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Li-Fan Lu check this Conceptualization, Funding acquisition, Project administration, Supervision, Validation, Visualization, Writing - original get lasix prescription draft, Writing - review &. Editing 1Division of Biological Sciences, University of California, San Diego, La Jolla, CA4Moores Cancer Center, University of California, San Diego, La Jolla, CA5Center for Microbiome Innovation, University of California, San Diego, La Jolla, CA Search for other works by this author on:Alexander N.R. Weber Conceptualization, Formal analysis, Funding acquisition, Investigation, Project administration, Resources, Supervision, Validation, Visualization, Writing - original draft, Writing - review &. Editing 1Interfaculty Institute for Cell Biology, Department of Immunology, University of Tübingen, Tübingen, Germany10Cluster of Excellence 2180, Image-Guided and Functionally Instructed Tumor Therapies, University of Tübingen, Tübingen, Germany14Cluster of Excellence 2124, Controlling Microbes to Fight , University of Tübingen, Tübingen, Germany.22German Cancer Consortium, Tübingen, Germany Search for other works by this author on:.

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Editor’s Note dogs on lasix (12/21/21) check my blog. This article is being showcased in a special collection about equity in health care that was made possible by the support of Takeda. The article was published dogs on lasix independently and without sponsorship. hypertension medications has cut a jarring and unequal path across the U.S.

The disease has disproportionately harmed and killed people of color. Compared with non-Hispanic white people, American Indian, Black and Latinx individuals, respectively, faced 3.5, 2.8 and 3.0 times the risk of dogs on lasix being hospitalized for the and 2.4, 1.9 and 2.3 times the chance of dying, according to the Centers for Disease Control and Prevention. The reason for these disparities is not biological but is the result of the deep-rooted and pervasive impacts of racism, says epidemiologist and family physician Camara Phyllis Jones. Racism, she explains, has led people of color to be more exposed and less protected from the lasix and has burdened them with chronic diseases.

For 14 dogs on lasix years Jones worked at the CDC as a medical officer and director of research on health inequities. As president of the American Public Health Association in 2016, she led a campaign to explicitly name racism as a direct threat to public health. She is currently a Presidential Visiting Fellow at the Yale School of Medicine and is writing a book proposing strategies for a national campaign against racism. As the country began to confront the dogs on lasix unequal impact of hypertension medications and the ongoing legacy of racial injustice it represents, Jones spoke with Scientific American contributing editor Claudia Wallis about the ways that discrimination has shaped the suffering produced by the lasix.

Along with age, male gender and certain chronic conditions, race has turned out to be a risk factor for a severe outcome from hypertension medications. Why is that?. Race doesn’t dogs on lasix put you at higher risk. Racism puts you at higher risk.

It does so dogs on lasix through two mechanisms. People of color are more infected because we are more exposed and less protected. Then, once infected, we are more likely to die because we carry a greater burden of chronic diseases from living in disinvested communities with poor food options [and] poisoned air and because we have less access to health care. Why do dogs on lasix you say Black, brown and Indigenous people are more exposed?.

We are more exposed because of the kinds of jobs that we have. The frontline jobs of home health aides, postal workers, warehouse workers, meat packers, hospital orderlies. And those frontline jobs—which, for dogs on lasix a long time, have been invisibilized and undervalued in terms of the pay—are now categorized as essential work. The overrepresentation [of people of color] in these jobs doesn’t just so happen.

(Nothing differential by race just so happens.) It is tied to residential and educational segregation in this country. If you have a poor neighborhood, then you’ll have poorly funded schools, dogs on lasix which often results in poor education outcomes and another generation lost. When you have poor educational outcomes, you have limited employment opportunities. We are also more exposed because we are overrepresented in prisons and jails—jails where people are often financial detainees because they can’t make bail.

And brown people dogs on lasix are more exposed in immigration detention centers. We are also more likely to be unhoused—with no access to water to wash our hands—or to live in smaller, more cramped quarters in more densely populated neighborhoods. You’re in dogs on lasix a one–bedroom apartment with five people living there, and one is your grandmother, and you can’t safely isolate from family members who are frontline workers. Why have people of color been less protected?.

We have been less protected because in these frontline jobs—but also in the nursing homes and in the jails, prisons and homeless shelters—the personal protective equipment [PPE] was very, very slow in coming. Look at dogs on lasix the meatpacking plants, for example. We are less protected because our roles and our lives are less valued—less valued in our job roles, less valued in our intellect and our humanity. You’ve noted that once infected, people of color are more likely to have a poor outcome or die.

Could you dogs on lasix break down the reasons?. This has two buckets. First, we are more burdened with chronic diseases. Black people have dogs on lasix 60 percent more diabetes and 40 percent more hypertension.

That’s not because we are not interested in health but because of the context of our lives. We are living in unhealthier places without the food choices we need. No grocery stores, so-called food deserts dogs on lasix and what some people describe as “fast-food swamps.” More polluted air, no place to exercise safely, toxic dump sites—all of these things go into communities that have been disempowered. That’s why we have more diseases, not because we don’t want to be healthy.

We very much dogs on lasix want to be healthy. It’s because of the burdens that racism has put on our bodies. What is the second bucket that raises risks from hypertension medications?. Health dogs on lasix care.

Even from the beginning, it was hard for Black folks to get tested because of where testing sites were initially located. They were in more affluent neighborhoods—or there was drive-through testing. What if you don’t have dogs on lasix a car?. And there was the need to have a physician’s order to get a test.

We heard about people who were symptomatic and presented at emergency departments but were sent back home without getting a test. A lot dogs on lasix of people died at home without ever having a confirmed diagnosis. So even though we know we are overrepresented, we may have been undercounted. Once you get into the hospital, there’s a whole spectrum of scarce resources, so different states and hospital systems had what they called “crisis standards of care.” In Massachusetts, they were very careful to say you cannot use race or language or zip code to discriminate [on who gets a ventilator].

But you dogs on lasix could use expected [long-term] survival. Then the question was. Do you have these dogs on lasix preexisting conditions?. This was going to systematically put Black and brown people at a lower priority or even disqualify them from access to these lifesaving therapies.

[Editor’s Note. Massachusetts later changed its dogs on lasix guidelines, but Jones viewed the revision as an incomplete fix.] Making sure that treatment campaigns reach communities of color is surely part of the solution, but what else can be done to better protect vulnerable minorities?. We need more PPE for all frontline workers. We need to value all those lives.

We need to offer hazard pay and something like conscientious objector status for frontline workers who feel it is too dangerous to go dogs on lasix back into the pouy or meatpacking plant. We know there are communities at higher risk, and we need to be doing more testing there. We need to broaden our gaze from a narrow focus on the individual (“treatment hesitancy”) to acknowledge that structural barriers continue to impact access to the treatments. Several states do not report racial and ethnic data on dogs on lasix hypertension medications cases.

Why is that a problem?. States should be reporting their data disaggregated by race, especially now we know Black and brown and Indigenous folks are at higher risk of being infected and then dying. It’s not just to document it, not just to alarm or to arm some people with a false sense of security dogs on lasix. It’s because we need to provide resources according to need.

Health-care resources, dogs on lasix testing resources and prevention types of resources. Are you concerned about how the CDC’s relaxation of its face mask guidance will impact essential workers and communities of color?. Yes. We need to recognize that we are all in this together, that masks provide dogs on lasix reciprocal protection with no downsides, and that asymptomatic spread continues to fuel this lasix, so that a continued mask mandate for all without regard to immunization status should be maintained until there are no hypertension medications s, hospitalizations or deaths.

It is such a simple, effective, and community-minded intervention that hurts no one and helps everyone. Over the past year we have seen people take to streets to protest another kind of deadly racial inequity. Police violence dogs on lasix against people of color, especially against Black men and boys. As awareness spreads about the pervasive nature of racism in systems ranging from law enforcement to health care to housing, do you see an opportunity for meaningful change?.

The outrage is encouraging because it has been expressed by folks from all parts of our population. The Black Lives Matter protests were potentially mixing bowls for the lasix, but at least they are not dogs on lasix frivolous mixing bowls like pool parties. Participants in such protests were thinking not just about their individual health and well-being but about the collective power they have now to possibly make things better for their children and grandchildren. This is both a treacherous time and a time of great promise.

Racism is a dogs on lasix system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call “race”) that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources. Perhaps this nation is awakening to the realization that racism does indeed hurt us all.Editor’s Note (12/21/21). This article is being showcased in a special collection about equity in health care that was made possible by the dogs on lasix support of Takeda. The article was published independently and without sponsorship.

The hypertension medications lasix has disproportionately hurt members of minority communities in the U.S. As of July 2020, 73.7 Black people out of every 100,000 had died of the hypertension—compared with 32.4 of every dogs on lasix 100,000 white people. Structural racism accounts for much of this disparity. Black people are more likely to have jobs that require them to leave their homes and to commute by public transport, for example, both of which increase the chances of getting infected.

They are dogs on lasix also more likely to get grievously ill when the lasix strikes. As of June 2020, the hospitalization rate for those who tested positive for hypertension was more than four times higher for Black people than for non-Hispanic white people. One reason for this alarming ratio is that Black people have higher rates of diabetes, hypertension and asthma—ailments linked to worse outcomes after with the hypertension. Decades of research show that these health conditions, usually diagnosed in adulthood, can reflect dogs on lasix hardships experienced while in the womb.

Children do not start on a level playing field at birth. Risk factors linked to maternal poverty—such as malnutrition, smoking, exposure to pollution, stress or lack of health care during pregnancy—can predispose babies to future disease. And mothers dogs on lasix from minority communities were and are more likely to be subjected to these risks. Today’s older Black Americans—those most endangered by hypertension medications—are more likely than not to have been born into poverty.

In 1959, 55 percent of Black people in dogs on lasix the U.S. Had incomes below the poverty level, compared with fewer than 10 percent of white people. Nowadays 20 percent of Black Americans live below the poverty line, whereas the poverty rate for white Americans remains roughly the same. Despite the reduction in income inequality between these dogs on lasix groups, ongoing racism works through circuitous routes to worsen the odds for minority infants.

For example, partly because of a history of redlining (practices through which financial and other institutions made it difficult for Black families to buy homes in predominantly white areas), even better-off Black people are more likely to live in polluted areas than are poorer white people—with a corresponding impact on fetal health. Worryingly, people disadvantaged in utero are more likely to have lower earnings and educational attainments, so that the effects of poverty and discrimination can span generations. Researchers now have hard evidence dogs on lasix that targeted programs can improve health and reduce inequality. Expansions of public health insurance offered to women, infants and children under Medicaid and the Children’s Health Insurance Program have already had a tremendous effect, improving the health and well-being of a generation—with the largest impacts on Black children.

And interventions after birth can often reverse much of the damage suffered prenatally. Along with other researchers, I have shown that nutrition programs for pregnant women, infants dogs on lasix and children. Home visits by nurses during pregnancy and after childbirth. High-quality child care.

And income support dogs on lasix can improve the outcomes for disadvantaged children. Such interventions came too late to help those born in the 1950s or earlier, but they have narrowed the health gaps between poor and rich children, as well as between white and Black children, in the subsequent decades. Enormous disparities in health and vulnerability remain, however, and raise disturbing dogs on lasix questions about how children born to poorer mothers during the current lasix, with all its social and economic dislocations, will fare. Alarmingly, just before the lasix hit, many of the most essential programs were being cut back.

Since the beginning of 2018, more than a million children have lost Medicaid coverage because of new work requirements and other regulations, and many have become uninsured. Now that the hypertension medications death toll has exposed stark inequalities in health status and their attendant risks, Americans must act urgently to reverse these setbacks and to strengthen public health systems and the social safety net, with special attention to the care dogs on lasix of mothers, infants and children. The Hunger Winter Decades of careful observation and analysis have gone into uncovering the manifold ways in which the fetal environment affects the future health and prospects of a child, and much remains mysterious. It would be unethical to run experiments to measure the toll on a fetus of, say, malnutrition or pollution.

But we can look dogs on lasix for so-called natural experiments—the (sometimes horrific) events that cause variations in these factors in ways that mimic an actual experiment. The late epidemiologist David Barker argued in the 1980s that poor nutrition during pregnancy could “program” babies in the womb to develop future ailments such as obesity, heart disease and diabetes. Initial evidence for such ideas came from studies of the Dutch “Hunger Winter.” In October 1944 Nazi occupiers cut off food supplies to the Netherlands, and by April 1945 mass starvation had set in. Decades later military, medical and employment records showed that adult men whose mothers were exposed to the famine while pregnant with them were twice as likely to be obese as other men and dogs on lasix were more likely to have schizophrenia, diabetes or heart disease.

Anyone born in the Netherlands during the famine is part of a cohort that can be followed over time through a variety of records. Nowadays many researchers, including me, look for natural experiments to delineate such cohorts and thereby tease out the long-term impacts of various harms experienced in utero. We also rely heavily on the most widely available measure of newborn health dogs on lasix. Birth weight.

A baby may have “low” birth weight, defined as less than 2,500 grams (about 5.5 pounds), or “very low” birth weight of less dogs on lasix than 1,500 grams (3.3 pounds). The lower the birth weight, the higher the risk of infant death. We have made enormous progress in saving premature babies, but low-birth-weight children are still at much higher risk for complications such as brain bleeds and respiratory problems that can lead to long-term disability. In recent years computer analysis of large-scale electronic records has made it possible to connect infant health, as measured by dogs on lasix birth weight, to long-term outcomes not just for cohorts but also for individuals.

Studies of twins or siblings, who have similar genetic and social inheritance, show that those with lower birth weight are more likely to have asthma or attention deficit hyperactivity disorder (ADHD) when they get older. Several studies also show that lower-birth-weight twins or siblings have worse scores on standardized tests. As adults, they are more likely to have lower wages, to reside dogs on lasix in lower-income areas or to be on disability-assistance programs. In combination, cohort and sibling studies demonstrate that low birth weight is predictive of several adverse health outcomes later in life, including increased probabilities of asthma, heart disease, diabetes, obesity and some mental health conditions.

Birth weight does not capture all aspects of a child’s health. A fetus gains most of its weight in the third trimester, for example, but many studies find that shocks in the first trimester dogs on lasix are particularly harmful. I nonetheless use the measure in my studies because it is important and commonly available, having been recorded for tens of millions of babies for decades. Significantly, low birth weight is much more common among infants born to poor and minority mothers.

In 2016 13.5 percent of Black mothers had low-birth-weight babies, compared with 7.0 percent of non-Hispanic whites and dogs on lasix 7.3 percent of Hispanic mothers. Among those with college educations, 9.6 percent of Black mothers had low-birth-weight babies, compared with 3.7 percent of non-Hispanic white mothers. These inequalities dogs on lasix in health at birth reflect large differences in exposure to several factors that affect fetal health. The Poverty Connection As already noted, the quality of a mother’s nutrition substantially influences the health of her babies.

In 1962 geneticist James V. Neel hypothesized that a so-called thrifty gene had programmed humankind’s hunter-gatherer ancestors to hold on to every calorie they could get and that in modern times, that tendency, combined with an abundance of high-calorie foods, led dogs on lasix to obesity and diabetes. Recent studies on laboratory animals indicate, however, that the link between starvation and disease is not genetic in origin but epigenetic, altering how certain genes are “expressed” as proteins. Prolonged calorie deprivation in a pregnant mouse, for example, prompts changes in gene expression in her offspring that predispose them to diabetes.

What is more, the effect may dogs on lasix be transmitted through generations. Outright starvation is now rare in developed countries, but poorer mothers in the U.S. Often lack a diet rich in fruits and vegetables, which contain essential micronutrients. Deficiencies in folate intake during pregnancy are linked to neural tube dogs on lasix defects in children, for example.

Credit. Amanda Montañez. Source. €œIs It Who You Are or Where You Live?.

Residential Segregation and Racial Gaps in Childhood Asthma,” by Diane Alexander and Janet Currie, in Journal of Health Economics, Vol. 55. July 25, 2017 At present, one of the leading causes of low birth weight in the U.S. Is smoking during pregnancy.

In the 1950s pregnant women were told that smoking was safe for their babies. Roughly half of all new mothers in 1960 reported smoking while pregnant. Today, thanks to public education campaigns, indoor-smoking bans and higher cigarette taxes, only 7.2 percent of pregnant women say that they smoke. And 55 percent of women who smoked in the three months before they got pregnant quit for at least the duration of their pregnancy.

Possibly because going to college places women in a milieu where smoking is strongly discouraged, mothers with higher education levels are less likely to smoke. Among mothers with less than a high school education, 11.7 percent smoke, compared with 1 percent of mothers with a bachelor’s degree. Among the many harmful chemicals in cigarette smoke is carbon monoxide (CO), which restricts the amount of oxygen carried by the blood to the fetus. In addition, nicotine affects the development of blood vessels in the uterus and disrupts developing neurotransmitter systems, leading to poorer psychological outcomes.

Maternal cigarette smoking during pregnancy has also been associated with epigenetic changes in the fetus, although how these alterations affect an individual in later years remains mysterious. The recent surge in vaping, which delivers high doses of nicotine and which surveys show has been tried by almost 40 percent of high school seniors, is an extremely worrying development that could have long-term implications for fetal and infant health. Yet another significant source of harm for fetuses is pollution. Pregnant women may be exposed to thousands of toxic chemicals in the air, water, soil and sundry products at home and at work.

Complicating matters, each pollutant acts in a different way. Particulates in the atmosphere are thought to cause inflammation throughout the body, which has been linked to preterm labor and, consequently, to low birth weight. Lead, ingested through water or air, crosses the placenta to accumulate in the fetus and harm brain development. In 2005 Jessica Wolpaw Reyes of Amherst College showed that the phaseout of leaded gasoline in the U.S.

Led to a decrease of up to 4 percent in infant mortality and low birth weight. A fetus may also receive less oxygen if its mother inhales CO from vehicle exhaust. In a 2009 study of mothers who lived near pollution monitors, my co-workers and I found that high levels of ambient CO were correlated with reduced birth weight. Worryingly, the effects of CO from air pollution are five times greater for smokers than for nonsmokers.

Reducing pollution can have immediate benefits for pregnant women and newborns. In a 2011 study of babies born in New Jersey and Pennsylvania, Reed Walker of the University of California, Berkeley, and I focused on mothers who lived near E-ZPass electronic toll plazas before and after they began operating. We compared them with mothers who lived a little farther from the toll plazas but along the same busy roads. Both groups of mothers were exposed to traffic, but before E-ZPass, the mothers near the toll plazas were exposed to more pollution because cars idled while waiting to pay the tolls.

E-ZPass greatly reduced pollution right around the toll plazas by allowing cars to drive straight through. Startlingly, the introduction of E-ZPass reduced the incidence of low birth weight by more than 10 percent in the neighborhoods nearest the toll plazas. In another study, my collaborators and I examined birth records for 11 million newborns in five states. We found that a shocking 45 percent of mothers lived within about a mile of a site that emitted toxic chemicals such as heavy metals or organic carcinogens—a number that rose to 61 percent among Black mothers.

Focusing on babies born to mothers who lived within a mile of a plant, we compared birth weights when the facility was operating with birth weights when it was closed. For additional context, we also compared babies born within a mile of a plant with babies born in a one-to-two-mile band around the plants. Both groups of mothers were likely to be similarly affected by the economics of factory openings and closings, but mothers who lived closer were more likely to have been exposed to pollution during pregnancy. We found that an operating plant increased the probability of low birth weight by 3 percent among babies whose mothers lived less than a mile from the plant.

The racial divide in pollution exposure is profound, in part because of continuing segregation in housing that makes it difficult for Black families to move out of historically Black neighborhoods. Disadvantaged communities may also lack the political power to fend off harmful development, such as a chemical plant, in their vicinity. In the E-ZPass study, roughly half of the mothers who lived next to toll plazas were Hispanic or Black, compared with only about a tenth of mothers who lived more than six miles away from a toll plaza. And in a paper published in 2020, John Voorheis of the U.S.

Census Bureau, Walker and I showed that across the entire U.S., neighborhoods with higher numbers of Black residents have systematically worse air quality than other neighborhoods. Black people are also twice as likely as others to live near a Superfund hazardous waste site. For these reasons, pollution-control measures such as the Clean Air Act have greatly benefited Black people. Fight or Flight Stress disproportionately impacts the poor—who have chronic worries about paying bills, for example—and also harms fetuses.

A stressful situation triggers the release of hormones that orchestrate a range of physical changes associated with the fight-or-flight response. Some of these hormones, including cortisol, have been linked to preterm labor, which in turn leads to low birth weight. High circulating levels of cortisol in the mother during pregnancy may damage the fetus’s cortisol-regulation system, making it more vulnerable to stress. And stress can trigger behavioral responses in a mother such as increased smoking or drinking, which are also harmful to the fetus.

One revealing study indicates that fetal exposure to maternal stress can have greater negative long-term effects on mental health than stress directly experienced by a child. Petra Persson and Maya Rossin-Slater, both at Stanford University, looked at the impact of the death of a close relative. Death can bring many unwelcome changes to a family, such as reduced income, which may also influence child development. To account for such complications, the researchers used administrative data from Sweden to compare children whose mothers were affected by a death during the prenatal period with those whose mothers were affected by a death during the child’s early years.

They found that children affected by a death prenatally were 23 percent more likely to use medication for ADHD at ages nine to 11 and 9 percent more likely to use antidepressants in adulthood than were children whose families experienced a death a few years after their birth. Another pathbreaking study measured levels of cortisol, an indicator of stress, during pregnancy. By age seven, children whose mothers had higher cortisol levels during pregnancy had received up to one year less schooling than their own siblings, indicating that they had been delayed in starting school. Moreover, for any given level of cortisol in the mother’s blood, the negative effects were more pronounced for children born to less educated mothers.

This finding suggests that although being stressed during pregnancy is damaging to the fetus, mothers with more education are better able to buffer the effects on their children—an important finding in view of the severe stress imposed by hypertension medications on families today. It is no surprise that disease can also harm a fetus. Douglas V. Almond of Columbia University looked at people born in the U.S.

At the peak of the influenza epidemic of 1918 and found that they were 1.5 times more likely to be poor as adults than were those born just before them. In work I conducted with Almond and Mariesa Herrmann of Mathematica looking at mothers born between 1960 and 1990 in the U.S., we found that women who were born in areas where an infectious disease was raging were more likely to have diabetes when they gave birth to their own children decades later—and the effects were twice as large for Black people. More recently, Hannes Schwandt of Northwestern University examined Danish data and found that maternal with ordinary seasonal influenza in the third trimester doubles the rate of premature birth and low birth weight, and in the second trimester leads to a 9 percent reduction in earnings and a 35 percent increase in welfare dependence once the child reaches adulthood. Preventing Harm Health at birth and beyond can nonetheless be improved through thoughtful interventions targeting pregnant women, babies and children and through reductions in pollution.

The food safety net in the U.S. Has already had tremendous success in preventing low birth weight in the babies of disadvantaged women. The rollout of the food stamp program (now called the Supplemental Nutrition Assistance Program, or SNAP) across the U.S. In the mid-1970s reduced the incidence of low birth weight by between 5 and 11 percent.

In addition, children who benefited from the rollout grew up to be less likely to have metabolic syndrome—a cluster of conditions that include obesity and diabetes. Notably, women who had benefited as fetuses or young children were more likely to be economically self-sufficient. The 1970s also saw the introduction of the Special Supplemental Nutrition Program for Women, Infants and Children, popularly known as WIC. Approximately half of eligible pregnant women in the U.S.

