hernandez of the L.A. County Business Federation wrote that the proposal would add “burdensome and convoluted programs that will further hinder an employer’s ability to meet demands, get back on their feet, and adequately serve their employees and customers.”But Jim Amen, president of the eight-store Super A Foods grocery chain, said businesses should welcome the councils as a way to keep lines of communication open. Such practices have kept infection rates low at his stores, even without a mandate, Amen said.“All I know is, for Super A, our employees are heavily involved in everything we do,” Amen said.Labor groups see the councils as a crucial way for workers to raise concerns without fear of retaliation.“In low-wage industries like the garment industry, workers coming together gets them fired,” said Marissa Nuncio, director of the Garment Worker Center, a nonprofit that mainly serves immigrants from Mexico and Central America.While disparities are narrowing in L.A.

County, some shops are still unsafe and potential whistleblowers aren’t confident their reports to the county’s tip line are being acted on, she said.“We continue to get calls from our members who are sick, have COVID and are hospitalized,” Nuncio said. €œAnd the most obvious location for them to have been infected is in their workplace, because so many precautions are not being taken.”KHN data reporter Hannah Recht contributed to this article. Anna Almendrala. aalmendrala@kff.org, @annaalmendrala Related Topics California Multimedia Public Health Race and Health States COVID-19.

Can’t see This Site the audio cheap zocor canada player?. Click here to listen on SoundCloud cheap zocor canada. Republicans appear to be on track to confirm Judge Amy Coney Barrett to the Supreme Court before Election Day, cementing a 6-3 conservative majority on the high court regardless of what happens Nov. 3.

Democrats, meanwhile, lacking the votes to block the nomination, used the high-profile hearings to batter Republicans for trying to overturn the Affordable Care Act.Meanwhile, a number of scientific journals that typically eschew politics, including the prestigious New England Journal of Medicine, threw their support to Democratic presidential candidate Joe Biden, citing what they call the Trump administration’s bungling of the coronavirus pandemic.This week’s panelists are Julie Rovner of Kaiser Health News, Mary Ellen McIntire of CQ Roll Call, Shefali Luthra of The 19th and Sarah Karlin-Smith of Pink Sheet.Among the takeaways from this week’s podcast:The lack of progress on a bipartisan coronavirus relief package is making both Democrats and Republicans nervous as they approach Election Day without something to help voters.During hearings on the nomination of Judge Amy Coney Barrett for the Supreme Court, Democrats were consistently on message, seeking to focus public attention before the election on the threat that Republicans pose to the Affordable Care Act as the law goes before the court next month. Four members of the Senate Judiciary Committee, which will vote on the nomination, are up for reelection. Also on the committee is Sen. Kamala Harris, the Democrats’ vice presidential candidate.The public health optics of the hearing were jarring for some viewers.

Although the committee chairman said the room was set up to meet federal health guidelines, Republican senators often did not wear masks, including Sens. Thom Tillis (N.C.) and Mike Lee (Utah), who both were diagnosed with COVID-19 after attending a White House celebration for Barrett.The lack of masks could add to confusion about public health messages. And voters sometimes find it insulting that politicians play down risks that the public is called upon to assume.Barrett’s testimony did not change many perceptions of her. Although she was extremely careful not to reveal her personal views on issues that could come before the court, including the ACA and abortion, both Democrats and Republicans highlighted her strong conservative credentials.Scientific American and the New England Journal of Medicine have published stinging critiques of the current administration’s policies on science and medicine.

Although it’s not clear what impact the editorials will have, they are a sign of the further politicization of public health.This week, Rovner also interviews Dr. Ashish Jha, dean of the Brown University School of Public Health. Jha talked about the challenges public health professionals have faced in trying to deal with the COVID-19 pandemic.Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:Julie Rovner. The Atlantic’s “How to Tell If Socializing Indoors Is Safe,” by Olga KhazanShefali Luthra.

The New York Times’ “A $52,112 Air Ambulance Ride. Coronavirus Patients Battle Surprise Bills,” by Sarah KliffMary Ellen McIntire. KHN’s “Making Money Off Masks, COVID-Spawned Chain Store Aims to Become Obsolete,” by Markian HawrylukSarah Karlin-Smith. Politico’s “Health Officials Scrambling to Produce Trump’s ‘Last-Minute’ Drug Cards by Election Day,” by Dan DiamondAlso mentioned in this week’s podcast:Bill of the Month update.

KHN’s “Moved by Plight of Young Heart Patient, Stranger Pays His Hospital Bill,” by Laura UngarScientific journal endorsements. The New England Journal of Medicine’s “Dying in a Leadership Vacuum”“Scientific American Endorses Joe Biden,” by The EditorsTo hear all our podcasts, click here.And subscribe to What the Health?. on iTunes, Stitcher, Google Play, Spotify, or Pocket Casts. Related Topics Courts Multimedia Public Health The Health Law COVID-19 KHN's 'What The Health?.

' PodcastsThis story also ran on NPR. This story can be republished for free (details). In late March, shortly after New York state closed nonessential businesses and asked people to stay home, Ashley Laderer began waking each morning with a throbbing headache.“The pressure was so intense it felt like my head was going to explode,” recalled the 27-year-old freelance writer from Long Island.She tried spending less time on the computer and taking over-the-counter pain medication, but the pounding kept breaking through — a constant drumbeat to accompany her equally incessant worries about COVID-19.After a month and a half with a pounding headache, Ashley Laderer decided to visit a neurologist, who ordered an MRI. But the doctor found no physical cause. The scan was clear.(Alissa Castleton)“Every day I lived in fear that I was going to get it and I was going to infect my whole family,” she said.After a month and a half, Laderer decided to visit a neurologist, who ordered an MRI. But the doctor found no physical cause.

