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€‹In response low cost lasix to the evolving Delta outbreak, NSW will extend the current lockdown in Greater Sydney until the end of September, and introduce new rules targeting the local government areas of concern, where the vast majority of new cases are emerging. NSW Health and Police have worked together to develop a set of additional hypertension medications controls for the state to reduce transmission and ensure compliance. Additional rules for the LGAs of concern:From 12.01am Monday, 23 August the following additional rules will apply for residents and businesses in the LGAs of concern:Curfews will be introduced from 9pm to 5am (except for authorised workers, emergencies or medical care) to help reduce the movement of young peopleOutdoor exercise is limited to one hour per dayThe following retail premises must close except for click and collect low cost lasix. Garden centres and plant nurseries, office supplies, hardware and building supplies, landscaping material supplies, rural supplies, and pet supplies (tradespeople are allowed to shop in-store where relevant). AndAll exams and other education or professional development related activities will move online, low cost lasix not including the HSC.

The government will provide further information on its education plan in due course.The following new restrictions around workplaces and authorised workers from the LGAs of concern will be introduced:Childcare workers and disability support workers who live or work in the LGAs of concern must have their first vaccination dose by 30 AugustAuthorised workers who work outside their LGA of concern are only permitted to work if rapid antigen testing is implemented at their work-site or they have had their first vaccination dose by 30 August. From Saturday, low cost lasix 28 August, authorised workers from the LGAs of concern are required to carry a permit from Service NSW declaring that they are an authorised worker and cannot work from home. AndFrom Saturday, 28 August, anyone entering an LGA of concern for the purposes of work must carry a worker permit issued by Service NSW.From 12.01am Monday, 23 August, workers from the Canterbury-Bankstown, Cumberland and Fairfield LGAs will no longer have to have been tested for hypertension medications in the previous 72 hours to work outside their LGA. Special powers will also be given to the NSW Police Force including:Power for the Commissioner of Police to lockdown apartment blocks low cost lasix while health assesses the hypertension medications risk. Power for the Commissioner of Police to declare a residential premise a hypertension medications-risk premise and require all people to present to police during compliance checks;Powers to allow police to direct a person who has been issued with an infringement notice to return to their place of residence.

AndIf a person from outside an LGA of concern is found to be in an LGA of concern without a reasonable excuse, they will be fined $1000 and required to isolate at home for 14 days.Additional measures for Greater Sydney (including regional NSW until 28 August) From 12.01am low cost lasix Monday, 23 August, the following additional rule will also be introduced for Greater Sydney (including regional NSW until 28 August):Mask wearing will be mandatory when outside your home, except when exercising.There have been a number of cases in Early Childhood Education and Care Services, so parents and carers across the state are strongly encouraged to keep their children at home, unless they need to be at those services. For the latest information visit nsw.gov.auGiven the ongoing number of infectious cases in the community, the current lockdown will be extended for at least another two weeks until 11:59pm on Friday, 30 July. We are constantly reviewing the health advice and will continue to update the community if any changes are low cost lasix required. This means the restrictions currently in place across Greater Sydney including the Central Coast, Blue Mountains, Wollongong and Shellharbour will remain in place until this time.In these areas, online learning for students will also continue for an additional two weeks.We understand this is a difficult time for the community and appreciate their ongoing patience. It is vital people low cost lasix continue to come forward for testing to help us find any hypertension medications cases in the community.

Restrictions in regional NSW remain unchanged. Read the latest hypertension medications information..

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AbstractIntroduction http://gmaxturf.com/?page_id=2 lasix in racehorses. We report a very rare case of familial breast cancer and diffuse gastric cancer, with germline pathogenic variants in both BRCA1 and CDH1 genes. To the lasix in racehorses best of our knowledge, this is the first report of such an association.Family description. The proband is a woman diagnosed with breast cancer at the age of 52 years. She requested genetic counselling in 2012, at the age of 91 years, because of a history lasix in racehorses of breast cancer in her daughter, her sister, her niece and her paternal grandmother and was therefore concerned about her relatives.

Her sister and maternal aunt also had gastric cancer. She was tested for several genes lasix in racehorses associated with hereditary breast cancer.Results. A large deletion of BRCA1 from exons 1 to 7 and two CDH1 pathogenic cis variants were identified.Conclusion. This complex situation is challenging for lasix in racehorses genetic counselling and management of at-risk individuals.cancer. Breastcancer.

Gastricclinical geneticsgenetic screening/counsellingmolecular geneticsIntroductionGLI-Kruppel family member 3 (GLI3) encodes for a zinc finger transcription factor which plays a key lasix in racehorses role in the sonic hedgehog (SHH) signalling pathway essential in both limb and craniofacial development.1 2 In hand development, SHH is expressed in the zone of polarising activity (ZPA) on the posterior side of the handplate. The ZPA expresses SHH, creating a gradient of SHH from the posterior to the anterior side of the handplate. In the presence of SHH, full length GLI3-protein is produced (GLI3A), whereas absence of SHH causes cleavage of GLI3 into its repressor form (GLI3R).3 4 Abnormal expression of this SHH/GLI3R gradient can cause both preaxial and postaxial polydactyly.2Concordantly, pathogenic DNA variants in the GLI3 gene are known to cause lasix in racehorses multiple syndromes with craniofacial and limb involvement, such as. Acrocallosal syndrome5 (OMIM. 200990), Greig cephalopolysyndactyly lasix in racehorses syndrome6 (OMIM.

175700) and Pallister-Hall syndrome7 (OMIM. 146510). Also, in non-syndromic polydactyly, such as preaxial polydactyly-type 4 (PPD4, OMIM. 174700),8 pathogenic variants in GLI3 have been described. Out of these diseases, Pallister-Hall syndrome is the most distinct entity, defined by the presence of central polydactyly and hypothalamic hamartoma.9 The other GLI3 syndromes are defined by the presence of preaxial and/or postaxial polydactyly of the hand and feet with or without syndactyly (Greig syndrome, PPD4).

Also, various mild craniofacial features such as hypertelorism and macrocephaly can occur. Pallister-Hall syndrome is caused by truncating variants in the middle third of the GLI3 gene.10–12 The truncation of GLI3 causes an overexpression of GLI3R, which is believed to be the key difference between Pallister-Hall and the GLI3-mediated polydactyly syndromes.9 11 Although multiple attempts have been made, the clinical and genetic distinction between the GLI3-mediated polydactyly syndromes is less evident. This has for example led to the introduction of subGreig and the formulation of an Oro-facial-digital overlap syndrome.10 Other authors, suggested that we should not regard these diseases as separate entities, but as a spectrum of GLI3-mediated polydactyly syndromes.13Although phenotype/genotype correlation of the different syndromes has been cumbersome, clinical and animal studies do provide evidence that distinct regions within the gene, could be related to the individual anomalies contributing to these syndromes. First, case studies show isolated preaxial polydactyly is caused by both truncating and non-truncating variants throughout the GLI3 gene, whereas in isolated postaxial polydactyly cases truncating variants at the C-terminal side of the gene are observed.12 14 These results suggest two different groups of variants for preaxial and postaxial polydactyly. Second, recent animal studies suggest that posterior malformations in GLI3-mediated polydactyly syndromes are likely related to a dosage effect of GLI3R rather than due to the influence of an altered GLI3A expression.15Past attempts for phenotype/genotype correlation in GLI3-mediated polydactyly syndromes have directly related the diagnosed syndrome to the observed genotype.10–12 16 Focusing on individual hand phenotypes, such as preaxial and postaxial polydactyly and syndactyly might be more reliable because it prevents misclassification due to inconsistent use of syndrome definition.

Subsequently, latent class analysis (LCA) provides the possibility to relate a group of observed variables to a set of latent, or unmeasured, parameters and thereby identifying different subgroups in the obtained dataset.17 As a result, LCA allows us to group different phenotypes within the GLI3-mediated polydactyly syndromes and relate the most important predictors of the grouped phenotypes to the observed GLI3 variants.The aim of our study was to further investigate the correlation of the individual phenotypes to the genotypes observed in GLI3-mediated polydactyly syndromes, using LCA. Cases were obtained by both literature review and the inclusion of local clinical cases. Subsequently, we identified two subclasses of limb anomalies that relate to the underlying GLI3 variant. We provide evidence for two different phenotypic and genotypic groups with predominantly preaxial and postaxial hand and feet anomalies, and we specify those cases with a higher risk for corpus callosum anomalies.MethodsLiterature reviewThe Human Gene Mutation Database (HGMD Professional 2019) was reviewed to identify known pathogenic variants in GLI3 and corresponding phenotypes.18 All references were obtained and cases were included when they were diagnosed with either Greig or subGreig syndrome or PPD4.10–12 Pallister-Hall syndrome and acrocallosal syndrome were excluded because both are regarded distinct syndromes and rather defined by the presence of the non-hand anomalies, than the presence of preaxial or postaxial polydactyly.13 19 Isolated preaxial or postaxial polydactyly were excluded for two reasons. The phenotype/genotype correlations are better understood and both anomalies can occur sporadically which could introduce falsely assumed pathogenic GLI3 variants in the analysis.

Additionally, cases were excluded when case-specific phenotypic or genotypic information was not reported or if these two could not be related to each other. Families with a combined phenotypic description, not reducible to individual family members, were included as one case in the analysis.Clinical casesThe Sophia Children’s Hospital Database was reviewed for cases with a GLI3 variant. Within this population, the same inclusion criteria for the phenotype were valid. Relatives of the index patients were also contacted for participation in this study, when they showed comparable hand, foot, or craniofacial malformations or when a GLI3 variant was identified. Phenotypes of the hand, foot and craniofacial anomalies of the patients treated in the Sophia Children's Hospital were collected using patient documentation.

Family members were identified and if possible, clinically verified. Alternatively, family members were contacted to verify their phenotypes. If no verification was possible, cases were excluded.PhenotypesThe phenotypes of both literature cases and local cases were extracted in a similar fashion. The most frequently reported limb and craniofacial phenotypes were dichotomised. The dichotomised hand and foot phenotypes were preaxial polydactyly, postaxial polydactyly and syndactyly.

Broad halluces or thumbs were commonly reported by authors and were dichotomised as a presentation of preaxial polydactyly. The extracted dichotomised craniofacial phenotypes were hypertelorism, macrocephaly and corpus callosum agenesis. All other phenotypes were registered, but not dichotomised.Pathogenic GLI3 variantsAll GLI3 variants were extracted and checked using Alamut Visual V.2.14. If indicated, variants were renamed according to standard Human Genome Variation Society nomenclature.20 Variants were grouped in either missense, frameshift, nonsense or splice site variants. In the group of frameshift variants, a subgroup with possible splice site effect were identified for subgroup analysis when indicated.

Similarly, nonsense variants prone for nonsense mediated decay (NMD) and nonsense variants with experimentally confirmed NMD were identified.21 Deletions of multiple exons, CNVs and translocations were excluded for analysis. A full list of included mutations is available in the online supplementary materials.Supplemental materialThe location of the variant was compared with five known structural domains of the GLI3 gene. (1) repressor domain, (2) zinc finger domain, (3) cleavage site, (4) activator domain, which we defined as a concatenation of the separately identified transactivation zones, the CBP binding domain and the mediator binding domain (MBD) and (5) the MID1 interaction region domain.1 6 22–24 The boundaries of each of the domains were based on available literature (figure 1, exact locations available in the online supplementary materials). The boundaries used by different authors did vary, therefore a consensus was made.In this figure the posterior probability of an anterior phenotype is plotted against the location of the variant, stratified for the type of mutation that was observed. For better overview, only variants with a location effect were displayed.

The full figure, including all variant types, can be found in the online supplementary figure 1. Each mutation is depicted as a dot, the size of the dot represents the number of observations for that variant. If multiple observations were made, the mean posterior odds and IQR are plotted. For the nonsense variants, variants that were predicted to produce nonsense mediated decay, are depicted using a triangle. Again, the size indicates the number of observations." data-icon-position data-hide-link-title="0">Figure 1 In this figure the posterior probability of an anterior phenotype is plotted against the location of the variant, stratified for the type of mutation that was observed.

For better overview, only variants with a location effect were displayed. The full figure, including all variant types, can be found in the online supplementary figure 1. Each mutation is depicted as a dot, the size of the dot represents the number of observations for that variant. If multiple observations were made, the mean posterior odds and IQR are plotted. For the nonsense variants, variants that were predicted to produce nonsense mediated decay, are depicted using a triangle.

Again, the size indicates the number of observations.Supplemental materialLatent class analysisTo cluster phenotypes and relate those to the genotypes of the patients, an explorative analysis was done using LCA in R (R V.3.6.1 for Mac. Polytomous variable LCA, poLCA V.1.4.1.). We used our LCA to detect the number of phenotypic subgroups in the dataset and subsequently predict a class membership for each case in the dataset based on the posterior probabilities.In order to make a reliable prediction, only phenotypes that were sufficiently reported and/or ruled out were feasible for LCA, limiting the analysis to preaxial polydactyly, postaxial polydactyly and syndactyly of the hands and feet. Only full cases were included. To determine the optimal number of classes, we fitted a series of models ranging from a one-class to a six-class model.

The optimal number of classes was based on the conditional Akaike information criterion (cAIC), the non adjusted and the sample-size adjusted Bayesian information criterion (BIC and aBIC) and the obtained entropy.25 The explorative LCA produces both posterior probabilities per case for both classes and predicted class membership. Using the predicted class membership, the phenotypic features per class were determined in a univariate analysis (χ2, SPSS V.25). Using the posterior probabilities on latent class (LC) membership, a scatter plot was created using the location of the variant on the x-axis and the probability of class membership on the y-axis for each of the types of variants (Tibco Spotfire V.7.14). Using these scatter plots, variants that give similar phenotypes were clustered.Genotype/phenotype correlationBecause an LC has no clinical value, the correlation between genotypes and phenotypes was investigated using the predictor phenotypes and the clustered phenotypes. First, those phenotypes that contribute most to LC membership were identified.

Second those phenotypes were directly related to the different types of variants (missense, nonsense, frameshift, splice site) and their clustered locations. Quantification of the relation was performed using a univariate analysis using a χ2 test. Because of our selection criteria, meaning patients at least have two phenotypes, a multivariate using a logistic regression analysis was used to detect the most significant predictors in the overall phenotype (SPSS V.25). Finally, we explored the relation of the clustered genotypes to the presence of corpus callosum agenesis, a rare malformation in GLI3-mediated polydactyly syndromes which cannot be readily diagnosed without additional imaging.ResultsWe included 251 patients from the literature and 46 local patients,10–12 16 21 26–43 in total 297 patients from 155 different families with 127 different GLI3 variants, 32 of which were large deletions, CNVs or translocations. In six local cases, the exact variant could not be retrieved by status research.The distribution of the most frequently observed phenotypes and variants are presented in table 1.

Other recurring phenotypes included developmental delay (n=22), broad nasal root (n=23), frontal bossing or prominent forehead (n=16) and craniosynostosis (n=13), camptodactyly (n=8) and a broad first interdigital webspace of the foot (n=6).View this table:Table 1 Baseline phenotypes and genotypes of selected populationThe LCA model was fitted using the six defined hand/foot phenotypes. Model fit indices for the LCA are displayed in table 2. Based on the BIC, a two-class model has the best fit for our data. The four-class model does show a best online lasix gain in entropy, however with a higher BIC and loss of df. Therefore, based on the majority of performance statistics and the interpretability of the model, a two-class model was chosen.

Table 3 displays the distribution of phenotypes and genotypes over the two classes.View this table:Table 2 Model fit indices for the one-class through six-class model evaluated in our LCAView this table:Table 3 Distribution of phenotypes and genotypes in the two latent classes (LC)Table 1 depicts the baseline phenotypes and genotypes in the obtained population. Note incomplete data especially in the cranium phenotypes. In total 259 valid genotypes were present. In total, 289 cases had complete data for all hand and foot phenotypes (preaxial polydactyly, postaxial polydactyly and syndactyly) and thus were available for LCA. Combined, for phenotype/genotype correlation 258 cases were available with complete genotypes and complete hand and foot phenotypes.Table 2 depicts the model fit indices for all models that have been fitted to our data.Table 3 depicts the distribution of phenotypes and genotypes over the two assigned LCs.