Receive nutritious food from WIC, along with nutrition counseling and improved access to medical care. Dozens of studies have shown that when women participate in WIC during pregnancy, their babies are less likely to have low birth weight. In work looking at mothers in South Carolina, Anna Chorniy of Northwestern University, Lyudmyla Ardan (Sonchak) of Susquehanna University and I were able to show that children whose mothers received WIC during pregnancy were also less likely to have ADHD and other mental health conditions that are commonly diagnosed in early childhood. Skyline of Flint, Mich., in 2016, after declaration of a federal emergency because of lead contamination in the water supply.

Credit. Brett Carlsen Getty Images In the late 1980s and early 1990s, state and federal governments worked together to greatly expand public health insurance for pregnant women under the Medicaid program. In work with Jonathan Gruber of the Massachusetts Institute of Technology, I showed that public health insurance lowered infant mortality and improved birth weight. Today the children whose mothers became eligible for health insurance coverage of their pregnancies in that period have higher levels of college attendance, employment and earnings than the children of mothers who did not.

They also have lower rates of chronic conditions and are less likely to have been hospitalized. The estimated effects are strongest for Black people, who, having lower average incomes, benefited the most from the expansions. The fact that these babies are more likely to eventually get a college education also increases the life chances of their children. In the U.S., an additional year of college education for the mother reduces the incidence of low birth weight in her children by 10 percent.

Even so, too many children are still born with low birth weight, especially if their mothers are Black. Significantly, targeted interventions after birth can improve their outcomes. Programs such as the Nurse-Family Partnership provide home visits by nurses to low-income women who are pregnant for the first time, many of whom are young and unmarried. The nurse visits every month during the pregnancy and for the first two years of the child’s life to provide guidance about healthy behavior.

The assistance reduces child abuse and adolescent crime and enhances children’s academic achievement. Providing cash payments to poor families with young children also improves both maternal health and child outcomes, suggesting that hypertension medications relief payments will have important protective effects. In the U.S., the largest preexisting program of this type is the Earned Income Tax Credit (EITC). Studies of beneficiaries of the EITC show that children in families that received increased amounts had higher test scores in school.

With financial stress being somewhat relieved, the mental health of mothers in these families also improved. In addition, quality early-childhood education programs augment future health, education and earnings and reduce crime. Head Start, the federally funded preschool program that was rolled out beginning in the 1960s, has also had substantial positive effects on health and education outcomes, especially in places with less access to alternative child care centers. A 2018 study, especially noteworthy in light of the tragic lead poisoning in Flint, Mich., shows that even some of the negative effects of lead can be reversed.

In Charlotte, N.C., lead-poisoned children who received lead remediation, nutritional and medical assessments, WIC and special training for their caregivers saw reductions in problem behaviors and advanced school performance. Looking Ahead Investments in pregnant women and infants have been paying off, their success reflected in dramatically falling infant mortality rates in the U.S.—despite rising inequality in income and wealth. Alarmingly, however, many successful programs, such as the Clean Air Act, SNAP and Medicaid, are under attack. The hypertension Aid, Relief and Economic Security (CARES) Act passed in March 2020 provided some relief, at least with respect to Medicaid.

CARES temporarily suspended disenrollment from the program, giving additional flexibility to state Medicaid programs in terms of time lines and eligibility procedures. Still, states may be hard-pressed to enroll the many who will become newly eligible for Medicaid because of job loss. Moreover, states that have not expanded the Medicaid program to cover otherwise ineligible low-income adults, as allowed by the Affordable Care Act, may see many more uninsured. A National Academies of Sciences, Engineering and Medicine report published in 2019 laid out a road map for reducing child poverty by half within 10 years.

One of the most stunning findings of the report is that it is feasible to meet that target by expanding programs that already exist. Following these directions would have a profound impact on health and health disparities. Targeted approaches, such as more thorough investigation of maternal deaths occurring up to one year after a birth, are also necessary. Even simple preventive measures such as giving pregnant women flu shots can have a tremendously positive effect on infant health and child development.

Diagnosis and treatment of conditions such as preeclampsia (high blood pressure associated with pregnancy) are key to both protecting babies and lowering maternal mortality rates. It is important to help pregnant women quit smoking and to develop new approaches relevant to a new generation addicted to vaping. Also needed are stronger protections for women at risk of domestic violence, which leads directly to chronic stress, premature deliveries and low birth weight. One salient open question is what effect the lasix will have on the generation of children affected by it in utero and in early life.

hypertension medications itself may have negative effects on the developing fetus. The latest data suggest that although the overall risk is low, pregnant women are at increased risk of becoming critically ill (as they are with influenza or SARS). Affected babies, however, do not seem to be at risk of obvious birth defects (as they are with the Zika lasix). Still, given the fact that hypertension medications affects many body systems, it may prove to have subtler negative effects on the developing fetus.

The lasix is also an extremely stressful event compounded by the sharpest economic downturn since the Great Depression. There are reports of increases in domestic violence, alcohol consumption and drug overdoses, all of which are known to be harmful to the developing fetus. In consequence, the generation now in utero is likely to be at increased risk going forward and will require intensive social investments to overcome its poorer start in life. In a recent sermon on the late civil rights leader John Robert Lewis, Reverend James Lawson recounted the significant gains for Americans of all colors that had resulted from that movement.

He went on to ask that America’s political leaders “work unfalteringly on behalf of every boy and every girl, so that every baby born on these shores will have access to the tree of life ... Let all the people of the U.S.A. Determine that we will not be quiet as long as any child dies in the first year of life in the United States. We will not be quiet as long as the largest poverty group in our nation are women and children.” As we rebuild our shattered safety nets and public health systems in the aftermath of hypertension medications, we need to seize the moment and use the knowledge we have gained about how to protect mothers and babies—to give every child the opportunity to flourish.Some people go home for the holidays hoping just to survive, burying their attention in their phones or football to avoid conflict with relatives.

Yet research now suggests that is the wrong idea. Family rituals—of any form—can save a holiday, making it well worth the effort of getting everyone in the same room. In a series of studies to be published in the Journal of the Association for Consumer Research, hundreds of online subjects described rituals they performed with their families during Christmas, New Year's Day and Easter, from tree decoration to egg hunts. Those who said they performed collective rituals, compared with those who said they did not, felt closer to their families, which made the holidays more interesting, which in turn made them more enjoyable.

Most surprising, the types of rituals they described—family dinners with special foods, religious ceremonies, watching the ball drop in Times Square—did not have a direct bearing on enjoyment. But the number of rituals did. Apparently having family rituals makes the holidays better and the more the merrier. The study could measure only correlations between subjects' responses, leaving causality uncertain—Do rituals increase holiday pleasure, or do people who already enjoy the holidays choose to perform more rituals?.

Yet enjoyment ratings were higher when given after, versus before, describing rituals, suggesting that simply thinking about rituals can put a warm filter on one's experience. €œWhatever the ritual is, and however small it may seem, it helps people to really get closer to one another,” says Ovul Sezer, a researcher at Harvard Business School and the paper's primary author. €œ[With] some rituals we don't even know why we do them, but they still work,” she says. It could be that rituals offer “small, nonobvious ways” to get people to share an experience without feeling awkward or forced, suggests Kathleen Vohs, a psychologist at the University of Minnesota and one of Sezer's co-authors.

She compares that with “obvious ploys” such as saying, “Hey, everyone, gather around the kitchen table, we're going to play Yahtzee,” which, she notes, “might be more likely to produce a whole lot of kickback.”Genome-edited food made with CRISPR–Cas9 technology is being sold on the open market for the first time. Since September, the Sicilian Rouge tomatoes, which are genetically edited to contain high amounts of γ-aminobutyric acid (GABA), have been sold direct to consumers in Japan by Tokyo-based Sanatech Seed. The company claims oral intake of GABA can help support lower blood pressure and promote relaxation. In Japan, dietary supplements and foods enriched for GABA are popular among the public, says Hiroshi Ezura, chief technology officer at Sanatech and a plant molecular biologist at the University of Tsukuba.

€œGABA is a famous health-promoting compound in Japan. It’s like vitamin C,” he says. More than 400 GABA-enriched food and beverage products, such as chocolates, are already on the Japanese market, he says. €œThat’s why we chose this as our first target for our genome editing technology,” he says.

Sanatech, a startup from the University of Tsukuba, first tested the appetite of consumers in Japan for the genome-edited fruit in May 2021 when it sent free seedling CRISPR-edited tomato plants to about 4,200 home gardeners who had requested them. Encouraged by the positive demand, the company started direct internet sales of fresh tomatoes in September and a month later took orders for seedlings for next growing season. Japan’s regulators approved the tomato in December 2020. Since its inception a decade ago, CRISPR–Cas9 genome editing has become a tool of choice for plant bioengineers.

Researchers have successfully used it to develop non-browning mushrooms, drought-tolerant soybeans and a host of other creative traits in plants. Many have received a green light from US regulators. But before Sanatech’s tomato, no CRISPR-edited food crops were known to have been commercialized. Consumers may find food ingredients made with some of the older DNA editing techniques, such as transcription activator-like effector nucleases (TALENs).

Indeed, Calyxt in 2019 commercialized a TALEN-edited soybean oil that is free of trans fats. Genome editing tools have also been used to transform a host of ornamental plants. So it was only a matter of time before a CRISPR-edited crop reached palates. More interesting, however, is that the developer chose this high GABA trait as a first target.

GABA is an amino acid and a neurotransmitter that blocks impulses between nerve cells in the brain. The molecule is found natively in the human body and is also ubiquitously present in plants, animals and microorganisms, as well as in food. It can be synthesized by fermenting food and has been developed as a nutritional supplement in some regions. Sanatech’s researchers increased the amount of GABA in tomato by manipulating a metabolic pathway called the GABA shunt.

There, they disabled a gene that encodes calmodulin-binding domain (CaMBD). Removal of CaMBD enables increased activity of the enzyme glutamic acid decarboxylase, which catalyzes the decarboxylation of glutamate to GABA, thus raising levels of the molecule. Sanatech has been careful not to claim that its tomatoes therapeutically lower blood pressure and promote relaxation. Instead, the company implies it, by advertising that consuming GABA, generally, can achieve these effects and that its tomatoes contain high levels of GABA.

This has raised some eyebrows in the research community, given the paucity of evidence supporting GABA as a health supplement. To support the blood-pressure assertion, Sanatech cites two human studies. A 2003 paper on the effect of consuming fermented milk containing GABA and a 2009 paper of the effects of GABA, vinegar and dried bonito. Both studies were conducted in people with mild hypertension and showed blood-pressure-lowering effects.

But the papers lack good control groups, and the effects in the experimental groups could be explained by factors other than GABA, says Maarten Jongsma, a molecular cell biologist at Wageningen University &. Research in the Netherlands, who studies the effects of plant compounds on human nutrition. €œThere’s no consensus” on the health benefits of consuming GABA, nor evidence that it can cross the blood–brain barrier and reach the central nervous system, adds Renger Witkamp, a nutrition scientist also at Wageningen. To support the claim that GABA promotes relaxation, Sanatech points to six studies in humans that examined the effect of orally consumed GABA on stress, mood, fatigue or sleep.

But a systematic review published in 2020 that examined all six of these papers plus eight more on the topic came to a different conclusion. The authors, who hailed from Japan, Australia and the United Kingdom, summarized. €œThere is limited evidence for stress and very limited evidence for sleep benefits of oral GABA intake.” Sanatech’s tomatoes, called the Sicilian Rouge High GABA, contain about four to five times more GABA than their conventional counterpart, Ezura says. Whether that will lower blood pressure any more than eating regular tomatoes is unclear.

Sanatech has not performed this kind of intervention study, although it plans to do so, Ezura says. The company is working to complete an additional notification with the Japanese government on the health benefit claim. Sanatech’s marketing strategy has been to target consumers directly and generate positive buzz among home gardeners. The company created an online platform for gardeners to swap tips.

It also held a contest to see which home gardener could grow tomatoes with the highest amount of GABA. (The winning tomato had 20 times more GABA than conventional tomatoes.) That’s a smart marketing strategy for genome-edited fruit and vegetables, especially those with boutique traits, says Cathie Martin, a plant scientist at the John Innes Centre in Norwich, UK. €œYou find a group of people who feel as though they have some ownership of the product,” she says. You then help build up a community of people who want to grow and eat the vegetable, and this launches the product on a positive track, she says.

Martin is the creator of the ‘purple tomato’, a variety that is genetically modified to contain higher levels of the anti-inflammatory compound anthocyanin, which she debuted in 2008 in these pages. Over the past 14 years, without the resources of a large company, she and an “un-financed, dedicated band of enthusiasts” have been trying to push the product to market on their own, she says. Her challenge of commercializing a bioengineered crop is one that most small plant biotech companies have also faced, particularly those developing boutique varieties. €œThe regulatory cost is so high that there are very few traits that you could actually even consider engineering in a crop like tomato,” says James Giovannoni, a plant molecular biologist at the Agricultural Research Service at the US Department of Agriculture (USDA).

That’s why, since the mid-1990s, most commercial efforts in the genetic engineering of plants have focused on high-dollar crops, such as soybean, corn (maize), wheat, canola and cotton, with traits that make farmer’s jobs easier and their harvests more profitable. Meanwhile, nutritionally enhanced crops have been stillborn. The few examples on the market include soybeans and canola with modified oil and fatty acid content, and nutritionally improved corn for animal feed. Scores more, such as the high β-carotene super-banana, have been developed but sit in limbo on laboratory shelves.

The storied ‘golden rice’, which is enhanced with provitamin A and has been in limbo for 20 years, just a few months ago received approval in the Philippines for commercial cultivation. So Sanatech’s high-GABA tomato, as a nutritionally enhanced crop, stands out. The fact that it was engineered using CRISPR seems to help with consumer acceptance, especially as such crops aren’t being called “GMOs,” or “genetically modified organisms.” Instead, they’re dubbed “genome-edited.” This change in nomenclature alone seems to have quelled a lot of the backlash historically launched against bioengineered plants. Some regulators are making a distinction between the old and new technologies too.

The USDA has repeatedly ruled that genome-edited crops fall outside of its purview. Plant biotechnologists who submit such inquiries through the agency’s “Am I Regulated?. € process typically get a response within a few months and receive a green light to grow their genome-edited plants without further oversight. This has reduced the US regulatory burden for genome-edited plants to next to nothing.

Brazil, Argentina and Australia have taken a similar approach. China has established a regulatory process for genome-edited agricultural organisms, although none has yet been approved, says Hongliang Zhu, a professor at China Agricultural University in Beijing, speaking on behalf of himself and not his employer or government. Europe has essentially banned genome-edited foods, lumping them in with first-generation GMOs, although there have been calls to rethink the policy. Many other countries still lack any policy on the technology, slowing commercial efforts.

Toolgen in Seoul, South Korea, has used CRISPR to generate color-modified petunias, high-oleic acid soybeans and browning-inhibited potatoes, “but they are not on sale yet because the domestic regulatory policy for CRISPR genome-edited crops has not been established,” says Yein Joen, a researcher at the company. Japan’s regulatory policy on genome-edited plants formed in tandem with its review of Sanatech’s tomato—a process that took about a year. Ezura “deserves great credit for single-handedly pushing the Japanese government to institute a policy where gene-edited crops can be brought to market,” says Harry Klee, a plant molecular biologist and tomato researcher at the University of Florida. €œThis is a big deal in Japan and he did a great job.” Ezura’s efforts have opened the door for genome-edited food in Japan.

In November, researchers at Nagoya University described in Scientific Reports a sweeter tomato developed by modifying a cell wall invertase inhibitor using CRISPR–Cas9. The variety has not been approved by regulators. And CRISPR–Cas9 edited food in Japan has leapt from the garden to the sea. In October, the island nation approved two CRISPR-edited fish.

A gene-edited tiger puffer that exhibits depressed appetite suppression and a red sea bream with increased muscle growth. Both fish grow larger than their counterparts in the wild and were developed by the Kyoto-based Regional Fish Institute. For Martin, it wasn’t possible to confer the anthocyanin trait in her purple tomatoes using genome editing. Instead, she transformed them using Agrobacterium tumefaciens, an older method of genetic modification that triggers considerably more regulatory oversight and resources, along with the moniker “GMO.” But the door to market may soon open for her too.

Martin says she expects a regulatory decision from the USDA by the end of February for purple tomatoes. Like Sanatech, Martin plans to initially market them directly to the public. She has not conducted human intervention studies comparing the health effects of high-anthocyanin and conventional tomatoes, and does not plan to make health benefit claims. This article is reproduced with permission and was first published on December 14 2021.Christmas trees are dead or dying.

But some conifers and other trees theoretically could live forever, according to a recent essay that reviews accumulating evidence on extremely long-lived trees—and calls for more scientifically rigorous methods to determine their age and study their longevity. Across the board, trees do not die so much as they are killed, write the authors of the review essay, entitled “On Tree Longevity.” Their killers are external physical or biological factors rather than old age alone. That is, there is no evidence that harmful genetic mutations pile up over time or that trees lose their ability to produce new tissue. “Trees can indeed live indefinitely, but this does not happen,” says co-author Franco Biondi, an ecoclimatologist and tree-ring scientist at the University of Nevada, Reno.

€œBecause eventually an external agent, biotic or abiotic [a living thing or a nonliving one such as a physical condition], ends up killing them.” Tree killers include environmental threats such as droughts, wildfires, harsh weather and pests—as well as human threats such as logging and fires set to clear forests for hunting or pastureland, write Biondi and his co-author Gianluca Piovesan of the University of Tuscia in Italy. Their essay was published in the August issue of New Phytologist. Tree longevity interests researchers in part because trees and other plants remove carbon from the atmosphere for photosynthesis, and older trees are thought to store more carbon than younger ones. The persistence of trees could thus play a role in slowing climate change (although rising temperatures caused by global warming also can put a strain on trees, making them more vulnerable to environmental threats).

The rings of old trees can also serve as an invaluable record of climate history, with wider rings indicating better years. Scientific models designed to study tree longevity have made incorrect assumptions, including the idea that highly shade-tolerant late-successional trees, which are found in older ecosystems that have developed larger trees and a lot of shrub cover, are longer-lived, the essay also notes. For example, extremely long-lived bristlecone pine trees are known to live in wide-open landscapes of the West and in ecosystems that have not changed much for thousands of years. David Stahle, a geographer and tree longevity researcher at the University of Arkansas, who was not involved in the review essay, used words such as “excellent” and “comprehensive” to describe it.

But he takes issue with the assertion that trees can potentially live forever. €œThe likelihood, all things being equal, that trees are immortal seems improbable to me,” he says. €œI love the idea. It’s a romantic idea, but, I mean, come on.” The hypothesis of tree immortality has grown popular in the past 20 years as researchers continue to report having found little to no genetic evidence of aging in extremely old trees’ meristem (tissue that generates new cells), Stahle says.

And this is one of the review essay’s most important points, he adds. But evidence of aging could be out there and just not yet found. Adverse conditions, including the harsh, rocky landscapes populated by stands of bristlecone pines, can kill trees. But not all disturbances are bad for trees in the long run, the essay’s authors write.

Many extremely old trees occur in mountain regions with limited soil and tough climate conditions. Biondi says it is as if trees that live a long time, up to thousands of years, abide by the axiom “that which doesn’t kill you makes you stronger.” Many long-lived trees grew up in environments in which they had to compete for resources, such as water in dry stands of trees or sunlight in dense forests with leafy treetops or crowns, Biondi says. Earlier in this century, an individual Great Basin bristlecone pine (Pinus longaeva) in California’s White Mountains was dated using tree-ring analysis, or dendrochronology, and found to be more than 5,000 years old. That would make it the oldest known living organism on Earth that reproduces sexually, according to various sources.

The age determination was made by the late Tom Harlan of the University of Arizona, who performed detailed analysis on a core sample taken from the tree in 1957. That estimate has not been confirmed by other researchers, according to a list of extremely old trees created by Rocky Mountain Tree-Ring Research, a nonprofit organization in Fort Collins, Colo. If we set aside that individual, the oldest living tree would be an around 4,850-year-old Great Basin bristlecone pine known as Methuselah, which is also located in the White Mountains, according to the nonprofit’s list. The uncertainty about the oldest living tree perhaps illustrates larger questions about nailing down tree ages—a point that the review essay tackles.

Some scientists’ estimates of tree ages draw on unreliable data and methods, including anecdotal reports, Piovesan and Biondi write. The most reliable age-determination methods are analyses of tree rings, with help from radiocarbon dating when necessary, they add. Stahle agrees. Some popular tree species chopped down for sale as Christmas trees, such as Colorado blue spruces, can live for hundreds of years, Stahle says.

But commercial forestry requires neither cutting short the lives of ancient and culturally valued trees nor practicing clear-cutting or other forms of deforestation. More sustainable practices include harvesting only individual trees in a stand or forest while maintaining the cover each tree provides, the water quality it protects and the carbon it sequesters. €œWe can do all these things, and we are,” Stahle says. €œThere are good actors and bad actors in the production of forest timber for society.”.

Editor’s Note https://2019.swissbiotechday.ch/can-you-buy-propecia-over-the-counter-in-canada (12/21/21) get lasix prescription. This article is being showcased in a special collection about equity in health care that was made possible by the support of Takeda. The article was published get lasix prescription independently and without sponsorship.

hypertension medications has cut a jarring and unequal path across the U.S. The disease has disproportionately harmed and killed people of color. Compared with non-Hispanic white people, American Indian, Black and Latinx individuals, respectively, faced 3.5, 2.8 and 3.0 times the risk of being get lasix prescription hospitalized for the and 2.4, 1.9 and 2.3 times the chance of dying, according to the Centers for Disease Control and Prevention.

The reason for these disparities is not biological but is the result of the deep-rooted and pervasive impacts of racism, says epidemiologist and family physician Camara Phyllis Jones. Racism, she explains, has led people of color to be more exposed and less protected from the lasix and has burdened them with chronic diseases. For 14 years get lasix prescription Jones worked at the CDC as a medical officer and director of research on health inequities.

As president of the American Public Health Association in 2016, she led a campaign to explicitly name racism as a direct threat to public health. She is currently a Presidential Visiting Fellow at the Yale School of Medicine and is writing a book proposing strategies for a national campaign against racism. As the country began to confront the unequal impact of hypertension medications and the ongoing legacy of racial injustice it represents, Jones spoke with Scientific American contributing editor Claudia Wallis about get lasix prescription the ways that discrimination has shaped the suffering produced by the lasix.

Along with age, male gender and certain chronic conditions, race has turned out to be a risk factor for a severe outcome from hypertension medications. Why is that?. Race doesn’t put get lasix prescription you at higher risk.

Racism puts you at higher risk. It does so through two mechanisms get lasix prescription. People of color are more infected because we are more exposed and less protected.

Then, once infected, we are more likely to die because we carry a greater burden of chronic diseases from living in disinvested communities with poor food options [and] poisoned air and because we have less access to health care. Why do you get lasix prescription say Black, brown and Indigenous people are more exposed?. We are more exposed because of the kinds of jobs that we have.

The frontline jobs of home health aides, postal workers, warehouse workers, meat packers, hospital orderlies. And those frontline jobs—which, for a long time, have been invisibilized and undervalued in terms of the pay—are now get lasix prescription categorized as essential work. The overrepresentation [of people of color] in these jobs doesn’t just so happen.

(Nothing differential by race just so happens.) It is tied to residential and educational segregation in this country. If you have a poor neighborhood, then you’ll have poorly funded schools, which get lasix prescription often results in poor education outcomes and another generation lost. When you have poor educational outcomes, you have limited employment opportunities.