The scan was clear.Then he asked. Are you under a lot of stress?. Throughout the pandemic, people who never had the coronavirus have been reporting a host of seemingly unrelated symptoms. Excruciating headaches, episodes of hair loss, upset stomach for weeks on end, sudden outbreaks of shingles and flare-ups of autoimmune disorders.

The disparate symptoms, often in otherwise healthy individuals, have puzzled doctors and patients alike, sometimes resulting in a series of visits to specialists with few answers. But it turns out there’s a common thread among many of these conditions, one that has been months in the making. Chronic stress.Although people often underestimate the influence of the mind on the body, a growing catalog of research shows that high levels of stress over an extended time can drastically alter physical function and affect nearly every organ system.Now, at least eight months into the pandemic, alongside a divisive election cycle and racial unrest, those effects are showing up in a variety of symptoms.“The mental health component of COVID is starting to come like a tsunami,” said Dr. Jennifer Love, a California-based psychiatrist and co-author of an upcoming book on how to heal from chronic stress.

Email Sign-Up Subscribe to KHN’s free Morning Briefing. Nationwide, surveys have found increasing rates of depression, anxiety and suicidal thoughts during the pandemic. But many medical experts said it’s too soon to measure the related physical symptoms, since they generally appear months after the stress begins.Still, some early research, such as a small Chinese study and an online survey of more than 500 people in Turkey, points to an uptick.In the U.S., data from FAIR Health, a nonprofit database that provides cost information to the health industry and consumers, showed slight to moderate increases in the percentage of medical claims related to conditions triggered or exacerbated by stress, like multiple sclerosis and shingles. The portion of claims for the autoimmune disease lupus, for example, showed one of the biggest increases — 12% this year — compared with the same period last year (January to August).Express Scripts, a major pharmacy benefit manager, reported that prescriptions for anti-insomnia medications increased 15% early in the pandemic.Perhaps the strongest indicator comes from doctors reporting a growing number of patients with physical symptoms for which they can’t determine a cause.Dr.

Shilpi Khetarpal, a dermatologist at the Cleveland Clinic, used to see about five patients a week with stress-related hair loss. Since mid-June, that number has jumped to 20 or 25. Mostly women, ages 20 to 80, are reporting hair coming out in fistfuls, Khetarpal said.In Houston, at least a dozen patients have told fertility specialist Dr. Rashmi Kudesia they’re having irregular menstrual cycles, changes in cervical discharge and breast tenderness, despite normal hormone levels.Stress is also the culprit dentists are pointing to for the rapid increase in patients with teeth grinding, teeth fractures and TMJ.“We, as humans, like to have the idea that we are in control of our minds and that stress isn’t a big deal,” Love said.

€œBut it’s simply not true.”How Mental Stress Becomes PhysicalStress causes physical changes in the body that can affect nearly every organ system.Although symptoms of chronic stress are often dismissed as being in one’s head, the pain is very real, said Kate Harkness, a professor of psychology and psychiatry at Queen’s University in Ontario.When the body feels unsafe — whether it’s a physical threat of attack or a psychological fear of losing a job or catching a disease — the brain signals adrenal glands to pump stress hormones. Adrenaline and cortisol flood the body, activating the fight-or-flight response. They also disrupt bodily functions that aren’t necessary for immediate survival, like digestion and reproduction.When the danger is over, the hormones return to normal levels. But during times of chronic stress, like a pandemic, the body keeps pumping out stress hormones until it tires itself out.

This leads to increased inflammation throughout the body and brain, and a poorly functioning immune system.Studies link chronic stress to heart disease, muscle tension, gastrointestinal issues and even physical shrinking of the hippocampus, an area of the brain associated with memory and learning. As the immune system acts up, some people can even develop new allergic reactions, Harkness said.The good news is that many of these symptoms are reversible. But it’s important to recognize them early, especially when it comes to the brain, said Barbara Sahakian, a professor of clinical neuropsychology at the University of Cambridge.“The brain is plastic, so we can to some extent modify it,” Sahakian said. €œBut we don’t know if there’s a cliff beyond which you can’t reverse a change.

So the sooner you catch something, the better.”The Day-to-Day ImpactIn some ways, mental health awareness has increased during the pandemic. TV shows are flush with ads for therapy and meditation apps, like Talkspace and Calm, and companies are announcing mental health days off for staff.For Alex Kostka, pandemic-related stress has brought on mood swings, nightmares and jaw pain.(Jordan Battiste)But those spurts of attention fail to reveal the full impact of poor mental health on people’s daily lives.For Alex Kostka, pandemic-related stress has brought on mood swings, nightmares and jaw pain.He’d been working at a Whole Foods coffee bar in New York City for only about a month before the pandemic hit, suddenly anointing him an essential worker. As deaths in the city soared, Kostka continued riding the subway to work, interacting with co-workers in the store and working longer hours for just a $2-per-hour wage increase. (Months later, he’d get a $500 bonus.) It left the 28-year-old feeling constantly unsafe and helpless.“It was hard not to break down on the subway the minute I got on it,” Kostka said.Soon he began waking in the middle of the night with pain from clenching his jaw so tightly.

Often his teeth grinding and chomping were loud enough to wake his girlfriend.Kostka tried Talkspace, but found texting about his troubles felt impersonal. By the end of the summer, he decided to start using the seven free counseling sessions offered by his employer. That’s helped, he said. But as the sessions run out, he worries the symptoms might return if he’s unable to find a new therapist covered by his insurance.“Eventually, I will be able to leave this behind me, but it will take time,” Kostka said.

€œI’m still very much a work in progress.”How to Mitigate Chronic StressWhen it comes to chronic stress, seeing a doctor for stomach pain, headaches or skin rashes may address those physical symptoms. But the root cause is mental, medical experts say.That means the solution will often involve stress-management techniques. And there’s plenty we can do to feel better:Exercise. Even low- to moderate-intensity physical activity can help counteract stress-induced inflammation in the body.