Hand and foot phenotypes were used as input for the LCA, thus are all complete cases. Malformation of the cranium and genotypes do have missing cases. Note that for the LCA, full case description was required, resulting in eight cases due to incomplete phenotypes. Out of these eight, one also had a genotype that thus needed to be excluded. Missingness of genotypic data was higher in LC2, mostly due to CNVs (table 1).In 54/60 cases, a missense variant produced a posterior phenotype.

Likewise, splice site variants show the same phenotype in 23/24 cases (table 3). For both frameshift and nonsense variants, this relation is not significant (52 anterior vs 54 posterior and 26 anterior vs 42 posterior, respectively). Therefore, only for nonsense and frameshift variants the location of the variant was plotted against the probability for LC2 membership in figure 1. A full scatterplot of all variants is available in online supplementary figure 1.Figure 1 reveals a pattern for these nonsense and frameshift variants that reveals that variants at the C-terminal of the gene predict anterior phenotypes. When relating the domains of the GLI3 protein to the observed phenotype, we observe that the majority of patients with a nonsense or frameshift variant in the repressor domain, the zinc finger domain or the cleavage site had a high probability of an LC2/anterior phenotype.

This group contains all variants that are either experimentally determined to be subject to NMD (triangle marker in figure 1) or predicted to be subject to NMD (diamond marker in figure 1). Frameshift and nonsense variants in the activator domain result in high probability for an LC1/posterior phenotype. These variants will be further referred to as truncating variants in the activator domain.The univariate relation of the individual phenotypes to these two groups of variants are estimated and presented in table 4. In our multivariate analysis, postaxial polydactyly of the foot and hand are the strongest predictors (Beta. 2.548, p<0001 and Beta.

1.47, p=0.013, respectively) for patients to have a truncating variant in the activator domain. Moreover, the effect sizes of preaxial polydactyly of the hand and feet (Beta. ˆ’0.797, p=0123 and −1.772, p=0.001) reveals that especially postaxial polydactyly of the foot is the dominant predictor for the genetic substrate of the observed anomalies.View this table:Table 4 Univariate and multivariate analysis of the phenotype/genotype correlationTable 4 shows exploration of the individual phenotypes on the genotype, both univariate and multivariate. The multivariate analysis corrects for the presence of multiple phenotypes in the underlying population.Although the craniofacial anomalies could not be included in the LCA, the relation between the observed anomalies and the identified genetic substrates can be studied. The prevalence of hypertelorism was equally distributed over the two groups of variants (47/135 vs 21/47 respectively, p<0.229).

However for corpus callosum agenesis and macrocephaly, there was a higher prevalence in patients with a truncating variant in the activator domain (3/75 vs 11/41, p<0.001. OR. 8.8, p<0.001) and 42/123 vs 24/48, p<0.05). Noteworthy is the fact that 11/14 cases with corpus callosum agenesis in the dataset had a truncating variant in the activator domain.DiscussionIn this report, we present new insights into the correlation between the phenotype and the genotype in patients with GLI3-mediated polydactyly syndromes. We illustrate that there are two LCs of patients, best predicted by postaxial polydactyly of the hand and foot for LC1, and the preaxial polydactyly of the hand and foot and syndactyly of the foot for LC2.

Patients with postaxial phenotypes have a higher risk of having a truncating variant in the activator domain of the GLI3 gene which is also related to a higher risk of corpus callosum agenesis. These results suggest a functional difference between truncating variants on the N-terminal and the C-terminal side of the GLI3 cleavage site.Previous attempts of phenotype to genotype correlation have not yet provided the clinical confirmation of these assumed mechanisms in the pathophysiology of GLI3-mediated polydactyly syndromes. Johnston et al have successfully determined the Pallister-Hall region in which truncating variants produce a Pallister-Hall phenotype rather than Greig syndrome.11 However, in their latest population study, subtypes of both syndromes were included to explain the full spectrum of observed malformations. In 2015, Demurger et al reported the higher incidence of corpus callosum agenesis in the Greig syndrome population with truncating mutations in the activator domain.12 Al-Qattan in his review summarises the concept of a spectrum of anomalies dependent on haplo-insufficiency (through different mechanisms) and repressor overexpression.13 However, he bases this theory mainly on reviewed experimental data. Our report is the first to provide an extensive clinical review of cases that substantiate the phenotypic difference between the two groups that could fit the suggested mechanisms.

We agree with Al-Qattan et al that a variation of anomalies can be observed given any pathogenic variant in the GLI3 gene, but overall two dominant phenotypes are present. A population with predominantly preaxial anomalies and one with postaxial anomalies. The presence of preaxial or postaxial polydactyly and syndactyly is not mutually exclusive for one of these two subclasses. Meaning that preaxial polydactyly can co-occur with postaxial polydactyly. However, truncating mutations in the activator domain produce a postaxial phenotype, as can be derived from the risk in table 4.

The higher risk of corpus callosum agenesis in this population shows that differentiating between a preaxial phenotype and a postaxial phenotype, instead of between the different GLI3-mediated polydactyly syndromes, might be more relevant regarding diagnostics for corpus callosum agenesis.We chose to use LCA as an exploratory tool only in our population for two reasons. First of all, LCA can be useful to identify subgroups, but there is no ‘true’ model or number of subgroups you can detect. The best fitting model can only be estimated based on the available measures and approximates the true subgroups that might be present. Second, LC membership assignment is a statistical procedure based on the posterior probability, with concordant errors of the estimation, rather than a clinical value that can be measured or evaluated. Therefore, we decided to use our LCA only in an exploratory tool, and perform our statistics using the actual phenotypes that predict LC membership and the associated genotypes.

Overall, this method worked well to differentiate the two subgroups present in our dataset. However, outliers were observed. A qualitative analysis of these outliers is available in the online supplementary data.The genetic substrate for the two phenotypic clusters can be discussed based on multiple experiments. Overall, we hypothesise two genetic clusters. One that is due to haploinsufficiency and one that is due to abnormal truncation of the activator.

The hypothesised cluster of variants that produce haploinsufficiency is mainly based on the experimental data that confirms NMD in two variants and the NMD prediction of other nonsense variants in Alamut. For the frameshift variants, it is also likely that the cleavage of the zinc finger domain results in functional haploinsufficiency either because of a lack of signalling domains or similarly due to NMD. Missense variants could cause haploinsufficiency through the suggested mechanism by Krauss et al who have illustrated that missense variants in the MID1 domain hamper the functional interaction with the MID1-α4-PP2A complex, leading to a subcellular location of GLI3.24 The observed missense variants in our study exceed the region to which Krauss et al have limited the MID-1 interaction domain. An alternative theory is suggested by Zhou et al who have shown that missense variants in the MBD can cause deficiency in the signalling of GLI3A, functionally implicating a relative overexpression of GLI3R.22 However, GLI3R overexpression would likely produce a posterior phenotype, as determined by Hill et al in their fixed homo and hemizygous GLI3R models.15 Therefore, our hypothesis is that all included missense variants have a similar pathogenesis which is more likely in concordance with the mechanism introduced by Krauss et al. To our knowledge, no splice site variants have been functionally described in literature.

However, it is noted that the 15 and last exon encompasses the entire activator domain, thus any splice site mutation is by definition located on the 5′ side of the activator. Based on the phenotype, we would suggest that these variants fail to produce a functional protein. We hypothesise that the truncating variants of the activator domain lead to overexpression of GLI3R in SHH rich areas. In normal development, the presence of SHH prevents the processing of full length GLI34 into GLI3R, thus producing the full length activator. In patients with a truncating variant of the activator domain of GLI3, thus these variants likely have the largest effect in SHH rich areas, such as the ZPA located at the posterior side of the hand/footplate.

Moreover, the lack of posterior anomalies in the GLI3∆699/- mouse model (hemizygous fixed repressor model) compared with the GLI3∆699/∆699 mouse model (homozygous fixed repressor model), suggesting a dosage effect of GLI3R to be responsible for posterior hand anomalies.15 These findings are supported by Lewandowski et al, who show that the majority of the target genes in GLI signalling are regulated by GLI3R rather than GLI3A.44 Together, these findings suggest a role for the location and type of variant in GLI3-mediated syndromes.Interestingly, the difference between Pallister-Hall syndrome and GLI3-mediated polydactyly syndromes has also been attributed to the GLI3R overexpression. However, the difference in phenotype observed in the cases with a truncating variant in the activator domain and Pallister-Hall syndrome suggest different functional consequences. When studying figure 1, it is noted that the included truncating variants on the 3′ side of the cleavage site seldomly affect the CBP binding region, which could provide an explanation for the observed differences. This binding region is included in the Pallister-Hall region as defined by Johnston et al and is necessary for the downstream signalling with GLI1.10 11 23 45 Interestingly, recent reports show that pathogenic variants in GLI1 can produce phenotypes concordant with Ellis von Krefeld syndrome, which includes overlapping features with Pallister-Hall syndrome.46 The four truncating variants observed in this study that do affect the CBP but did not result in a Pallister-Hall phenotype are conflicting with this theory. Krauss et al postulate an alternative hypothesis, they state that the MID1-α4-PP2A complex, which is essential for GLI3A signalling, could also be the reason for overlapping features of Opitz syndrome, caused by variants in MID1, and Pallister-Hall syndrome.

Further analysis is required to fully appreciate the functional differences between truncating mutations that cause Pallister-Hall syndrome and those that result in GLI3-mediated polydactyly syndromes.For the clinical evaluation of patients with GLI3-mediated polydactyly syndromes, intracranial anomalies are likely the most important to predict based on the variant. Unfortunately, the presence of corpus callosum agenesis was not routinely investigated or reported thus this feature could not be used as an indicator phenotype for LC membership. Interestingly when using only hand and foot phenotypes, we did notice a higher prevalence of corpus callosum agenesis in patients with posterior phenotypes. The suggested relation between truncating mutations in the activator domain causing these posterior phenotypes and corpus callosum agenesis was statistically confirmed (OR. 8.8, p<0.001).

Functionally this relation could be caused by the GLI3-MED12 interaction at the MBD. Pathogenic DNA variants in MED12 can cause Opitz-Kaveggia syndrome, a syndrome in which presentation includes corpus callosum agenesis, broad halluces and thumbs.47In conclusion, there are two distinct phenotypes within the GLI3-mediated polydactyly population. Patients with more posteriorly and more anteriorly oriented hand anomalies. Furthermore, this difference is related to the observed variant in GLI3. We hypothesise that variants that cause haploinsufficiency produce anterior anomalies of the hand, whereas variants with abnormal truncation of the activator domain have more posterior anomalies.

Furthermore, patients that have a variant that produces abnormal truncation of the activator domain, have a greater risk for corpus callosum agenesis. Thus, we advocate to differentiate preaxial or postaxial oriented GLI3 phenotypes to explain the pathophysiology as well as to get a risk assessment for corpus callosum agenesis.Data availability statementData are available upon reasonable request.Ethics statementsPatient consent for publicationNot required.Ethics approvalThe research protocol was approved by the local ethics board of the Erasmus MC University Medical Center (MEC 2015-679)..

AbstractIntroduction http://morecookiesplease.com/sample-page/ low cost lasix. We report a very rare case of familial breast cancer and diffuse gastric cancer, with germline pathogenic variants in both BRCA1 and CDH1 genes. To the low cost lasix best of our knowledge, this is the first report of such an association.Family description. The proband is a woman diagnosed with breast cancer at the age of 52 years. She requested genetic counselling in 2012, at the age of 91 years, because of a history of breast cancer in her daughter, her low cost lasix sister, her niece and her paternal grandmother and was therefore concerned about her relatives.

Her sister and maternal aunt also had gastric cancer. She was tested for several genes associated with low cost lasix hereditary breast cancer.Results. A large deletion of BRCA1 from exons 1 to 7 and two CDH1 pathogenic cis variants were identified.Conclusion. This complex situation is challenging for genetic counselling and low cost lasix management of at-risk individuals.cancer. Breastcancer.

Gastricclinical geneticsgenetic screening/counsellingmolecular geneticsIntroductionGLI-Kruppel family member 3 (GLI3) encodes low cost lasix for a zinc finger transcription factor which plays a key role in the sonic hedgehog (SHH) signalling pathway essential in both limb and craniofacial development.1 2 In hand development, SHH is expressed in the zone of polarising activity (ZPA) on the posterior side of the handplate. The ZPA expresses SHH, creating a gradient of SHH from the posterior to the anterior side of the handplate. In the presence of SHH, full length GLI3-protein is produced (GLI3A), whereas low cost lasix absence of SHH causes cleavage of GLI3 into its repressor form (GLI3R).3 4 Abnormal expression of this SHH/GLI3R gradient can cause both preaxial and postaxial polydactyly.2Concordantly, pathogenic DNA variants in the GLI3 gene are known to cause multiple syndromes with craniofacial and limb involvement, such as. Acrocallosal syndrome5 (OMIM. 200990), Greig cephalopolysyndactyly syndrome6 low cost lasix (OMIM.

175700) and Pallister-Hall syndrome7 (OMIM. 146510). Also, in non-syndromic polydactyly, such as preaxial polydactyly-type 4 (PPD4, OMIM. 174700),8 pathogenic variants in GLI3 have been described. Out of these diseases, Pallister-Hall syndrome is the most distinct entity, defined by the presence of central polydactyly and hypothalamic hamartoma.9 The other GLI3 syndromes are defined by the presence of preaxial and/or postaxial polydactyly of the hand and feet with or without syndactyly (Greig syndrome, PPD4).

Also, various mild craniofacial features such as hypertelorism and macrocephaly can occur. Pallister-Hall syndrome is caused by truncating variants in the middle third of the GLI3 gene.10–12 The truncation of GLI3 causes an overexpression of GLI3R, which is believed to be the key difference between Pallister-Hall and the GLI3-mediated polydactyly syndromes.9 11 Although multiple attempts have been made, the clinical and genetic distinction between the GLI3-mediated polydactyly syndromes is less evident. This has for example led to the introduction of subGreig and the formulation of an Oro-facial-digital overlap syndrome.10 Other authors, suggested that we should not regard these diseases as separate entities, but as a spectrum of GLI3-mediated polydactyly syndromes.13Although phenotype/genotype correlation of the different syndromes has been cumbersome, clinical and animal studies do provide evidence that distinct regions within the gene, could be related to the individual anomalies contributing to these syndromes. First, case studies show isolated preaxial polydactyly is caused by both truncating and non-truncating variants throughout the GLI3 gene, whereas in isolated postaxial polydactyly cases truncating variants at the C-terminal side of the gene are observed.12 14 These results suggest two different groups of variants for preaxial and postaxial polydactyly. Second, recent animal studies suggest that posterior malformations in GLI3-mediated polydactyly syndromes are likely related to a dosage effect of GLI3R rather than due to the influence of an altered GLI3A expression.15Past attempts for phenotype/genotype correlation in GLI3-mediated polydactyly syndromes have directly related the diagnosed syndrome to the observed genotype.10–12 16 Focusing on individual hand phenotypes, such as preaxial and postaxial polydactyly and syndactyly might be more reliable because it prevents misclassification due to inconsistent use of syndrome definition.

Subsequently, latent class analysis (LCA) provides the possibility to relate a group of observed variables to a set of latent, or unmeasured, parameters and thereby identifying different subgroups in the obtained dataset.17 As a result, LCA allows us to group different phenotypes within the GLI3-mediated polydactyly syndromes and relate the most important predictors of the grouped phenotypes to the observed GLI3 variants.The aim of our study was to further investigate the correlation of the individual phenotypes to the genotypes observed in GLI3-mediated polydactyly syndromes, using LCA. Cases were obtained by both literature review and the inclusion of local clinical cases. Subsequently, we identified two subclasses of limb anomalies that relate to the underlying GLI3 variant. We provide evidence for two different phenotypic and genotypic groups with predominantly preaxial and postaxial hand and feet anomalies, and we specify those cases with a higher risk for corpus callosum anomalies.MethodsLiterature reviewThe Human Gene Mutation Database (HGMD Professional 2019) was reviewed to identify known pathogenic variants in GLI3 and corresponding phenotypes.18 All references were obtained and cases were included when they were diagnosed with either Greig or subGreig syndrome or PPD4.10–12 Pallister-Hall syndrome and acrocallosal syndrome were excluded because both are regarded distinct syndromes and rather defined by the presence of the non-hand anomalies, than the presence of preaxial or postaxial polydactyly.13 19 Isolated preaxial or postaxial polydactyly were excluded for two reasons. The phenotype/genotype correlations are better understood and both anomalies can occur sporadically which could introduce falsely assumed pathogenic GLI3 variants in the analysis.