We are also more exposed because we are overrepresented in prisons and jails—jails where people are often financial detainees because they can’t make bail. And brown people are more exposed in immigration detention get lasix prescription centers. We are also more likely to be unhoused—with no access to water to wash our hands—or to live in smaller, more cramped quarters in more densely populated neighborhoods.

You’re in a one–bedroom apartment with five people living there, and one is your grandmother, and you can’t get lasix prescription safely isolate from family members who are frontline workers. Why have people of color been less protected?. We have been less protected because in these frontline jobs—but also in the nursing homes and in the jails, prisons and homeless shelters—the personal protective equipment [PPE] was very, very slow in coming.

Look at the get lasix prescription meatpacking plants, for example. We are less protected because our roles and our lives are less valued—less valued in our job roles, less valued in our intellect and our humanity. You’ve noted that once infected, people of color are more likely to have a poor outcome or die.

Could you break down the get lasix prescription reasons?. This has two buckets. First, we are more burdened with chronic diseases.

Black people have 60 percent more diabetes get lasix prescription and 40 percent more hypertension. That’s not because we are not interested in health but because of the context of our lives. We are living in unhealthier places without the food choices we need.

No grocery stores, so-called food deserts and what some people describe as “fast-food swamps.” More polluted air, no place to exercise safely, toxic dump get lasix prescription sites—all of these things go into communities that have been disempowered. That’s why we have more diseases, not because we don’t want to be healthy. We very much want to be healthy get lasix prescription.

It’s because of the burdens that racism has put on our bodies. What is the second bucket that raises risks from hypertension medications?. Health care get lasix prescription.

Even from the beginning, it was hard for Black folks to get tested because of where testing sites were initially located. They were in more affluent neighborhoods—or there was drive-through testing. What if you don’t have a get lasix prescription car?.

And there was the need to have a physician’s order to get a test. We heard about people who were symptomatic and presented at emergency departments but were sent back home without getting a test. A lot of people get lasix prescription died at home without ever having a confirmed diagnosis.

So even though we know we are overrepresented, we may have been undercounted. Once you get into the hospital, there’s a whole spectrum of scarce resources, so different states and hospital systems had what they called “crisis standards of care.” In Massachusetts, they were very careful to say you cannot use race or language or zip code to discriminate [on who gets a ventilator]. But you could use get lasix prescription expected [long-term] survival.

Then the question was. Do you get lasix prescription have these preexisting conditions?. This was going to systematically put Black and brown people at a lower priority or even disqualify them from access to these lifesaving therapies.

[Editor’s Note. Massachusetts later changed its guidelines, but Jones viewed the revision as an incomplete fix.] Making sure that treatment campaigns reach communities of color get lasix prescription is surely part of the solution, but what else can be done to better protect vulnerable minorities?. We need more PPE for all frontline workers.

We need to value all those lives. We need to offer hazard pay and something like conscientious objector status for frontline workers who feel get lasix prescription it is too dangerous to go back into the pouy or meatpacking plant. We know there are communities at higher risk, and we need to be doing more testing there.

We need to broaden our gaze from a narrow focus on the individual (“treatment hesitancy”) to acknowledge that structural barriers continue to impact access to the treatments. Several states do get lasix prescription not report racial and ethnic data on hypertension medications cases. Why is that a problem?.

States should be reporting their data disaggregated by race, especially now we know Black and brown and Indigenous folks are at higher risk of being infected and then dying. It’s not just to document it, not just to alarm or to arm some people with a false sense get lasix prescription of security. It’s because we need to provide resources according to need.

Health-care resources, testing resources and prevention types get lasix prescription of resources. Are you concerned about how the CDC’s relaxation of its face mask guidance will impact essential workers and communities of color?. Yes.

We need to recognize that we are all in this together, that masks provide reciprocal protection with no downsides, and that asymptomatic spread continues to fuel this lasix, so that a continued mask get lasix prescription mandate for all without regard to immunization status should be maintained until there are no hypertension medications s, hospitalizations or deaths. It is such a simple, effective, and community-minded intervention that hurts no one and helps everyone. Over the past year we have seen people take to streets to protest another kind of deadly racial inequity.

Police violence against people of color, especially against Black men get lasix prescription and boys. As awareness spreads about the pervasive nature of racism in systems ranging from law enforcement to health care to housing, do you see an opportunity for meaningful change?. The outrage is encouraging because it has been expressed by folks from all parts of our population.

The Black get lasix prescription Lives Matter protests were potentially mixing bowls for the lasix, but at least they are not frivolous mixing bowls like pool parties. Participants in such protests were thinking not just about their individual health and well-being but about the collective power they have now to possibly make things better for their children and grandchildren. This is both a treacherous time and a time of great promise.

Racism is a system of structuring opportunity get lasix prescription and assigning value based on the social interpretation of how one looks (which is what we call “race”) that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources. Perhaps this nation is awakening to the realization that racism does indeed hurt us all.Editor’s Note (12/21/21). This article is being showcased in a special collection about equity get lasix prescription in health care that was made possible by the support of Takeda.

The article was published independently and without sponsorship. The hypertension medications lasix has disproportionately hurt members of minority communities in the U.S. As of get lasix prescription July 2020, 73.7 Black people out of every 100,000 had died of the hypertension—compared with 32.4 of every 100,000 white people.

Structural racism accounts for much of this disparity. Black people are more likely to have jobs that require them to leave their homes and to commute by public transport, for example, both of which increase the chances of getting infected. They are also more likely to get get lasix prescription grievously ill when the lasix strikes.

As of June 2020, the hospitalization rate for those who tested positive for hypertension was more than four times higher for Black people than for non-Hispanic white people. One reason for this alarming ratio is that Black people have higher rates of diabetes, hypertension and asthma—ailments linked to worse outcomes after with the hypertension. Decades of research show get lasix prescription that these health conditions, usually diagnosed in adulthood, can reflect hardships experienced while in the womb.

Children do not start on a level playing field at birth. Risk factors linked to maternal poverty—such as malnutrition, smoking, exposure to pollution, stress or lack of health care during pregnancy—can predispose babies to future disease. And mothers get lasix prescription from minority communities were and are more likely to be subjected to these risks.

Today’s older Black Americans—those most endangered by hypertension medications—are more likely than not to have been born into poverty. In 1959, 55 percent get lasix prescription of Black people in the U.S. Had incomes below the poverty level, compared with fewer than 10 percent of white people.

Nowadays 20 percent of Black Americans live below the poverty line, whereas the poverty rate for white Americans remains roughly the same. Despite the reduction in income inequality between these groups, ongoing racism works through get lasix prescription circuitous routes to worsen the odds for minority infants. For example, partly because of a history of redlining (practices through which financial and other institutions made it difficult for Black families to buy homes in predominantly white areas), even better-off Black people are more likely to live in polluted areas than are poorer white people—with a corresponding impact on fetal health.

Worryingly, people disadvantaged in utero are more likely to have lower earnings and educational attainments, so that the effects of poverty and discrimination can span generations. Researchers now have hard evidence that targeted programs get lasix prescription can improve health and reduce inequality. Expansions of public health insurance offered to women, infants and children under Medicaid and the Children’s Health Insurance Program have already had a tremendous effect, improving the health and well-being of a generation—with the largest impacts on Black children.

And interventions after birth can often reverse much of the damage suffered prenatally. Along with get lasix prescription other researchers, I have shown that nutrition programs for pregnant women, infants and children. Home visits by nurses during pregnancy and after childbirth.

High-quality child care. And income support can improve the outcomes for disadvantaged get lasix prescription children. Such interventions came too late to help those born in the 1950s or earlier, but they have narrowed the health gaps between poor and rich children, as well as between white and Black children, in the subsequent decades.

Enormous disparities in health and vulnerability remain, however, and raise disturbing questions about how children born to poorer mothers during the current lasix, with get lasix prescription all its social and economic dislocations, will fare. Alarmingly, just before the lasix hit, many of the most essential programs were being cut back. Since the beginning of 2018, more than a million children have lost Medicaid coverage because of new work requirements and other regulations, and many have become uninsured.

Now that get lasix prescription the hypertension medications death toll has exposed stark inequalities in health status and their attendant risks, Americans must act urgently to reverse these setbacks and to strengthen public health systems and the social safety net, with special attention to the care of mothers, infants and children. The Hunger Winter Decades of careful observation and analysis have gone into uncovering the manifold ways in which the fetal environment affects the future health and prospects of a child, and much remains mysterious. It would be unethical to run experiments to measure the toll on a fetus of, say, malnutrition or pollution.

But we can look for so-called natural get lasix prescription experiments—the (sometimes horrific) events that cause variations in these factors in ways that mimic an actual experiment. The late epidemiologist David Barker argued in the 1980s that poor nutrition during pregnancy could “program” babies in the womb to develop future ailments such as obesity, heart disease and diabetes. Initial evidence for such ideas came from studies of the Dutch “Hunger Winter.” In October 1944 Nazi occupiers cut off food supplies to the Netherlands, and by April 1945 mass starvation had set in.

Decades later military, medical and employment records showed that adult men whose mothers were exposed to the famine while pregnant with them were twice as likely to be obese as other men and get lasix prescription were more likely to have schizophrenia, diabetes or heart disease. Anyone born in the Netherlands during the famine is part of a cohort that can be followed over time through a variety of records. Nowadays many researchers, including me, look for natural experiments to delineate such cohorts and thereby tease out the long-term impacts of various harms experienced in utero.

We also rely heavily on the most widely available measure get lasix prescription of newborn health. Birth weight. A baby may have “low” birth weight, defined as get lasix prescription less than 2,500 grams (about 5.5 pounds), or “very low” birth weight of less than 1,500 grams (3.3 pounds).

The lower the birth weight, the higher the risk of infant death. We have made enormous progress in saving premature babies, but low-birth-weight children are still at much higher risk for complications such as brain bleeds and respiratory problems that can lead to long-term disability. In recent years computer analysis of large-scale electronic records has made get lasix prescription it possible to connect infant health, as measured by birth weight, to long-term outcomes not just for cohorts but also for individuals.

Studies of twins or siblings, who have similar genetic and social inheritance, show that those with lower birth weight are more likely to have asthma or attention deficit hyperactivity disorder (ADHD) when they get older. Several studies also show that lower-birth-weight twins or siblings have worse scores on standardized tests. As adults, they are more likely to have lower wages, get lasix prescription to reside in lower-income areas or to be on disability-assistance programs.

In combination, cohort and sibling studies demonstrate that low birth weight is predictive of several adverse health outcomes later in life, including increased probabilities of asthma, heart disease, diabetes, obesity and some mental health conditions. Birth weight does not capture all aspects of a child’s health. A fetus gains most of its get lasix prescription weight in the third trimester, for example, but many studies find that shocks in the first trimester are particularly harmful.

I nonetheless use the measure in my studies because it is important and commonly available, having been recorded for tens of millions of babies for decades. Significantly, low birth weight is much more common among infants born to poor and minority mothers. In 2016 13.5 percent of Black mothers had low-birth-weight babies, compared with 7.0 percent of non-Hispanic whites and 7.3 percent of get lasix prescription Hispanic mothers.

Among those with college educations, 9.6 percent of Black mothers had low-birth-weight babies, compared with 3.7 percent of non-Hispanic white mothers. These inequalities in health at birth reflect large differences in exposure to several get lasix prescription factors that affect fetal health. The Poverty Connection As already noted, the quality of a mother’s nutrition substantially influences the health of her babies.

In 1962 geneticist James V. Neel hypothesized that a so-called thrifty gene had programmed humankind’s hunter-gatherer ancestors to hold on to every calorie they could get and that in modern times, that tendency, combined with get lasix prescription an abundance of high-calorie foods, led to obesity and diabetes. Recent studies on laboratory animals indicate, however, that the link between starvation and disease is not genetic in origin but epigenetic, altering how certain genes are “expressed” as proteins.

Prolonged calorie deprivation in a pregnant mouse, for example, prompts changes in gene expression in her offspring that predispose them to diabetes. What is get lasix prescription more, the effect may be transmitted through generations. Outright starvation is now rare in developed countries, but poorer mothers in the U.S.

Often lack a diet rich in fruits and vegetables, which contain essential micronutrients. Deficiencies in folate intake during pregnancy are linked to get lasix prescription neural tube defects in children, for example. Credit.

Amanda Montañez. Source. €œIs It Who You Are or Where You Live?.

Residential Segregation and Racial Gaps in Childhood Asthma,” by Diane Alexander and Janet Currie, in Journal of Health Economics, Vol. 55. July 25, 2017 At present, one of the leading causes of low birth weight in the U.S.

Is smoking during pregnancy. In the 1950s pregnant women were told that smoking was safe for their babies. Roughly half of all new mothers in 1960 reported smoking while pregnant.

Today, thanks to public education campaigns, indoor-smoking bans and higher cigarette taxes, only 7.2 percent of pregnant women say that they smoke. And 55 percent of women who smoked in the three months before they got pregnant quit for at least the duration of their pregnancy. Possibly because going to college places women in a milieu where smoking is strongly discouraged, mothers with higher education levels are less likely to smoke.

Among mothers with less than a high school education, 11.7 percent smoke, compared with 1 percent of mothers with a bachelor’s degree. Among the many harmful chemicals in cigarette smoke is carbon monoxide (CO), which restricts the amount of oxygen carried by the blood to the fetus. In addition, nicotine affects the development of blood vessels in the uterus and disrupts developing neurotransmitter systems, leading to poorer psychological outcomes.

Maternal cigarette smoking during pregnancy has also been associated with epigenetic changes in the fetus, although how these alterations affect an individual in later years remains mysterious. The recent surge in vaping, which delivers high doses of nicotine and which surveys show has been tried by almost 40 percent of high school seniors, is an extremely worrying development that could have long-term implications for fetal and infant health. Yet another significant source of harm for fetuses is pollution.

Pregnant women may be exposed to thousands of toxic chemicals in the air, water, soil and sundry products at home and at work. Complicating matters, each pollutant acts in a different way. Particulates in the atmosphere are thought to cause inflammation throughout the body, which has been linked to preterm labor and, consequently, to low birth weight.

Lead, ingested through water or air, crosses the placenta to accumulate in the fetus and harm brain development. In 2005 Jessica Wolpaw Reyes of Amherst College showed that the phaseout of leaded gasoline in the U.S. Led to a decrease of up to 4 percent in infant mortality and low birth weight.

A fetus may also receive less oxygen if its mother inhales CO from vehicle exhaust. In a 2009 study of mothers who lived near pollution monitors, my co-workers and I found that high levels of ambient CO were correlated with reduced birth weight. Worryingly, the effects of CO from air pollution are five times greater for smokers than for nonsmokers.

Reducing pollution can have immediate benefits for pregnant women and newborns. In a 2011 study of babies born in New Jersey and Pennsylvania, Reed Walker of the University of California, Berkeley, and I focused on mothers who lived near E-ZPass electronic toll plazas before and after they began operating. We compared them with mothers who lived a little farther from the toll plazas but along the same busy roads.

Both groups of mothers were exposed to traffic, but before E-ZPass, the mothers near the toll plazas were exposed to more pollution because cars idled while waiting to pay the tolls. E-ZPass greatly reduced pollution right around the toll plazas by allowing cars to drive straight through. Startlingly, the introduction of E-ZPass reduced the incidence of low birth weight by more than 10 percent in the neighborhoods nearest the toll plazas.

In another study, my collaborators and I examined birth records for 11 million newborns in five states. We found that a shocking 45 percent of mothers lived within about a mile of a site that emitted toxic chemicals such as heavy metals or organic carcinogens—a number that rose to 61 percent among Black mothers. Focusing on babies born to mothers who lived within a mile of a plant, we compared birth weights when the facility was operating with birth weights when it was closed.

For additional context, we also compared babies born within a mile of a plant with babies born in a one-to-two-mile band around the plants. Both groups of mothers were likely to be similarly affected by the economics of factory openings and closings, but mothers who lived closer were more likely to have been exposed to pollution during pregnancy. We found that an operating plant increased the probability of low birth weight by 3 percent among babies whose mothers lived less than a mile from the plant.

The racial divide in pollution exposure is profound, in part because of continuing segregation in housing that makes it difficult for Black families to move out of historically Black neighborhoods. Disadvantaged communities may also lack the political power to fend off harmful development, such as a chemical plant, in their vicinity. In the E-ZPass study, roughly half of the mothers who lived next to toll plazas were Hispanic or Black, compared with only about a tenth of mothers who lived more than six miles away from a toll plaza.

And in a paper published in 2020, John Voorheis of the U.S. Census Bureau, Walker and I showed that across the entire U.S., neighborhoods with higher numbers of Black residents have systematically worse air quality than other neighborhoods. Black people are also twice as likely as others to live near a Superfund hazardous waste site.

For these reasons, pollution-control measures such as the Clean Air Act have greatly benefited Black people. Fight or Flight Stress disproportionately impacts the poor—who have chronic worries about paying bills, for example—and also harms fetuses. A stressful situation triggers the release of hormones that orchestrate a range of physical changes associated with the fight-or-flight response.

Some of these hormones, including cortisol, have been linked to preterm labor, which in turn leads to low birth weight. High circulating levels of cortisol in the mother during pregnancy may damage the fetus’s cortisol-regulation system, making it more vulnerable to stress. And stress can trigger behavioral responses in a mother such as increased smoking or drinking, which are also harmful to the fetus.

One revealing study indicates that fetal exposure to maternal stress can have greater negative long-term effects on mental health than stress directly experienced by a child. Petra Persson and Maya Rossin-Slater, both at Stanford University, looked at the impact of the death of a close relative. Death can bring many unwelcome changes to a family, such as reduced income, which may also influence child development.

To account for such complications, the researchers used administrative data from Sweden to compare children whose mothers were affected by a death during the prenatal period with those whose mothers were affected by a death during the child’s early years. They found that children affected by a death prenatally were 23 percent more likely to use medication for ADHD at ages nine to 11 and 9 percent more likely to use antidepressants in adulthood than were children whose families experienced a death a few years after their birth. Another pathbreaking study measured levels of cortisol, an indicator of stress, during pregnancy.

By age seven, children whose mothers had higher cortisol levels during pregnancy had received up to one year less schooling than their own siblings, indicating that they had been delayed in starting school. Moreover, for any given level of cortisol in the mother’s blood, the negative effects were more pronounced for children born to less educated mothers. This finding suggests that although being stressed during pregnancy is damaging to the fetus, mothers with more education are better able to buffer the effects on their children—an important finding in view of the severe stress imposed by hypertension medications on families today.

It is no surprise that disease can also harm a fetus. Douglas V. Almond of Columbia University looked at people born in the U.S.

At the peak of the influenza epidemic of 1918 and found that they were 1.5 times more likely to be poor as adults than were those born just before them. In work I conducted with Almond and Mariesa Herrmann of Mathematica looking at mothers born between 1960 and 1990 in the U.S., we found that women who were born in areas where an infectious disease was raging were more likely to have diabetes when they gave birth to their own children decades later—and the effects were twice as large for Black people. More recently, Hannes Schwandt of Northwestern University examined Danish data and found that maternal with ordinary seasonal influenza in the third trimester doubles the rate of premature birth and low birth weight, and in the second trimester leads to a 9 percent reduction in earnings and a 35 percent increase in welfare dependence once the child reaches adulthood.

Preventing Harm Health at birth and beyond can nonetheless be improved through thoughtful interventions targeting pregnant women, babies and children and through reductions in pollution. The food safety net in the U.S. Has already had tremendous success in preventing low birth weight in the babies of disadvantaged women.

The rollout of the food stamp program (now called the Supplemental Nutrition Assistance Program, or SNAP) across the U.S. In the mid-1970s reduced the incidence of low birth weight by between 5 and 11 percent. In addition, children who benefited from the rollout grew up to be less likely to have metabolic syndrome—a cluster of conditions that include obesity and diabetes.

Notably, women who had benefited as fetuses or young children were more likely to be economically self-sufficient. The 1970s also saw the introduction of the Special Supplemental Nutrition Program for Women, Infants and Children, popularly known as WIC. Approximately half of eligible pregnant women in the U.S.

Receive nutritious food from WIC, along with nutrition counseling and improved access to medical care. Dozens of studies have shown that when women participate in WIC during pregnancy, their babies are less likely to have low birth weight. In work looking at mothers in South Carolina, Anna Chorniy of Northwestern University, Lyudmyla Ardan (Sonchak) of Susquehanna University and I were able to show that children whose mothers received WIC during pregnancy were also less likely to have ADHD and other mental health conditions that are commonly diagnosed in early childhood.

Skyline of Flint, Mich., in 2016, after declaration of a federal emergency because of lead contamination in the water supply. Credit. Brett Carlsen Getty Images In the late 1980s and early 1990s, state and federal governments worked together to greatly expand public health insurance for pregnant women under the Medicaid program.

In work with Jonathan Gruber of the Massachusetts Institute of Technology, I showed that public health insurance lowered infant mortality and improved birth weight. Today the children whose mothers became eligible for health insurance coverage of their pregnancies in that period have higher levels of college attendance, employment and earnings than the children of mothers who did not. They also have lower rates of chronic conditions and are less likely to have been hospitalized.

The estimated effects are strongest for Black people, who, having lower average incomes, benefited the most from the expansions. The fact that these babies are more likely to eventually get a college education also increases the life chances of their children. In the U.S., an additional year of college education for the mother reduces the incidence of low birth weight in her children by 10 percent.

Even so, too many children are still born with low birth weight, especially if their mothers are Black. Significantly, targeted interventions after birth can improve their outcomes. Programs such as the Nurse-Family Partnership provide home visits by nurses to low-income women who are pregnant for the first time, many of whom are young and unmarried.

The nurse visits every month during the pregnancy and for the first two years of the child’s life to provide guidance about healthy behavior. The assistance reduces child abuse and adolescent crime and enhances children’s academic achievement. Providing cash payments to poor families with young children also improves both maternal health and child outcomes, suggesting that hypertension medications relief payments will have important protective effects.

In the U.S., the largest preexisting program of this type is the Earned Income Tax Credit (EITC). Studies of beneficiaries of the EITC show that children in families that received increased amounts had higher test scores in school. With financial stress being somewhat relieved, the mental health of mothers in these families also improved.

In addition, quality early-childhood education programs augment future health, education and earnings and reduce crime. Head Start, the federally funded preschool program that was rolled out beginning in the 1960s, has also had substantial positive effects on health and education outcomes, especially in places with less access to alternative child care centers. A 2018 study, especially noteworthy in light of the tragic lead poisoning in Flint, Mich., shows that even some of the negative effects of lead can be reversed.

In Charlotte, N.C., lead-poisoned children who received lead remediation, nutritional and medical assessments, WIC and special training for their caregivers saw reductions in problem behaviors and advanced school performance. Looking Ahead Investments in pregnant women and infants have been paying off, their success reflected in dramatically falling infant mortality rates in the U.S.—despite rising inequality in income and wealth. Alarmingly, however, many successful programs, such as the Clean Air Act, SNAP and Medicaid, are under attack.

The hypertension Aid, Relief and Economic Security (CARES) Act passed in March 2020 provided some relief, at least with respect to Medicaid. CARES temporarily suspended disenrollment from the program, giving additional flexibility to state Medicaid programs in terms of time lines and eligibility procedures. Still, states may be hard-pressed to enroll the many who will become newly eligible for Medicaid because of job loss.