It can also increase neuronal connections in the brain.Meditation and mindfulness. Research shows this can lead to positive, structural and functional changes in the brain.Fostering social connections. Talking to family and friends, even virtually, or staring into a pet’s eyes can release a hormone that may counteract inflammation.Learning something new. Whether it’s a formal class or taking up a casual hobby, learning supports brain plasticity, the ability to change and adapt as a result of experience, which can be protective against depression and other mental illness.“We shouldn’t think of this stressful situation as a negative sentence for the brain,” said Harkness, the psychology professor in Ontario.

€œBecause stress changes the brain, that means positive stuff can change zocor blood pressure the brain, too. And there is plenty we can do to help ourselves feel better in the face of adversity.” Aneri Pattani. apattani@kff.org, @aneripattani Related Topics Mental Health Public Health COVID-19About HealthBent KHN's chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years, offers insight and analysis of policies and politics in her regular HealthBent columns.Send questions to jrovner@kff.org. Use Our Content This story can be republished for free (details). Democrats on the Senate Judiciary Committee know that, barring something unexpected, they lack the votes to block President Donald Trump from installing his third justice in four years on the Supreme Court and creating a 6-3 conservative majority.They also know that, in a normal year, by mid-October Congress would be out of session and members home campaigning.

But 2020 is obviously no normal year. So, while the rest of Congress is home, Democratic Judiciary members are trying something very different in the hearings for nominee Amy Coney Barrett. Rather than prosecuting their case against Barrett, currently a federal appeals court judge, they are refighting the war that helped them pick up seats in 2018 — banging on Republicans for trying to eliminate the Affordable Care Act.Conveniently, the ACA is relevant to the Supreme Court debate because the justices are scheduled to hear a case that could invalidate the law on Nov. 10 — exactly a week after Election Day.As California Sen.

Kamala Harris, a member of the Judiciary Committee and the Democratic vice presidential candidate, put it to Barrett on Tuesday, “Republicans are scrambling to confirm this nominee as fast as possible because they need one more Trump judge on the bench before Nov. 10th to win and strike down the entire Affordable Care Act. This is not hyperbole. This is not hypothetical.

This is happening.”Said Sen. Richard Durbin (D-Ill.), also on Tuesday. €œWe really believe the Supreme Court’s consideration of that case is going — could literally change America for millions of people.” Email Sign-Up Subscribe to KHN’s free Morning Briefing. To be sure, Republicans too were playing to their electorate during the questioning of Barrett, as they expounded on her conservative credentials on issues such as gun rights.Nonetheless, Democrats were uniformly disciplined in their assault on her potential vote in the ACA case.

They chided both Barrett and the Republicans who are rushing her nomination to the floor literally days before a presidential election. In addition, Democrats criticized Republicans for spending time on a nonemergency nomination while continuing to ignore the need for financial and other relief for the COVID-19 pandemic.And they raised what in more normal times would be the featured talking point for Democrats. The threat to abortion and other reproductive rights from Barrett, who before her elevation to the federal bench publicly opposed abortion and taught law at Notre Dame, one of the nation’s preeminent Catholic universities.“For many people, and particularly for women, this is a fundamental question,” said Sen. Dianne Feinstein (D-Calif.), the committee’s top Democrat.Barrett, like every other Supreme Court nominee for the past three decades, declined to offer positions that could suggest which way she might rule on hot-button issues, including abortion and the ACA.She repeatedly cited what has come to be called the “Ginsburg rule” — after the justice she would replace, Ruth Bader Ginsburg — saying “no hints, no previews, no forecasts.”Still, Democrats suggested that she may have tipped her hand on the Affordable Care Act case.

In pointing out that the issues in the case, now known as California v. Texas, are different from the previous cases upholding the health law in 2012 and 2015, she said the current case will turn on “severability.”She was referring to the question of whether, if one portion of a law is found to be unconstitutional, the rest of the law can stand without it. In the current ACA case, a group of Republican attorneys general — and the Trump administration — are arguing that when Congress reduced the ACA’s penalty for not having insurance to zero, the requirement to be covered no longer had a tax attached, and therefore the law is now unconstitutional. They based their argument on Chief Justice John Roberts’ 2012 conclusion that the ACA was valid because that penalty was a constitutionally appropriate tax.The law’s opponents say the rest of the law cannot be “severed” and must therefore fall, too.

A federal district judge in Texas agreed with them.But merely saying the case turns on severability suggests that Barrett has already prejudged major parts of the case, Democrats said. Sen. Chris Coons (D-Del.) noted, “You don’t get to the question of severability if you haven’t already determined the question of constitutionality.”Barrett insisted repeatedly that despite an article she wrote in 2017 suggesting that the 2012 case upholding the law was wrongly decided, “I have no animus to nor agenda for the ACA,” as she told Sen. Amy Klobuchar (D-Minn.) on Wednesday.In their rare show of unity of message, Democrats made clear that their primary audience in these hearings was not their Senate colleagues, but the voting public.

While this battle looks lost, they hope to win the War of Nov. 3.HealthBent, a regular feature of KHN, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years. Julie Rovner. jrovner@kff.org, @jrovner Related Topics Courts Elections HealthBent The Health Law Abortion U.S.