Additionally, cases were excluded when case-specific phenotypic or genotypic information was not reported or if these two could not be related to each other. Families with a combined phenotypic description, not reducible to individual family members, were included as one case in the analysis.Clinical casesThe Sophia Children’s Hospital Database was reviewed for cases with a GLI3 variant. Within this population, the same inclusion criteria for the phenotype were valid. Relatives of the index patients were also contacted for participation in this study, when they showed comparable hand, foot, or craniofacial malformations or when a GLI3 variant was identified. Phenotypes of the hand, foot and craniofacial anomalies of the patients treated in the Sophia Children's Hospital were collected using patient documentation.

Family members were identified and if possible, clinically verified. Alternatively, family members were contacted to verify their phenotypes. If no verification was possible, cases were excluded.PhenotypesThe phenotypes of both literature cases and local cases were extracted in a similar fashion. The most frequently reported limb and craniofacial phenotypes were dichotomised. The dichotomised hand and foot phenotypes were preaxial polydactyly, postaxial polydactyly and syndactyly.

Broad halluces or thumbs were commonly reported by authors and were dichotomised as a presentation of preaxial polydactyly. The extracted dichotomised craniofacial phenotypes were hypertelorism, macrocephaly and corpus callosum agenesis. All other phenotypes were registered, but not dichotomised.Pathogenic GLI3 variantsAll GLI3 variants were extracted and checked using Alamut Visual V.2.14. If indicated, variants were renamed according to standard Human Genome Variation Society nomenclature.20 Variants were grouped in either missense, frameshift, nonsense or splice site variants. In the group of frameshift variants, a subgroup with possible splice site effect were identified for subgroup analysis when indicated.

Similarly, nonsense variants prone for nonsense mediated decay (NMD) and nonsense variants with experimentally confirmed NMD were identified.21 Deletions of multiple exons, CNVs and translocations were excluded for analysis. A full list of included mutations is available in the online supplementary materials.Supplemental materialThe location of the variant was compared with five known structural domains of the GLI3 gene. (1) repressor domain, (2) zinc finger domain, (3) cleavage site, (4) activator domain, which we defined as a concatenation of the separately identified transactivation zones, the CBP binding domain and the mediator binding domain (MBD) and (5) the MID1 interaction region domain.1 6 22–24 The boundaries of each of the domains were based on available literature (figure 1, exact locations available in the online supplementary materials). The boundaries used by different authors did vary, therefore a consensus was made.In this figure the posterior probability of an anterior phenotype is plotted against the location of the variant, stratified for the type of mutation that was observed. For better overview, only variants with a location effect were displayed.

The full figure, including all variant types, can be found in the online supplementary figure 1. Each mutation is depicted as a dot, the size of the dot represents the number of observations for that variant. If multiple observations were made, the mean posterior odds and IQR are plotted. For the nonsense variants, variants that were predicted to produce nonsense mediated decay, are depicted using a triangle. Again, the size indicates the number of observations." data-icon-position data-hide-link-title="0">Figure 1 In this figure the posterior probability of an anterior phenotype is plotted against the location of the variant, stratified for the type of mutation that was observed.

For better overview, only variants with a location effect were displayed. The full figure, including all variant types, can be found in the online supplementary figure 1. Each mutation is depicted as a dot, the size of the dot represents the number of observations for that variant. If multiple observations were made, the mean posterior odds and IQR are plotted. For the nonsense variants, variants that were predicted to produce nonsense mediated decay, are depicted using a triangle.

Again, the size indicates the number of observations.Supplemental materialLatent class analysisTo cluster phenotypes and relate those to the genotypes of the patients, an explorative analysis was done using LCA in R (R V.3.6.1 for Mac. Polytomous variable LCA, poLCA V.1.4.1.). We used our LCA to detect the number of phenotypic subgroups in the dataset and subsequently predict a class membership for each case in the dataset based on the posterior probabilities.In order to make a reliable prediction, only phenotypes that were sufficiently reported and/or ruled out were feasible for LCA, limiting the analysis to preaxial polydactyly, postaxial polydactyly and syndactyly of the hands and feet. Only full cases were included. To determine the optimal number of classes, we fitted a series of models ranging from a one-class to a six-class model.

The optimal number of classes was based on the conditional Akaike information criterion (cAIC), the non adjusted and the sample-size adjusted Bayesian information criterion (BIC and aBIC) and the obtained entropy.25 The explorative LCA produces both posterior probabilities per case for both classes and predicted class membership. Using the predicted class membership, the phenotypic features per class were determined in a univariate analysis (χ2, SPSS V.25). Using the posterior probabilities on latent class (LC) membership, a scatter plot was created using the location of the variant on the x-axis and the probability of class membership on the y-axis for each of the types of variants (Tibco Spotfire V.7.14). Using these scatter plots, variants that give similar phenotypes were clustered.Genotype/phenotype correlationBecause an LC has no clinical value, the correlation between genotypes and phenotypes was investigated using the predictor phenotypes and the clustered phenotypes. First, those phenotypes that contribute most to LC membership were identified.

Second those phenotypes were directly related to the different types of variants (missense, nonsense, frameshift, splice site) and their clustered locations. Quantification of the relation was performed using a univariate analysis using a χ2 test. Because of our selection criteria, meaning patients at least have two phenotypes, a multivariate using a logistic regression analysis was used to detect the most significant predictors in the overall phenotype (SPSS V.25). Finally, we explored the relation of the clustered genotypes to the presence of corpus callosum agenesis, a rare malformation in GLI3-mediated polydactyly syndromes which cannot be readily diagnosed without additional imaging.ResultsWe included 251 patients from the literature and 46 local patients,10–12 16 21 26–43 in total 297 patients from 155 different families with 127 different GLI3 variants, 32 of which were large deletions, CNVs or translocations. In six local cases, the exact variant could not be retrieved by status research.The distribution of the most frequently observed phenotypes and variants are presented in table 1.

Other recurring phenotypes included developmental delay (n=22), broad nasal root (n=23), frontal bossing or prominent forehead (n=16) and craniosynostosis (n=13), camptodactyly (n=8) and a broad first interdigital webspace of the foot (n=6).View this table:Table 1 Baseline phenotypes and genotypes of selected populationThe LCA model was fitted using the six defined hand/foot phenotypes. Model fit indices for the LCA are displayed in table 2. Based on the BIC, a two-class model has the best fit for our data. The four-class model does show a gain in entropy, however with a higher BIC and loss of df lasix 100mg price. Therefore, based on the majority of performance statistics and the interpretability of the model, a two-class model was chosen.

Table 3 displays the distribution of phenotypes and genotypes over the two classes.View this table:Table 2 Model fit indices for the one-class through six-class model evaluated in our LCAView this table:Table 3 Distribution of phenotypes and genotypes in the two latent classes (LC)Table 1 depicts the baseline phenotypes and genotypes in the obtained population. Note incomplete data especially in the cranium phenotypes. In total 259 valid genotypes were present. In total, 289 cases had complete data for all hand and foot phenotypes (preaxial polydactyly, postaxial polydactyly and syndactyly) and thus were available for LCA. Combined, for phenotype/genotype correlation 258 cases were available with complete genotypes and complete hand and foot phenotypes.Table 2 depicts the model fit indices for all models that have been fitted to our data.Table 3 depicts the distribution of phenotypes and genotypes over the two assigned LCs.

Hand and foot phenotypes were used as input for the LCA, thus are all complete cases. Malformation of the cranium and genotypes do have missing cases. Note that for the LCA, full case description was required, resulting in eight cases due to incomplete phenotypes. Out of these eight, one also had a genotype that thus needed to be excluded. Missingness of genotypic data was higher in LC2, mostly due to CNVs (table 1).In 54/60 cases, a missense variant produced a posterior phenotype.

Likewise, splice site variants show the same phenotype in 23/24 cases (table 3). For both frameshift and nonsense variants, this relation is not significant (52 anterior vs 54 posterior and 26 anterior vs 42 posterior, respectively). Therefore, only for nonsense and frameshift variants the location of the variant was plotted against the probability for LC2 membership in figure 1. A full scatterplot of all variants is available in online supplementary figure 1.Figure 1 reveals a pattern for these nonsense and frameshift variants that reveals that variants at the C-terminal of the gene predict anterior phenotypes. When relating the domains of the GLI3 protein to the observed phenotype, we observe that the majority of patients with a nonsense or frameshift variant in the repressor domain, the zinc finger domain or the cleavage site had a high probability of an LC2/anterior phenotype.

This group contains all variants that are either experimentally determined to be subject to NMD (triangle marker in figure 1) or predicted to be subject to NMD (diamond marker in figure 1). Frameshift and nonsense variants in the activator domain result in high probability for an LC1/posterior phenotype. These variants will be further referred to as truncating variants in the activator domain.The univariate relation of the individual phenotypes to these two groups of variants are estimated and presented in table 4. In our multivariate analysis, postaxial polydactyly of the foot and hand are the strongest predictors (Beta. 2.548, p<0001 and Beta.

1.47, p=0.013, respectively) for patients to have a truncating variant in the activator domain. Moreover, the effect sizes of preaxial polydactyly of the hand and feet (Beta. ˆ’0.797, p=0123 and −1.772, p=0.001) reveals that especially postaxial polydactyly of the foot is the dominant predictor for the genetic substrate of the observed anomalies.View this table:Table 4 Univariate and multivariate analysis of the phenotype/genotype correlationTable 4 shows exploration of the individual phenotypes on the genotype, both univariate and multivariate. The multivariate analysis corrects for the presence of multiple phenotypes in the underlying population.Although the craniofacial anomalies could not be included in the LCA, the relation between the observed anomalies and the identified genetic substrates can be studied. The prevalence of hypertelorism was equally distributed over the two groups of variants (47/135 vs 21/47 respectively, p<0.229).

However for corpus callosum agenesis and macrocephaly, there was a higher prevalence in patients with a truncating variant in the activator domain (3/75 vs 11/41, p<0.001. OR. 8.8, p<0.001) and 42/123 vs 24/48, p<0.05). Noteworthy is the fact that 11/14 cases with corpus callosum agenesis in the dataset had a truncating variant in the activator domain.DiscussionIn this report, we present new insights into the correlation between the phenotype and the genotype in patients with GLI3-mediated polydactyly syndromes. We illustrate that there are two LCs of patients, best predicted by postaxial polydactyly of the hand and foot for LC1, and the preaxial polydactyly of the hand and foot and syndactyly of the foot for LC2.

Patients with postaxial phenotypes have a higher risk of having a truncating variant in the activator domain of the GLI3 gene which is also related to a higher risk of corpus callosum agenesis. These results suggest a functional difference between truncating variants on the N-terminal and the C-terminal side of the GLI3 cleavage site.Previous attempts of phenotype to genotype correlation have not yet provided the clinical confirmation of these assumed mechanisms in the pathophysiology of GLI3-mediated polydactyly syndromes. Johnston et al have successfully determined the Pallister-Hall region in which truncating variants produce a Pallister-Hall phenotype rather than Greig syndrome.11 However, in their latest population study, subtypes of both syndromes were included to explain the full spectrum of observed malformations. In 2015, Demurger et al reported the higher incidence of corpus callosum agenesis in the Greig syndrome population with truncating mutations in the activator domain.12 Al-Qattan in his review summarises the concept of a spectrum of anomalies dependent on haplo-insufficiency (through different mechanisms) and repressor overexpression.13 However, he bases this theory mainly on reviewed experimental data. Our report is the first to provide an extensive clinical review of cases that substantiate the phenotypic difference between the two groups that could fit the suggested mechanisms.

We agree with Al-Qattan et al that a variation of anomalies can be observed given any pathogenic variant in the GLI3 gene, but overall two dominant phenotypes are present. A population with predominantly preaxial anomalies and one with postaxial anomalies. The presence of preaxial or postaxial polydactyly and syndactyly is not mutually exclusive for one of these two subclasses. Meaning that preaxial polydactyly can co-occur with postaxial polydactyly. However, truncating mutations in the activator domain produce a postaxial phenotype, as can be derived from the risk in table 4.

The higher risk of corpus callosum agenesis in this population shows that differentiating between a preaxial phenotype and a postaxial phenotype, instead of between the different GLI3-mediated polydactyly syndromes, might be more relevant regarding diagnostics for corpus callosum agenesis.We chose to use LCA as an exploratory tool only in our population for two reasons. First of all, LCA can be useful to identify subgroups, but there is no ‘true’ model or number of subgroups you can detect. The best fitting model can only be estimated based on the available measures and approximates the true subgroups that might be present. Second, LC membership assignment is a statistical procedure based on the posterior probability, with concordant errors of the estimation, rather than a clinical value that can be measured or evaluated. Therefore, we decided to use our LCA only in an exploratory tool, and perform our statistics using the actual phenotypes that predict LC membership and the associated genotypes.

Overall, this method worked well to differentiate the two subgroups present in our dataset. However, outliers were observed. A qualitative analysis of these outliers is available in the online supplementary data.The genetic substrate for the two phenotypic clusters can be discussed based on multiple experiments. Overall, we hypothesise two genetic clusters. One that is due to haploinsufficiency and one that is due to abnormal truncation of the activator.

The hypothesised cluster of variants that produce haploinsufficiency is mainly based on the experimental data that confirms NMD in two variants and the NMD prediction of other nonsense variants in Alamut. For the frameshift variants, it is also likely that the cleavage of the zinc finger domain results in functional haploinsufficiency either because of a lack of signalling domains or similarly due to NMD. Missense variants could cause haploinsufficiency through the suggested mechanism by Krauss et al who have illustrated that missense variants in the MID1 domain hamper the functional interaction with the MID1-α4-PP2A complex, leading to a subcellular location of GLI3.24 The observed missense variants in our study exceed the region to which Krauss et al have limited the MID-1 interaction domain. An alternative theory is suggested by Zhou et al who have shown that missense variants in the MBD can cause deficiency in the signalling of GLI3A, functionally implicating a relative overexpression of GLI3R.22 However, GLI3R overexpression would likely produce a posterior phenotype, as determined by Hill et al in their fixed homo and hemizygous GLI3R models.15 Therefore, our hypothesis is that all included missense variants have a similar pathogenesis which is more likely in concordance with the mechanism introduced by Krauss et al. To our knowledge, no splice site variants have been functionally described in literature.

However, it is noted that the 15 and last exon encompasses the entire activator domain, thus any splice site mutation is by definition located on the 5′ side of the activator. Based on the phenotype, we would suggest that these variants fail to produce a functional protein. We hypothesise that the truncating variants of the activator domain lead to overexpression of GLI3R in SHH rich areas. In normal development, the presence of SHH prevents the processing of full length GLI34 into GLI3R, thus producing the full length activator. In patients with a truncating variant of the activator domain of GLI3, thus these variants likely have the largest effect in SHH rich areas, such as the ZPA located at the posterior side of the hand/footplate.