Moreover, states that have not expanded the Medicaid program to cover otherwise ineligible low-income adults, as allowed by the Affordable Care Act, may see many more uninsured. A National Academies of Sciences, Engineering and Medicine report published in 2019 laid out a road map for reducing child poverty by half within 10 years. One of the most stunning findings of the report is that it is feasible to meet that target by expanding programs that already exist.

Following these directions would have a profound impact on health and health disparities. Targeted approaches, such as more thorough investigation of maternal deaths occurring up to one year after a birth, are also necessary. Even simple preventive measures such as giving pregnant women flu shots can have a tremendously positive effect on infant health and child development.

Diagnosis and treatment of conditions such as preeclampsia (high blood pressure associated with pregnancy) are key to both protecting babies and lowering maternal mortality rates. It is important to help pregnant women quit smoking and to develop new approaches relevant to a new generation addicted to vaping. Also needed are stronger protections for women at risk of domestic violence, which leads directly to chronic stress, premature deliveries and low birth weight.

One salient open question is what effect the lasix will have on the generation of children affected by it in utero and in early life. hypertension medications itself may have negative effects on the developing fetus. The latest data suggest that although the overall risk is low, pregnant women are at increased risk of becoming critically ill (as they are with influenza or SARS).

Affected babies, however, do not seem to be at risk of obvious birth defects (as they are with the Zika lasix). Still, given the fact that hypertension medications affects many body systems, it may prove to have subtler negative effects on the developing fetus. The lasix is also an extremely stressful event compounded by the sharpest economic downturn since the Great Depression.

There are reports of increases in domestic violence, alcohol consumption and drug overdoses, all of which are known to be harmful to the developing fetus. In consequence, the generation now in utero is likely to be at increased risk going forward and will require intensive social investments to overcome its poorer start in life. In a recent sermon on the late civil rights leader John Robert Lewis, Reverend James Lawson recounted the significant gains for Americans of all colors that had resulted from that movement.

He went on to ask that America’s political leaders “work unfalteringly on behalf of every boy and every girl, so that every baby born on these shores will have access to the tree of life ... Let all the people of the U.S.A. Determine that we will not be quiet as long as any child dies in the first year of life in the United States.

We will not be quiet as long as the largest poverty group in our nation are women and children.” As we rebuild our shattered safety nets and public health systems in the aftermath of hypertension medications, we need to seize the moment and use the knowledge we have gained about how to protect mothers and babies—to give every child the opportunity to flourish.Some people go home for the holidays hoping just to survive, burying their attention in their phones or football to avoid conflict with relatives. Yet research now suggests that is the wrong idea. Family rituals—of any form—can save a holiday, making it well worth the effort of getting everyone in the same room.

In a series of studies to be published in the Journal of the Association for Consumer Research, hundreds of online subjects described rituals they performed with their families during Christmas, New Year's Day and Easter, from tree decoration to egg hunts. Those who said they performed collective rituals, compared with those who said they did not, felt closer to their families, which made the holidays more interesting, which in turn made them more enjoyable. Most surprising, the types of rituals they described—family dinners with special foods, religious ceremonies, watching the ball drop in Times Square—did not have a direct bearing on enjoyment.

But the number of rituals did. Apparently having family rituals makes the holidays better and the more the merrier. The study could measure only correlations between subjects' responses, leaving causality uncertain—Do rituals increase holiday pleasure, or do people who already enjoy the holidays choose to perform more rituals?.

Yet enjoyment ratings were higher when given after, versus before, describing rituals, suggesting that simply thinking about rituals can put a warm filter on one's experience. €œWhatever the ritual is, and however small it may seem, it helps people to really get closer to one another,” says Ovul Sezer, a researcher at Harvard Business School and the paper's primary author. €œ[With] some rituals we don't even know why we do them, but they still work,” she says.

It could be that rituals offer “small, nonobvious ways” to get people to share an experience without feeling awkward or forced, suggests Kathleen Vohs, a psychologist at the University of Minnesota and one of Sezer's co-authors. She compares that with “obvious ploys” such as saying, “Hey, everyone, gather around the kitchen table, we're going to play Yahtzee,” which, she notes, “might be more likely to produce a whole lot of kickback.”Genome-edited food made with CRISPR–Cas9 technology is being sold on the open market for the first time. Since September, the Sicilian Rouge tomatoes, which are genetically edited to contain high amounts of γ-aminobutyric acid (GABA), have been sold direct to consumers in Japan by Tokyo-based Sanatech Seed.

The company claims oral intake of GABA can help support lower blood pressure and promote relaxation. In Japan, dietary supplements and foods enriched for GABA are popular among the public, says Hiroshi Ezura, chief technology officer at Sanatech and a plant molecular biologist at the University of Tsukuba. €œGABA is a famous health-promoting compound in Japan.

It’s like vitamin C,” he says. More than 400 GABA-enriched food and beverage products, such as chocolates, are already on the Japanese market, he says. €œThat’s why we chose this as our first target for our genome editing technology,” he says.

Sanatech, a startup from the University of Tsukuba, first tested the appetite of consumers in Japan for the genome-edited fruit in May 2021 when it sent free seedling CRISPR-edited tomato plants to about 4,200 home gardeners who had requested them. Encouraged by the positive demand, the company started direct internet sales of fresh tomatoes in September and a month later took orders for seedlings for next growing season. Japan’s regulators approved the tomato in December 2020.

Since its inception a decade ago, CRISPR–Cas9 genome editing has become a tool of choice for plant bioengineers. Researchers have successfully used it to develop non-browning mushrooms, drought-tolerant soybeans and a host of other creative traits in plants. Many have received a green light from US regulators.

But before Sanatech’s tomato, no CRISPR-edited food crops were known to have been commercialized. Consumers may find food ingredients made with some of the older DNA editing techniques, such as transcription activator-like effector nucleases (TALENs). Indeed, Calyxt in 2019 commercialized a TALEN-edited soybean oil that is free of trans fats.

Genome editing tools have also been used to transform a host of ornamental plants. So it was only a matter of time before a CRISPR-edited crop reached palates. More interesting, however, is that the developer chose this high GABA trait as a first target.

GABA is an amino acid and a neurotransmitter that blocks impulses between nerve cells in the brain. The molecule is found natively in the human body and is also ubiquitously present in plants, animals and microorganisms, as well as in food. It can be synthesized by fermenting food and has been developed as a nutritional supplement in some regions.

Sanatech’s researchers increased the amount of GABA in tomato by manipulating a metabolic pathway called the GABA shunt. There, they disabled a gene that encodes calmodulin-binding domain (CaMBD). Removal of CaMBD enables increased activity of the enzyme glutamic acid decarboxylase, which catalyzes the decarboxylation of glutamate to GABA, thus raising levels of the molecule.

Sanatech has been careful not to claim that its tomatoes therapeutically lower blood pressure and promote relaxation. Instead, the company implies it, by advertising that consuming GABA, generally, can achieve these effects and that its tomatoes contain high levels of GABA. This has raised some eyebrows in the research community, given the paucity of evidence supporting GABA as a health supplement.

To support the blood-pressure assertion, Sanatech cites two human studies. A 2003 paper on the effect of consuming fermented milk containing GABA and a 2009 paper of the effects of GABA, vinegar and dried bonito. Both studies were conducted in people with mild hypertension and showed blood-pressure-lowering effects.

But the papers lack good control groups, and the effects in the experimental groups could be explained by factors other than GABA, says Maarten Jongsma, a molecular cell biologist at Wageningen University &. Research in the Netherlands, who studies the effects of plant compounds on human nutrition. €œThere’s no consensus” on the health benefits of consuming GABA, nor evidence that it can cross the blood–brain barrier and reach the central nervous system, adds Renger Witkamp, a nutrition scientist also at Wageningen.

To support the claim that GABA promotes relaxation, Sanatech points to six studies in humans that examined the effect of orally consumed GABA on stress, mood, fatigue or sleep. But a systematic review published in 2020 that examined all six of these papers plus eight more on the topic came to a different conclusion. The authors, who hailed from Japan, Australia and the United Kingdom, summarized.

€œThere is limited evidence for stress and very limited evidence for sleep benefits of oral GABA intake.” Sanatech’s tomatoes, called the Sicilian Rouge High GABA, contain about four to five times more GABA than their conventional counterpart, Ezura says. Whether that will lower blood pressure any more than eating regular tomatoes is unclear. Sanatech has not performed this kind of intervention study, although it plans to do so, Ezura says.

The company is working to complete an additional notification with the Japanese government on the health benefit claim. Sanatech’s marketing strategy has been to target consumers directly and generate positive buzz among home gardeners. The company created an online platform for gardeners to swap tips.

It also held a contest to see which home gardener could grow tomatoes with the highest amount of GABA. (The winning tomato had 20 times more GABA than conventional tomatoes.) That’s a smart marketing strategy for genome-edited fruit and vegetables, especially those with boutique traits, says Cathie Martin, a plant scientist at the John Innes Centre in Norwich, UK. €œYou find a group of people who feel as though they have some ownership of the product,” she says.

You then help build up a community of people who want to grow and eat the vegetable, and this launches the product on a positive track, she says. Martin is the creator of the ‘purple tomato’, a variety that is genetically modified to contain higher levels of the anti-inflammatory compound anthocyanin, which she debuted in 2008 in these pages. Over the past 14 years, without the resources of a large company, she and an “un-financed, dedicated band of enthusiasts” have been trying to push the product to market on their own, she says.

Her challenge of commercializing a bioengineered crop is one that most small plant biotech companies have also faced, particularly those developing boutique varieties. €œThe regulatory cost is so high that there are very few traits that you could actually even consider engineering in a crop like tomato,” says James Giovannoni, a plant molecular biologist at the Agricultural Research Service at the US Department of Agriculture (USDA). That’s why, since the mid-1990s, most commercial efforts in the genetic engineering of plants have focused on high-dollar crops, such as soybean, corn (maize), wheat, canola and cotton, with traits that make farmer’s jobs easier and their harvests more profitable.

Meanwhile, nutritionally enhanced crops have been stillborn. The few examples on the market include soybeans and canola with modified oil and fatty acid content, and nutritionally improved corn for animal feed. Scores more, such as the high β-carotene super-banana, have been developed but sit in limbo on laboratory shelves.

The storied ‘golden rice’, which is enhanced with provitamin A and has been in limbo for 20 years, just a few months ago received approval in the Philippines for commercial cultivation. So Sanatech’s high-GABA tomato, as a nutritionally enhanced crop, stands out. The fact that it was engineered using CRISPR seems to help with consumer acceptance, especially as such crops aren’t being called “GMOs,” or “genetically modified organisms.” Instead, they’re dubbed “genome-edited.” This change in nomenclature alone seems to have quelled a lot of the backlash historically launched against bioengineered plants.

Some regulators are making a distinction between the old and new technologies too. The USDA has repeatedly ruled that genome-edited crops fall outside of its purview. Plant biotechnologists who submit such inquiries through the agency’s “Am I Regulated?.

€ process typically get a response within a few months and receive a green light to grow their genome-edited plants without further oversight. This has reduced the US regulatory burden for genome-edited plants to next to nothing. Brazil, Argentina and Australia have taken a similar approach.

China has established a regulatory process for genome-edited agricultural organisms, although none has yet been approved, says Hongliang Zhu, a professor at China Agricultural University in Beijing, speaking on behalf of himself and not his employer or government. Europe has essentially banned genome-edited foods, lumping them in with first-generation GMOs, although there have been calls to rethink the policy. Many other countries still lack any policy on the technology, slowing commercial efforts.

Toolgen in Seoul, South Korea, has used CRISPR to generate color-modified petunias, high-oleic acid soybeans and browning-inhibited potatoes, “but they are not on sale yet because the domestic regulatory policy for CRISPR genome-edited crops has not been established,” says Yein Joen, a researcher at the company. Japan’s regulatory policy on genome-edited plants formed in tandem with its review of Sanatech’s tomato—a process that took about a year. Ezura “deserves great credit for single-handedly pushing the Japanese government to institute a policy where gene-edited crops can be brought to market,” says Harry Klee, a plant molecular biologist and tomato researcher at the University of Florida.

€œThis is a big deal in Japan and he did a great job.” Ezura’s efforts have opened the door for genome-edited food in Japan. In November, researchers at Nagoya University described in Scientific Reports a sweeter tomato developed by modifying a cell wall invertase inhibitor using CRISPR–Cas9. The variety has not been approved by regulators.

And CRISPR–Cas9 edited food in Japan has leapt from the garden to the sea. In October, the island nation approved two CRISPR-edited fish. A gene-edited tiger puffer that exhibits depressed appetite suppression and a red sea bream with increased muscle growth.

Both fish grow larger than their counterparts in the wild and were developed by the Kyoto-based Regional Fish Institute. For Martin, it wasn’t possible to confer the anthocyanin trait in her purple tomatoes using genome editing. Instead, she transformed them using Agrobacterium tumefaciens, an older method of genetic modification that triggers considerably more regulatory oversight and resources, along with the moniker “GMO.” But the door to market may soon open for her too.

Martin says she expects a regulatory decision from the USDA by the end of February for purple tomatoes. Like Sanatech, Martin plans to initially market them directly to the public. She has not conducted human intervention studies comparing the health effects of high-anthocyanin and conventional tomatoes, and does not plan to make health benefit claims.

This article is reproduced with permission and was first published on December 14 2021.Christmas trees are dead or dying. But some conifers and other trees theoretically could live forever, according to a recent essay that reviews accumulating evidence on extremely long-lived trees—and calls for more scientifically rigorous methods to determine their age and study their longevity. Across the board, trees do not die so much as they are killed, write the authors of the review essay, entitled “On Tree Longevity.” Their killers are external physical or biological factors rather than old age alone.

That is, there is no evidence that harmful genetic mutations pile up over time or that trees lose their ability to produce new tissue. “Trees can indeed live indefinitely, but this does not happen,” says co-author Franco Biondi, an ecoclimatologist and tree-ring scientist at the University of Nevada, Reno. €œBecause eventually an external agent, biotic or abiotic [a living thing or a nonliving one such as a physical condition], ends up killing them.” Tree killers include environmental threats such as droughts, wildfires, harsh weather and pests—as well as human threats such as logging and fires set to clear forests for hunting or pastureland, write Biondi and his co-author Gianluca Piovesan of the University of Tuscia in Italy.

Their essay was published in the August issue of New Phytologist. Tree longevity interests researchers in part because trees and other plants remove carbon from the atmosphere for photosynthesis, and older trees are thought to store more carbon than younger ones. The persistence of trees could thus play a role in slowing climate change (although rising temperatures caused by global warming also can put a strain on trees, making them more vulnerable to environmental threats).

The rings of old trees can also serve as an invaluable record of climate history, with wider rings indicating better years. Scientific models designed to study tree longevity have made incorrect assumptions, including the idea that highly shade-tolerant late-successional trees, which are found in older ecosystems that have developed larger trees and a lot of shrub cover, are longer-lived, the essay also notes. For example, extremely long-lived bristlecone pine trees are known to live in wide-open landscapes of the West and in ecosystems that have not changed much for thousands of years.

David Stahle, a geographer and tree longevity researcher at the University of Arkansas, who was not involved in the review essay, used words such as “excellent” and “comprehensive” to describe it. But he takes issue with the assertion that trees can potentially live forever. €œThe likelihood, all things being equal, that trees are immortal seems improbable to me,” he says.

€œI love the idea. It’s a romantic idea, but, I mean, come on.” The hypothesis of tree immortality has grown popular in the past 20 years as researchers continue to report having found little to no genetic evidence of aging in extremely old trees’ meristem (tissue that generates new cells), Stahle says. And this is one of the review essay’s most important points, he adds.

But evidence of aging could be out there and just not yet found. Adverse conditions, including the harsh, rocky landscapes populated by stands of bristlecone pines, can kill trees. But not all disturbances are bad for trees in the long run, the essay’s authors write.

Many extremely old trees occur in mountain regions with limited soil and tough climate conditions. Biondi says it is as if trees that live a long time, up to thousands of years, abide by the axiom “that which doesn’t kill you makes you stronger.” Many long-lived trees grew up in environments in which they had to compete for resources, such as water in dry stands of trees or sunlight in dense forests with leafy treetops or crowns, Biondi says. Earlier in this century, an individual Great Basin bristlecone pine (Pinus longaeva) in California’s White Mountains was dated using tree-ring analysis, or dendrochronology, and found to be more than 5,000 years old.

That would make it the oldest known living organism on Earth that reproduces sexually, according to various sources. The age determination was made by the late Tom Harlan of the University of Arizona, who performed detailed analysis on a core sample taken from the tree in 1957. That estimate has not been confirmed by other researchers, according to a list of extremely old trees created by Rocky Mountain Tree-Ring Research, a nonprofit organization in Fort Collins, Colo.

If we set aside that individual, the oldest living tree would be an around 4,850-year-old Great Basin bristlecone pine known as Methuselah, which is also located in the White Mountains, according to the nonprofit’s list. The uncertainty about the oldest living tree perhaps illustrates larger questions about nailing down tree ages—a point that the review essay tackles. Some scientists’ estimates of tree ages draw on unreliable data and methods, including anecdotal reports, Piovesan and Biondi write.

The most reliable age-determination methods are analyses of tree rings, with help from radiocarbon dating when necessary, they add. Stahle agrees. Some popular tree species chopped down for sale as Christmas trees, such as Colorado blue spruces, can live for hundreds of years, Stahle says.

But commercial forestry requires neither cutting short the lives of ancient and culturally valued trees nor practicing clear-cutting or other forms of deforestation. More sustainable practices include harvesting only individual trees in a stand or forest while maintaining the cover each tree provides, the water quality it protects and the carbon it sequesters. €œWe can do all these things, and we are,” Stahle says.

€œThere are good actors and bad actors in the production of forest timber for society.”.

Where should I keep Lasix?

Keep out of the reach of children.

Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F). Protect from light. Throw away any unused medicine after the expiration date.

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How to over the counter substitute for lasix cite this article:Singh OP https://really-delicious.com/where-can-i-get-zithromax/. Comprehensive Mental Health Action Plan 2013–2030. We must rise to the challenge over the counter substitute for lasix. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development. Further, in September 2021, the 74th World Health Assembly accepted the updates to the action plan, including over the counter substitute for lasix updates to the target options for indicators and implementation.

This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity for the psychiatric community to implement things that we always have been talking about over the counter substitute for lasix like:Global target 2.2 – Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing. It is an opportunity for us to expand psychiatry by over the counter substitute for lasix being involved in general medical care and reduce stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization.

Mental Health Action over the counter substitute for lasix Plan 2013-2020. Geneva. World Health over the counter substitute for lasix Organization. 2013. 2.World over the counter substitute for lasix Health Organization.

Comprehensive Mental Health Action Plan 2013-2030. Geneva. World Health Organization. 2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background. Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence.

However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim. This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods.

This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy. The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA.

Correlation was done using Pearson's correlation test.Results. Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.

Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 15];63:418-23.

Available from. Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence.

This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males.

Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence. Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used.

The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).

The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant. Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis.

The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families.

None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016).

This means that men with alcohol dependence who are more empathic tend to have lesser relapses. Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent.

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71).

Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11). Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2].

However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation.

Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking.

Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial.

It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics. CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE.

Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected. Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management.

Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C.

Alcohol dependence. A public health perspective. Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence.

Alcohol Res Health 2010;33:55-63. 3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ. An attributional analysis of Alcoholics Anonymous.

J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment. Int J Psychoanal 1972;53:51-9. 7.Miller WR.

Motivation for treatment. A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin.

A factor-analytic study. Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension.

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain. How, when and why?. Trends Cogn Sci 2006;10:435-41.

11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy. J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L.

Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61. 13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3.

14.Krebs D. Empathy and auism. J Pers Soc Psychol 1975;32:1134-46. 15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale.

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles. Psychol Psychother 1983;20:368-75.

17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis. Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS.

Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda. Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism.

A link to prefrontal cortex dysfunction?. Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40.

21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48. 22.Miller PA, Eisenberg N.

The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W. The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study.

Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B.

Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21. 28.Decety J, Jackson PL. A social-neuroscience perspective on empathy.

Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism. Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR.

Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84. 31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70.

32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

How to cite this get lasix prescription article:Singh OP. Comprehensive Mental Health Action Plan 2013–2030. We must get lasix prescription rise to the challenge.

Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development. Further, in September 2021, the 74th World Health Assembly accepted the updates get lasix prescription to the action plan, including updates to the target options for indicators and implementation. This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1.

Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there is get lasix prescription an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 – Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 – Integration of mental health care into primary healthcareGlobal target 3.2 – Reduction in suicide rate by one-third by 2030Global target 3.3 – Psychological care for disasterGlobal target 4.2 – Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing. It is an get lasix prescription opportunity for us to expand psychiatry by being involved in general medical care and reduce stigma.

We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization. Mental Health Action Plan 2013-2020 get lasix prescription. Geneva.

World Health get lasix prescription Organization. 2013. 2.World get lasix prescription Health Organization.

Comprehensive Mental Health Action Plan 2013-2030. Geneva. World Health Organization.

2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal. AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background.

Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence. However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation.

Assessment based on cognitive and affective dimensions of empathy is needed.Aim. This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods.

This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy. The University of Rhode Island Change Assessment Scale was used to assess motivation.

Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA. Correlation was done using Pearson's correlation test.Results.

Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages.

Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions. Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses.

Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 15];63:418-23. Available from.

Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking.

It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls.

Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases.

Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males. Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department).

Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence. Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA).

The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.

We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).

The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY.

IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables. Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate.

The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.

Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married.

Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families.

None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence.

[Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses.

Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09).

About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent. Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI.

2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71).

Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11).

Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <.

0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2.

Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls.

This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this.

Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment.

Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement.

Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics.

CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE.

Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed.

We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation. As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE.

Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected.

Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy.

The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C.

Alcohol dependence. A public health perspective. Addiction 2002;97:633-45.

2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63.

3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model.

J Addict Nurs 2005;16:5-12. 4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers.

J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ. An attributional analysis of Alcoholics Anonymous.

J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment.

Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment.

A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP.

Motivation to withdraw from heroin. A factor-analytic study. Br J Addict 1992;87:245-50.

9.Maurage P, Grynberg D, Noël X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension.

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain.

How, when and why?. Trends Cogn Sci 2006;10:435-41. 11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA.

The QCAE. A questionnaire of cognitive and affective empathy. J Pers Assess 2011;93:84-95.

12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L. Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61.

13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3.

14.Krebs D. Empathy and auism. J Pers Soc Psychol 1975;32:1134-46.

15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale. J Adolesc 2006;29:589-611.

16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles.

Psychol Psychother 1983;20:368-75. 17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy.

A preliminary analysis. Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS.

Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda. Drug Alcohol Rev 2018;37:316-32.

19.Uekermann J, Daum I. Social cognition in alcoholism. A link to prefrontal cortex dysfunction?.

Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism.

Addiction 2007;102:232-40. 21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy.

Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48. 22.Miller PA, Eisenberg N.

The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W.

The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study. Br J Addict 1990;85:635-7.

24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78.

25.Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders. Neurosci Biobehav Rev 2013;37:448-70.

26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21.

28.Decety J, Jackson PL. A social-neuroscience perspective on empathy. Curr Dir Psychol Sci 2006;15:54-8.

29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism. Alcohol Clin Exp Res 1988;12:471-80.

30.Moyers TB, Miller WR. Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84.

31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70.

32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling.