CongressThis story also ran on LAist. This story can be republished for free (details). Los Angeles County officials attribute a dramatic decline in COVID-19 death and case rates among Blacks and Latinos over the past two months to aggressive workplace health enforcement and the opening of tip lines to report violations.Now, officials intend to cement those gains by creating workplace councils among employees trained to look for COVID-19 prevention violations and correct or report them — without fear of being fired or punished.Cal/OSHA, the state’s workplace safety and health authority, is overwhelmed with complaints and tips about COVID-19 violations, and the county’s health investigators — there were officially 346 of them as of last Friday — can’t possibly keep tabs on all of Los Angeles’ more than 240,000 businesses, labor advocates say.The councils could help keep Los Angeles from backsliding on its progress in mitigating cases and racial disparities in the fall as more businesses are likely to reopen, said Tia Koonse, a researcher with the UCLA Labor Center and co-author of an assessment of the workplace council proposal. The L.A. County Board of Supervisors is expected to approve an ordinance this month requiring businesses to permit employees to form the councils, which would troubleshoot compliance issues and report to the health department when necessary. Email Sign-Up Subscribe to KHN’s free Morning Briefing.

Critics, including many business leaders, say the measure will create more red tape at the worst possible time for the economy. But labor groups and some businesses say it is crucial to fighting the pandemic. Workers around the country have been sacked or reprimanded for complaining about COVID-related safety violations, and laws protecting them are spotty.“Workers have a right to be in a safe space and shouldn’t face any retaliation” for noting poor practices, said Barbara Ferrer, director of the L.A. County Public Health Department.

Low-wage workers have been “tremendously disadvantaged” by having to work outside the home in contact with other people, often without sufficient protection, she said.During the upsurge of COVID cases that followed Memorial Day weekend family gatherings and business openings, Latinos in Los Angeles were dying at a rate more than four times higher than that of whites, while Blacks were twice as likely as whites to die of the disease. Two months later, death rates among Blacks and Latinos had fallen by more than half and were approaching the rate for whites, according to age-adjusted data from the county health department. While four times as many Latinos as whites were reported COVID-positive in late July, the Latino case rates were only 64% higher by mid-September. The positivity rate among Blacks was 60% higher than that of whites in late July, but the disparity had waned by mid-September.Experts can’t be certain that any one policy is responsible for the decline in deaths among Blacks and Latinos in Los Angeles — and state and county rates have declined for the entire population in recent weeks.

But Ferrer attributed the progress to her department’s focus on workplace enforcement of health orders, which include rules about physical distancing, providing face coverings for workers and requiring face coverings for customers.“If you’re in violation, at this point we can either issue citations, or there are cases where we just close the place down because the violations are egregious,” she said.The sharp racial disparities that characterized the pandemic from the beginning are under even more scrutiny now that California has become the first state to make “health equity” a factor in its decisions to allow expanded reopening.Large counties may not advance toward full reopening until their most disadvantaged neighborhoods, and not just the county as a whole, meet or are lower than the targeted levels of disease. The criteria prod local governments to invest more in testing, contact tracing and education in poor neighborhoods with high levels of the disease.Ferrer’s focus on workplaces crystallized during a crackdown on Los Angeles Apparel, a clothing factory that had pivoted to face mask manufacturing during the pandemic. Despite the ready inventory of masks, an outbreak at the factory resulted in at least 300 cases — and four deaths.The health department, acting on a tip from community health centers flooded with sick Los Angeles Apparel workers, shut down the factory on June 27. That action highlighted the need to bring the government and labor unions together to fight the pandemic, said Jim Mangia, CEO of St.

John’s Well Child &. Family Center, a chain of community health centers in South L.A.“At St. John’s, almost all of our patients are the working poor,” Mangia said. €œThey were getting infected at work and bringing it home to their families, and I think intervening at the workplace is what really made all the difference.”Early in the pandemic, Ferrer had also set up an anonymous complaint line for employees who want to report workplace violations.

It gets about 2,000 calls a week, she said. As of Oct. 10, the department’s website lists 132 workplaces that have had three or more confirmed COVID-19 cases, with a total of 2,191 positives. Another table dated Oct.

7 lists 124 citations — mostly to gyms and places of worship — for failing to comply with a health officer order.“Fortunately, we’re not like Cal/OSHA, in the sense that it doesn’t take us months to complete an investigation,” Ferrer said. €œWe’re able to move more swiftly under the health officer orders to actually make sure that we’re protecting workers.”Public health councils are the next phase in Ferrer’s plan to keep workers safe. The plan stemmed from the response of Overhill Farms, a frozen-food factory in Vernon, California, after an outbreak of more than 20 cases and one death. The factory and its temporary job agency were hit with more than $200,000 in proposed penalties from Cal/OSHA in September, but before the fines landed, the factory leadership was already responding by beginning to hold meetings with workers to improve safety there.“They found that the workers helped them bring down infection rates and helped solve problems,” said Roxana Tynan, executive director of the Los Angeles Alliance for a New Economy, a worker advocacy organization.While it’s not exactly a feel-good story about corporate beneficence, the turnaround at Overhill Farms added credence to the benefits of workplace councils, said Koonse of UCLA.No company would have to spend more than 0.44% of its payroll cost on the health councils, she estimated.Still, the idea has gotten a mixed reception from businesses.

In an Aug. 24 statement, CEO Tracy Hernandez of the L.A. County Business Federation wrote that the proposal would add “burdensome and convoluted programs that will further hinder an employer’s ability to meet demands, get back on their feet, and adequately serve their employees and customers.”But Jim Amen, president of the eight-store Super A Foods grocery chain, said businesses should welcome the councils as a way to keep lines of communication open. Such practices have kept infection rates low at his stores, even without a mandate, Amen said.“All I know is, for Super A, our employees are heavily involved in everything we do,” Amen said.Labor groups see the councils as a crucial way for workers to raise concerns without fear of retaliation.“In low-wage industries like the garment industry, workers coming together gets them fired,” said Marissa Nuncio, director of the Garment Worker Center, a nonprofit that mainly serves immigrants from Mexico and Central America.While disparities are narrowing in L.A.