Moreover, the lack of posterior anomalies in the GLI3∆699/- mouse model (hemizygous fixed repressor model) compared with the GLI3∆699/∆699 mouse model (homozygous fixed repressor model), suggesting a dosage effect of GLI3R to be responsible for posterior hand anomalies.15 These findings are supported by Lewandowski et al, who show that the majority of the target genes in GLI signalling are regulated by GLI3R rather than GLI3A.44 Together, these findings suggest a role for the location and type of variant in GLI3-mediated syndromes.Interestingly, the difference between Pallister-Hall syndrome and GLI3-mediated polydactyly syndromes has also been attributed to the GLI3R overexpression. However, the difference in phenotype observed in the cases with a truncating variant in the activator domain and Pallister-Hall syndrome suggest different functional consequences. When studying figure 1, it is noted that the included truncating variants on the 3′ side of the cleavage site seldomly affect the CBP binding region, which could provide an explanation for the observed differences. This binding region is included in the Pallister-Hall region as defined by Johnston et al and is necessary for the downstream signalling with GLI1.10 11 23 45 Interestingly, recent reports show that pathogenic variants in GLI1 can produce phenotypes concordant with Ellis von Krefeld syndrome, which includes overlapping features with Pallister-Hall syndrome.46 The four truncating variants observed in this study that do affect the CBP but did not result in a Pallister-Hall phenotype are conflicting with this theory. Krauss et al postulate an alternative hypothesis, they state that the MID1-α4-PP2A complex, which is essential for GLI3A signalling, could also be the reason for overlapping features of Opitz syndrome, caused by variants in MID1, and Pallister-Hall syndrome.

Further analysis is required to fully appreciate the functional differences between truncating mutations that cause Pallister-Hall syndrome and those that result in GLI3-mediated polydactyly syndromes.For the clinical evaluation of patients with GLI3-mediated polydactyly syndromes, intracranial anomalies are likely the most important to predict based on the variant. Unfortunately, the presence of corpus callosum agenesis was not routinely investigated or reported thus this feature could not be used as an indicator phenotype for LC membership. Interestingly when using only hand and foot phenotypes, we did notice a higher prevalence of corpus callosum agenesis in patients with posterior phenotypes. The suggested relation between truncating mutations in the activator domain causing these posterior phenotypes and corpus callosum agenesis was statistically confirmed (OR. 8.8, p<0.001).

Functionally this relation could be caused by the GLI3-MED12 interaction at the MBD. Pathogenic DNA variants in MED12 can cause Opitz-Kaveggia syndrome, a syndrome in which presentation includes corpus callosum agenesis, broad halluces and thumbs.47In conclusion, there are two distinct phenotypes within the GLI3-mediated polydactyly population. Patients with more posteriorly and more anteriorly oriented hand anomalies. Furthermore, this difference is related to the observed variant in GLI3. We hypothesise that variants that cause haploinsufficiency produce anterior anomalies of the hand, whereas variants with abnormal truncation of the activator domain have more posterior anomalies.

Furthermore, patients that have a variant that produces abnormal truncation of the activator domain, have a greater risk for corpus callosum agenesis. Thus, we advocate to differentiate preaxial or postaxial oriented GLI3 phenotypes to explain the pathophysiology as well as to get a risk assessment for corpus callosum agenesis.Data availability statementData are available upon reasonable request.Ethics statementsPatient consent for publicationNot required.Ethics approvalThe research protocol was approved by the local ethics board of the Erasmus MC University Medical Center (MEC 2015-679)..

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Ethacrynic acid to lasix conversion

hypertension medications impact on cisgender ethacrynic acid to lasix conversion gay men and other men who have sex with men (MSM) http://augenaerzte-georgstr.de/viagra-best-price/ on a global scaleThe hypertension medications lasix is thought to disproportionately threaten the health of underserved and underinvestigated populations. To investigate the impact of hypertension medications transmission mitigation measures on MSM, an international team did a cross-sectional study that included 2732 MSM from 103 countries ethacrynic acid to lasix conversion who responded to a questionnaire distributed through a gay social networking app. Findings suggest that the spread of hypertension medications, and the global response to contain it, has variably disrupted economic, mental health, general health and clinical services among MSM populations, with a greater impact on those living with HIV, racial/ethnic minorities, immigrants, sex workers and socioeconomically disadvantaged groups.

As hypertension medications may deepen health disparities and social inequalities, continued monitoring and creative strategies are needed ethacrynic acid to lasix conversion to mitigate reduction in access to services for MSM with intersecting vulnerabilities.Santos GM, Ackerman B, Rao A, et al. Economic, mental health, HIV prevention and HIV treatment impacts of hypertension medications and the hypertension medications response on a global sample of cisgender gay men and other men who have sex with men. AIDS Beha 2020 ethacrynic acid to lasix conversion.

11:1–11.https://doi.org/10.1007/s10461-020-02969-0Influence of sexual positioning on syphilis acquisition ethacrynic acid to lasix conversion and its stage at diagnosisIn a retrospective study of MSM in Melbourne, Australia, researchers examined the association between sexual positioning and a diagnosis of primary (n=338) or secondary (n=221) syphilis. Of 247 penile chancres, 244 (98.7%) occurred in MSM who reported versatile or exclusive top sexual positioning. Of 77 anal chancres, 75 (97.4%) occurred in MSM who reported versatile or ethacrynic acid to lasix conversion exclusive bottom sexual positioning.

MSM who practised receptive anal sex were more likely to present with secondary rather than primary syphilis (OR 3.90. P<0.001, adjusted ethacrynic acid to lasix conversion for age, HIV status and condom use). This suggests that because anorectal chancres are less noticeable, they are less likely to prompt evaluation.

Findings highlight the need for improved screening of ethacrynic acid to lasix conversion MSM who report receptive anal sex to ensure early syphilis detection and treatment.Cornelisse VJ, Chow EPF, Latimer RL, et al. Getting to the bottom ethacrynic acid to lasix conversion of it. Sexual positioning and stage of syphilis at diagnosis, and implications for syphilis screening.

Clin Infect Dis ethacrynic acid to lasix conversion 2020;71(2):318–322. Https://doi.org/10.1093/cid/ciz802A novel rapid, point-of-care test (POCT) for confirmatory testing of active syphilis The re-emergence of syphilis is a global public health concern especially in resource-limited settings. Current POCTs detect Treponema pallidum (TP) total antibodies but do not distinguish between ethacrynic acid to lasix conversion active and past/treated syphilis, resulting in potential overtreatment and contributing to shortages of penicillin.

A new, investigational POCT based on the detection of TP-IgA was evaluated against standard laboratory-based serological tests in 458 stored plasma samples from China and 503 venous blood samples from South Africa. Sensitivity and specificity of ethacrynic acid to lasix conversion TP-IgA POCT for identifying active syphilis were 96.1% (95% CI. 91.7% to ethacrynic acid to lasix conversion 98.5%) and 84.7% (95% CI.

80.1% to 88.6%) in Chinese samples, and 100% (95% CI. 59% to ethacrynic acid to lasix conversion 100%) and 99.4% (95% CI. 98.2% to 99.9%) in South African samples, respectively.

These preliminary findings suggest that this TP-IgA-based POCT meets the WHO target product profile for confirmatory diagnosis of active ethacrynic acid to lasix conversion syphilis.Pham MD, Wise A, Garcia ML, et al. Improving the coverage and accuracy of syphilis testing. The development ethacrynic acid to lasix conversion of a novel rapid, point-of-care test for confirmatory testing of active syphilis and its early evaluation in China and South Africa.

EClinicalMedicine 2020;24:100440 ethacrynic acid to lasix conversion. Https://doi.org/10.1016/j.eclinm.2020.100440Early antiretroviral therapy (ART) initiation and wide coverage reduces population-level HIV s in FranceIn 2013, France implemented the early initiation of ART irrespective of CD4 counts to fast-track progress toward UNAIDS (Joint United Nations Programme on HIV/AIDS) 90-90-90 goals (90% of people with HIV diagnosed, 90% on ART, 90% virologically suppressed).1 An analysis of 61 822 HIV-diagnosed people within the national Dat’AIDS prospective cohort study shows that 91.9% of HIV-diagnosed people were receiving ART by 2014 and 90.5% were virologically suppressed by 2013. This was accompanied by a 36% and 25% decrease in the number of primary (diagnosed with symptoms of acute HIV) ethacrynic acid to lasix conversion and recent HIV (diagnosed with CD4 cell count ≥500/mm3), respectively, between 2013 and 2017.

These findings on two of three goals support the effectiveness of ‘Treatment as Prevention’ in dramatically reducing HIV incidence at the population level.Le Guillou A, Pugliese P, Raffi F, Cabie A, Cuzin L, Katlama C, et al. Reaching the second and third joint United Nations Programme on Human Immunodeficiency lasix ethacrynic acid to lasix conversion (HIV)/AIDS 90-90-90 targets is accompanied by a dramatic reduction in primary HIV and in recent HIV s in a large French nationwide HIV cohort. Clinical Infectious Diseases 2019;71(2):293–300.

Https://doi.org/10.1093/cid/ciz800No evidence of an association ethacrynic acid to lasix conversion between human papillomalasix (HPV) vaccination and infertilityDespite well-established evidence of effectiveness and safety, HPV treatment uptake remains below target in many countries, often due to safety concerns. To evaluate claims that HPV vaccination increases female infertility, researchers analysed 2013–2016 National Health and Nutrition Examination Survey data from 1114 US women aged 20 ethacrynic acid to lasix conversion to 33 years—those young enough to have been offered HPV treatments and old enough to have been asked about infertility. The 8.1% of women who self-reported infertility were neither more nor less likely to have received an HPV treatment.

Vaccinated women who had ever been married were less likely to report infertility ethacrynic acid to lasix conversion. Findings should engender confidence among healthcare providers, whose recommendation is a key factor in patients’ acceptance of HPV vaccination.Schmuhl N, Mooney KE, Zhang X, Cooney LG, Conway JH, and LoCont NK. No association between HPV vaccination and infertility in ethacrynic acid to lasix conversion U.S.

Females 18–33 years old. treatment 2020;38(24):4038–4043 ethacrynic acid to lasix conversion. Https://doi.org/10.1016/j.treatment.2020.03.035A pay-it-forward approach to ethacrynic acid to lasix conversion improve uptake of gonorrhoea and chlamydia testingDespite WHO recommendations that MSM receive gonorrhoea and chlamydia testing, affordability remains a barrier in many countries.

In a randomised trial, researchers tested three incentivising strategies, randomising 301 MSM in MSM-run community-based organisations in Guangzhou and Beijing, China. Gonorrhoea and chlamydia test uptake was 56% in the ethacrynic acid to lasix conversion pay-it-forward arm (free testing and an invitation to donate to a future person’s test), 46% in a pay-what-you-want arm and 18% in the standard-cost arm (¥150, €1.2). The estimated difference in test uptake between pay-it-forward and standard cost was 38.4% (95% CI lower bound 28.4%).

Almost 95% of MSM ethacrynic acid to lasix conversion in the pay-it-forward arm donated to testing for future participants. The pay-it-forward strategy significantly increased gonorrhoea and chlamydia testing uptake in China and has potential to drive testing in other settings.Yang F, Zhang TP, Tang W, Ong JJ, Alexander M, Forastiere L, Kumar N, Li KT, Zou F, Yang L, Mi G, Wang Y, Huang W, Lee A, Zhu W, Luo D, Vickerman P, Wu D, Yang B, Christakis NA, Tucker JD. Pay-it-forward gonorrhoea and chlamydia testing among men who have sex with men ethacrynic acid to lasix conversion in China.

A randomised ethacrynic acid to lasix conversion controlled trial. Lancet Infect Dis 2020;20(8)976-982. Https://doi.org/10.1016/S1473-3099(20)30172-9The Shape of Training review1 and the Future Hospital Commission2 identified the need for a reform of postgraduate medical training in the UK for doctors to adapt to changing population and service needs ethacrynic acid to lasix conversion.

The focus of postgraduate training needed to move from a ‘time-served’ approach to a competency-based one with doctors developing high-level learning outcomes, capabilities in practice (CiPs). The General Medical Council (GMC) also recommended that all revised curricula from 2020 should include generic professional capabilities (GPCs), including communication, leadership, multidisciplinary teamwork and patient safety, which are crucial to safe and effective patient care.Genitourinary medicine (GUM), along with many other physicianly specialities, will adopt a dual training model from August 2022, leading to accreditation in both GUM and general ethacrynic acid to lasix conversion internal medicine (GIM). The GUM curriculum will continue to offer training in the diagnosis, investigation and management of sexually transmitted s and related conditions, contraception, HIV inpatient and outpatient care, management of ….

hypertension medications impact on cisgender gay men and other men who have sex with men (MSM) on a global scaleThe hypertension medications lasix is thought to disproportionately threaten the health of low cost lasix underserved and underinvestigated populations. To investigate the impact of hypertension medications transmission mitigation measures on MSM, an international team did a cross-sectional study that included 2732 MSM from 103 countries who low cost lasix responded to a questionnaire distributed through a gay social networking app. Findings suggest that the spread of hypertension medications, and the global response to contain it, has variably disrupted economic, mental health, general health and clinical services among MSM populations, with a greater impact on those living with HIV, racial/ethnic minorities, immigrants, sex workers and socioeconomically disadvantaged groups. As hypertension medications may deepen health disparities and social inequalities, continued monitoring and creative strategies are needed to mitigate reduction in access to services for MSM with low cost lasix intersecting vulnerabilities.Santos GM, Ackerman B, Rao A, et al. Economic, mental health, HIV prevention and HIV treatment impacts of hypertension medications and the hypertension medications response on a global sample of cisgender gay men and other men who have sex with men.

AIDS Beha 2020 low cost lasix. 11:1–11.https://doi.org/10.1007/s10461-020-02969-0Influence of sexual positioning on syphilis acquisition and its stage at diagnosisIn a retrospective study of MSM in Melbourne, Australia, researchers examined the association between sexual positioning and a low cost lasix diagnosis of primary (n=338) or secondary (n=221) syphilis. Of 247 penile chancres, 244 (98.7%) occurred in MSM who reported versatile or exclusive top sexual positioning. Of 77 anal chancres, 75 low cost lasix (97.4%) occurred in MSM who reported versatile or exclusive bottom sexual positioning. MSM who practised receptive anal sex were more likely to present with secondary rather than primary syphilis (OR 3.90.

P<0.001, adjusted for low cost lasix age, HIV status and condom use). This suggests that because anorectal chancres are less noticeable, they are less likely to prompt evaluation. Findings highlight the need for improved screening of MSM who report receptive anal sex to ensure early syphilis detection and treatment.Cornelisse VJ, Chow EPF, Latimer RL, low cost lasix et al. Getting to the low cost lasix bottom of it. Sexual positioning and stage of syphilis at diagnosis, and implications for syphilis screening.

Clin Infect low cost lasix Dis 2020;71(2):318–322. Https://doi.org/10.1093/cid/ciz802A novel rapid, point-of-care test (POCT) for confirmatory testing of active syphilis The re-emergence of syphilis is a global public health concern especially in resource-limited settings. Current POCTs low cost lasix detect Treponema pallidum (TP) total antibodies but do not distinguish between active and past/treated syphilis, resulting in potential overtreatment and contributing to shortages of penicillin. A new, investigational POCT based on the detection of TP-IgA was evaluated against standard laboratory-based serological tests in 458 stored plasma samples from China and 503 venous blood samples from South Africa. Sensitivity and specificity of TP-IgA POCT for low cost lasix identifying active syphilis were 96.1% (95% CI.

91.7% to low cost lasix 98.5%) and 84.7% (95% CI. 80.1% to 88.6%) in Chinese samples, and 100% (95% CI. 59% to 100%) low cost lasix and 99.4% (95% CI. 98.2% to 99.9%) in South African samples, respectively. These preliminary findings suggest that this TP-IgA-based POCT meets the WHO low cost lasix target product profile for confirmatory diagnosis of active syphilis.Pham MD, Wise A, Garcia ML, et al.