J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

Generic lasix for dogs

Using larger generic lasix for dogs businesses as https://kompatech.de/how-to-get-prescribed-kamagra/ sites for rural vaccination clinics could help decrease treatment hesitancy and contribute to economic turnarounds in those areas, experts say. On September 9, President Joe Biden issued sweeping treatment mandates calling for federal employees, federal contractors and healthcare workers at facilities receiving Medicare or Medicaid funds to be vaccinated. The “Path Out of the lasix” also called on businesses with 100 or more employees to ensure generic lasix for dogs that their employees are either vaccinated or being tested. Using businesses as a place to get vaccinations could overcome some treatment hesitancy in rural areas, said Jeanne Bonds, professor at the University of North Carolina Kenan-Flagler Business School. Bonds’ research focuses on West Virginia, South Carolina and North Carolina.

€œOne of the bigger challenges is that in (rural) areas … generic lasix for dogs they don’t have coordinated transportation systems that you really have to have to get the treatment out to the people,” Bonds said. €œSo I think one of the advantages to requiring it at the workplace, if it’s a business with 100 [employees] or more, is that it probably opens up the option for actually delivering the treatments out to those places where inconvenience is an issue.” Those vaccination clinics also allow trusted voices in rural areas, like pharmacists and family doctors, to talk with workers about the treatment. Getting out the right message via the right messenger is important, Bonds said. €œIt’s a great opportunity for (workers) to have trusted messengers deliver the message about the generic lasix for dogs treatments,” she said. €œWe talked to people all over the state (North Carolina).

Community leaders as well as just generic lasix for dogs low-income households, and one of the pieces that jumps out is that people just don’t trust the messenger — they don’t naturally trust the government. They trust their local pharmacist. I think it’s an opportunity for those businesses to bring treatments on site and also bring that message on site and increase the vaccination rate.” For example, at Tyson Foods, providing vaccination clinics onsite has increased the number of workers with at least one dose of the treatment, a spokesman with Tyson said in an email interview. In early generic lasix for dogs August, the company decided to vaccinate its workforce and combined incentives for workers to get the shots with education and information. Like this story?.

Sign up for our newsletter. “Like many other businesses, generic lasix for dogs we are taking steps to protect all of these things by requiring all U.S. Team members to be fully vaccinated,” Tyson President and CEO Donnie King said in an August blog post. €œWe did not take generic lasix for dogs this decision lightly. We have spent months encouraging our team members to get vaccinated – today, under half of our team members are.

We take this step today because nothing is more important than our team members’ health and safety, and we thank them for the work they do, every day, to help us feed this country, and our world.” Tyson frontline employees have until November 1 to get vaccinated, and all new employees must show proof of vaccination prior to starting with the company. €œWe believe that getting vaccinated is the single most effective thing our team members can do to protect themselves, their families, and the communities where we generic lasix for dogs operate,” the spokesman said. €œWe continue to provide our U.S. Workers with free, on-site access to hypertension medications vaccinations.” Tyson is providing a $200 “thank you gift” to fully vaccinated frontline workers and is running sweepstakes worth $6 million to incentivize vaccinations. “We’re also conducting an extensive outreach campaign to educate and generic lasix for dogs inform team members about the hypertension medications vaccinations.

These efforts include one on one conversations with team members to answer questions and address concerns.” As a result, the company has approximately 100,000 vaccinated workers – more than 80% of its U.S. Workforce. Since the initiative started in August, more than 45,000 workers have been vaccinated. Increasing vaccinations is important, not just in ensuring people don’t get sick, but also in helping rural communities begin their economic recovery. According to the Brookings Institution, areas with low vaccination rates will continue to struggle as hypertension medications keeps workers, shoppers and children at home.

€œThe treatment divide (between counties that are vaccinated and counties that are not)… will likely exacerbate the other economic divides that are already weakening the nation,” the report said. The more unvaccinated communities continue to resist safety precautions and vaccinations, the institute found, the more their economies could fall further behind faster-recovering communities with higher vaccination rates. In some areas with low vaccination rates, UNC’s Bonds said, the communities are dying. Low vaccination rates mean more sick people who put more pressure on rural healthcare systems, she said. More sick people also means higher rates of death.

In some cases, rural counties are seeing more deaths than there are births leading to the counties slowly dying off. The most recent Daily Yonder analysis found that the rural hypertension medications death rate is twice that of urban areas. About 40% of the total rural population has completed a hypertension medications vaccination, while about 52% of the urban population has. Low vaccination rates also mean fewer people to work and shop, which means less money circulating through a community and fewer tax dollars supporting it. Increasing the vaccination rates could turn things around in some rural areas, Bonds said.

€œWe have these different tiers of counties,” she said. €œWe have the ones that are in really dramatically bad shape, which are going to take a lot of effort to bring back. We have some that are kind of teetering on the edge, which I do think they can come back if they can attract people to come there.” But in some counties, economic issues like lack of affordable housing, lack of childcare and lack of capital to invest in the area will continue to be a problem, no matter what the vaccination rate is, she said. €œDepending on the county, bringing the vaccination rate up won’t necessarily turn them around,” she said. €œIt would have to be that combined with some other issues.” You Might Also LikeIn July, well before the hypertension medications treatments were approved by the U.S.

Food and Drug Administration, a group of medical professionals at St. Claire Regional Medical Center in Morehead, Kentucky, voted to mandate hospital employees take the treatment or be terminated. By the September 15 deadline, the healthcare system had terminated 24 of its 1,200 employees, including six nurses, Don Lloyd, St. Claire’s president and CEO, said. While some medical exemptions were granted, the healthcare system held firm on its decision to mandate treatments for its employees.

€œWe tried to accommodate those special needs and requests, but I’m proud to tell you right now that 100% of our employees and medical staff are fully vaccinated,” Lloyd said. €œDoes it hurt?. Yes. Did we want to lose any of our employees?. No.

But our clinical leadership really feels strongly that we have an obligation to provide a safe environment and so that was the position we took and we’re glad we did.” The healthcare system has been able to fill most of those positions, he said. But some rural hospital administrators worry that a new treatment mandate for healthcare workers could mean fewer staff members. While most administrators agree that vaccinations are an important step in protecting patients, employees, and other community members, some fear that treatment mandates could result in staff members quitting rather than getting the shot, leaving hospitals with fewer staff. On September 9, President Joe Biden announced a series of treatment mandates, including one that required all hospitals receiving Medicare or Medicaid funds to have their employees vaccinated. The mandate would affect more than 17 million healthcare workers, the White House said, and would create a consistent nationwide standard to “alleviate patient concerns” over whether or not healthcare providers were vaccinated.

With the mandate in place, hospitals should be focusing on how to fill staff openings if they occur, said one rural health advocate. €œInstead of being wrapped around the axle of should we mandate or should we not mandate, the question we should be asking is if we’re going to mandate, how are we going to ensure rural hospitals continue to have adequate staffing,” said Alan Morgan, CEO of the National Rural Health Association (NRHA). Rural hospitals are already understaffed, Morgan said, and recent surges in hypertension medications patients are putting more strain on limited resources. NRHA members are worried, he said, about having a sufficient workforce to meet the current needs if workers quit over treatments. What’s missing, he said, is a plan to address staffing issues once mandates are put into place.

€œThere will be service disruptions, and there are multiple measures available to respond to them, but it appears that no one has taken the time to think this through yet at the federal level,” he said. Like this story?. Sign up for our newsletter. Throughout the lasix, he said, federal and state officials have used several measures – from deploying FEMA disaster teams or National Guard members, to utilizing nursing or medical school students as clinical help, to using provider relief funds on traveling nurses. €œI’m sure there are other measures available here, but these need to be communicated so that hospitals and clinics can proceed with implementing treatment mandates with confidence that patient care will not be compromised, and the delivery of care can continue,” he said.

Already, the treatment mandates are having an impact on hospital staffing in some areas of the country. In North Carolina, two hospital systems have seen resignations because of treatment requirements. At Novant Health in Winston-Salem, North Carolina, 375, or about 1%, of its more than 35,000 employees were placed on suspension for not complying with a treatment mandate, the hospital system said in a press release. At UNC Health in Chapel Hill, North Carolina, 60 of its 30,000 employees — about 0.2% of the workforce — had resigned from their jobs, citing the healthcare system’s vaccination requirement. UNC Health announced in July that it would require its employees to get vaccinated by September 21.

However, on September 20, the healthcare system pushed the deadline back to November 2. An estimated 95% of its employees have been vaccinated or granted exemptions, the system said, but it is still working to confirm the status of about 1,100 employees. At Yale New Haven Health, in New Haven, Connecticut, about 700 of its 30,000 employees are unvaccinated and could face termination if they do not comply with the hospital’s treatment mandate by Oct. 1. Marna Borgstrom, the system’s CEO, told the Register Citizen that if people were going to resign it would likely be at the end of September, but that she expected that most of the unvaccinated would get the treatment.

€œWe’ve done everything possible in my opinion to do this the right way and as humanely as possible, not only for our patients and their loved ones but also for our valued colleagues, and I think the number of people who end up exiting the organization is going to be relatively small,” Borgstrom told the Citizen. In Rhode Island, Governor Dan McKee and the Rhode Island Department of Health (RIDOH) announced the state would enact a new treatment enforcement strategy for healthcare workers who aren’t vaccinated to prevent disruptions to care. Healthcare workers in that state who aren’t vaccinated by October 1 will be given 30 days to come into compliance, during which time the employer can find a fully vaccinated replacement for that position. Healthcare facilities will be required to outline their plan to get workers into compliance while demonstrating that any unvaccinated staff member still working after October 1 is doing so to assure quality of care. About 87% of the state’s 57,600 healthcare workers have been vaccinated, the health department reported.

But for some rural hospitals, losing even a fraction of those numbers of workers would be devastating, NRHA’s Morgan said. €œFor larger systems, losing 24 employees may not be a struggle,” he said. €œBut for smaller hospitals that could amount to 5 to 10% of their staff which would be devastating.” Morgan said the organization has reached out to the White House to see if there is a plan to help rural hospitals with staffing, but as of September 21 it had not responded.To combat treatment hesitancy, the NRHA launched the Rural treatment Confidence Initiative on September 21 that provides rural hospitals with action items and talking points that are rural specific and promote treatment confidence to healthcare workers and rural community members. You Might Also Like.

Using larger businesses as sites for get lasix prescription rural vaccination clinics could help decrease treatment hesitancy and contribute to economic turnarounds in https://kompatech.de/how-to-get-prescribed-kamagra/ those areas, experts say. On September 9, President Joe Biden issued sweeping treatment mandates calling for federal employees, federal contractors and healthcare workers at facilities receiving Medicare or Medicaid funds to be vaccinated. The “Path Out of the lasix” also called on businesses get lasix prescription with 100 or more employees to ensure that their employees are either vaccinated or being tested.

Using businesses as a place to get vaccinations could overcome some treatment hesitancy in rural areas, said Jeanne Bonds, professor at the University of North Carolina Kenan-Flagler Business School. Bonds’ research focuses on West Virginia, South Carolina and North Carolina. €œOne of the bigger challenges is that in (rural) areas … they don’t have coordinated transportation systems that you really have to have to get the treatment out to the people,” Bonds get lasix prescription said.

€œSo I think one of the advantages to requiring it at the workplace, if it’s a business with 100 [employees] or more, is that it probably opens up the option for actually delivering the treatments out to those places where inconvenience is an issue.” Those vaccination clinics also allow trusted voices in rural areas, like pharmacists and family doctors, to talk with workers about the treatment. Getting out the right message via the right messenger is important, Bonds said. €œIt’s a great opportunity for (workers) to have trusted messengers deliver the message get lasix prescription about the treatments,” she said.

€œWe talked to people all over the state (North Carolina). Community leaders as well as just low-income households, and get lasix prescription one of the pieces that jumps out is that people just don’t trust the messenger — they don’t naturally trust the government. They trust their local pharmacist.

I think it’s an opportunity for those businesses to bring treatments on site and also bring that message on site and increase the vaccination rate.” For example, at Tyson Foods, providing vaccination clinics onsite has increased the number of workers with at least one dose of the treatment, a spokesman with Tyson said in an email interview. In early August, the company decided to vaccinate its workforce and combined incentives for workers get lasix prescription to get the shots with education and information. Like this story?.

Sign up for our newsletter. “Like get lasix prescription many other businesses, we are taking steps to protect all of these things by requiring all U.S. Team members to be fully vaccinated,” Tyson President and CEO Donnie King said in an August blog post.

€œWe did not take get lasix prescription this decision lightly. We have spent months encouraging our team members to get vaccinated – today, under half of our team members are. We take this step today because nothing is more important than our team members’ health and safety, and we thank them for the work they do, every day, to help us feed this country, and our world.” Tyson frontline employees have until November 1 to get vaccinated, and all new employees must show proof of vaccination prior to starting with the company.

€œWe believe that getting vaccinated is the single most effective thing our team members can do to protect get lasix prescription themselves, their families, and the communities where we operate,” the spokesman said. €œWe continue to provide our U.S. Workers with free, on-site access to hypertension medications vaccinations.” Tyson is providing a $200 “thank you gift” to fully vaccinated frontline workers and is running sweepstakes worth $6 million to incentivize vaccinations.

“We’re also conducting an extensive outreach campaign to educate and inform team members about the hypertension medications get lasix prescription vaccinations. These efforts include one on one conversations with team members to answer questions and address concerns.” As a result, the company has approximately 100,000 vaccinated workers – more than 80% of its U.S. Workforce.

Since the initiative started in August, more than 45,000 workers have been vaccinated. Increasing vaccinations is important, not just in ensuring people don’t get sick, but also in helping rural communities begin their economic recovery. According to the Brookings Institution, areas with low vaccination rates will continue to struggle as hypertension medications keeps workers, shoppers and children at home.

€œThe treatment divide (between counties that are vaccinated and counties that are not)… will likely exacerbate the other economic divides that are already weakening the nation,” the report said. The more unvaccinated communities continue to resist safety precautions and vaccinations, the institute found, the more their economies could fall further behind faster-recovering communities with higher vaccination rates. In some areas with low vaccination rates, UNC’s Bonds said, the communities are dying.

Low vaccination rates mean more sick people who put more pressure on rural healthcare systems, she said. More sick people also means higher rates of death. In some cases, rural counties are seeing more deaths than there are births leading to the counties slowly dying off.

The most recent Daily Yonder analysis found that the rural hypertension medications death rate is twice that of urban areas. About 40% of the total rural population has completed a hypertension medications vaccination, while about 52% of the urban population has. Low vaccination rates also mean fewer people to work and shop, which means less money circulating through a community and fewer tax dollars supporting it.

Increasing the vaccination rates could turn things around in some rural areas, Bonds said. €œWe have these different tiers of counties,” she said. €œWe have the ones that are in really dramatically bad shape, which are going to take a lot of effort to bring back.

We have some that are kind of teetering on the edge, which I do think they can come back if they can attract people to come there.” But in some counties, economic issues like lack of affordable housing, lack of childcare and lack of capital to invest in the area will continue to be a problem, no matter what the vaccination rate is, she said. €œDepending on the county, bringing the vaccination rate up won’t necessarily turn them around,” she said. €œIt would have to be that combined with some other issues.” You Might Also LikeIn July, well before the hypertension medications treatments were approved by the U.S.

Food and Drug Administration, a group of medical professionals at St. Claire Regional Medical Center in Morehead, Kentucky, voted to mandate hospital employees take the treatment or be terminated. By the September 15 deadline, the healthcare system had terminated 24 of its 1,200 employees, including six nurses, Don Lloyd, St.

Claire’s president and CEO, said. While some medical exemptions were granted, the healthcare system held firm on its decision to mandate treatments for its employees. €œWe tried to accommodate those special needs and requests, but I’m proud to tell you right now that 100% of our employees and medical staff are fully vaccinated,” Lloyd said.

€œDoes it hurt?. Yes. Did we want to lose any of our employees?.

No. But our clinical leadership really feels strongly that we have an obligation to provide a safe environment and so that was the position we took and we’re glad we did.” The healthcare system has been able to fill most of those positions, he said. But some rural hospital administrators worry that a new treatment mandate for healthcare workers could mean fewer staff members.

While most administrators agree that vaccinations are an important step in protecting patients, employees, and other community members, some fear that treatment mandates could result in staff members quitting rather than getting the shot, leaving hospitals with fewer staff. On September 9, President Joe Biden announced a series of treatment mandates, including one that required all hospitals receiving Medicare or Medicaid funds to have their employees vaccinated. The mandate would affect more than 17 million healthcare workers, the White House said, and would create a consistent nationwide standard to “alleviate patient concerns” over whether or not healthcare providers were vaccinated.

With the mandate in place, hospitals should be focusing on how to fill staff openings if they occur, said one rural health advocate. €œInstead of being wrapped around the axle of should we mandate or should we not mandate, the question we should be asking is if we’re going to mandate, how are we going to ensure rural hospitals continue to have adequate staffing,” said Alan Morgan, CEO of the National Rural Health Association (NRHA). Rural hospitals are already understaffed, Morgan said, and recent surges in hypertension medications patients are putting more strain on limited resources.

NRHA members are worried, he said, about having a sufficient workforce to meet the current needs if workers quit over treatments. What’s missing, he said, is a plan to address staffing issues once mandates are put into place. €œThere will be service disruptions, and there are multiple measures available to respond to them, but it appears that no one has taken the time to think this through yet at the federal level,” he said.

Like this story?. Sign up for our newsletter. Throughout the lasix, he said, federal and state officials have used several measures – from deploying FEMA disaster teams or National Guard members, to utilizing nursing or medical school students as clinical help, to using provider relief funds on traveling nurses.

€œI’m sure there are other measures available here, but these need to be communicated so that hospitals and clinics can proceed with implementing treatment mandates with confidence that patient care will not be compromised, and the delivery of care can continue,” he said. Already, the treatment mandates are having an impact on hospital staffing in some areas of the country. In North Carolina, two hospital systems have seen resignations because of treatment requirements.

At Novant Health in Winston-Salem, North Carolina, 375, or about 1%, of its more than 35,000 employees were placed on suspension for not complying with a treatment mandate, the hospital system said in a press release. At UNC Health in Chapel Hill, North Carolina, 60 of its 30,000 employees — about 0.2% of the workforce — had resigned from their jobs, citing the healthcare system’s vaccination requirement. UNC Health announced in July that it would require its employees to get vaccinated by September 21.

However, on September 20, the healthcare system pushed the deadline back to November 2. An estimated 95% of its employees have been vaccinated or granted exemptions, the system said, but it is still working to confirm the status of about 1,100 employees. At Yale New Haven Health, in New Haven, Connecticut, about 700 of its 30,000 employees are unvaccinated and could face termination if they do not comply with the hospital’s treatment mandate by Oct.

1. Marna Borgstrom, the system’s CEO, told the Register Citizen that if people were going to resign it would likely be at the end of September, but that she expected that most of the unvaccinated would get the treatment. €œWe’ve done everything possible in my opinion to do this the right way and as humanely as possible, not only for our patients and their loved ones but also for our valued colleagues, and I think the number of people who end up exiting the organization is going to be relatively small,” Borgstrom told the Citizen.

In Rhode Island, Governor Dan McKee and the Rhode Island Department of Health (RIDOH) announced the state would enact a new treatment enforcement strategy for healthcare workers who aren’t vaccinated to prevent disruptions to care. Healthcare workers in that state who aren’t vaccinated by October 1 will be given 30 days to come into compliance, during which time the employer can find a fully vaccinated replacement for that position. Healthcare facilities will be required to outline their plan to get workers into compliance while demonstrating that any unvaccinated staff member still working after October 1 is doing so to assure quality of care.

About 87% of the state’s 57,600 healthcare workers have been vaccinated, the health department reported. But for some rural hospitals, losing even a fraction of those numbers of workers would be devastating, NRHA’s Morgan said. €œFor larger systems, losing 24 employees may not be a struggle,” he said.

€œBut for smaller hospitals that could amount to 5 to 10% of their staff which would be devastating.” Morgan said the organization has reached out to the White House to see if there is a plan to help rural hospitals with staffing, but as of September 21 it had not responded.To combat treatment hesitancy, the NRHA launched the Rural treatment Confidence Initiative on September 21 that provides rural hospitals with action items and talking points that are rural specific and promote treatment confidence to healthcare workers and rural community members. You Might Also Like.

Is furosemide and lasix the same thing

With summer in full swing, many people web link are kicking off their shoes — and it’s not just happening is furosemide and lasix the same thing at the beach or in the park. Walking or running barefoot has gained popularity over the past decade, as have minimalist shoes designed to imitate the feel of going barefoot.Claims abound that ditching shoes can improve strength and balance, resolve hip, back or knee ailments, and prevent painful foot deformities like bunions or fallen arches. But is barefoot actually better or is is furosemide and lasix the same thing it just a fad?. Like all other animals, humans evolved to walk without shoes. Then, as our ancestors strode across the savannas in search of food and shelter, they eventually figured out how to protect their feet from extreme is furosemide and lasix the same thing temperatures and sharp objects.

Wrap them in animal hides. These early versions of shoes likely enabled our species to travel farther, faster, and more safely.The oldest shoes discovered date back to is furosemide and lasix the same thing 8,000 years ago. However, fossil evidence indicates that our species probably began wearing sandals or moccasins over 40,000 years ago. Cushioned shoes, however, only came on the scene about 300 years ago. Some studies show that these padded soles have is furosemide and lasix the same thing shifted the foot’s form and function.Human feet are complicated and sophisticated machines, containing almost one-quarter of all bones in the body.

Each foot has 200,000 nerve endings, 26 bones, 30 joints, and more than 100 muscles, tendons and ligaments, all of which work together seamlessly as we move around. So it stands to reason that covering those many intricate parts with a shoe will change how we move.In his 2009 bestseller Born To Run Christopher McDougall is furosemide and lasix the same thing championed the now-popular idea that modern, cushioned shoes are the cause of many muscular-skeletal injuries — at least for runners. McDougall studied the Tarahumara tribe in Mexico, whose members often run over 100 miles up and down stony trails in nothing but thin, homemade sandals. He ditched his padded sneakers, curing his own running-related injuries and spawning a movement to go back to barefoot basics.A 2010 study showed that barefoot runners do is furosemide and lasix the same thing put less stress on their feet. They take shorter strides, and strike with the middle of their foot first while curling their toes more.

This spreads out the force more evenly across the foot.Wearing a cushioned shoe with a heightened heel, on the other hand, enables runners to take is furosemide and lasix the same thing longer strides and strike the ground heel-first. Landing on the heel generates up to three times more force than landing on the forefoot, sending shock waves up the skeletal system.Shoes seem to change the way we walk, too. Barefoot walkers take shorter strides and step more lightly — mostly to test whether there’s something painful beneath the foot before it takes the body’s full weight.Some research shows that modern shoes have changed humans’ foot shape over time. For example, people in India who is furosemide and lasix the same thing are habitually barefoot have wider feet than Westerners, whose more slender, shorter feet gave less ability to spread out the pressure of impact.Shoes can also interfere with neural messages set from our feet to our brain about the ground beneath us. Researchers from Harvard recently studied 100 adults, mostly from Kenya, to see whether calluses act similarly to shoes in terms of dulling the signaling between foot and brain.Calluses are the evolutionary solution for thorns or stones.

The skin on our feet is thicker than almost anywhere else is furosemide and lasix the same thing on the body. Study subjects who walked barefoot most of the time had more calluses than their shod peers, which protected their feet but still allowed better tactile stimulation than shoes. Researchers also found that uncushioned, minimal shoes functioned more similarly to walking on callused bare feet than to wearing cushioned shoes.But the jury is still out on whether going shoeless translates to is furosemide and lasix the same thing better overall outcomes for the body.A literature review from 2017 evaluated the long-term effects of habitually walking or running barefoot, and found no difference in relative injury rates compared to shoe-wearing folks. However, walking or running barefoot did appear to result in less foot deformities.As for children, a study released this year found no statistical differences in the gait or force exerted by 75 children, aged 3 to 9 years old, who walked both barefoot and in shoes across the same ground. A different is furosemide and lasix the same thing study published in 2017 found that “evidence is small" for barefoot locomotion’s long-term effects on foot characteristics.