County, some shops are still unsafe and potential whistleblowers aren’t confident their reports to the county’s tip line are being acted on, she said.“We continue to get calls from our members who are sick, have COVID and are hospitalized,” Nuncio said. €œAnd the most obvious location for them to have been infected is in their workplace, because so many precautions are not being taken.”KHN data reporter Hannah Recht contributed to this article. Anna Almendrala. aalmendrala@kff.org, @annaalmendrala Related Topics California Multimedia Public Health Race and Health States COVID-19.

Why does zocor cause muscle pain

Buried in frozen soil across the why does zocor cause muscle pain Arctic, billions of tons of carbon lies zocor blood pressure trapped in the ground. Just a few degrees of warming could unleash it into the atmosphere. At least, that’s why does zocor cause muscle pain what the past would suggest. According to a new study, it’s happened before.

The research, published Friday in the journal Science Advances, looks back 27,000 years into Arctic history. On at least three occasions, the study finds, periods of why does zocor cause muscle pain rapid climate change caused huge swaths of permafrost—a layer of carbon-rich frozen soil widespread in the Arctic—to quickly thaw or collapse. As a result, huge volumes of carbon dioxide poured into the air. Today, the planet is once again enduring a period of rapid climate change—this time caused by human emissions of greenhouse gases.

In fact, research suggests, the Earth is warming at one of why does zocor cause muscle pain its fastest rates in millions of years. If the past is any lesson for the future, that could mean a little more warming may trigger yet another massive destabilization of Arctic permafrost. It’s a red flag scientists have been waving for years. As Arctic temperatures rise, permafrost begins to warm why does zocor cause muscle pain up.

And as it thaws out, it releases carbon dioxide and methane into the air. Researchers have warned repeatedly that these why does zocor cause muscle pain emissions could speed the pace of climate change. That could lead to a dangerous runaway feedback cycle, in which more warming causes more permafrost to thaw and release even more carbon into the air. Just how fast that might happen is still a matter of debate.

Multiple studies have documented widespread warming and thawing in why does zocor cause muscle pain permafrost regions across the Arctic. But researchers still are working to determine how quickly permafrost may respond to future climate warming and how much carbon it will release in the process. That makes permafrost something of a wild card in climate research—a major uncertainty in scientists’ predictions about future climate change. The new study suggests rapid climate change—even just a few degrees why does zocor cause muscle pain of warming—could trigger dramatic bursts of carbon from the thawing Arctic.

The scientists used data from ancient sediments, drilled from the bottom of the Arctic Ocean north of Siberia, where they’d been buried for thousands of years. By conducting careful chemical analyses of these sediments, the scientists were able to document changes in the amount of organic matter flowing into the ocean from collapsing permafrost landscapes. Thanks to similar studies, why does zocor cause muscle pain also relying on analyses of long-buried sediments and ancient ice samples, scientists have a good idea of what was going on with the Earth’s climate and its carbon dioxide levels thousands of years ago. The study suggests that three distinct periods of rapid climate change over the past 27,000 years each coincided with massive thawing and collapsing on permafrost landscapes.

Rising temperatures were why does zocor cause muscle pain likely a big part of it. As the climate warmed, permafrost would have begun to thaw out and soften, sending mushy rivers of sludge pouring into the sea and releasing carbon into the air. But that’s not the whole story. The researchers believe that rising sea levels, fueled by warming oceans why does zocor cause muscle pain and melting glaciers, also played a big role.

Rising oceans severely eroded much of the Arctic coastline during at least two of these warming events, the study suggests. The rapid erosion likely caused large tracts of frozen permafrost to abruptly collapse into the sea. The study doesn’t necessarily guarantee what happened in the why does zocor cause muscle pain past will happen again in the future. But it does warn it’s a possibility.

And it’s a growing concern as world leaders struggle to reduce greenhouse gas emissions fast enough to meet the goals of the Paris climate agreement. Scientists say the world is on track why does zocor cause muscle pain to warm by several degrees before the end of the century if carbon emissions don’t start falling faster. €œAny release from thawing permafrost means that there is even less room for anthropogenic greenhouse gas release in the Earth-climate system budget before dangerous thresholds are reached,” Örjan Gustafsson, a scientist at Stockholm University and a co-author of the study, said in a statement. €œThe only way to limit permafrost-related greenhouse gas releases is to mitigate climate warming by lowering anthropogenic greenhouse gas emissions.” Reprinted from Climatewire with permission from E&E News.

E&E provides daily coverage of essential energy and environmental news at www.eenews.net.When why does zocor cause muscle pain the Food and Drug Administration ran into White House resistance to its proposed vaccine safety standards in early October, the agency took a bold step. It published the guidance on its Web site. The public could now see why does zocor cause muscle pain what vaccine manufacturers and the FDA’s own independent advisory panel would require to ensure a longer, scientifically rigorous process. The two public health agencies responsible for overseeing the approval, distribution and use of a coronavirus vaccine—the FDA and the Centers for Disease Control and Prevention—have been undermined and politicized.

The FDA’s proposed guidelines for emergency use of a coronavirus vaccine did finally clear the White House, but the well-publicized resistance has further undermined public trust in Operation Warp Speed just as the United States inches toward a viable vaccine. At a why does zocor cause muscle pain time when trust should be growing, the opposite is happening. What should give Americans hope, however, is that both the FDA and the CDC have a last line of defense when it comes to approval and distribution of a vaccine. Panels of outside experts who now merit the nation’s attention and unequivocal support.