Improving the coverage and accuracy of syphilis testing. The development of a novel rapid, point-of-care low cost lasix test for confirmatory testing of active syphilis and its early evaluation in China and South Africa. EClinicalMedicine 2020;24:100440 low cost lasix. Https://doi.org/10.1016/j.eclinm.2020.100440Early antiretroviral therapy (ART) initiation and wide coverage reduces population-level HIV s in FranceIn 2013, France implemented the early initiation of ART irrespective of CD4 counts to fast-track progress toward UNAIDS (Joint United Nations Programme on HIV/AIDS) 90-90-90 goals (90% of people with HIV diagnosed, 90% on ART, 90% virologically suppressed).1 An analysis of 61 822 HIV-diagnosed people within the national Dat’AIDS prospective cohort study shows that 91.9% of HIV-diagnosed people were receiving ART by 2014 and 90.5% were virologically suppressed by 2013. This was accompanied low cost lasix by a 36% and 25% decrease in the number of primary (diagnosed with symptoms of acute HIV) and recent HIV (diagnosed with CD4 cell count ≥500/mm3), respectively, between 2013 and 2017.

These findings on two of three goals support the effectiveness of ‘Treatment as Prevention’ in dramatically reducing HIV incidence at the population level.Le Guillou A, Pugliese P, Raffi F, Cabie A, Cuzin L, Katlama C, et al. Reaching the second and third joint United Nations Programme on Human Immunodeficiency lasix (HIV)/AIDS 90-90-90 targets is accompanied low cost lasix by a dramatic reduction in primary HIV and in recent HIV s in a large French nationwide HIV cohort. Clinical Infectious Diseases 2019;71(2):293–300. Https://doi.org/10.1093/cid/ciz800No evidence of an association between human papillomalasix (HPV) vaccination and infertilityDespite well-established evidence of effectiveness and safety, HPV treatment low cost lasix uptake remains below target in many countries, often due to safety concerns. To evaluate low cost lasix claims that HPV vaccination increases female infertility, researchers analysed 2013–2016 National Health and Nutrition Examination Survey data from 1114 US women aged 20 to 33 years—those young enough to have been offered HPV treatments and old enough to have been asked about infertility.

The 8.1% of women who self-reported infertility were neither more nor less likely to have received an HPV treatment. Vaccinated women who low cost lasix had ever been married were less likely to report infertility. Findings should engender confidence among healthcare providers, whose recommendation is a key factor in patients’ acceptance of HPV vaccination.Schmuhl N, Mooney KE, Zhang X, Cooney LG, Conway JH, and LoCont NK. No association between HPV low cost lasix vaccination and infertility in U.S. Females 18–33 years old.

treatment 2020;38(24):4038–4043 low cost lasix. Https://doi.org/10.1016/j.treatment.2020.03.035A pay-it-forward approach to low cost lasix improve uptake of gonorrhoea and chlamydia testingDespite WHO recommendations that MSM receive gonorrhoea and chlamydia testing, affordability remains a barrier in many countries. In a randomised trial, researchers tested three incentivising strategies, randomising 301 MSM in MSM-run community-based organisations in Guangzhou and Beijing, China. Gonorrhoea and chlamydia test uptake was 56% in the pay-it-forward low cost lasix arm (free testing and an invitation to donate to a future person’s test), 46% in a pay-what-you-want arm and 18% in the standard-cost arm (¥150, €1.2). The estimated difference in test uptake between pay-it-forward and standard cost was 38.4% (95% CI lower bound 28.4%).

Almost 95% of low cost lasix MSM in the pay-it-forward arm donated to testing for future participants. The pay-it-forward strategy significantly increased gonorrhoea and chlamydia testing uptake in China and has potential to drive testing in other settings.Yang F, Zhang TP, Tang W, Ong JJ, Alexander M, Forastiere L, Kumar N, Li KT, Zou F, Yang L, Mi G, Wang Y, Huang W, Lee A, Zhu W, Luo D, Vickerman P, Wu D, Yang B, Christakis NA, Tucker JD. Pay-it-forward gonorrhoea and chlamydia testing among men who have sex with men low cost lasix in China. A randomised low cost lasix controlled trial. Lancet Infect Dis 2020;20(8)976-982.

Https://doi.org/10.1016/S1473-3099(20)30172-9The Shape of Training review1 and the Future Hospital Commission2 identified the need for a reform of postgraduate medical training in the UK for doctors to adapt to changing population low cost lasix and service needs. The focus of postgraduate training needed to move from a ‘time-served’ approach to a competency-based one with doctors developing high-level learning outcomes, capabilities in practice (CiPs). The General Medical low cost lasix Council (GMC) also recommended that all revised curricula from 2020 should include generic professional capabilities (GPCs), including communication, leadership, multidisciplinary teamwork and patient safety, which are crucial to safe and effective patient care.Genitourinary medicine (GUM), along with many other physicianly specialities, will adopt a dual training model from August 2022, leading to accreditation in both GUM and general internal medicine (GIM). The GUM curriculum will continue to offer training in the diagnosis, investigation and management of sexually transmitted s and related conditions, contraception, HIV inpatient and outpatient care, management of ….

What does lasix pill look like

A fourth view it now wave of the opioid epidemic is coming, what does lasix pill look like a national expert on drug use and policy said during a virtual panel discussion this week hosted by the Berkshire County, Massachusetts, District Attorney’s Office and the Berkshire Opioid Addiction Prevention Collaborative.Dr. Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco (UCSF) School of Medicine, said the next wave in the country’s opioid health emergency will focus on stimulants like methamphetamine and cocaine, and drug combinations where stimulants are what does lasix pill look like used in conjunction with opioids.“The use of methamphetamines is back and it’s back big time,” said Ciccarone, whose most recent research has focused on heroin use.Previously, officials had said there were three waves of the opioid epidemic – the first being prescription pills, the second being heroin, and the third being synthetic drugs, like fentanyl.Now, Ciccarone said, what federal law enforcement and medical experts are seeing is an increase in the use of stimulants, especially methamphetamines.The increase in deaths due to stimulants may be attributed to a number of causes. The increase in supply, both imported and domestically produced, as well as the increase of the drugs’ potency.“Meth’s purity and potency has gone up to historical levels,” he said. €œAs of what does lasix pill look like 2018, we’ve reached unseen heights of 97 percent potency and 97 percent purity. In a prohibitionist world, we should not be seeing such high quality.

This is almost pharmaceutical quality.”Additionally, law enforcement and public health what does lasix pill look like experts like Ciccarone are seeing an increase in the co-use of stimulants with opioids, he said. Speedballs, cocaine mixed with heroin, and goofballs, methamphetamines used with heroin or fentanyl, are becoming more common from the Midwest into Appalachia and up through New England, he said.Federal law enforcement officials are recommending local communities prepare for the oncoming rise in illegal drugs coming into their communities.“Some people will use them both at the same time, but some may use them in some combination regularly,” he said. €œThey may use meth in the morning to go to work, and use heroin at night to come down.”The co-use, he said, was an organic response to the fentanyl overdose epidemic.“Some of what does lasix pill look like the things that we heard … is that meth is popularly construed as helping to decrease heroin and fentanyl use. Helping with heroin withdraw symptoms and helping with heroin overdoses,” he said. €œWe debated this for many years that people were using stimulants to reverse overdoses – we’re what does lasix pill look like hearing it again.”“Supply is up, purity is up, price is down,” he said.

€œWe know from economics that when drug patterns go in that direction, use is going up.”Ciccarone said that there should not be deaths because of stimulants, but that heroin/fentanyl is the deadly element in the equation.His recommendations to communities were not to panic, but to lower the stigma surrounding drug use in order to affect change. Additionally, he said, policies should focus on what does lasix pill look like reduction. supply reduction, demand reduction and harm reduction. But not focus on only one single drug.Additionally, he said that by addressing issues within communities and by healing communities socially, economically and what does lasix pill look like spiritually, communities can begin to reduce demand.“We’ve got to fix the cracks in our society, because drugs fall into the cracks,” he said.Shutterstock U.S. Rep.

Annie Kuster (D-NH) recently held two virtual roundtables addressing how hypertension medications has affected New Hampshire’s healthcare industry.“The health and economic crisis caused by hypertension medications has created significant challenges for Granite State healthcare, mental health, and substance use treatment providers — at the same time, we are seeing increases in substance abuse and mental illness what does lasix pill look like across New Hampshire,” Kuster said. €œFrom the transition to telehealth care and cancellations of elective procedures to a lack of personal protective equipment and increasing what does lasix pill look like health needs of our communities – providers have overcome a multitude of obstacles due to hypertension medications in recent months. I was glad to hear from these hard-working Granite Staters, whose insights will continue to guide my work in Congress as we respond to this lasix. I’m committed to ensuring that communities across New Hampshire can safely access the care and treatment they deserve.”The first roundtable addressed substance-use disorder (SUD) and mental health.The second virtual roundtable was an opportunity for health care providers to speak about their workplace challenges during the lasix what does lasix pill look like. Kuster is the founder and co-chairwoman of the Bipartisan Opioid Task Force, which held a virtual discussion in June on the opioid crisis and the lasix.Shutterstock Opioid prescription rates for outpatient knee surgery vary nationwide, according to a study recently published in BMJ Open.

€œWe found massive what does lasix pill look like levels of variation in the proportion of patients who are prescribed opioids between states, even after adjusting for nuances of the procedure and differences in patient characteristics,” said Dr. M. Kit Delgado, what does lasix pill look like the study’s senior author and an assistant professor of Emergency Medicine and Epidemiology in the Perelman School of Medicine at the University of Pennsylvania. €œWe’ve also seen that the average number of pills prescribed was extremely high for outpatient procedures of this type, particularly for patients who had not been taking opioids prior to surgery.”Researchers examined insurance claims for nearly 100,000 patients who had arthroscopic knee surgery between 2015 and 2019 and had not used any opioid prescriptions in the six months before the surgery.Within three days of a procedure, 72 percent of patients filled an opioid prescription. High prescription what does lasix pill look like rates were found in the Midwest and the Rocky Mountain regions.

The coasts had lower rates.Nationwide, the average prescription strength was equivalent to 250 milligrams of morphine over five days. This is the threshold for increased risk of opioid overdose death, according to what does lasix pill look like the Centers for Disease Control and Prevention.Shutterstock U.S. Secretary of Labor Eugene Scalia awarded nearly $20 million to four states significantly impacted by the opioid crisis, the Department of Labor announced Thursday. The Florida Department of Economic Opportunity, the Maryland Department of Labor, the Ohio Department of Job and Family Services, and what does lasix pill look like the Wisconsin Department of Workforce Development were awarded the money as part of the DOL’s “Support to Communities. Fostering Opioid Recovery through Workforce Development” created after the passage of the SUPPORT for Patients and Communities Act of 2018.

The money will what does lasix pill look like be used to retrain workers in areas with high rates of substance use disorders. At a press conference in Piketon, Ohio, Scalia said the DOL had awarded Ohio’s Department of Job and Family Services $5 million what does lasix pill look like to help communities in southern Ohio combat the opioid crisis in that area. €œToday’s funding represents this Administration’s continued commitment to serving those most in need,” said Assistant Secretary for Employment and Training John Pallasch. €œThe U.S what does lasix pill look like. Department of Labor is taking a strong stand to support individuals and communities impacted by the crisis.”Grantees will use the funds to collaborate with community partners, such as employers, local workforce development boards, treatment and recovery centers, law enforcement officials, faith-based community organizations, and others, to address the economic effects of substance misuse, opioid use, addiction, and overdose.Shutterstock CVS Health has completed the installation of time-delayed safe technology at all 446 Massachusetts locations as part of its initiatives aimed at reducing the misuse and diversion of prescription medications in Massachusetts, the company announced Thursday.

The safes are intended to prevent robberies of controlled substance medications, such as oxycodone and hydrocodone, by electronically delaying the time it takes for what does lasix pill look like pharmacy employees to open the safe where those drugs are stored.The company also announced that it had added 50 new medication disposal units in select stores throughout Massachusetts. Those units join 106 secure disposal units previously installed at CVS locations across the state and another 43 units previously donated to Massachusetts law enforcement agencies. The company plans to install another six units in stores what does lasix pill look like by the year’s end. €œWhile our nation and our company focus on hypertension medications treatment, testing, and other measures to prevent community transmission of the lasix, the misuse of prescription drugs remains an ongoing challenge in Massachusetts and elsewhere that warrants our continued attention,” said John Hering, Region Director for CVS Health. €œThese steps to reduce the theft and diversion of opioid medications bring added security to our stores and more disposal options for our communities.”In 2015, CVS implemented time-delayed safe technology in CVS what does lasix pill look like pharmacies across Indianapolis in response to the high volume of pharmacy robberies in that city.

The company saw a 70 percent decline in pharmacy robberies in stores where the time-delayed safes were installed. Since then, the company has installed 4,760 time-delayed safes in 15 states and the District of Columbia what does lasix pill look like and has seen a 50 percent decline in pharmacy robberies in those areas. The company said it would add an additional 1,000 in-store medication disposal units to the 2,500 units it currently has in CVS pharmacies nationwide. The units allow customers to drop unused prescriptions into a safe place for their disposal to prevent those drugs from being misused. CVS stores that do not offer medication disposal units offer all customers filling opioid prescriptions for the first time with DisposeRX packets that effectively and efficiently breakdown unused drugs into a biodegradable gel for safe disposal in the trash at home..

A fourth wave of the opioid epidemic is coming, a national expert on drug low cost lasix use and policy said during a virtual panel discussion this week hosted by the http://www.ec-centre-lingolsheim.ac-strasbourg.fr/lecole/horaires/ Berkshire County, Massachusetts, District Attorney’s Office and the Berkshire Opioid Addiction Prevention Collaborative.Dr. Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco (UCSF) School of Medicine, said the next wave in the country’s opioid health emergency will focus on stimulants like methamphetamine and cocaine, and drug combinations where stimulants are used in conjunction with opioids.“The use of methamphetamines is back and it’s back low cost lasix big time,” said Ciccarone, whose most recent research has focused on heroin use.Previously, officials had said there were three waves of the opioid epidemic – the first being prescription pills, the second being heroin, and the third being synthetic drugs, like fentanyl.Now, Ciccarone said, what federal law enforcement and medical experts are seeing is an increase in the use of stimulants, especially methamphetamines.The increase in deaths due to stimulants may be attributed to a number of causes. The increase in supply, both imported and domestically produced, as well as the increase of the drugs’ potency.“Meth’s purity and potency has gone up to historical levels,” he said.

€œAs of 2018, we’ve reached unseen heights of 97 percent potency low cost lasix and 97 percent purity. In a prohibitionist world, we should not be seeing such high quality. This is almost pharmaceutical quality.”Additionally, law enforcement and public health experts like Ciccarone are seeing an increase in the co-use of stimulants with opioids, low cost lasix he said.

Speedballs, cocaine mixed with heroin, and goofballs, methamphetamines used with heroin or fentanyl, are becoming more common from the Midwest into Appalachia and up through New England, he said.Federal law enforcement officials are recommending local communities prepare for the oncoming rise in illegal drugs coming into their communities.“Some people will use them both at the same time, but some may use them in some combination regularly,” he said. €œThey may use meth in the morning to go to work, and use heroin at night to come down.”The co-use, he said, was an organic response to the fentanyl overdose epidemic.“Some of the things that we heard … is that meth is popularly construed as helping to decrease heroin and fentanyl low cost lasix use. Helping with heroin withdraw symptoms and helping with heroin overdoses,” he said.

€œWe debated this for many years that people were using stimulants to low cost lasix reverse overdoses – we’re hearing it again.”“Supply is up, purity is up, price is down,” he said. €œWe know from economics that when drug patterns go in that direction, use is going up.”Ciccarone said that there should not be deaths because of stimulants, but that heroin/fentanyl is the deadly element in the equation.His recommendations to communities were not to panic, but to lower the stigma surrounding drug use in order to affect change. Additionally, he low cost lasix said, policies should focus on reduction.

supply reduction, demand reduction and harm reduction. But not focus on only one single drug.Additionally, he said that by addressing low cost lasix issues within communities and by healing communities socially, economically and spiritually, communities can begin to reduce demand.“We’ve got to fix the cracks in our society, because drugs fall into the cracks,” he said.Shutterstock U.S. Rep.