In fact, after comparing the foot morphology of 810 children and adolescents who were habitually shod versus habitually barefoot, they concluded that “permanent footwear use may play an important role in childhood foot development and might actually be beneficial for the development of the foot arch.”Minimalist shoes that give a barefoot feel but protective covering might just be the wave of the future — or, rather, a return to our prehistoric roots. A 2020 study evaluated the gait of 64 adults and found they had better gait performance walking with minimalist shoes than walking barefoot.It seems our ancestors were on to something when they began wrapping their feet in leather millennia ago. While letting your feet roam naked occasionally certainly isn’t a bad idea, is furosemide and lasix the same thing most of us probably shouldn’t toss our shoes in the trash any time soon.This article contains affiliate links to products. We may receive a commission for purchases made through these links.When it comes to finding the best CBD gummies for sleep, you have a lot of choices. The problem is that they aren’t necessarily all made with your wellness in mind.Even though CBD-lovers everywhere are more educated about CBD than they were when the market first took off, there are still plenty of misconceptions and misinformation driving an inconsistent industry.On one end, you have CBD companies dedicated is furosemide and lasix the same thing to creating the safest, purest, best CBD products on the market.

On the other, companies just out to make a quick buck with no concern for the customer or the environment.We have put together a list to make it easier to find the kind of CBD gummies that promote a great night’s sleep with only the finest ingredients and highest standards. The brands listed here make some of the best is furosemide and lasix the same thing CBD gummies for sleep that you can find on the market today.1. Verma Farms CBD GummiesHere’s the thing with CBD gummies. They don’t is furosemide and lasix the same thing always taste very good. Gummy candies are already difficult enough to get right as far as texture and flavor are concerned, but then add the pungent taste of most CBD products and you have a whole new challenge.Verma Farms, however, has perfected the CBD gummy hands-down.They come in a variety of juicy, Hawaiian-inspired flavors, a couple of different textures, and there are even sugar-free gummies for people with dietary restrictions.Choose between sweet and sour sugar-coated fruit rings with flavors like Blueberry Wave and Peachy Pau Hana.

Or go with a classic gummy bear texture and mixed fruit flavors. The choice is yours, and you can pick between a potent concentration of 25 mg per gummy, or something milder at 12.5 mg per gummy.Verma Farms CBD is extracted from naturally and sustainably grown is furosemide and lasix the same thing hemp. The CO2 method of extraction is clean and easy on the environment, and it leads to some of the best, purest finished products you can find.Made with the purest CBD you will ever find, Verma Farms gummies are 100 percent free of THC.2. Penguin CBD GummiesPenguin CBD’s mascot (a penguin, in case you couldn’t guess) is a textbook example of how CBD is supposed is furosemide and lasix the same thing to help you feel. Ready to deal with life’s ups and downs, all the while keeping calm and waddling on.Penguins are super chill, and that’s how you should feel when you incorporate Penguin CBD’s sweet and sour little gummies into your daily or bedtime routine.Penguin CBD’s gummies come in just one flavor, but it’s a classic.

They are coated in a sweet and is furosemide and lasix the same thing sour sugar, bright and cheerful like the jar they come in. Each gummy is tender, tangy, and tastes incredible.Because they are made with a CBD isolate, much of the pungent “earthy” flavor typical of hemp products is eliminated. What’s left is delicious, fruit-flavored gummies that pack 10 mg of CBD in each serving—perfect for snacking!. They’re also one of is furosemide and lasix the same thing the highest rated CBD gummies on the market now. Just take a look at what sources such as Cannabis Culture and Merry Jane have said about them in their reviews.3.

Medterra Sleep Tight GummiesMedterra’s products are all made based on the latest scientific research, and their philosophy is that outstanding CBD does not have to drain your wallet.Many companies claim that their products are more expensive because they use naturally and domestically grown hemp, or that they employ extensive third-party testing to confirm their purity and potency.However, Medterra has managed to give you all the quality and assurance while keeping down the cost to you.The Sleep Tight Gummies are made with 25 is furosemide and lasix the same thing mg of broad-spectrum CBD, with melatonin and additional botanicals like lemon balm and chamomile thrown in to support the best sleep you can get.They are vegan, flavored with strawberry extract (so no corn syrup or artificial flavors or colors), and the package they come in was made with 20 percent post-consumer recycled products. Great-tasting, healthy for you, and easy on the environment as well as your bank account. That’s the kind of gummy is furosemide and lasix the same thing anyone can get behind.4. Leaf RemedysLeaf Remedys Gummies are infused with Full Spectrum oil extracted from extremely high quality organically grown Colorado hemp. With 50mg of CBD each, Leaf is furosemide and lasix the same thing Remedys Gummies are one of the strongest on the market and are very reasonably priced at $49.99 for a 30 Pack a total of 1500mg.

These gummies will help you drift off to sleep, without the groggy nest morning. Although very potent, the texture and flavor are not compromised at all. They feel and taste is furosemide and lasix the same thing exactly like a Gummy should taste, but with a potent CBD twist to them. They come in 3 delicious flavors (blue Raspberry, Strawberry, and Lime) and are only 8 calories each. Leaf Remedys is a brand dedicated is furosemide and lasix the same thing to the cause and proud to offer an all-American product at a very fair price.

They offer free shipping within the united states. 20% with discount is furosemide and lasix the same thing code. DM205. Sunday ScariesSunday Scaries is a is furosemide and lasix the same thing CBD company with a sense of humor. With the brand name referring to those anxious feelings you get when you aren’t looking forward to Monday, these gummies aim to take it all away and make you smile in the moment.Sunday Scaries’ regular CBD gummies are a cool take on the classic original gummy bears.

Fruit-flavored and made with 10 mg of CBD each, they are free of THC and a perfect snack any time, day or night. Choose between the standard recipe and the Vegan AF recipe.One of the great things about the Sunday Scaries brand is their unique gummies meant to celebrate their community and their chosen causes.Their Rainbow Jerky contains 10 mg of CBD as well, but comes in bite-sized rainbow-colored is furosemide and lasix the same thing pieces that are coated in sweet and sour sugar. The best thing about these is that $1 from every purchase goes to The Trevor Project, an organization with a mission of preventing suicide among LGBTQ+ youth.You can also choose for your purchase to go toward helping to fund breast cancer research. For every order you is furosemide and lasix the same thing place of the latest addition, Bra Berries (strawberry-flavored CBD gummies with vitamin C infused), Sunday Scaries will donate $2 to The Pink Agenda.6. R+R MedicinalsR+R Medicinals is the brand that finally makes the CBD gummy right - with their 25mg Full-Spectrum Gummies, you can really feel the difference.

Vegan, sugar coated, no artificial flavors or colors, and simple ingredients make this gummy is furosemide and lasix the same thing option a clear winner compared to other gummies on the market. Each gummy is packed with 25mg of Full-Spectrum CBD and other minor cannabinoids from their CO2 extracted, USDA Certified Organic, proprietary Cherry strain of hemp. R+R partnered with a local candy manufacturer to create these is furosemide and lasix the same thing one-of-a-kind gummies. Unlike most other ‘sprayed’ gummies, they truly infuse their CBD into the formula and ensure the hemp flavor doesn’t overpower the deliciousness of each piece. Each jar has 30 gummies at 25mg each - 750mg total for the jar, with a mix of peach, strawberry, and green apple flavors.

This is is furosemide and lasix the same thing an outstanding bang for your buck for a Full-Spectrum product at only $46.99. Full-battery certificates of analysis are available for each batch on their website along with a 30-Day Risk Free Trial. New customers can use the code "RRWORKS20" for is furosemide and lasix the same thing 20% off their first order!. 7. Evn CBD GummiesEvn CBD understands that, while CBD oil is the most direct route to hemp-based wellness, CBD gummies are a lot tastier and more fun.Evn uses 100 percent THC-free CBD extracted from organically grown hemp plants, to ensure that professionals and athletes can get their daily dose in worry-free.Pop them into your gym bag or your briefcase and enjoy them as a discreet snack any time you’re feeling the strain throughout the day.When you want to get a great night’s sleep, take 1-3 of these 10 mg CBD gummies and feel yourself start to relax.Choose between a classic sweet gummy bear flavor, gummies with a sour is furosemide and lasix the same thing punch, or order a package of both.

After all, variety is the spice of life!. 8. Charlotte’s Web Sleep CBD GummiesWhile full-spectrum CBD gummies have a more pungent flavor than their CBD isolate counterparts, there are some benefits to getting a gummy made with a more robust formula.Charlotte’s Web CBD gummies are made with the full-spectrum CBD that made the brand famous. They include a potent combination of additional cannabinoids like CBC, CBG, and CBN, and are made with some of the best hemp grown in the United States.One thing that may make the sleep CBD gummies a little more palatable is the fact that the CBD used to make them is CO2 extracted. The flavor is milder than it is in the oil made with an ethanol extraction, and you may find you appreciate the way they taste.These CBD gummies are infused with 3 mg of melatonin in addition to their 10 mg of CBD.

They are flavored with natural flavorings and contain no artificial colors.We like that you can choose different sizes. Go with a 30-count jar if you are just giving them a try. Or if you know what you are looking for, order the 90-count jar to take you through a couple of months.9. ElixinolElixinol has been involved in the hemp industry since before it was an industry in the US. For 25 years, the company has been doing research, educating the public, and perfecting the products it offers.The brand is a partner of the Realm of Caring, which is an organization dedicated to advocacy, research, and education, for individuals with conditions that can be improved with the use of CBD and cannabis products.These CBD gummies may have a strong, bitter aftertaste because they are made with full-spectrum CBD, but they are vegan, cruelty-free, and naturally flavored.Choose between mixed berry, passionfruit, or pineapple flavors, or order an assortment of flavors if you’re having trouble picking just one.When you are just getting started and you aren’t sure which kinds of gummies are right for you, you can try a 4-pack of any of the flavors you want.

Otherwise, go for a jar of 30 to get quality sleep all through the month.10. Bluebird BotanicalsAnother great company with a conscience, Bluebird Botanicals puts its heart and soul into every batch of CBD it makes.The CBD gummies are no exception. Made with 15 mg of full-spectrum hemp extract each, these gummies are sweetened with pure organic cane sugar. They contain no artificial flavors or colors.Bluebird Botanicals is on a mission to make CBD radically accessible to everyone, through education, support and advocacy.The company is a certified B Corporation, meaning that it lives up to its reputation of care and concern for its customers, its employees, its community, and the environment.11. Joy OrganicsJoy Organics has quickly made a name for itself in the CBD industry because of its careful attention to quality, its consistent products, and its focus in putting the customer first.Joy Organics is one of the few CBD companies out there that you can just call anytime you have a question.

Service agents genuinely care about the consumer, and it is evident in the fact that they work until your questions are answered and you are satisfied. The CBD gummies from Joy Organics are flavored naturally, and they come in green apple and strawberry lemonade.They are made with 10 mg of THC-free broad-spectrum CBD each, and customers give their flavor rave reviews. All Joy Organics products come with a 30-day money back guarantee, and you are encouraged to try the whole product before requesting a refund.Bonus. Infinite CBD GummiesInfinite CBD makes a variety of CBD-infused gummies, and you are certain to find something you absolutely love from this creative company.We think it’s a blast that all of its products are outer-space themed, and the asteroid gummies are out of this world.Choose between classic-flavored or sour CBD asteroids made with CBD isolate for a milder flavor, broad-spectrum CBD gummies for a THC-free entourage effect, or the seasonal flavor, warm apple pie.This article contains affiliate links to products. Discover may receive a commission for purchases made through these links.Our liver plays a major role in supporting our overall health, including helping with the metabolic process, digestion, and proper blood circulation, as well as cleansing the body of harmful toxins.

However, most people damage their livers without even knowing it, with things like drinking too much alcohol, eating processed or fried foods, or even being just a little overweight. That’s why many people have been turning to natural liver health supplements. A good quality liver supplement is an effective solution to help repair liver damage and optimize liver functioning. Ranking the Best Liver Health Supplements On The Market We reviewed the top brands and found the best 5 liver supplements on the market today. See our full list below.

1MD LiverMD Live Conscious LiverWell Gaia Herbs Liver Cleanse 1. 1MD LiverMD LiverMD delivers 6 powerful, clinically studied ingredients in one groundbreaking, exclusive 1MD formula to help purify and optimize liver function for better energy, metabolism, and overall health. This doctor-formulated liver support stands out because it includes EvnolMax, which is a clinical strength tocotrienol, and Siliphos, the bioavailable active ingredient in milk thistle. LiverMD is also made with zinc, selenium, and other ingredients that work to help detox and repair your liver. Additionally, 1MD offers a 90-day, risk-free, money-back guarantee, proving the company stands behind its products.

BUY HERE 2. Live Conscious LiverWell LiverWell’s formula combines optimal liver health ingredients, including clinically studied milk thistle, NAC, and alpha lipoic acid to name a few. Their product is shown to aid liver function, metabolism, and whole-body detoxification. LiverWell is best for those who need to reduce the effects of environmental toxins and struggle with metabolic issues. LiverWell’s use of powerful antioxidants has also been shown to reduce and repair damage done to liver and kidney health from free radicals in the body.

Beyond that, LiveWell offers a comprehensive 365-day return policy, so everyone can try their products completely risk-free. BUY HERE 3. Gaia Herbs Liver Cleanse Liver Cleanse’s unique proprietary blend covers a vast range of liver supporting nutrients that are all-natural and entirely herbal. While it does contain milk thistle, it lacks several key ingredients, such as zinc, selenium, or any form of Vitamin E. This limits its ability to support your liver health.

The transparent labeling showcases all the ingredients included in its proprietary formula. Gaia Herbs takes a simple approach to producing a good quality liver support supplement for a low price range.Ask any nutritionist and they'll tell you that our health is a reflection of the lifestyle we lead and what we put on our plates. The food we eat not only satisfies our hunger. It also fuels our bodies with energy to carry on. In today’s fast-paced life, there's limited time to make elaborate home-cooked meals.

It's no wonder that 80 percent of Americans' total calorie consumption is thought to come from how to get prescribed lasix store-bought foods and beverages. Many of these food items are considered ua-processed, causing a growing rate of concern for human health among scientists.Breaking Down Ua-Processed FoodsYou may be wondering what exactly ua-processed foods are. The concept of processing refers to changing food from its natural state, according to Harvard Health Publishing. Methods of accomplishing this include canning, smoking, pasteurizing and drying. Ua-processed foods take processing one step further by adding multiple ingredients such as sugar, preservatives and artificial flavors and colors.

Commercially prepared cookies, chips and sodas are just a few of many examples of foods that fall into the highly processed category. In order to further understand ua-processed foods, we must first explore the different levels of food processing. The term ua-processed was first coined by Carlos Monteiro, a professor of nutrition and public health at the University of Sao Paulo, Brazil. Monteiro also created a food classification system called NOVA that has become a popular tool in categorizing different food items. The NOVA Food Classification system contains four different groups:Unprocessed/Minimally Processed Foods.

Think 100 percent natural and healthy. This group includes foods such as fruits, vegetables, eggs, meats and milk. Unprocessed foods are considered completely natural and are typically obtained directly from plants and animals. Minimally processed foods are also natural foods that have had very minor changes such as removal of inedible parts, fermentation, cooling, freezing, and any other processes that won't add extra ingredients or substances to the original product.Processed Culinary Ingredients. This group has everything to do with flavor and typically contains ingredients such as fats and aromatic herbs that are extracted from natural foods.

These ingredients are then used in homes and restaurants to season and cook items such as soups, salads and sweets. Many of these extracted ingredients can also be stored for later use. Processed Foods. Most processed foods contain at least two or three added ingredients such as salt, sugar and oil. Think of this group as a combination of the first two groups.

In other words, processed culinary ingredients or flavors that are added to natural foods. Examples include fruits in sugar syrup, bacon, beef jerky and salted nuts. Ua-Processed Foods. Last and least healthy on the NOVA scale are ua-processed foods. This group is considered highly processed due to a large amount of added ingredients.

Nova typically classifies this group as industrial formulations made entirely or mostly from substances such as oils, fats, sugar, starch and proteins as well as flavor enhancers and artificial colors that make these foods appear more attractive. Frozen items such as pre-prepared burgers or pizzas, candies, sodas, chips and ice cream are a few examples. On a daily basis, the ua-processed category is not the best source of your nutritional intake. But there's still hope for our frozen pizza and chocolate lovers. Caroline Passerrello, spokesperson for the Academy of Nutrition and Dietetics, suggests that there may be a place on our plates for processed foods.

Everything in ModerationIt's often said that most things are OK in moderation. But does this saying ring true for ua-processed foods?. According to Passerrello, ua-processed foods like cookies, chips and sodas are more energy than nutrient-dense. This means that while the energy and calories are present, the nutrients we require like vitamins and minerals are often lacking. This can become a cause for concern because our bodies require both energy and nutrients to function properly.A 2017 study that followed the dietary intakes of 9,317 participants found that Americans were eating ua-processed foods at alarming rates.

Foods, in this case, were classified according to the NOVA scale. The results of the study showed that on average more than half of the calories of the participants came from ua-processed foods. These foods failed to deliver proper nutrients. Participants that consumed more ua-processed food lacked proper protein, calcium, fiber, potassium, and vitamins A, C, D and E in their diets. In contrast, participants that consumed higher amounts of unprocessed or minimally processed foods had a better overall diet with adequate amounts of the different nutrients.So, a balanced diet of the different food groups may just be the way to go.

But what happens when we overindulge in ua-processed foods on a regular basis?. Because ua-processed foods are typically filled with sugar and fat, they've been linked to numerous health risks including obesity, heart disease and stroke, type-2 diabetes, cancer and depression.Passerrello explains that overconsumption of highly processed foods over time can also lead to vitamin and mineral deficiencies. In addition, processed foods tend to have higher amounts of sodium, which is often used to extend their shelf life. Consuming too much sodium can lead to feelings of dehydration and cause muscle twitches.The health risks associated with overconsumption of ua-processed foods can easily pile up, but luckily, there are some healthy alternatives that we can choose to incorporate into our diet. Eat This Not ThatCutting down on ua-processed foods definitely seems like a good start to a healthy and balanced diet, but it's only the first step.

"It's not just the ua-processed food itself that is the concern, but what else we are, or are not, eating — as well as what our bodies need and ultimately, what foods we have access to on a regular basis," says Passerrello.Health and nutrition can vary from person to person, so there is definitely no hard and fast rule as to what goes and what stays. However, Passerrello advises that if you are in a position in life with your time, taste and budget to make a choice between an ua-processed food item and a minimally processed food item, you should typically opt for the minimally processed food.Yes, frozen dinners may be an easy option after a long day of work. However, an easy alternative that can save time could be meal prepping in advance. A homemade alternative such as a simple rice dish or burritos can be easy to make in batches and store away for the week. Another simple way to slowly decrease your intake of processed foods is to check food labels for excess amounts of salt or sugar.

Instead of sodas, Passerrello suggests opting for orange juice or milk that are fortified with calcium and vitamin D.Ultimately, choosing healthy foods is a matter of providing your body with the proper nutrients it needs while also incorporating your personal tastes and preferences. A handful of chips and a frozen pizza may not be the healthiest treat, but they won't do serious damage as long as ua-processed foods aren't your main and only form of nutrients.Like many people, Stephanie Holm made holiday cookies with her family last year. Her daughter found a recipe on the internet, and the two of them set to making them in the kitchen of their apartment.Together, they mixed the dough, rolled it out, put the cookies on a pan and popped it in the oven — “literally covered in sprinkles on the outside…cute, and very delicious,” says Holm, a pediatric environmental medicine specialist at UC San Francisco.But as the cookies baked, Holm noticed that the cute sugary coating burned a little in the oven, though not enough to ruin the cookies. Then Holm heard her daughter exclaim, “Mama, it’s purple!. € and she saw that the air quality sensor she keeps in their apartment had indeed turned from green (good air quality) to purple (very unhealthy).

Could a single batch of slightly singed cookies have been to blame?. What happened with Holm’s cookies wasn’t a fluke. All cooking releases a complex mixture of chemicals, some of which would be classified as unhealthy pollutants. As for whether cooking is hazardous to your health — the short answer is, it depends. But generally, if you have good ventilation, you should be fine.“We all cook, and the average life expectancy is 78 or 79 years old.

So we shouldn’t get too worried,” says Delphine Farmer, an atmospheric chemist at Colorado State University. €œBut it is an opportunity to think about how to reduce your exposure to pollutants.”Out of the Frying PanFarmer’s research found that cooking releases a mixture of hundreds of different chemical compounds into the air. Every ingredient gives off its own unique blend of particles and gases. Proteins in meat can break down and give off ammonia. Roasting can produce isocyanates.

Oils from frying and sautéing can aerosolize (that’s how your counters end up with a fine layer of grease on them). The airborne molecules can continue to react and change as they drift around your kitchen and bump into each other.“You can see some of these really interesting compounds,” Farmer says. €œBut are they at levels that are toxic?. We don't know.” Part of the uncertainty when it comes to health effects comes from the fact that most air quality studies and standards are based on outdoor air — despite our world where people today spend an estimated 90 percent of their time indoors. While Canada and the World Health Organization have indoor air quality guidelines, the U.S.

Does not.In general, indoor air chemistry fluctuates a lot more than outdoor air. The average air quality can be good, but as Holm and her daughter experienced, some activities — like cooking and cleaning — can cause dramatic changes. Pollutant levels will spike in the kitchen while cooking is actively happening and then drift back down as the airborne molecules disperse.“The pattern of exposure is different. And we really don't have great scientific data on what the difference of that pattern of exposures means for people's health.” Holm says.Acquiring that scientific data is no easy task. Variables that can affect cooking fumes and their contents include how often a person cooks, what they cook, how they cook it, what kind of appliance they use, what kind of ventilation they have and maybe even the type of pots and pans they use, says Iain Walker, an engineer at Lawrence Berkeley National Lab who studies home air quality and ventilation.

The best researchers can do is try to gauge the relative impact of each factor. Gas stove or electric?. Boiling or frying?. Meat or vegetables?. Nonstick pan or stainless steel?.

Into the FireThe main pollutant of concern linked to cooking is particulate matter. This catchall term refers to a complex mix of microscopic solid bits and uafine liquid droplets that could be made up of hundreds of different chemical compounds. The chemistry doesn’t matter nearly as much as the size. Particles smaller than 10 microns (less than 1/5 the width of a human hair) can make their way into the lungs and lodge there. Even smaller particles can make their way into the bloodstream.Particulate matter is the reason you don’t want to breathe in smoke or car exhaust.

Chronic exposure to high levels of particulate matter exacerbates asthma, but also makes it more likely that a child will develop asthma, says Holm. It’s also linked to changes in childhood growth, metabolism and brain development, and it’s classified as a carcinogen by the WHO.All cooking produces some particulate matter in the form of aerosols and tiny bits of char generated from food and dust being heated up. If you can smell burning, you’re likely breathing in quite a bit of particulate matter. €œAnything with a red-hot element is going to generate particles,” says Walker. That includes most stovetops, ovens and even small appliances like toasters.