If, in the days ahead, either of these independent bodies are sidelined, ignored or in any way circumvented, a red line why does zocor cause muscle pain will have been crossed, and the safety and/or efficacy of a coronavirus vaccine can reasonably be questioned. For the CDC, it’s the Advisory Committee on Immunization Practices, or ACIP, which next meets October 28–30. We each served terms on this committee at different times, and neither of us ever felt any political pressure during our tenures. The FDA equivalent is the Vaccines and Related Biological why does zocor cause muscle pain Products Advisory Committee, or VRBPAC, which next meets October 22.

Most Americans have never heard generic zocor prices of either. These panels of health experts, with expertise in vaccinology, immunology, pediatrics, internal medicine, why does zocor cause muscle pain infectious diseases and preventive medicine, among other disciplines, have been studying and assessing the myriad coronavirus vaccines under consideration. Each has been scouring data from phase I and phase II trials, and now are awaiting phase III data about some of the most promising vaccines in development. The advisory panels operate with intentional transparency.

The public has access, often in real time via livestream, to their discussions and discoveries, and public records document their work why does zocor cause muscle pain. The 15 voting members on each advisory committee all undergo conflict-of-interest reviews, with annual filings to safeguard compliance. Vaccine interests and financial attachments are disclosed, and members must recuse themselves from related votes. Whether for a coronavirus vaccine or other vaccines, these panels why does zocor cause muscle pain make recommendations as to whether a vaccine is safe, efficacious and ready to be licensed (FDA), as well as how and to which populations a vaccine should be distributed (CDC).

Though the members on each committee surely understand the politics of the moment, they will never bend to it. Today, despite regular political pressure being applied on FDA and CDC to meet arbitrary deadlines for a vaccine release, the time-tested vaccine vetting and approval system has held up since it was established nearly four decades ago. However, the why does zocor cause muscle pain threat to this system is real. Having both worked within it, we’ve identified several scenarios that would be troubling and even dangerous from a public health perspective.

First, it will be problematic if the advisory panels’ work is interrupted or circumvented why does zocor cause muscle pain. Each one has established protocols and defined responsibilities that must not be short-circuited or compromised. If the FDA commissioner or CDC director rejects or modifies the panels’ recommendations, which rarely occurs, the decision will merit close scrutiny and an accompanying strong justification. Second, FDA has now released strict guidance for why does zocor cause muscle pain approving vaccines for emergency use.

If manufacturers fail to comply with this guidance, the panels may not have sufficient information to assess the safety of the vaccines. Third, if anyone in the executive branch of government were to override FDA or CDC decisions and guidance regarding coronavirus vaccines under consideration, this would be a red flag. If ACIP and VRBPAC are each allowed to do their work unencumbered, and there is fidelity to this tried-and-true process, Americans should feel confident that the recommendations of the advisory panels why does zocor cause muscle pain were based on rigorous science showing both safety and efficacy. These committees’ work is not about politics, but people, and their evidence-based approach helps to counteract vaccine misinformation and disinformation.

Today, only about half of adults in the U.S. Say they would get a coronavirus vaccine if one became why does zocor cause muscle pain available this year. Unless public trust improves, the U.S. Likely will see thousands of avoidable deaths and needless suffering.

The pandemic itself will be given a longer life as we are forced to crawl toward herd immunity, which would require a vaccination rate well why does zocor cause muscle pain above 50 percent. In many communities—particularly communities of color—the trust in government’s role in medical care was low even before this pandemic, with seeds sown over many generations because of violations of trust, systemic barriers and racist policies. Physicians across the nation, including in underserved communities, depend on the scientific integrity of why does zocor cause muscle pain ACIP and VRBPAC recommendations to determine whether they are confident in bringing a vaccine to their patients. We know that patients put trust in their physicians when it comes to determining whether to get a vaccine.

That’s why it’s all the more imperative that this trust not be eroded by putting politics above science. There is a why does zocor cause muscle pain reason the U.S. Has had remarkable success with its vaccine programs and has been a global leader in disease control and prevention. We cannot let the trust developed over decades be diminished further during this pandemic.

The preservation of that trust, after why does zocor cause muscle pain all, will serve us not just today, but for generations to come.The 1930s and early 1940s were a good time to fish for sardines off California. Catches soared in a boom that was centered on Monterey Bay and supported the state's flourishing economy. But the tides began to turn in 1946, and sardine catches eventually fell from an average of 234,000 tons to just 24,000 tons. The industry went belly-up why does zocor cause muscle pain.

Scientists have speculated for decades about what factors drove this infamous boom and bust, but they lacked data to test their theories. Now researchers why does zocor cause muscle pain have finally found one apparent culprit. Cycles of ocean upwelling, a defining feature of the West Coast marine environment in which deep, nutrient-rich water rises to the nutrient-poor surface and replenishes the food supply there. The key that unlocked this mystery turned out to be old seaweed specimens gathered from herbaria around the U.S.

€œPlants are just sitting there, recording data about the state of the ocean,” says Kyle Van Houtan, chief scientist at the Monterey Bay Aquarium and senior author of the new study, why does zocor cause muscle pain published in June in the Proceedings of the Royal Society B. €œIf we can access physical specimens from museums and natural history repositories, we can get information about historical ecosystems embedded in those tissues.” Van Houtan and others had suspected upwelling played a role in sardine population trends, but scientists only started measuring the process in Monterey Bay in 1946. Historic seaweed specimens, Van Houtan realized, might fill in the blanks for earlier years—similar to the way ice cores can help reconstruct carbon dioxide levels from times before researchers started collecting real-time measurements. For the new study, the scientists relied on the fact that deeper water near Monterey typically hosts more of a particular nitrogen isotope, a why does zocor cause muscle pain rarer version of nitrogen with an extra neutron that makes each atom heavier.