Annie Kuster (D-NH) recently held two virtual roundtables addressing how hypertension medications has affected New Hampshire’s healthcare industry.“The health and economic crisis caused low cost lasix by hypertension medications has created significant challenges for Granite State healthcare, mental health, and substance use treatment providers — at the same time, we are seeing increases in substance abuse and mental illness across New Hampshire,” Kuster said. €œFrom the transition to telehealth care and cancellations of elective procedures to a lack of personal protective equipment and increasing health needs of our communities – providers have overcome low cost lasix a multitude of obstacles due to hypertension medications in recent months. I was glad to hear from these hard-working Granite Staters, whose insights will continue to guide my work in Congress as we respond to this lasix.

I’m committed to ensuring that communities across New Hampshire can safely access the care and treatment they deserve.”The first roundtable addressed substance-use disorder (SUD) and mental health.The second virtual roundtable was an opportunity for health care providers to speak about their workplace low cost lasix challenges during the lasix. Kuster is the founder and co-chairwoman of the Bipartisan Opioid Task Force, which held a virtual discussion in June on the opioid crisis and the lasix.Shutterstock Opioid prescription rates for outpatient knee surgery vary nationwide, according to a study recently published in BMJ Open. €œWe found low cost lasix massive levels of variation in the proportion of patients who are prescribed opioids between states, even after adjusting for nuances of the procedure and differences in patient characteristics,” said Dr.

M. Kit Delgado, low cost lasix the study’s senior author lasix 40mg cost and an assistant professor of Emergency Medicine and Epidemiology in the Perelman School of Medicine at the University of Pennsylvania. €œWe’ve also seen that the average number of pills prescribed was extremely high for outpatient procedures of this type, particularly for patients who had not been taking opioids prior to surgery.”Researchers examined insurance claims for nearly 100,000 patients who had arthroscopic knee surgery between 2015 and 2019 and had not used any opioid prescriptions in the six months before the surgery.Within three days of a procedure, 72 percent of patients filled an opioid prescription.

High prescription rates were found in the Midwest low cost lasix and the Rocky Mountain regions. The coasts had lower rates.Nationwide, the average prescription strength was equivalent to 250 milligrams of morphine over five days. This is the threshold for increased low cost lasix risk of opioid overdose death, according to the Centers for Disease Control and Prevention.Shutterstock U.S.

Secretary of Labor Eugene Scalia awarded nearly $20 million to four states significantly impacted by the opioid crisis, the Department of Labor announced Thursday. The Florida Department of Economic Opportunity, the Maryland Department of Labor, the Ohio Department of Job and Family Services, and the Wisconsin Department of Workforce Development were awarded the money as low cost lasix part of the DOL’s “Support to Communities. Fostering Opioid Recovery through Workforce Development” created after the passage of the SUPPORT for Patients and Communities Act of 2018.

The money will low cost lasix be used to retrain workers in areas with high rates of substance use disorders. At a press conference in Piketon, Ohio, Scalia said the DOL had awarded Ohio’s Department of Job and Family Services $5 million to help low cost lasix communities in southern Ohio combat the opioid crisis in that area. €œToday’s funding represents this Administration’s continued commitment to serving those most in need,” said Assistant Secretary for Employment and Training John Pallasch.

€œThe U.S low cost lasix. Department of Labor is taking a strong stand to support individuals and communities impacted by the crisis.”Grantees will use the funds to collaborate with community partners, such as employers, local workforce development boards, treatment and recovery centers, law enforcement officials, faith-based community organizations, and others, to address the economic effects of substance misuse, opioid use, addiction, and overdose.Shutterstock CVS Health has completed the installation of time-delayed safe technology at all 446 Massachusetts locations as part of its initiatives aimed at reducing the misuse and diversion of prescription medications in Massachusetts, the company announced Thursday. The safes are intended to prevent robberies of controlled substance medications, such as oxycodone and hydrocodone, by electronically delaying the time it takes for pharmacy employees to open the safe where those drugs are stored.The company also announced low cost lasix that it had added 50 new medication disposal units in select stores throughout Massachusetts.

Those units join 106 secure disposal units previously installed at CVS locations across the state and another 43 units previously donated to Massachusetts law enforcement agencies. The company plans to install low cost lasix another six units in stores by the year’s end. €œWhile our nation and our company focus on hypertension medications treatment, testing, and other measures to prevent community transmission of the lasix, the misuse of prescription drugs remains an ongoing challenge in Massachusetts and elsewhere that warrants our continued attention,” said John Hering, Region Director for CVS Health.

€œThese steps to reduce the theft and diversion of opioid medications bring added security to our stores and more disposal options for our communities.”In 2015, CVS implemented time-delayed safe technology in low cost lasix CVS pharmacies across Indianapolis in response to the high volume of pharmacy robberies in that city. The company saw a 70 percent decline in pharmacy robberies in stores where the time-delayed safes were installed. Since then, the company has installed 4,760 time-delayed safes in 15 states and the District of Columbia low cost lasix and has seen a 50 percent decline in pharmacy robberies in those areas.

The company said it would add an additional 1,000 in-store medication disposal units to the 2,500 units it currently has in CVS pharmacies nationwide. The units allow customers to drop unused prescriptions into a safe place for their low cost lasix disposal to prevent those drugs from being misused. CVS stores that do not offer medication disposal units offer all customers filling opioid prescriptions for the first time with DisposeRX packets that effectively and efficiently breakdown unused drugs into a biodegradable gel for safe disposal in the trash at home..

Lasix iv

€œThere’s virtually https://alistkandb.co.uk/buy-propecia-online-cheap no difference between white, Black, Hispanic, lasix iv Asian American,” referring to vaccination rates among Americans 65 and up. President Joe Biden, May 3 During May 3 remarks on the American Families Plan, President Joe Biden boasted that there was not much disparity in the vaccination rates for white Americans and Americans of color who are at least 65. “And what’s happening now is all the talk about how people were not going to get shots, they lasix iv were not going to be involved — look at what that was — we were told that was most likely to be among people over 65 years of age,” said Biden. €œBut now people over 65 years of age, over 80%, have now been vaccinated, and 66% fully vaccinated.

And there’s virtually no difference between white, Black, Hispanic, Asian American.” This isn’t the only time that Biden has made that claim. He went even further on April 27 during remarks on the lasix iv hypertension medications response. €œAnd, by the way, based on reported data, the proportion — the proportion of seniors who have been vaccinated is essentially equal between white and seniors of color. €¦ As a matter of a fact, if I’m not mistaken, there are more Latinos and African American seniors that have been vaccinated, as a percentage, than white seniors.” However, the national data that Biden keeps touting — vaccination statistics regarding both race and age — is not public.

We asked the White House for the information underlying this claim, but officials did not lasix iv provide specifics. So, we moved on to the Centers for Disease Control and Prevention. Spokesperson Chandra Zeikel told KHN-PolitiFact on May 6 that “unfortunately, we don’t have available a data breakdown of both racial demographics and age together.” Zeikel didn’t respond to a follow-up question asking when or if the CDC would be publishing this data, but current CDC vaccination data is broken down only by race/ethnicity and shows significant differences, with white Americans far outpacing the percentage of other groups getting a shot. It also shows that the rate of vaccinations among some groups, including Black and Latino Americans, does not match their share of the population, though new CDC data shows there has been some progress on this front lasix iv in the past two weeks.

That made us wonder about the premise of Biden’s statement. We turned to experts for their take lasix iv. €œAs far as I know, there is no comprehensive publicly available data on vaccination rates by race/ethnicity and age,” Samantha Artiga, vice president and director of the racial equity and health policy program at KFF, wrote in an email. €œAs such, we are not able to assess whether there are racial disparities in vaccinations among people over 65 years of age.” What about other state-level data or anecdotes that might support Biden’s claim?.

Let’s lasix iv dive in and see. A Small Number of States Report Both Age and Race Together At least seven states track vaccination based on a combination of age and race, according to Artiga. Michigan, South Carolina, West Virginia, Kansas, Minnesota, Washington and Vermont. (Vermont tracks only lasix iv two racial categories.

Non-Hispanic white and a combination of Black, Indigenous and people of color.) The results from some of these states show that racial disparities do exist in the older age groups. In Michigan, for instance, over 50% of non-Hispanic white people ages 65 to 74 had completed their vaccinations as of May 11. Other racial groups — non-Hispanic Black lasix iv people. Asian American and Pacific Islanders.

And Hispanics — all trailed by about 10 percentage points. The exception was the Native American and Alaska Natives category, which was within 4 percentage lasix iv points of white people. And as of May 11 in Kansas, the rate at which white people in that same age group were vaccinated was higher than the rates of Black people and Native Hawaiian/Pacific Islanders. In Vermont, for those 65 and up, about 79% of people of color had received at least one dose of the treatment, compared with 85% of white people as of that date lasix iv.

€œWith the exception of Vermont, which has the distinction of being the only state to target BIPOC [Black, Indigenous and people of color] populations by race explicitly, these are examples of states in which the numbers are not doing well in their equity efforts,” Dayna Bowen Matthew, dean of the George Washington University Law School and an expert in racial disparities in health care, wrote in an email. Minnesota is one of the few states in which people of color are actually being vaccinated at higher rates than white people — with 93% of Asian/Pacific Islanders and 87.5% of Black/African Americans age 65 and over having received at least one shot, compared with 81.5% of white people as of May 11. Some states are vaccinating similar percentages of their population of Black or Hispanic lasix iv people, Matthew said, however that data does not distinguish by age group. According to Bloomberg’s hypertension medications Vaccination Racial Gap tracker, New Mexico, Idaho, Oregon and Utah have vaccinated approximately the same percentage of Black Americans as are represented in each state’s population.

Maine, Ohio, Alabama, Louisiana and Missouri have achieved similar population-based rates for the Hispanic population. KFF provides weekly updates on national and state race/ethnicity data of those who have received vaccinations, which have consistently shown lasix iv that Black and Hispanic people are receiving smaller shares of vaccinations compared with their shares of the total population, while white people are receiving a higher share. The May 5 weekly update, for instance, found that based on the 42 states that share race/ethnicity data, the percentage of white people who have received at least one hypertension medications treatment dose (39%) was roughly 1.5 times higher than the rates for Black (25%) and Hispanic people (27%). (KHN is an editorially independent program of KFF.) It’s also important to note that data on race and ethnicity information has not been gathered for many people who have been vaccinated.

As of May 3, the CDC reported that race and ethnicity were known for only 55% of lasix iv all people who had received at least one treatment dose. And three states, Montana, New Hampshire and Wyoming, don’t report race/ethnicity data at all. How to Approach treatment Equity, Experts Say Nneka Sederstrom, chief health equity officer at Hennepin Healthcare in Minneapolis, said that her state has done an “excellent job” vaccinating the 65-and-older population but that there’s still a lot of work to be done to reach communities of color. We “will need more direct tactics to reach” those who haven’t yet been vaccinated, “and help address any lasix iv issues of hesitancy due to lack of knowledge or systemic barriers,” Sederstrom wrote in an email.

Ensuring that treatments are available at primary care providers is also important, said Dr. Georges Benjamin, executive director lasix iv of the American Public Health Association. €œThe truth of the matter is, the more vaccinators that we can get that are placed where people are every day, where it becomes a routine part of your life, such as going … into your doctor’s office for a regular visit, that’s a winner,” said Benjamin. But, Dr.

Uché Blackstock, founder of Advancing Health Equity, an organization lasix iv that advocates to end bias and racism in health care, said she would set the bar for treatment equity success higher than just an equally proportionate share of a certain racial/ethnic population receiving their treatment doses. €œWhat success in treatment equity would look like would be if Black people or Hispanic people were overrepresented in terms of treatment received since they have been disproportionately impacted by the lasix,” said Blackstock. So even though Biden quotes these statistics that lack data behind them, if the evidence did support them, it would still not be enough, she said. In fact, the CDC does describe lasix iv treatment equity in those terms.

€œpreferential access and administration to those who have been most affected by hypertension medications.” Our Ruling Biden has repeatedly claimed that vaccination rates among white people and people of color age 65 and older are virtually the same — or even higher among people of color. No public national data from the CDC or another database has been released to support this assertion. For the few states that do report data on age and race/ethnicity combined, the numbers suggest lasix iv that, for the most part, obvious disparities persist in the vaccination rates for white seniors and seniors of color. In several states, treatment administration rates are more proportional to the percentage of the Black and Hispanic populations, but the data covers all age groups.

National data for all age groups also shows that rates of vaccinations for Black and Hispanic people lag behind that of white people. Existing data paints one story on treatment equity, while Biden’s lasix iv words paint another. Without data to back it up, we rate Biden’s statement False. Sources:The Associated lasix iv Press, “AP Fact check.

Biden overstates how many Americans immunized,” May 3, 2021Bloomberg News, hypertension medications Racial Gap Tracker, accessed May 5, 2021Centers for Disease Control and Prevention, “Demographic Characteristics of People Receiving hypertension medications Vaccinations in the United States,” accessed May 10, 2021Centers for Disease Control and Prevention, “County-Level hypertension medications Vaccination Coverage and Social Vulnerability — United States, December 14, 2020-March 1, 2021,” March 26, 2021Email exchange with Centers for Disease Control and Prevention spokesperson Chandra Zeikel, May 6, 2021Email exchange with White House administration official, May 6, 2021Email interview with Manuel Pastor, director of the University of Southern California Equity Research Institute, May 5, 2021Email interview with Nneka Sederstrom, chief health equity officer at Hennepin Healthcare in Minneapolis, May 5, 2021Email interview with Samantha Artiga, vice president and director of the racial equity and health policy program at KFF, May 5-6, 2021Kansas.gov, hypertension medications Demographics, accessed May 10, 2021KFF, Latest Data on hypertension medications Vaccinations Race/Ethnicity, May 5, 2021Michigan.gov, hypertension medications treatment dashboard, accessed May 10, 2021Minnesota.gov, “treatment Data,” accessed May 10, 2021NBC News, “Biden Hails Progress on treatment Equity, but Some Local Leaders Paint a Different Picture,” May 3, 2021Phone/email interview with Dayna Bowen Matthew, dean and Harold H. Greene Professor of Law at the George Washington University Law School, May 6-7, 2021Phone interview with Dr. Georges Benjamin, executive director of the American Public Health Association, May lasix iv 6, 2021Phone interview with Dr. Uché Blackstock, founder of Advancing Health Equity, May 6, 2021Vermont.gov, hypertension medications treatment Dashboard, accessed May 10, 2021White House, “Remarks by President Biden on the American Families Plan,” May 3, 2021White House, “Remarks by President Biden on the hypertension medications Response,” April 27, 2021 Victoria Knight.

vknight@kff.org, @victoriaregisk Related Topics Contact Us Submit a Story TipEAST LOS ANGELES — For the past year, 13-year-old twins Ariel Jr. And Abraham Osorio have logged lasix iv on to their online classes from their parents’ flower shop. Ariel nestles in a corner among flowers, bows and stuffed animals. Abraham sets up on a small table in the back, where his dad used to work trimming flowers and keeping the books.

It’s not lasix iv ideal for learning. It’s loud. It’s cramped. It’s bustling lasix iv with people.

Still, when the twins’ mother, Graciela Osorio, recently had the chance to send her kids back to Brightwood Elementary in Monterey Park, California, she decided against it. €œAfter what we went through with their father, I’d rather keep them at home where lasix iv I know they are safe,” said Graciela, 51. €œThere’s only a month left. It doesn’t make sense that they return for such a short time.” The boys’ father, Ariel Osorio Sr., 51, died of hypertension medications in January, four weeks after a trip to Mexico to visit his mother.

He fell ill quickly and wasn’t lasix iv able to say goodbye to his children. Graciela Osorio is mourning the loss of her husband, Ariel Osorio, who died of hypertension medications in January. (Heidi de Marco/KHN) “I miss his presence,” Abraham said. €œI’m used to seeing him sit in his chair working, but not anymore.” Latinos have been hit disproportionately hard by hypertension medications, and many families lasix iv are opting out of in-person learning.

In California, Latinos make up 39% of the state’s population but account for 47% of hypertension medications deaths, according to the state Department of Public Health. Nationally, their risk of death from hypertension medications is 2.3 times higher than that of whites. Latinos are lasix iv vulnerable to the highly transmissible hypertension because they are more likely than non-Hispanic whites to work essential jobs that expose them to the public, said David Hayes-Bautista, a professor of public health and medicine at UCLA and co-author of a January study on this topic. They are more likely to lack health insurance, which may make them less likely to seek medical care, he said.