Frying and roasting cook methods both produce a lot more particulate matter than boiling or steaming. And fatty foods give off more than veggies.Gas stoves are particularly bad for indoor air quality. Not only do they produce more particulate matter by virtue of creating an open flame, but the actual fossil fuel combustion also generates other gases, such as carbon dioxide and nitrogen dioxide. From a health perspective, the thing that raises the biggest concern in this scenario is nitrogen dioxide.Nitrogen dioxide, like particulate matter, contributes to breathing problems like asthma and is regulated in outdoor air. The gas has also been linked to heart problems, lower birth weight in newborns and shorter lifespans for people who are chronically exposed.A 2016 study from Lawrence Berkeley National Lab found that simply boiling water on a gas stove produces nearly twice the amount of nitrogen dioxide as the EPA’s outdoor standard.

Considering that about a third of American homes use natural gas for cooking, that’s a lot of potential exposure.“Somehow, we've just become used to an unvented fossil fuel device in our homes,” says Brady Seals, who manages the carbon-free buildings program at the Rocky Mountain Institute, a clean energy think tank. She wants to raise awareness of nitrogen dioxide’s health risks as a way to discourage natural gas use in homes. And she’s not alone in this mission. The Massachusetts Medical Society passed a resolution in 2019 to recognize the link between gas stoves and pediatric asthma. Several cities in California, including San Francisco, have passed bans on natural gas in new construction, citing both climate and health hazards.If you have a gas cooktop, Seals and Walker recommend swapping it out for an electric one if you have the means and ability to do so.

€œNot only are you reducing carbon impact [on the environment], but you can have a healthier home if you get rid of combustion appliances,” Walker says.The best option from both an energy-efficiency and air-quality perspective, he says, is an induction stove, which uses magnets to transfer heat directly to your pots and pans. No red-hot elements means less particulate matter. If you can’t replace your gas stove, Seals recommends a plug-in induction cooktop.Vented AirRealistically, few people are going to swear off stir frying or using their oven for the sake of producing less particulate matter. €œEverybody’s going to cook what they’re going to cook,” says Farmer, noting that people use whatever kitchen appliances they have. That’s why all these experts stress the importance of good ventilation.Holm was part of a 2018 study looking at particulate matter in the homes of children with asthma.

One of the most surprising findings. In homes that never used a range hood or range fan, people were exposed to unhealthy levels of particulate matter for roughly 10 percent more time than in homes that used range ventilation.Walker, the ventilation expert, recommends that people should use a high setting on their kitchen range hood whenever possible, since the quieter low settings capture only about half of pollutants. Since most range hoods don’t extend over the front burners, you might want to consider using the back burners, especially if you have a gas stove. Walker also advises that people keep the ventilation on for about 15 minutes after they’re done cooking. That’s about how long it takes for all of the air in the room to be replaced.

But that only applies if your vent is sending fumes outside, which is not often the case.Unless you have a new, higher-end kitchen and stove, your built-in range ventilation might essentially be a fan. It’s just pushing the fumes around the room, which helps disperse the concentration of pollutants more quickly but doesn’t actually remove them from your house. Many homes and apartments, including Holm’s, don’t even have that option. In that case, Holm recommends opening some windows if the outside air quality is good, or using a portable air purifier with a HEPA filter.In the end, there are still a lot of unknowns about how cooking fumes affect us. To some extent, we simply have to accept them as a byproduct of enjoying our favorite foods, much like we accept pet hair as a part of having a furry friend.

€œYou start realizing how pollutants are a part of our life,” Seals says. €œLet’s reduce pollution wherever we can. But I’m not going to give up my dog and I’m not going to stop cooking.”[Correction. A previous version of this story erroneously stated the findings of Holm's 2018 air quality study and the type of portable air purifier that Holm recommends using in homes. We apologize for the errors, which have been corrected in this current version.].

With summer get lasix prescription in full swing, many people are kicking off their shoes additional hints — and it’s not just happening at the beach or in the park. Walking or running barefoot has gained popularity over the past decade, as have minimalist shoes designed to imitate the feel of going barefoot.Claims abound that ditching shoes can improve strength and balance, resolve hip, back or knee ailments, and prevent painful foot deformities like bunions or fallen arches. But is get lasix prescription barefoot actually better or is it just a fad?.

Like all other animals, humans evolved to walk without shoes. Then, as our ancestors strode across the savannas in search of food and shelter, they eventually figured out how to get lasix prescription protect their feet from extreme temperatures and sharp objects. Wrap them in animal hides.

These early versions of shoes likely enabled our species to travel farther, faster, and more safely.The oldest shoes discovered date back to 8,000 get lasix prescription years ago. However, fossil evidence indicates that our species probably began wearing sandals or moccasins over 40,000 years ago. Cushioned shoes, however, only came on the scene about 300 years ago.

Some studies show that these padded soles have shifted the foot’s get lasix prescription form and function.Human feet are complicated and sophisticated machines, containing almost one-quarter of all bones in the body. Each foot has 200,000 nerve endings, 26 bones, 30 joints, and more than 100 muscles, tendons and ligaments, all of which work together seamlessly as we move around. So it stands to reason that covering those many intricate parts with a shoe get lasix prescription will change how we move.In his 2009 bestseller Born To Run Christopher McDougall championed the now-popular idea that modern, cushioned shoes are the cause of many muscular-skeletal injuries — at least for runners.

McDougall studied the Tarahumara tribe in Mexico, whose members often run over 100 miles up and down stony trails in nothing but thin, homemade sandals. He ditched his padded sneakers, curing his own running-related injuries and spawning a movement to go back to barefoot basics.A get lasix prescription 2010 study showed that barefoot runners do put less stress on their feet. They take shorter strides, and strike with the middle of their foot first while curling their toes more.

This spreads out the force more evenly across the foot.Wearing a cushioned shoe with a heightened heel, on the other hand, enables runners to take longer strides and strike the ground heel-first get lasix prescription. Landing on the heel generates up to three times more force than landing on the forefoot, sending shock waves up the skeletal system.Shoes seem to change the way we walk, too. Barefoot walkers take shorter strides and step more lightly — mostly to test whether there’s something painful beneath the foot before it takes the body’s full weight.Some research shows that modern shoes have changed humans’ foot shape over time.

For example, people in India who are get lasix prescription habitually barefoot have wider feet than Westerners, whose more slender, shorter feet gave less ability to spread out the pressure of impact.Shoes can also interfere with neural messages set from our feet to our brain about the ground beneath us. Researchers from Harvard recently studied 100 adults, mostly from Kenya, to see whether calluses act similarly to shoes in terms of dulling the signaling between foot and brain.Calluses are the evolutionary solution for thorns or stones. The skin on our feet is thicker than almost anywhere else on get lasix prescription the body.

Study subjects who walked barefoot most of the time had more calluses than their shod peers, which protected their feet but still allowed better tactile stimulation than shoes. Researchers also found that uncushioned, minimal shoes functioned more similarly to walking on callused bare feet than to wearing get lasix prescription cushioned shoes.But the jury is still out on whether going shoeless translates to better overall outcomes for the body.A literature review from 2017 evaluated the long-term effects of habitually walking or running barefoot, and found no difference in relative injury rates compared to shoe-wearing folks. However, walking or running barefoot did appear to result in less foot deformities.As for children, a study released this year found no statistical differences in the gait or force exerted by 75 children, aged 3 to 9 years old, who walked both barefoot and in shoes across the same ground.

A different study published in 2017 found that “evidence get lasix prescription is small" for barefoot locomotion’s long-term effects on foot characteristics. In fact, after comparing the foot morphology of 810 children and adolescents who were habitually shod versus habitually barefoot, they concluded that “permanent footwear use may play an important role in childhood foot development and might actually be beneficial for the development of the foot arch.”Minimalist shoes that give a barefoot feel but protective covering might just be the wave of the future — or, rather, a return to our prehistoric roots. A 2020 study evaluated the gait of 64 adults and found they had better gait performance walking with minimalist shoes than walking barefoot.It seems our ancestors were on to something when they began wrapping their feet in leather millennia ago.

While letting your feet roam naked occasionally certainly isn’t a bad idea, most of us probably shouldn’t toss our shoes in the trash any time soon.This article contains affiliate links get lasix prescription to products. We may receive a commission for purchases made through these links.When it comes to finding the best CBD gummies for sleep, you have a lot of choices. The problem is that they aren’t necessarily all made with your wellness in mind.Even though CBD-lovers everywhere are more educated about CBD than they were when the market first took off, there are still plenty of misconceptions and misinformation driving an inconsistent industry.On one end, you have CBD companies dedicated to creating the safest, purest, best CBD products get lasix prescription on the market.

On the other, companies just out to make a quick buck with no concern for the customer or the environment.We have put together a list to make it easier to find the kind of CBD gummies that promote a great night’s sleep with only the finest ingredients and highest standards. The brands get lasix prescription listed here make some of the best CBD gummies for sleep that you can find on the market today.1. Verma Farms CBD GummiesHere’s the thing with CBD gummies.

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What’s left is delicious, fruit-flavored gummies that pack 10 mg of CBD in each serving—perfect for snacking!. They’re also one of the highest rated CBD gummies on get lasix prescription the market now. Just take a look at what sources such as Cannabis Culture and Merry Jane have said about them in their reviews.3.

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Although very potent, the texture and flavor are not compromised at all. They feel and taste exactly like a Gummy should taste, but with a potent CBD get lasix prescription twist to them. They come in 3 delicious flavors (blue Raspberry, Strawberry, and Lime) and are only 8 calories each.

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Fruit-flavored and made with 10 mg of CBD each, they are free of THC and a perfect snack any time, day or night. Choose between the standard recipe and the Vegan AF recipe.One of the great things about the Sunday Scaries brand is their unique gummies meant to celebrate their community and their chosen causes.Their get lasix prescription Rainbow Jerky contains 10 mg of CBD as well, but comes in bite-sized rainbow-colored pieces that are coated in sweet and sour sugar. The best thing about these is that $1 from every purchase goes to The Trevor Project, an organization with a mission of preventing suicide among LGBTQ+ youth.You can also choose for your purchase to go toward helping to fund breast cancer research.

For every order you place of the latest addition, Bra Berries (strawberry-flavored CBD gummies with vitamin C infused), Sunday Scaries will donate $2 to The Pink get lasix prescription Agenda.6. R+R MedicinalsR+R Medicinals is the brand that finally makes the CBD gummy right - with their 25mg Full-Spectrum Gummies, you can really feel the difference. Vegan, sugar coated, no artificial flavors or colors, and simple ingredients make get lasix prescription this gummy option a clear winner compared to other gummies on the market.

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After all, variety is the spice of life!. 8. Charlotte’s Web Sleep CBD GummiesWhile full-spectrum CBD gummies have a more pungent flavor than their CBD isolate counterparts, there are some benefits to getting a gummy made with a more robust formula.Charlotte’s Web CBD gummies are made with the full-spectrum CBD that made the brand famous.

They include a potent combination of additional cannabinoids like CBC, CBG, and CBN, and are made with some of the best hemp grown in the United States.One thing that may make the sleep CBD gummies a little more palatable is the fact that the CBD used to make them is CO2 extracted. The flavor is milder than it is in the oil made with an ethanol extraction, and you may find you appreciate the way they taste.These CBD gummies are infused with 3 mg of melatonin in addition to their 10 mg of CBD. They are flavored with natural flavorings and contain no artificial colors.We like that you can choose different sizes.

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LiverWell is best for those who need to reduce the effects of environmental toxins and struggle with metabolic issues. LiverWell’s use of powerful antioxidants has also been shown to reduce and repair damage done to liver and kidney health from free radicals in the body. Beyond that, LiveWell offers a comprehensive 365-day return policy, so everyone can try their products completely risk-free.

BUY HERE 3. Gaia Herbs Liver Cleanse Liver Cleanse’s unique proprietary blend covers a vast range of liver supporting nutrients that are all-natural and entirely herbal. While it does contain milk thistle, it lacks several key ingredients, such as zinc, selenium, or any form of Vitamin E.

This limits its ability to support your liver health. The transparent labeling showcases all the ingredients included in its proprietary formula. Gaia Herbs takes a simple approach to producing a good quality liver support supplement for a low price range.Ask any nutritionist and they'll tell you that our health is a reflection of the lifestyle we lead and what we put on our plates.

The food we eat not only satisfies our hunger. It also fuels our bodies with energy to carry on. In today’s fast-paced life, there's limited time to make elaborate home-cooked meals.

It's no wonder that 80 percent of Americans' total calorie consumption is thought to come from store-bought foods and beverages. Many of these food items are considered ua-processed, causing a growing rate of concern for human health among scientists.Breaking Down Ua-Processed FoodsYou may be wondering what exactly ua-processed foods are. The concept of processing refers to changing food from its natural state, according to Harvard Health Publishing.

Methods of accomplishing this include canning, smoking, pasteurizing and drying. Ua-processed foods take processing one step further by adding multiple ingredients such as sugar, preservatives and artificial flavors and colors. Commercially prepared cookies, chips and sodas are just a few of many examples of foods that fall into the highly processed category.

In order to further understand ua-processed foods, we must first explore the different levels of food processing. The term ua-processed was first coined by Carlos Monteiro, a professor of nutrition and public health at the University of Sao Paulo, Brazil. Monteiro also created a food classification system called NOVA that has become a popular tool in categorizing different food items.

The NOVA Food Classification system contains four different groups:Unprocessed/Minimally Processed Foods. Think 100 percent natural and healthy. This group includes foods such as fruits, vegetables, eggs, meats and milk.

Unprocessed foods are considered completely natural and are typically obtained directly from plants and animals. Minimally processed foods are also natural foods that have had very minor changes such as removal of inedible parts, fermentation, cooling, freezing, and any other processes that won't add extra ingredients or substances to the original product.Processed Culinary Ingredients. This group has everything to do with flavor and typically contains ingredients such as fats and aromatic herbs that are extracted from natural foods.

These ingredients are then used in homes and restaurants to season and cook items such as soups, salads and sweets. Many of these extracted ingredients can also be stored for later use. Processed Foods.

Most processed foods contain at least two or three added ingredients such as salt, sugar and oil. Think of this group as a combination of the first two groups. In other words, processed culinary ingredients or flavors that are added to natural foods.

Examples include fruits in sugar syrup, bacon, beef jerky and salted nuts. Ua-Processed Foods. Last and least healthy on the NOVA scale are ua-processed foods.

This group is considered highly processed due to a large amount of added ingredients. Nova typically classifies this group as industrial formulations made entirely or mostly from substances such as oils, fats, sugar, starch and proteins as well as flavor enhancers and artificial colors that make these foods appear more attractive. Frozen items such as pre-prepared burgers or pizzas, candies, sodas, chips and ice cream are a few examples.

On a daily basis, the ua-processed category is not the best source of your nutritional intake. But there's still hope for our frozen pizza and chocolate lovers. Caroline Passerrello, spokesperson for the Academy of Nutrition and Dietetics, suggests that there may be a place on our plates for processed foods.

Everything in ModerationIt's often said that most things are OK in moderation. But does this saying ring true for ua-processed foods?. According to Passerrello, ua-processed foods like cookies, chips and sodas are more energy than nutrient-dense.

This means that while the energy and calories are present, the nutrients we require like vitamins and minerals are often lacking. This can become a cause for concern because our bodies require both energy and nutrients to function properly.A 2017 study that followed the dietary intakes of 9,317 participants found that Americans were eating ua-processed foods at alarming rates. Foods, in this case, were classified according to the NOVA scale.

The results of the study showed that on average more than half of the calories of the participants came from ua-processed foods. These foods failed to deliver proper nutrients. Participants that consumed more ua-processed food lacked proper protein, calcium, fiber, potassium, and vitamins A, C, D and E in their diets.

In contrast, participants that consumed higher amounts of unprocessed or minimally processed foods had a better overall diet with adequate amounts of the different nutrients.So, a balanced diet of the different food groups may just be the way to go. But what happens when we overindulge in ua-processed foods on a regular basis?. Because ua-processed foods are typically filled with sugar and fat, they've been linked to numerous health risks including obesity, heart disease and stroke, type-2 diabetes, cancer and depression.Passerrello explains that overconsumption of highly processed foods over time can also lead to vitamin and mineral deficiencies.

In addition, processed foods tend to have higher amounts of sodium, which is often used to extend their shelf life. Consuming too much sodium can lead to feelings of dehydration and cause muscle twitches.The health risks associated with overconsumption of ua-processed foods can easily pile up, but luckily, there are some healthy alternatives that we can choose to incorporate into our diet. Eat This Not ThatCutting down on ua-processed foods definitely seems like a good start to a healthy and balanced diet, but it's only the first step.

"It's not just the ua-processed food itself that is the concern, but what else we are, or are not, eating — as well as what our bodies need and ultimately, what foods we have access to on a regular basis," says Passerrello.Health and nutrition can vary from person to person, so there is definitely no hard and fast rule as to what goes and what stays. However, Passerrello advises that if you are in a position in life with your time, taste and budget to make a choice between an ua-processed food item and a minimally processed food item, you should typically opt for the minimally processed food.Yes, frozen dinners may be an easy option after a long day of work. However, an easy alternative that can save time could be meal prepping in advance.

A homemade alternative such as a simple rice dish or burritos can be easy to make in batches and store away for the week. Another simple way to slowly decrease your intake of processed foods is to check food labels for excess amounts of salt or sugar. Instead of sodas, Passerrello suggests opting for orange juice or milk that are fortified with calcium and vitamin D.Ultimately, choosing healthy foods is a matter of providing your body with the proper nutrients it needs while also incorporating your personal tastes and preferences.

A handful of chips and a frozen pizza may not be the healthiest treat, but they won't do serious damage as long as ua-processed foods aren't your main and only form of nutrients.Like many people, Stephanie Holm made holiday cookies with her family last year. Her daughter found a recipe on the internet, and the two of them set to making them in the kitchen of their apartment.Together, they mixed the dough, rolled it out, put the cookies on a pan and popped it in the oven — “literally covered in sprinkles on the outside…cute, and very delicious,” says Holm, a pediatric environmental medicine specialist at UC San Francisco.But as the cookies baked, Holm noticed that the cute sugary coating burned a little in the oven, though not enough to ruin the cookies. Then Holm heard her daughter exclaim, “Mama, it’s purple!.

€ and she saw that the air quality sensor she keeps in their apartment had indeed turned from green (good air quality) to purple (very unhealthy). Could a single batch of slightly singed cookies have been to blame?. What happened with Holm’s cookies wasn’t a fluke.

All cooking releases a complex mixture of chemicals, some of which would be classified as unhealthy pollutants. As for whether cooking is hazardous to your health — the short answer is, it depends. But generally, if you have good ventilation, you should be fine.“We all cook, and the average life expectancy is 78 or 79 years old.

So we shouldn’t get too worried,” says Delphine Farmer, an atmospheric chemist at Colorado State University. €œBut it is an opportunity to think about how to reduce your exposure to pollutants.”Out of the Frying PanFarmer’s research found that cooking releases a mixture of hundreds of different chemical compounds into the air. Every ingredient gives off its own unique blend of particles and gases.

Proteins in meat can break down and give off ammonia. Roasting can produce isocyanates. Oils from frying and sautéing can aerosolize (that’s how your counters end up with a fine layer of grease on them).

The airborne molecules can continue to react and change as they drift around your kitchen and bump into each other.“You can see some of these really interesting compounds,” Farmer says. €œBut are they at levels that are toxic?. We don't know.” Part of the uncertainty when it comes to health effects comes from the fact that most air quality studies and standards are based on outdoor air — despite our world where people today spend an estimated 90 percent of their time indoors.

While Canada and the World Health Organization have indoor air quality guidelines, the U.S. Does not.In general, indoor air chemistry fluctuates a lot more than outdoor air. The average air quality can be good, but as Holm and her daughter experienced, some activities — like cooking and cleaning — can cause dramatic changes.

Pollutant levels will spike in the kitchen while cooking is actively happening and then drift back down as the airborne molecules disperse.“The pattern of exposure is different. And we really don't have great scientific data on what the difference of that pattern of exposures means for people's health.” Holm says.Acquiring that scientific data is no easy task. Variables that can affect cooking fumes and their contents include how often a person cooks, what they cook, how they cook it, what kind of appliance they use, what kind of ventilation they have and maybe even the type of pots and pans they use, says Iain Walker, an engineer at Lawrence Berkeley National Lab who studies home air quality and ventilation.

The best researchers can do is try to gauge the relative impact of each factor. Gas stove or electric?. Boiling or frying?.

Meat or vegetables?. Nonstick pan or stainless steel?. Into the FireThe main pollutant of concern linked to cooking is particulate matter.

This catchall term refers to a complex mix of microscopic solid bits and uafine liquid droplets that could be made up of hundreds of different chemical compounds. The chemistry doesn’t matter nearly as much as the size. Particles smaller than 10 microns (less than 1/5 the width of a human hair) can make their way into the lungs and lodge there.

Even smaller particles can make their way into the bloodstream.Particulate matter is the reason you don’t want to breathe in smoke or car exhaust. Chronic exposure to high levels of particulate matter exacerbates asthma, but also makes it more likely that a child will develop asthma, says Holm. It’s also linked to changes in childhood growth, metabolism and brain development, and it’s classified as a carcinogen by the WHO.All cooking produces some particulate matter in the form of aerosols and tiny bits of char generated from food and dust being heated up.

If you can smell burning, you’re likely breathing in quite a bit of particulate matter. €œAnything with a red-hot element is going to generate particles,” says Walker. That includes most stovetops, ovens and even small appliances like toasters.

Frying and roasting cook methods both produce a lot more particulate matter than boiling or steaming. And fatty foods give off more than veggies.Gas stoves are particularly bad for indoor air quality. Not only do they produce more particulate matter by virtue of creating an open flame, but the actual fossil fuel combustion also generates other gases, such as carbon dioxide and nitrogen dioxide.

From a health perspective, the thing that raises the biggest concern in this scenario is nitrogen dioxide.Nitrogen dioxide, like particulate matter, contributes to breathing problems like asthma and is regulated in outdoor air. The gas has also been linked to heart problems, lower birth weight in newborns and shorter lifespans for people who are chronically exposed.A 2016 study from Lawrence Berkeley National Lab found that simply boiling water on a gas stove produces nearly twice the amount of nitrogen dioxide as the EPA’s outdoor standard. Considering that about a third of American homes use natural gas for cooking, that’s a lot of potential exposure.“Somehow, we've just become used to an unvented fossil fuel device in our homes,” says Brady Seals, who manages the carbon-free buildings program at the Rocky Mountain Institute, a clean energy think tank.

She wants to raise awareness of nitrogen dioxide’s health risks as a way to discourage natural gas use in homes. And she’s not alone in this mission. The Massachusetts Medical Society passed a resolution in 2019 to recognize the link between gas stoves and pediatric asthma.

Several cities in California, including San Francisco, have passed bans on natural gas in new construction, citing both climate and health hazards.If you have a gas cooktop, Seals and Walker recommend swapping it out for an electric one if you have the means and ability to do so. €œNot only are you reducing carbon impact [on the environment], but you can have a healthier home if you get rid of combustion appliances,” Walker says.The best option from both an energy-efficiency and air-quality perspective, he says, is an induction stove, which uses magnets to transfer heat directly to your pots and pans. No red-hot elements means less particulate matter.

If you can’t replace your gas stove, Seals recommends a plug-in induction cooktop.Vented AirRealistically, few people are going to swear off stir frying or using their oven for the sake of producing less particulate matter. €œEverybody’s going to cook what they’re going to cook,” says Farmer, noting that people use whatever kitchen appliances they have. That’s why all these experts stress the importance of good ventilation.Holm was part of a 2018 study looking at particulate matter in the homes of children with asthma.