Looking at modern upwelling data and recently collected seaweed, they found that higher levels of this nitrogen in the plants' cells corresponded with periods of more upwelling. Next they measured the isotope levels in 70 historic specimens of the red seaweed Gelidium, gathered from Monterey as far back as 1878. The results suggested a gradual increase in upwelling and then a dramatic decrease, which lined up with the sardine why does zocor cause muscle pain population's growth and decline. €œThis paper is an excellent example of the creative detective work of historical ecology,” says Loren McClenachan, a marine ecologist at Colby College, who was not involved in the research.

€œThere are thousands and thousands of similar specimens in collections around the world, and applying similar methods could teach us a great deal about long-term ocean change.”.

Buried in frozen cheap zocor canada soil across the Arctic, billions of tons of carbon lies trapped in the ground. Just a few degrees of warming could unleash it into the atmosphere. At least, cheap zocor canada that’s what the past would suggest.

According to a new study, it’s happened before. The research, published Friday in the journal Science Advances, looks back 27,000 years into Arctic history. On at least three occasions, the study finds, periods of rapid climate change caused huge swaths of permafrost—a layer of carbon-rich frozen soil widespread in the Arctic—to quickly cheap zocor canada thaw or collapse.

As a result, huge volumes of carbon dioxide poured into the air. Today, the planet is once again enduring a period of rapid climate change—this time caused by human emissions of greenhouse gases. In fact, research suggests, the Earth is warming at one of its fastest rates cheap zocor canada in millions of years.

If the past is any lesson for the future, that could mean a little more warming may trigger yet another massive destabilization of Arctic permafrost. It’s a red flag scientists have been waving for years. As Arctic temperatures rise, permafrost cheap zocor canada begins to warm up.

And as it thaws out, it releases carbon dioxide and methane into the air. Researchers have warned repeatedly that cheap zocor canada these emissions could speed the pace of climate change. That could lead to a dangerous runaway feedback cycle, in which more warming causes more permafrost to thaw and release even more carbon into the air.

Just how fast that might happen is still a matter of debate. Multiple studies have documented widespread warming and thawing in permafrost cheap zocor canada regions across the Arctic. But researchers still are working to determine how quickly permafrost may respond to future climate warming and how much carbon it will release in the process.

That makes permafrost something of a wild card in climate research—a major uncertainty in scientists’ predictions about future climate change. The new study suggests rapid climate change—even just a few degrees cheap zocor canada of warming—could trigger dramatic bursts of carbon from the thawing Arctic. The scientists used data from ancient sediments, drilled from the bottom of the Arctic Ocean north of Siberia, where they’d been buried for thousands of years.

By conducting careful chemical analyses of these sediments, the scientists were able to document changes in the amount of organic matter flowing into the ocean from collapsing permafrost landscapes. Thanks to similar cheap zocor canada studies, also relying on analyses of long-buried sediments and ancient ice samples, scientists have a good idea of what was going on with the Earth’s climate and its carbon dioxide levels thousands of years ago. The study suggests that three distinct periods of rapid climate change over the past 27,000 years each coincided with massive thawing and collapsing on permafrost landscapes.

Rising temperatures were likely a big part of it cheap zocor canada. As the climate warmed, permafrost would have begun to thaw out and soften, sending mushy rivers of sludge pouring into the sea and releasing carbon into the air. But that’s not the whole story.

The researchers believe cheap zocor canada that rising sea levels, fueled by warming oceans and melting glaciers, also played a big role. Rising oceans severely eroded much of the Arctic coastline during at least two of these warming events, the study suggests. The rapid erosion likely caused large tracts of frozen permafrost to abruptly collapse into the sea.

The study doesn’t necessarily guarantee cheap zocor canada what happened in the past will happen again in the future. But it does warn it’s a possibility. And it’s a growing concern as world leaders struggle to reduce greenhouse gas emissions fast enough to meet the goals of the Paris climate agreement.

Scientists say the world is on track to warm by cheap zocor canada several degrees before the end of the century if carbon emissions don’t start falling faster. €œAny release from thawing permafrost means that there is even less room for anthropogenic greenhouse gas release in the Earth-climate system budget before dangerous thresholds are reached,” Örjan Gustafsson, a scientist at Stockholm University and a co-author of the study, said in a statement. €œThe only way to limit permafrost-related greenhouse gas releases is to mitigate climate warming by lowering anthropogenic greenhouse gas emissions.” Reprinted from Climatewire with permission from E&E News.

E&E provides daily coverage of essential energy and environmental news at www.eenews.net.When the Food and Drug Administration cheap zocor canada ran into White House resistance to its proposed vaccine safety standards in early October, the agency took a bold step. It published the guidance on its Web site. The public could now see what vaccine manufacturers and the FDA’s own independent advisory panel would require cheap zocor canada to ensure a longer, scientifically rigorous process.

The two public health agencies responsible for overseeing the approval, distribution and use of a coronavirus vaccine—the FDA and the Centers for Disease Control and Prevention—have been undermined and politicized. The FDA’s proposed guidelines for emergency use of a coronavirus vaccine did finally clear the White House, but the well-publicized resistance has further undermined public trust in Operation Warp Speed just as the United States inches toward a viable vaccine. At a time when trust should be growing, the opposite cheap zocor canada is happening.

What should give Americans hope, however, is that both the FDA and the CDC have a last line of defense when it comes to approval and distribution of a vaccine. Panels of outside experts who now merit the nation’s attention and unequivocal support. If, in cheap zocor canada the days ahead, either of these independent bodies are sidelined, ignored or in any way circumvented, a red line will have been crossed, and the safety and/or efficacy of a coronavirus vaccine can reasonably be questioned.

For the CDC, it’s the Advisory Committee on Immunization Practices, or ACIP, which next meets October 28–30. We each served terms on this committee at different times, and neither of us ever felt any political pressure during our tenures. The FDA equivalent is the Vaccines and cheap zocor canada Related Biological Products Advisory Committee, or VRBPAC, which next meets October 22.