And they are more likely to live in multigenerational households, which means the lasix can spread quickly and easily within families. €œMany of them are essential workers and the breadwinners for their families and don’t have the luxury of telework, of physical distancing and self-isolation,” said Alberto González, a senior health strategist at UnidosUS, a Latino advocacy group lasix iv in Washington, D.C. The Osorio family has lived in a multigenerational household since Ariel died, and Graciela had to keep other family members in mind when deciding whether to send her boys back into the classroom. In February, Graciela and the twins moved in with her lasix iv 74-year-old mother, Cleotilde Servin, in East Los Angeles.

Ten people now share the roughly 1,000-square-foot home, squeezing by one another in the kitchen every morning. Cleotilde Servin makes lunch for the family members who live with her, including two daughters, a son and several grandchildren. (Heidi de Marco/KHN) Graciela’s mother and the lasix iv other adults in the home have been vaccinated, but the children haven’t. Even though she instructs her sons to wear their masks and doesn’t allow them to visit friends, she’s terrified of what could happen if her kids caught the lasix at school and brought it home.

€œMy mother is active and takes vitamins, but it still worries me,” Graciela said. She got hypertension medications from her lasix iv husband and gave it to her sister and niece. €œI don’t want anyone else to get sick,” she said. State and local education officials don’t have recent data on in-person attendance by race, but an EdSource analysis of California Public Health Department data from February shows that white students were more likely to attend school in person than other students.

The analysis showed that 12% of Latinos were attending in-person classes at least some of the time, compared lasix iv with 32% of whites and 18% of all students. The Los Angeles Unified School District, the second-largest in the country, serves more than 600,000 students and reopened for in-person learning in mid-April. Only some campuses are open, mostly elementary schools, and are running on hybrid schedules, combining on-campus classes with distance learning. €œWe’ve upgraded the air fiation systems in every classroom, reconfigured school facilities to keep all at a school appropriately distanced, doubled the custodial staff, and we’ll lasix iv provide weekly hypertension medications testing at school for every student and staff member,” district superintendent Austin Beutner said in his weekly recorded video update on March 22.

In a statement released May 4, Beutner said 40% to 50% of elementary school students are now back in schools in “more affluent” communities compared with roughly 20% in low-income communities. €œWe see the greatest reluctance for children to be back in schools from families who live in some of the highest-needs communities we serve,” he lasix iv said. Brightwood Elementary is a K-8 school with 870 students, about half of whom are Asian American and 40% Latino, said principal Robby Jung. Just 15% of students are back on campus, he said, and, of those, about one-third are Latino.

Ariel lasix iv Osorio Jr. Works on his school homework at the back of the flower shop. (Heidi de Marco/KHN) Graciela Osorio owns Gracy’s Flower Shop in East Los Angeles, California, which she used to run with her husband. (Heidi de Marco/KHN) For the Osorio family, the overriding reason lasix iv the eighth grade twins are not back at Brightwood is fear.

Like so many other Latino families — roughly 28,000 Latinos have died of hypertension medications in California — they are reeling from the grief and trauma that the disease has already wrought, and the fear of what it could do if it struck again. €œThe boys are seeing a therapist to deal with their dad’s death,” Graciela said. €œI know I should probably talk to someone, too.” With the memory of her husband’s death still so fresh that she can’t speak of him without crying, Graciela is still adjusting to the lasix iv emotional toll, and to the day-to-day realities of running a flower shop by herself. Originally from Guerrero, Mexico, she started Gracy’s Flower Shop with her husband in 1997.

Ariel took care of the finances at home and at the shop and was the better English speaker of the two. €œNow being alone with lasix iv the boys, it’s more difficult to keep up,” she said. After losing her husband to hypertension medications, Graciela Osorio decided not to let her sons return to in-person learning out of fear they might contract the lasix at school. €œI tell them they have to stay focused now that their dad isn’t around to push them,” she lasix iv says.

(Heidi de Marco/KHN) During the hypertension medications lockdowns, the boys joined the couple at the shop. Her husband sat next to their children while they attended school online, helping with their homework and acting as the main contact for the school. €œThey were always with us,” Graciela lasix iv said. €œThey grew up in the flower shop, so they didn’t have a problem setting up their school stations there.” Brightwood reopened its doors April 12, offering in-person learning two days a week for a few hours a day, with the rest of the sessions online.

Graciela said the limited schedule doesn’t work with her role as the family breadwinner. €œI would have to take them to school, pick them up for lunch and then lasix iv bring them back,” she said. €œI can’t do that. I have to work.” But mostly she’s keeping them off campus because she doesn’t want to lose another family member.

She said she knows online classes aren’t the same as in-person instruction “but they have lasix iv been keeping their grades up,” she said. €œI thank God I have good boys. They listen. They understand why I lasix iv kept them home.” Abraham Osorio and Ariel Osorio Jr.

Outside their mother’s flower shop. (Heidi de Marco/KHN) The lasix iv last day of school is May 28. Ariel and Abraham said they’re looking forward to high school in the fall. Still dealing with their father’s death, the boys, who are shy and reserved by nature, are torn between returning to school in person or continuing their classes online.

€œWe might go back,” Abraham said lasix iv. €œFor now, we keep each other company.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Heidi de Marco. heidid@kff.org, @Heidi_deMarco Related Topics Contact Us Submit a Story TipAn exclusive Montana resort wants to turn sewage into snow so that its rich and famous members can ski its slopes in a winter season that’s shrinking because of climate lasix iv change.

The Yellowstone Club — a ski and golf resort just north of Yellowstone National Park that counts Bill Gates, Justin Timberlake and Jessica Biel among its members — has asked the Montana Department of Environmental Quality for a permit to allow it to use wastewater for snowmaking operations on its ski slopes. About a dozen other ski areas across the U.S. Have used wastewater to make artificial snow before, but the Yellowstone Club lasix iv would be the first in Montana. The technique has also been used in Europe and Australia.

Officials at the club say the program would not only ensure the slopes can open on time, usually in late November and early December, but also replenish the area’s watershed and keep streams running longer into the season. And it would allow the growing Big Sky resort area to handle its increasing lasix iv wastewater volumes. €œIt’s an outside-the-box-idea,” said Rich Chandler, environmental manager for the club. €œBut it also checks a lot of boxes.” Is it a safe plan lasix iv for the rich and famous who will occasionally ingest it when they wipe out on the slopes?.

The short answer from state officials is yes. The method is safe for people and the environment as long as there is close monitoring to ensure contamination levels stay within standards, according to an environmental analysis. But, the state officials said, that analysis did not study potential pollutants for which there are no environmental standards in lasix iv wastewater, such as traces of prescription drugs. A similar effort to turn wastewater into snow was controversial at the Arizona Snowbowl ski resort near Flagstaff.

To combat snowless winters there, the resort in the early 2000s purchased wastewater from Flagstaff and pumped it from the treatment plant to the ski area, where it would be turned into snow and sprayed onto the San Francisco Peaks. That drew protests from the Hopi Tribe, which said the artificial snow posed risks lasix iv to public health and the environment and would desecrate a mountain it considers sacred. The tribe lost a legal challenge to prevent the Arizona ski area from moving ahead with the plan. In December 2012, the ski area fired up its snow guns and started making powder.

During the legal fight, environmental groups, including the Center for Biological Diversity, raised specific concerns about how wastewater can reduce local aquatic populations and cause some male fish to take on lasix iv female appearances and reproductive traits. Wastewater’s effect on human health also raises concerns. Although modern water treatment can eliminate many pollutants — and, in some instances, prepare that water for human consumption — some elements still escape the process, specifically pharmaceuticals. The research is in its infancy, but a 2017 study by the United Nations Educational, Scientific and Cultural lasix iv Organization found that only half of the pharmaceutical compounds were removed in the water treatment process.

It noted that evidence suggests some of the chemicals could affect human reproductive systems, too, just as studies have shown on aquatic life. “Modern wastewater treatment plants mostly reduce lasix iv solids and bacteria by oxidizing the water. They were not designed to deal with complex chemical compounds,” said Birguy Lamizana-Diallo, program management officer at the United Nations Environment Program and an expert on wastewater treatment. Officials in Montana are quick to point out differences between their plan and what happened in Arizona.

For one, the ski area near Flagstaff often makes all its snow from treated wastewater, whereas the Yellowstone Club will use it, at least initially, on only about 10% of the 2,700 acres of skiable terrain and usually only lasix iv in October and November to create a base layer for its ski runs. Come December, most of the snow people would be skiing and riding on would be natural. But perhaps the biggest difference between the two projects is the level of support the Yellowstone Club has for its plan, which is backed by environmental and conservation groups including the Gallatin River Task Force, the Association of Gallatin Agricultural Irrigators and Trout Unlimited. The idea lasix iv to turn Big Sky’s wastewater into snow has been brewing for more than a decade and emerged from a collaboration between the Yellowstone Club and other local groups concerned about depleted snowpack due to climate change, which could starve area creeks and streams of water later in the season.

Yellowstone already uses treated wastewater to hydrate its golf courses, and in 2011 it teamed up with the Montana DEQ and the Gallatin River Task Force to see if they could safely turn the same water into snow. Chandler, the club’s environmental manager, said they successfully turned a half-million gallons of wastewater into 2 acres of snow about 18 inches deep. Kristin Gardner, executive director of the Gallatin River Task Force, said the snowmaking process effectively re-treats the wastewater by blasting it out of a filtered snowmaking gun lasix iv that atomizes the water. €œIt’s an added layer of security for the human health side of things,” Chandler said.

Chandler said lasix iv the information gathered from the pilot study forms the core of the ski club’s application with the Montana DEQ. A draft permit tentatively approving the project has been issued by the state agency, and a final decision is expected later this year. Officials at DEQ said that the wastewater used to make snow will be treated to the highest standards possible and that they can issue permits only to projects that will not pollute state waters. But the effect of pharmaceuticals remains lasix iv uncharted territory.

Amy Steinmetz, public water supply bureau chief, said that neither the DEQ nor the U.S. Environmental Protection Agency has standards to specifically treat wastewater for pharmaceuticals. €œThe science is still lasix iv emerging on that,” she said. If the DEQ does issue its final permit this year, the Yellowstone Club will most likely begin turning wastewater into snow in late 2022.

It would then be required to post signage advising skiers not to consume the snow. Similar signage lasix iv can be found at Arizona Snowbowl. Chandler said that the Yellowstone Club is proud of the collaborative work and that, ultimately, the process will benefit the community and watershed. Making more snow and increasing the snowpack during the winter, Chandler estimates, will increase the summer runoff in area creeks by about 19 days, a big win in the increasingly arid West.

It’s also better than the alternative, he lasix iv said. Treating the wastewater and then just pushing it directly into the Gallatin River. €œIt’s not like the Earth is producing more water, so we have to use lasix iv what we have effectively,” he said. Related Topics Contact Us Submit a Story Tip[Editor’s note.

If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado Crisis Services at 1-844-493-TALK (8255) lasix iv or text TALK to 38255.] KIOWA, Colo. €” The yellow-and-green facade of Patty Ann’s Cafe stands out on the main street of this ranching community just 25 miles from the Denver suburbs. Before the lasix, the cafe was a place for ranchers to gather for meals and to swap stories.

“Some people would call it almost like lasix iv a conference room,” said Lance Wheeler, a local rancher and regular at the cafe. €œThere are some guys that, if you drive by Patty Ann’s at a certain time of day, their car or truck will always be there on certain days.” When hypertension medications restrictions closed in-person dining across Colorado last year, Patty Ann’s opened a takeout window. Customers spread their food on the hoods of their trucks and ate there while sharing news and commiserating over the stresses of ranching during the lasix. Keeping that community hub operating has been vital for the ranchers around Kiowa as the lasix takes its toll on lasix iv mental health in agricultural communities where health providers are scarce and a “pull yourself up by your own bootstraps” mentality is prevalent.

Wheeler heads into Patty Ann’s Cafe for lunch. Ranchers often come to the Kiowa, Colorado, cafe for breakfast or lunch, which Wheeler said is a way to connect with others experiencing similar stresses. €œThat’s your support group, because lasix iv you have commonality, a common experience, common difficulty.” (Eli Imadali for KHN) Roberta Kusma (left) laughs with her old friend Betty Hood at Patty Ann’s Cafe. The two worked in the same building when it was a grocery store years ago.

(Eli Imadali for lasix iv KHN) The lasix over the past year has been a surprising boon for many farms and ranches as higher consumer demand amid food shortages has boosted business. But coupled with everyday worries about weather and commodity prices, the lasix also has led to mental health challenges, including serious stress, anxiety and depression among farmers and ranchers, health officials said. The American Farm Bureau Federation found that about 3 in 5 rural adults reported that the lasix has affected mental health in their communities, while two-thirds of farmers and farmworkers said the lasix has impacted their mental health. Treatment for mental health problems caused or worsened by the stress and isolation of the lasix has obstacles lasix iv particular to ranching and farming country.

The stigma of acknowledging the need for mental health care can prevent people from seeking it. For those who overcome that obstacle and look for help, they are likely to find underfunded, understaffed and underequipped health providers who often don’t have the bandwidth or expertise for sufficient mental health support. €œI guess lasix iv my cows are my therapists,” joked Wheeler. The 54-year-old rancher said he has felt the stress of the added responsibility of providing meat to customers in a time of food shortages, particularly at the beginning of the lasix.

But he feels lucky to have a family that supports him. Because drought has impeded hay production in Colorado, Wheeler has had to have bales shipped in lasix iv from South Dakota. Wheeler says the lack of rain has been his biggest stressor. (Eli Imadali for KHN) Similar to other Rocky Mountain states, Colorado has one of the highest suicide rates in the country.

The rates are often worse in the state’s lasix iv rural communities, a factor consistent with rural Americans’ risks nationwide. A Centers for Disease Control and Prevention report examining 2001-15 data found the suicide rate in rural counties was more than 17 per 100,000 people, compared with about 15 per 100,000 in small and medium-sized metro counties and about 12 per 100,000 in large metro counties. Kiowa is in Elbert County, whose 1,850 square miles of mostly dusty, flat plains start where lasix iv the affluent bedroom communities of Denver end. The county has no urgent care center or hospital like its suburban neighbors, just four clinics to serve a population of 27,000.

A health care center in Elizabeth, Colorado, offers counseling, among other services. The few physical lasix iv and mental health resources available in Elbert County are concentrated in the west, closer to Denver. (Eli Imadali for KHN) Dwayne Smith, Elbert County’s public health director, said that to help solve the problem residents need to talk with their health providers as candidly about their mental health challenges as about skin cancer or heart disease. €œIn a more conservative community, where historically mental health issues may not have been talked about as openly and as comfortably as in the [Denver] area, you have to work diligently to increase people’s comfort level,” Smith said.

€œEven saying the words ‘anxiety,’ ‘depression,’ ‘mental health’ — all those things that in prior generations were very much a taboo subject.” Elbert County Public Health Director Dwayne Smith poses outside the Department lasix iv of Health and Human Services, surrounded by prairie. (Eli Imadali for KHN) The public health crisis is just an added burden to the already high stress on people in the agricultural industry. €œFarmers and ranchers are absorbing a lot of the shocks to the system for us. Hailstorms, pest outbreaks, drought, markets — they’re adjusting for all that to lasix iv keep food production moving,” said Colorado’s agriculture commissioner, Kate Greenberg.

Unpredictable weather, a volatile commodity market and a 700-acre grass fire cost Laura Negley, a rancher in the southeastern town of Eads, a lot of income around 2012. Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land. But she lasix iv was devastated after those losses, followed by her youngest child’s departure for college. €œThat’s kind of when the wheels fell off for me.