One of the most surprising findings. In homes that never used a range hood or range fan, people were exposed to unhealthy levels of particulate matter for roughly 10 percent more time than in homes that used range ventilation.Walker, the ventilation expert, recommends that people should use a high setting on their kitchen range hood whenever possible, since the quieter low settings capture only about half of pollutants. Since most range hoods don’t extend over the front burners, you might want to consider using the back burners, especially if you have a gas stove.

Walker also advises that people keep the ventilation on for about 15 minutes after they’re done cooking. That’s about how long it takes for all of the air in the room to be replaced. But that only applies if your vent is sending fumes outside, which is not often the case.Unless you have a new, higher-end kitchen and stove, your built-in range ventilation might essentially be a fan.

It’s just pushing the fumes around the room, which helps disperse the concentration of pollutants more quickly but doesn’t actually remove them from your house. Many homes and apartments, including Holm’s, don’t even have that option. In that case, Holm recommends opening some windows if the outside air quality is good, or using a portable air purifier with a HEPA filter.In the end, there are still a lot of unknowns about how cooking fumes affect us.

To some extent, we simply have to accept them as a byproduct of enjoying our favorite foods, much like we accept pet hair as a part of having a furry friend. €œYou start realizing how pollutants are a part of our life,” Seals says. €œLet’s reduce pollution wherever we can.

But I’m not going to give up my dog and I’m not going to stop cooking.”[Correction. A previous version of this story erroneously stated the findings of Holm's 2018 air quality study and the type of portable air purifier that Holm recommends using in homes. We apologize for the errors, which have been corrected in this current version.].

Lasix for hyponatremia

Start Preamble Centers lasix for hyponatremia for Medicare &. Medicaid Services (CMS), HHS. Notice of meeting lasix for hyponatremia. This notice announces a virtual meeting of the Advisory Panel on Hospital Outpatient Payment (the Panel) for Calendar Year 2021. The purpose of the Panel lasix for hyponatremia is to advise the Secretary of the Department of Health and Human Services and the Administrator of the Centers for Medicare &.

Medicaid Services concerning the clinical integrity of the Ambulatory Payment Classification groups and their associated weights, and supervision of hospital outpatient therapeutic services. The advice provided by the Panel will be considered as we prepare the annual updates for the hospital lasix for hyponatremia outpatient prospective payment system. Meeting date. The virtual lasix for hyponatremia meeting of the Panel is scheduled for Monday, August 23, 2021, from 9:30 a.m. To 5:00 p.m.

Eastern Daylight Time (EDT) lasix for hyponatremia. The times listed in this notice are EDT and are approximate times. Consequently, the meetings may last longer or be shorter than the times listed in this notice, but would not begin before the posted time. Deadline for presentations lasix for hyponatremia and comment letters. Presentations or Start Printed Page 39026comment letters, and form CMS-20017 (located at https://www.cms.gov/​Medicare/​CMS-Forms/​CMS-Forms/​downloads/​cms20017.pdf), must be received by 5:00 p.m.

EDT, Friday, August 6, lasix for hyponatremia 2021. We note that form CMS-20017 must accompany each presentation or comment letter submission. Presentations and lasix for hyponatremia comment letters that are not received by the due date and time, or that do not include a completed form CMS-20017 are considered late or incomplete, and cannot be included on the agenda. In commenting, refer to file code CMS-1764-N. Meeting Registration lasix for hyponatremia Timeframe.

All presentation or comment letter speakers, including any alternates, with items on the agenda must register electronically to our Panel mailbox, [email protected] no later than 5:00 p.m. EDT, Friday, August 6, lasix for hyponatremia 2021. The subject of the email may state “Agenda Speaker Registration for HOP Panel Meeting.” Meeting location and webinar. The meeting will be held virtually. The public lasix for hyponatremia may participate in this meeting by webinar, or listen-only via teleconference.

Closed captioning will be available on the webinar. Teleconference dial-in lasix for hyponatremia and webinar information will appear on the final meeting agenda, which will be posted on our website when available at. Https://www.cms.gov/​Regulations-and-Guidance/​Guidance/​FACA/​AdvisoryPanelonAmbulatoryPaymentClassificationGroups. News media lasix for hyponatremia. Press inquiries are handled through the CMS Press Office at (202) 690-6145.

Advisory committees information line lasix for hyponatremia. The telephone number for the Advisory Panel on Hospital Outpatient Payment Committee Hotline is (410) 786-3985. Websites lasix for hyponatremia. For additional information on the Panel, including the Panel charter, and updates to the Panel's activities, we refer readers to view our website at. Https://www.cms.gov/​Regulations-and-Guidance/​Guidance/​FACA/​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.

Information about the Panel and its membership in the Federal Advisory Committee Act (FACA) database are also located at lasix for hyponatremia. Https://www.facadatabase.gov. Start Further Info Elise lasix for hyponatremia Barringer, Designated Federal Official (DFO) (410) 786-9222, email at. [email protected]. End Further Info End Preamble Start Supplemental lasix for hyponatremia Information I.

Background The Secretary of the Department of Health and Human Services (the Secretary) is required by section 1833(t)(9)(A) of the Social Security Act (the Act) and is allowed by section 222 of the Public Health Service Act (PHA) to consult with an expert outside Panel, such as the Advisory Panel on Hospital Outpatient Payment (the Panel), regarding the clinical integrity of the Ambulatory Payment Classification (APC) groups and relative payment weights. The Panel is governed by the provisions of the Federal Advisory lasix for hyponatremia Committee Act (Pub. L. 92-463), as amended (5 lasix for hyponatremia U.S.C. Appendix 2), to set forth standards for the formation and use of advisory Panels.

We consider the technical advice provided by the Panel as we prepare the proposed and final rules to update the Hospital Outpatient Prospective Payment System (OPPS) for the following calendar year (CY). II. Annual Advisory Panel Meeting A. Meeting Agenda The agenda for the August 23, 2021 Panel meeting will provide for discussion and comment on the following topics as designated in the Panel's Charter. Addressing whether procedures within an APC group are similar both clinically and in terms of resource use.

Reconfiguring APCs. Evaluating APC group weights. Reviewing packaging the cost of items and services, including drugs and devices, into procedures and services, including the methodology for packaging and the impact of packaging the cost of those items and services on APC group structure and payment. Removing procedures from the inpatient only list for payment under the OPPS. Using claims and cost report data for Centers for Medicare &.

Medicaid Services (CMS) determination of APC group costs. Addressing other technical issues concerning APC group structure. Evaluating the required level of supervision for hospital outpatient services. OPPS APC rates for covered Ambulatory Surgical Center (ASC) procedures. The Agenda will be posted on our website at.

Https://www.cms.gov/​Regulations-and-Guidance/​Guidance/​FACA/​AdvisoryPanelonAmbulatoryPaymentClassificationGroups approximately 1 week before the meeting. B. Meeting Information Updates The actual meeting hours and days will be posted in the agenda. As information and updates regarding this webinar and listen-only teleconference, including the agenda, become available, they will be posted to our website at. Https://www.cms.gov/​Regulations-and-Guidance/​Guidance/​FACA/​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.

C. Presentations and Comment Letters The subject matter of any presentation and comment letter must be within the scope of the Panel as designated in the Charter. Any presentations or comments outside of the scope of the Panel will be returned or requested for amendment. Unrelated topics include, but are not limited to. The conversion factor, charge compression, revisions to the cost report, pass-through payments, correct coding, new technology applications (including supporting information/documentation), provider payment adjustments, supervision of hospital outpatient diagnostic services, and the types of practitioners that are permitted to supervise hospital outpatient services.

The Panel may not recommend that services be designated as nonsurgical extended duration therapeutic services. Presentations or Comment Letters that address OPPS APC rates as they relate to covered ASC procedures are within the scope of the Panel's charter. However, ASC payment rates, ASC payment indicators, the ASC covered procedures list, or other ASC payment system matters will be considered out of scope. The Panel may use data collected or developed by entities and organizations other than Department of Health and Human Services and CMS in conducting its review. We recommend organizations submit data for CMS staff and the Panel's review.

All presentations are limited to 5 minutes, regardless of the number of individuals or organizations represented by a single presentation. Presenters may use their 5 minutes to present either one or more agenda items. In the email, all of the following information must be submitted when registering. Speaker's name. Speaker's organization or company name.

Company or organization that the speaker is representing that submitted a presentation or comment letter that is on the agenda. Email addresses to which materials regarding meeting registration and instructions on connecting to the meeting may be sent.Start Printed Page 39027 Registration details may not be revised once they are submitted. If registration details require changes, a new registration entry must be submitted by August 06, 2021. In addition, registration information must reflect individual-level content and not reflect an organization entry. Also, each individual may only register one person at a time (that is, one individual may not register multiple individuals at the same time).

A confirmation email will be sent upon receipt of the registration. The email will provide information to the speaker in preparation for the meeting. Registration is only required for agenda speakers and alternates and must be submitted by the deadline specified above. We note that no registration is required for participants who plan to view the Panel meeting by webinar or listen teleconference. Section 508 Compliance For this meeting, we are aiming to have all presentations and comment letters available on our website.

Materials on our website must be Section 508 compliant to ensure access to federal employees and members of the public with and without disabilities. We encourage presenters and commenters to reference the guidance on making documents section 508 compliant as they draft their submissions, and, whenever possible, to submit their presentations and comment letters in a 508 compliant form. Such guidance is available at. Https://www.cms.gov/​research-statistics-data-and-systems/​cms-information-technology/​section508. We will review presentations and comment letters for 508 compliance and place compliant materials on our website.

As resources permit, we will also convert non-compliant submissions to 508 compliant forms, and offer assistance to submitters who are making their submissions 508 compliant. All 508 compliant presentations and comment letters will be made available on the CMS website. If difficulties are encountered accessing the materials, contact the Designated Federal Official (DFO) (the DFO's address, email, and phone number are provided in the FOR FURTHER INFORMATION CONTACT section of this notice). In order to consider presentations and/or comment letters, we will need to receive the following. 1.

An email copy of the presentation or comment letters sent to the DFO mailbox. [email protected]. 2. Form CMS-20017, with complete contact information that includes the names, addresses, phone numbers, and email addresses for all presenters. Comment letters.

And a contact person who can answer any questions and provide revisions that are requested for the presentation or comment letter. Presenters and commenter letters must clearly explain the actions that they are requesting CMS take in the appropriate section of the form. A presenter or commenter's relationship with the organization that they represent must also be clearly listed. D. Formal Presentations In addition to formal presentations (limited to 5 minutes total per presentation), there will be an opportunity during the meeting for public comments as time permits (limited to 1 minute for each individual and a total of 3 minutes per organization).

E. Panel Recommendations and Discussions The Panel's recommendations at any Panel meeting generally are not final until they have been reviewed and approved by the Panel on the last day of the meeting, before the final adjournment. These recommendations will be posted to our website after the meeting. F. Membership Appointments to the Advisory Panel on Hospital Outpatient Payment The Panel Charter provides that the Panel may meet up to 3 times annually.

We consider the technical advice provided by the Panel as we prepare the proposed and final rules to update the OPPS for the following calendar year. The Panel may consist of a chair and up to 15 members who are full-time employees of hospitals, hospital systems, or other Medicare providers that are subject to the OPPS. The Panel may also include a representative of the provider with ASC expertise, who may advise CMS only on OPPS APC rates, as appropriate, impacting ASC covered procedures within the context and purview of the Panel's scope. The Secretary or a designee selects the Panel membership based upon either self-nominations or nominations submitted by Medicare providers and other interested organizations of candidates determined to have the required expertise. For supervision deliberations, the Panel may include members that represent the interests of Critical Access Hospitals, who advise CMS only regarding the level of supervision for hospital outpatient therapeutic services.

New appointments are made in a manner that ensures a balanced membership under the FACA guidelines. The Secretary rechartered the Panel in 2020 for a 2-year period effective through November 20, 2022. The current charter is available on the CMS website at. Https://www.cms.gov/​files/​document/​2020-hop-panel-charter.pdf. The Panel presently consists of members and a Chair named below.

E.L. Hambrick, M.D., J.D., CMS Chairperson Terry Bohlke, C.P.A., C.M.A, M.H.A., C.A.S.C Carmen Cooper-Oguz, P.T., D.P.T, M.B.A, C.W.S, W.C.C Paul Courtney, M.D. Peter Duffy, M.D. Lisa Gangarosa, M.D. Michael Kuettel, M.D., M.B.A, Ph.D.

Scott Manaker, M.D., Ph.D. Brian Nester, D.O., M.B.A. Bo Gately, M.B.A. Matthew Wheatley, M.D., F.A.C.E.P. III.

Collection of Information Requirements This document does not impose information collection requirements, that is, reporting, recordkeeping or third-party disclosure requirements. Consequently, there is no need for review by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). The Administrator of the Centers for Medicare &. Medicaid Services (CMS), Chiquita Brooks-LaSure, having reviewed and approved this document, authorizes Lynette Wilson, who is the Federal Register Liaison, to electronically sign this document for purposes of publication in the Federal Register.

Start Signature Dated. July 20, 2021. Lynette Wilson, Federal Register Liaison, Centers for Medicare &. Medicaid Services. End Signature End Supplemental Information [FR Doc.

2021-15727 Filed 7-22-21. 8:45 am]BILLING CODE 4120-01-P.

Start Preamble get lasix prescription Centers for Medicare & lasix 40mg price. Medicaid Services (CMS), HHS. Notice of get lasix prescription meeting. This notice announces a virtual meeting of the Advisory Panel on Hospital Outpatient Payment (the Panel) for Calendar Year 2021. The purpose of the Panel is get lasix prescription to advise the Secretary of the Department of Health and Human Services and the Administrator of the Centers for Medicare &.

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EDT, Friday, August get lasix prescription 6, 2021. We note that form CMS-20017 must accompany each presentation or comment letter submission. Presentations and comment letters that are not received by the due date and time, or that do not include a completed form get lasix prescription CMS-20017 are considered late or incomplete, and cannot be included on the agenda. In commenting, refer to file code CMS-1764-N. Meeting Registration Timeframe get lasix prescription.

All presentation or comment letter speakers, including any alternates, with items on the agenda must register electronically to our Panel mailbox, [email protected] no later than 5:00 p.m. EDT, Friday, August 6, 2021 get lasix prescription. The subject of the email may state “Agenda Speaker Registration for HOP Panel Meeting.” Meeting location and webinar. The meeting will be held virtually. The public may participate in this meeting by webinar, or listen-only via get lasix prescription teleconference.

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Advisory committees get lasix prescription information line. The telephone number for the Advisory Panel on Hospital Outpatient Payment Committee Hotline is (410) 786-3985. Websites get lasix prescription. For additional information on the Panel, including the Panel charter, and updates to the Panel's activities, we refer readers to view our website at. Https://www.cms.gov/​Regulations-and-Guidance/​Guidance/​FACA/​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.

Information about the Panel and its membership in the Federal Advisory Committee Act get lasix prescription (FACA) database are also located at. Https://www.facadatabase.gov. Start Further Info Elise Barringer, Designated Federal Official (DFO) (410) 786-9222, get lasix prescription email at. [email protected]. End get lasix prescription Further Info End Preamble Start Supplemental Information I.

Background The Secretary of the Department of Health and Human Services (the Secretary) is required by section 1833(t)(9)(A) of the Social Security Act (the Act) and is allowed by section 222 of the Public Health Service Act (PHA) to consult with an expert outside Panel, such as the Advisory Panel on Hospital Outpatient Payment (the Panel), regarding the clinical integrity of the Ambulatory Payment Classification (APC) groups and relative payment weights. The Panel is governed by the provisions of the Federal Advisory Committee Act get lasix prescription (Pub. L. 92-463), as amended (5 get lasix prescription U.S.C. Appendix 2), to set forth standards for the formation and use of advisory Panels.

We consider the technical advice provided by the Panel as we prepare the proposed and final rules to update the Hospital Outpatient Prospective Payment System (OPPS) for the following calendar year (CY). II. Annual Advisory Panel Meeting A. Meeting Agenda The agenda for the August 23, 2021 Panel meeting will provide for discussion and comment on the following topics as designated in the Panel's Charter. Addressing whether procedures within an APC group are similar both clinically and in terms of resource use.

Reconfiguring APCs. Evaluating APC group weights. Reviewing packaging the cost of items and services, including drugs and devices, into procedures and services, including the methodology for packaging and the impact of packaging the cost of those items and services on APC group structure and payment. Removing procedures from the inpatient only list for payment under the OPPS. Using claims and cost report data for Centers for Medicare &.

Medicaid Services (CMS) determination of APC group costs. Addressing other technical issues concerning APC group structure. Evaluating the required level of supervision for hospital outpatient services. OPPS APC rates for covered Ambulatory Surgical Center (ASC) procedures. The Agenda will be posted on our website at.

Https://www.cms.gov/​Regulations-and-Guidance/​Guidance/​FACA/​AdvisoryPanelonAmbulatoryPaymentClassificationGroups approximately 1 week before the meeting. B. Meeting Information Updates The actual meeting hours and days will be posted in the agenda. As information and updates regarding this webinar and listen-only teleconference, including the agenda, become available, they will be posted to our website at. Https://www.cms.gov/​Regulations-and-Guidance/​Guidance/​FACA/​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.

C. Presentations and Comment Letters The subject matter of any presentation and comment letter must be within the scope of the Panel as designated in the Charter. Any presentations or comments outside of the scope of the Panel will be returned or requested for amendment. Unrelated topics include, but are not limited to. The conversion factor, charge compression, revisions to the cost report, pass-through payments, correct coding, new technology applications (including supporting information/documentation), provider payment adjustments, supervision of hospital outpatient diagnostic services, and the types of practitioners that are permitted to supervise hospital outpatient services.

The Panel may not recommend that services be designated as nonsurgical extended duration therapeutic services. Presentations or Comment Letters that address OPPS APC rates as they relate to covered ASC procedures are within the scope of the Panel's charter. However, ASC payment rates, ASC payment indicators, the ASC covered procedures list, or other ASC payment system matters will be considered out of scope. The Panel may use data collected or developed by entities and organizations other than Department of Health and Human Services and CMS in conducting its review. We recommend organizations submit data for CMS staff and the Panel's review.

All presentations are limited to 5 minutes, regardless of the number of individuals or organizations represented by a single presentation. Presenters may use their 5 minutes to present either one or more agenda items. In the email, all of the following information must be submitted when registering. Speaker's name. Speaker's organization or company name.

Company or organization that the speaker is representing that submitted a presentation or comment letter that is on the agenda. Email addresses to which materials regarding meeting registration and instructions on connecting to the meeting may be sent.Start Printed Page 39027 Registration details may not be revised once they are submitted. If registration details require changes, a new registration entry must be submitted by August 06, 2021. In addition, registration information must reflect individual-level content and not reflect an organization entry. Also, each individual may only register one person at a time (that is, one individual may not register multiple individuals at the same time).

A confirmation email will be sent upon receipt of the registration. The email will provide information to the speaker in preparation for the meeting. Registration is only required for agenda speakers and alternates and must be submitted by the deadline specified above. We note that no registration is required for participants who plan to view the Panel meeting by webinar or listen teleconference. Section 508 Compliance For this meeting, we are aiming to have all presentations and comment letters available on our website.

Materials on our website must be Section 508 compliant to ensure access to federal employees and members of the public with and without disabilities. We encourage presenters and commenters to reference the guidance on making documents section 508 compliant as they draft their submissions, and, whenever possible, to submit their presentations and comment letters in a 508 compliant form. Such guidance is available at. Https://www.cms.gov/​research-statistics-data-and-systems/​cms-information-technology/​section508. We will review presentations and comment letters for 508 compliance and place compliant materials on our website.

As resources permit, we will also convert non-compliant submissions to 508 compliant forms, and offer assistance to submitters who are making their submissions 508 compliant. All 508 compliant presentations and comment letters will be made available on the CMS website. If difficulties are encountered accessing the materials, contact the Designated Federal Official (DFO) (the DFO's address, email, and phone number are provided in the FOR FURTHER INFORMATION CONTACT section of this notice). In order to consider presentations and/or comment letters, we will need to receive the following. 1.

An email copy of the presentation or comment letters sent to the DFO mailbox. [email protected]. 2. Form CMS-20017, with complete contact information that includes the names, addresses, phone numbers, and email addresses for all presenters. Comment letters.

And a contact person who can answer any questions and provide revisions that are requested for the presentation or comment letter. Presenters and commenter letters must clearly explain the actions that they are requesting CMS take in the appropriate section of the form. A presenter or commenter's relationship with the organization that they represent must also be clearly listed. D. Formal Presentations In addition to formal presentations (limited to 5 minutes total per presentation), there will be an opportunity during the meeting for public comments as time permits (limited to 1 minute for each individual and a total of 3 minutes per organization).

E. Panel Recommendations and Discussions The Panel's recommendations at any Panel meeting generally are not final until they have been reviewed and approved by the Panel on the last day of the meeting, before the final adjournment. These recommendations will be posted to our website after the meeting. F. Membership Appointments to the Advisory Panel on Hospital Outpatient Payment The Panel Charter provides that the Panel may meet up to 3 times annually.

We consider the technical advice provided by the Panel as we prepare the proposed and final rules to update the OPPS for the following calendar year. The Panel may consist of a chair and up to 15 members who are full-time employees of hospitals, hospital systems, or other Medicare providers that are subject to the OPPS. The Panel may also include a representative of the provider with ASC expertise, who may advise CMS only on OPPS APC rates, as appropriate, impacting ASC covered procedures within the context and purview of the Panel's scope. The Secretary or a designee selects the Panel membership based upon either self-nominations or nominations submitted by Medicare providers and other interested organizations of candidates determined to have the required expertise. For supervision deliberations, the Panel may include members that represent the interests of Critical Access Hospitals, who advise CMS only regarding the level of supervision for hospital outpatient therapeutic services.

New appointments are made in a manner that ensures a balanced membership under the FACA guidelines. The Secretary rechartered the Panel in 2020 for a 2-year period effective through November 20, 2022. The current charter is available on the CMS website at. Https://www.cms.gov/​files/​document/​2020-hop-panel-charter.pdf. The Panel presently consists of members and a Chair named below.

E.L. Hambrick, M.D., J.D., CMS Chairperson Terry Bohlke, C.P.A., C.M.A, M.H.A., C.A.S.C Carmen Cooper-Oguz, P.T., D.P.T, M.B.A, C.W.S, W.C.C Paul Courtney, M.D. Peter Duffy, M.D. Lisa Gangarosa, M.D. Michael Kuettel, M.D., M.B.A, Ph.D.

Scott Manaker, M.D., Ph.D. Brian Nester, D.O., M.B.A. Bo Gately, M.B.A. Matthew Wheatley, M.D., F.A.C.E.P. III.

Collection of Information Requirements This document does not impose information collection requirements, that is, reporting, recordkeeping or third-party disclosure requirements. Consequently, there is no need for review by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.). The Administrator of the Centers for Medicare &. Medicaid Services (CMS), Chiquita Brooks-LaSure, having reviewed and approved this document, authorizes Lynette Wilson, who is the Federal Register Liaison, to electronically sign this document for purposes of publication in the Federal Register.

Start Signature Dated. July 20, 2021. Lynette Wilson, Federal Register Liaison, Centers for Medicare &. Medicaid Services. End Signature End Supplemental Information [FR Doc.

2021-15727 Filed 7-22-21. 8:45 am]BILLING CODE 4120-01-P.