Most Americans have never heard of either. These panels of health experts, with expertise cheap zocor canada in vaccinology, immunology, pediatrics, internal medicine, infectious diseases and preventive medicine, among other disciplines, have been studying and assessing the myriad coronavirus vaccines under consideration. Each has been scouring data from phase I and phase II trials, and now are awaiting phase III data about some of the most promising vaccines in development.

The advisory panels operate with intentional transparency. The public has access, cheap zocor canada often in real time via livestream, to their discussions and discoveries, and public records document their work. The 15 voting members on each advisory committee all undergo conflict-of-interest reviews, with annual filings to safeguard compliance.

Vaccine interests and financial attachments are disclosed, and members must recuse themselves from related votes. Whether for a coronavirus vaccine or other vaccines, these panels make recommendations as to whether a vaccine is safe, efficacious and ready to be licensed (FDA), as well as how and to cheap zocor canada which populations a vaccine should be distributed (CDC). Though the members on each committee surely understand the politics of the moment, they will never bend to it.

Today, despite regular political pressure being applied on FDA and CDC to meet arbitrary deadlines for a vaccine release, the time-tested vaccine vetting and approval system has held up since it was established nearly four decades ago. However, the threat cheap zocor canada to this system is real. Having both worked within it, we’ve identified several scenarios that would be troubling and even dangerous from a public health perspective.

First, it will cheap zocor canada be problematic if the advisory panels’ work is interrupted or circumvented. Each one has established protocols and defined responsibilities that must not be short-circuited or compromised. If the FDA commissioner or CDC director rejects or modifies the panels’ recommendations, which rarely occurs, the decision will merit close scrutiny and an accompanying strong justification.

Second, FDA has now released strict guidance for approving cheap zocor canada vaccines for emergency use. If manufacturers fail to comply with this guidance, the panels may not have sufficient information to assess the safety of the vaccines. Third, if anyone in the executive branch of government were to override FDA or CDC decisions and guidance regarding coronavirus vaccines under consideration, this would be a red flag.

If ACIP and VRBPAC are each allowed to do their work unencumbered, and there is fidelity to this tried-and-true process, Americans should feel confident that the recommendations of the advisory panels cheap zocor canada were based on rigorous science showing both safety and efficacy. These committees’ work is not about politics, but people, and their evidence-based approach helps to counteract vaccine misinformation and disinformation. Today, only about half of adults in the U.S.

Say they would get a cheap zocor canada coronavirus vaccine if one became available this year. Unless public trust improves, the U.S. Likely will see thousands of avoidable deaths and needless suffering.

The pandemic itself will be given a longer life as we cheap zocor canada are forced to crawl toward herd immunity, which would require a vaccination rate well above 50 percent. In many communities—particularly communities of color—the trust in government’s role in medical care was low even before this pandemic, with seeds sown over many generations because of violations of trust, systemic barriers and racist policies. Physicians across the nation, including in underserved communities, cheap zocor canada depend on the scientific integrity of ACIP and VRBPAC recommendations to determine whether they are confident in bringing a vaccine to their patients.

We know that patients put trust in their physicians when it comes to determining whether to get a vaccine. That’s why it’s all the more imperative that this trust not be eroded by putting politics above science. There is cheap zocor canada a reason the U.S.

Has had remarkable success with its vaccine programs and has been a global leader in disease control and prevention. We cannot let the trust developed over decades be diminished further during this pandemic. The preservation of that trust, after all, will serve us not just today, but for generations to come.The 1930s and early 1940s were a good cheap zocor canada time to fish for sardines off California.

Catches soared in a boom that was centered on Monterey Bay and supported the state's flourishing economy. But the tides began to turn in 1946, and sardine catches eventually fell from an average of 234,000 tons to just 24,000 tons. The industry went cheap zocor canada belly-up.

Scientists have speculated for decades about what factors drove this infamous boom and bust, but they lacked data to test their theories. Now researchers have finally found one cheap zocor canada apparent culprit. Cycles of ocean upwelling, a defining feature of the West Coast marine environment in which deep, nutrient-rich water rises to the nutrient-poor surface and replenishes the food supply there.

The key that unlocked this mystery turned out to be old seaweed specimens gathered from herbaria around the U.S. €œPlants are just sitting there, recording data about cheap zocor canada the state of the ocean,” says Kyle Van Houtan, chief scientist at the Monterey Bay Aquarium and senior author of the new study, published in June in the Proceedings of the Royal Society B. €œIf we can access physical specimens from museums and natural history repositories, we can get information about historical ecosystems embedded in those tissues.” Van Houtan and others had suspected upwelling played a role in sardine population trends, but scientists only started measuring the process in Monterey Bay in 1946.

Historic seaweed specimens, Van Houtan realized, might fill in the blanks for earlier years—similar to the way ice cores can help reconstruct carbon dioxide levels from times before researchers started collecting real-time measurements. For the new study, the scientists relied on the fact cheap zocor canada that deeper water near Monterey typically hosts more of a particular nitrogen isotope, a rarer version of nitrogen with an extra neutron that makes each atom heavier. Looking at modern upwelling data and recently collected seaweed, they found that higher levels of this nitrogen in the plants' cells corresponded with periods of more upwelling.

Next they measured the isotope levels in 70 historic specimens of the red seaweed Gelidium, gathered from Monterey as far back as 1878. The results suggested cheap zocor canada a gradual increase in upwelling and then a dramatic decrease, which lined up with the sardine population's growth and decline. €œThis paper is an excellent example of the creative detective work of historical ecology,” says Loren McClenachan, a marine ecologist at Colby College, who was not involved in the research.

€œThere are thousands and thousands of similar specimens in collections around the world, and applying similar methods could teach us a great deal about long-term ocean change.”.

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