And then I kind lasix iv of spiraled down,” Negley said. The lasix exacerbated Laura Negley’s anxiety, isolating her from extended family and causing worry about her elderly parents.(Eli Imadali for KHN) Negley, now 59, said she initially didn’t recognize she needed help even though she was deep into her “dark place” of depression and anxiety, but her brother encouraged her to see a counselor near him in Greeley. So, when the cattle were done grazing for the season, Negley spent six winter weeks getting counseling 200 miles north. Those visits eventually transitioned to lasix iv phone counseling and an anti-anxiety medication.

€œI do think you have to have a support group,” said Negley, who said her faith has helped her, too. Over the years, slashed budgets to local health departments have cut to the bone. In Elbert County, Smith is one of just lasix iv three full-time employees in his department. About 15 years ago, it had at least six nurses.

It now has none. It is lasix iv trying to hire one. €œWe have a lack of health providers” in rural America, Negley said. €œThe ones we do have are doing their best — but they’re trying to wear multiple hats.” Negley talks with son Jayce as he repairs a sweep plow on their family land in Eads, Colorado.

(Eli Imadali for KHN) Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation lasix iv on the same Colorado land. (Eli Imadali for KHN) Stressors like severe drought and exhaustion from unrelenting hard work can lead to mental health struggles for farmers and ranchers. Negley will likely not have cattle this year because drought impeded lasix iv grass growth.(Eli Imadali for KHN) Agencies in Colorado recognize the need to improve mental health services offered to rural residents. Colorado Crisis Services has a hotline and text-messaging number to refer people to free, confidential support.

And the state is working on tailored messaging campaigns to help farmers and ranchers understand those numbers are free and confidential to contact. These services can lasix iv help. According to the CDC, for every adult death by suicide, about 230 people think seriously about suicide. A bill introduced in Colorado’s legislature would boost funding for rural rehabilitation specialists and help provide vouchers for rural Coloradans to get behavioral health services.

€œWe have lasix iv to be flexible. What works in Denver does not work in La Junta” or the rest of rural Colorado, said Robert Werthwein, director of the state’s Office of Behavioral Health. But in tightknit small towns, ranchers say, even if the resources are there the stigma remains. €œThese are lasix iv normal people with normal problems.

We’re just trying to, perhaps first and foremost, destigmatize mental health needs and resources,” Smith said. €œTimecards and schedules have had no meaning for the past year,” says Smith, one of three full-time employees in his department. €œIt’s just been never-ending.” (Eli Imadali for KHN) Stigmas are something 26-year-old Jacob Walter and his lasix iv family want to help tackle. As Walter was growing up, a friend’s father and another friend’s mother died by suicide.

Before Walter left the family’s ranch in lasix iv southeastern Colorado to start his sophomore year in college, he lost his own father, Rusty, to suicide in 2016. Walter said there were few local resources at the time to help people like his dad, and the nearest town was 45 minutes away. Rusty was involved in many community service organizations and gave a lot of his time to others, Walter said, but he suffered from depression. €œThe day before he committed lasix iv suicide, we had been talking at the kitchen table, and he was just talking about [his depression], and he said.

€˜You know, you can always get help and stuff.’” That’s the message agricultural leaders like Ray Atkinson, communications director at the American Farm Bureau Federation, say should be conveyed most. It’s OK to acknowledge when you need help. €œIf your tractor needed maintenance … you would stop what you’re doing and lasix iv you’d get it working right before you go try and go out in the field,” Atkinson said. €œYou are the most important piece of equipment on your farm.” Cattle eat hay on Rafter W Ranch near Simla, Colorado.

Drought hasn’t allowed grazing on grassy pastures. (Eli Imadali for KHN) lasix iv [Editor’s note. If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado Crisis Services at 1-844-493-TALK (8255) or text TALK to 38255.] Related Topics Contact Us Submit a Story TipKALISPELL, Mont.

€” The hypertension medications vaccination lasix iv operation at the Flathead County fairgrounds can dole out 1,000 doses in seven hours. But demand has plummeted recently, down to fewer than 70 requests for the shots a day. So, at the start of lasix iv May, the northwestern Montana county dropped its mass vaccination offerings from three to two clinics a week. Though most of those eligible in the county haven’t yet gotten a dose, during the final Thursday clinic on April 29, few cars pulled up and nurses had time to chat between patients.

€œIt’s a trickle,” said Flathead City-County Health Officer Joe Russell. €œNot enough people will get vaccinated to reach lasix iv herd immunity, not in Flathead County and maybe not in Montana.” Daily hypertension medications vaccination rates are falling nationwide. Gaps in treatment uptake are starting to show, especially in rural America. That leaves many communities grappling with an imperfect lasix endgame.

Flathead stands out as one of Montana’s most populated counties to lasix iv fall behind. There, 25% of people had been fully vaccinated by May 10. To compare, nearly 33% of Montanans were fully vaccinated, and that figure is closer to 35% nationwide. Flathead County is a medical destination for the top corner of the state, a gateway to lasix iv Glacier National Park and neighbor to two tribal nations.

It’s Montana’s fourth-largest county by population with more than 103,000 people, yet it’s rural — 18 people per square mile. It’s also conservative, with the majority of residents voting for former President Donald Trump last year. National polling has shown rural Americans and Republicans to be among the most lasix iv resistant to getting treatments. Russell said he hopes at least 40% of Flathead County residents eventually get the shots.

That’s well below the 70% to 80% believed to be needed to create widespread protection from the pathogen that has stalled lasix iv normal life. Public health experts worry about reservoirs of the lasix fueling outbreaks. That possibility further strains year-old tensions in places such as Flathead County, where strangers and family members alike can be split on whether the lasix is a threat and the decision to wear a mask marks where people stand. hypertension medications treatments are the latest phase of lasix iv that divide.

Cameron Gibbons, who lives outside Kalispell, has worried about how hypertension medications could affect her 13-year-old son. He’s had coughs turn into lung s that landed him in the emergency room for trouble breathing, so the family has played it safe during the lasix. €œWe haven’t seen family in a long time because they haven’t chosen to be careful, which is OK, lasix iv as long as when we get back to normal we can all set our differences aside,” Gibbons said. €œNow there’s this judgment of ‘Oh, you got the treatment.’” Some of Montana’s most vaccinated places overlap with tribal nations.

Chelsea Kleinmeyer, the health director of the Confederated Salish and Kootenai Tribes, said the tribes’ members seemed to largely accept treatments after the lasix disproportionately sickened and killed Native Americans. But the reservation crosses four counties, including Flathead lasix iv. €œWe travel to those counties every single day,” Kleinmeyer said. €œIt goes back to.

Are we really protected against this lasix, these lasix iv variants, if we don’t achieve herd immunity?. € States are shifting from mass clinics to bringing shots to where people are, but that strategy, too, can be unpredictable. The same day of the county’s final Thursday clinic, the local health system hosted a walk-in clinic in the middle of the Flathead Valley Community College campus lasix iv in Kalispell. Most of the chairs for people to wait 15 minutes post-shot remained empty and, by early afternoon, the clinic had to send 200 doses to the county health department to avoid wastage.

Although organizers had hoped to vaccinate at least 100 people that day, Audra Saranto, a registered nurse who heads Kalispell Regional Healthcare’s vaccination team, said she counts the college event as a success — 50 people got treatments who might otherwise not have. As daily hypertension medications vaccination rates slow across the nation, states are shifting from lasix iv mass clinics to bringing shots more directly to people. But results can be unpredictable. Organizers of a Flathead Valley Community College clinic on April 29 had hoped to vaccinate at least 100 people, but ended up giving out only half as many shots.

(Katheryn Houghton / KHN) The health system may host similar clinics at major lasix iv job sites, like for a lumber company. A mobile team will offer shots in busy places like farmers markets, even if it means risking people not following up for a second dose. It’s not surprising that hypertension medications vaccinations aren’t universally accepted yet in this divided county. Flathead’s board of health deadlocked over mask rules and crowd size limits amid lasix iv the area’s worst hypertension medications outbreaks.

Two top county health officials resigned in the past year. Thousands of people have signed dueling petitions to remove or keep one board of health member who had stirred doubt over hypertension medications cases and opposed mask rules. And the lasix iv city of Kalispell is home to state Sen. Keith Regier, a Republican who repeated false claims on the Senate floor last month that hypertension medications treatments may contain microchips to track people.

Regier said in an interview he was “offering caution in how we progress with this vaccination.” Meanwhile, Whitefish, roughly a 20-minute drive from Kalispell, has maintained lasix iv a mask ordinance that has outlasted the statewide mandate. Banners downtown show local leaders asking people to mask up so people can pray together and keep schools open. Even so, the rule isn’t always followed there. At the county’s final Thursday clinic, John Calhoun, lasix iv 67, undid his pearl snap shirt to get his second shot and joked with the nurse, “I’m doing this so Joe Biden doesn’t throw me in jail.” Calhoun said he hopes being vaccinated will help him ease tensions the next time someone tells him to wear a mask.

He believes hypertension medications is real but doesn’t think it’s as serious as health officials claim, even though he has diabetes, a risk factor for hypertension medications complications. €œNothing seems to bother me all that bad,” Calhoun said. €œI had a horse fall on me, broke my lasix iv hip, and once stabbed myself with a hunting knife. All that caused me a bit of a problem, but other stuff just doesn’t bother me.” He decided to get the shot after an old high school friend with a degree in biochemistry told him it was important — an opinion Calhoun trusted over those of government-paid experts and liberal politicians who he said have used the lasix to grab more power.

John Calhoun doesn’t trust that hypertension medications is as dangerous as national leaders have said, but a friend talked him into getting a shot. He hopes being vaccinated will ease tensions the next lasix iv time someone tells him to wear a mask.(Katheryn Houghton / KHN) Calhoun said he’s still trying to talk his wife, Lola, into getting vaccinated to play it safe. €œShe’s one of those ladies that you don’t talk her into much.” Lola Calhoun, 59, said she got her shingles treatment within the past year because she trusts the protection it offers. When it comes to hypertension medications, she said she’d rather risk the lasix than be injected with treatments that feel too new, despite decades of research underpinning their unprecedented development.

€œThe hypertension medications treatment to me is experimental and we are the case studies,” she said. €œMaybe a year from now, I’ll see what happens to these people who got the treatment.” On a recent evening, Ray Sederdahl, 63, sat on his girlfriend’s Kalispell porch while his grandkids picked dandelions. The Air Force veteran said even if he wasn’t skeptical of the treatments, he thinks of hypertension medications as an illness that’s much like the flu. €œThe VA keeps trying to get me to schedule an appointment and I just say, ‘At this time, I’ll pass,’” Sederdahl said.

€œA lot of the older vets I talk to, they didn’t get it either, and they’re not gonna get it.” To Sederdahl, things feel normal enough. Businesses are open and he doesn’t have to wear a mask most places. Erica Lengacher, an intensive care unit nurse in Kalispell who has worked hypertension medications units and treatment clinics, said she’s sad but not surprised that treatment rates are slowing. But, she said, the overall feeling at the county’s treatment clinics is hopefulness — people are still showing up, even if the crowds are smaller.

Lengacher said Flathead was hit so hard this winter, she hopes some natural immunity from those already infected, along with the growing vaccination levels, will be enough to hold off further outbreaks over the next few months. €œJust given our lifestyle — single-family homes, no public transportation, a few people per square mile — we may get away with it,” Lengacher said. €œBut there’s a big question mark of how variants show up here. There are just a lot of big question marks.” As of May 10, the county had 116 confirmed active cases of hypertension medications, up from 71 on April 23.

Katheryn Houghton. khoughton@kff.org, @K_Hought Related Topics Contact Us Submit a Story Tip.

€œThere’s virtually no difference between white, Black, Hispanic, Asian American,” referring to low cost lasix https://alistkandb.co.uk/buy-propecia-online-cheap vaccination rates among Americans 65 and up. President Joe Biden, May 3 During May 3 remarks on the American Families Plan, President Joe Biden boasted that there was not much disparity in the vaccination rates for white Americans and Americans of color who are at least 65. “And what’s happening now is all the talk about how low cost lasix people were not going to get shots, they were not going to be involved — look at what that was — we were told that was most likely to be among people over 65 years of age,” said Biden. €œBut now people over 65 years of age, over 80%, have now been vaccinated, and 66% fully vaccinated.

And there’s virtually no difference between white, Black, Hispanic, Asian American.” This isn’t the only time that Biden has made that claim. He went even further on April 27 low cost lasix during remarks on the hypertension medications response. €œAnd, by the way, based on reported data, the proportion — the proportion of seniors who have been vaccinated is essentially equal between white and seniors of color. €¦ As a matter of a fact, if I’m not mistaken, there are more Latinos and African American seniors that have been vaccinated, as a percentage, than white seniors.” However, the national data that Biden keeps touting — vaccination statistics regarding both race and age — is not public.

We asked the White House for the information underlying this claim, low cost lasix but officials did not provide specifics. So, we moved on to the Centers for Disease Control and Prevention. Spokesperson Chandra Zeikel told KHN-PolitiFact on May 6 that “unfortunately, we don’t have available a data breakdown of both racial demographics and age together.” Zeikel didn’t respond to a follow-up question asking when or if the CDC would be publishing this data, but current CDC vaccination data is broken down only by race/ethnicity and shows significant differences, with white Americans far outpacing the percentage of other groups getting a shot. It also shows that the rate of vaccinations among some groups, including Black and Latino Americans, does not match their share of the population, though new CDC data shows there has been some low cost lasix progress on this front in the past two weeks.

That made us wonder about the premise of Biden’s statement. We turned to low cost lasix experts for their take. €œAs far as I know, there is no comprehensive publicly available data on vaccination rates by race/ethnicity and age,” Samantha Artiga, vice president and director of the racial equity and health policy program at KFF, wrote in an email. €œAs such, we are not able to assess whether there are racial disparities in vaccinations among people over 65 years of age.” What about other state-level data or anecdotes that might support Biden’s claim?.

Let’s dive low cost lasix in and see. A Small Number of States Report Both Age and Race Together At least seven states track vaccination based on a combination of age and race, according to Artiga. Michigan, South Carolina, West Virginia, Kansas, Minnesota, Washington and Vermont. (Vermont tracks only two racial categories low cost lasix.

Non-Hispanic white and a combination of Black, Indigenous and people of color.) The results from some of these states show that racial disparities do exist in the older age groups. In Michigan, for instance, over 50% of non-Hispanic white people ages 65 to 74 had completed their vaccinations as of May 11. Other racial low cost lasix groups — non-Hispanic Black people. Asian American and Pacific Islanders.

And Hispanics — all trailed by about 10 percentage points. The exception was the Native American and Alaska Natives category, low cost lasix which was within 4 percentage points of white people. And as of May 11 in Kansas, the rate at which white people in that same age group were vaccinated was higher than the rates of Black people and Native Hawaiian/Pacific Islanders. In Vermont, for those 65 and up, about 79% of low cost lasix people of color had received at least one dose of the treatment, compared with 85% of white people as of that date.

€œWith the exception of Vermont, which has the distinction of being the only state to target BIPOC [Black, Indigenous and people of color] populations by race explicitly, these are examples of states in which the numbers are not doing well in their equity efforts,” Dayna Bowen Matthew, dean of the George Washington University Law School and an expert in racial disparities in health care, wrote in an email. Minnesota is one of the few states in which people of color are actually being vaccinated at higher rates than white people — with 93% of Asian/Pacific Islanders and 87.5% of Black/African Americans age 65 and over having received at least one shot, compared with 81.5% of white people as of May 11. Some states are vaccinating similar percentages of their population of Black or Hispanic people, Matthew said, however that data does not distinguish by low cost lasix age group. According to Bloomberg’s hypertension medications Vaccination Racial Gap tracker, New Mexico, Idaho, Oregon and Utah have vaccinated approximately the same percentage of Black Americans as are represented in each state’s population.

Maine, Ohio, Alabama, Louisiana and Missouri have achieved similar population-based rates for the Hispanic population. KFF provides weekly low cost lasix updates on national and state race/ethnicity data of those who have received vaccinations, which have consistently shown that Black and Hispanic people are receiving smaller shares of vaccinations compared with their shares of the total population, while white people are receiving a higher share. The May 5 weekly update, for instance, found that based on the 42 states that share race/ethnicity data, the percentage of white people who have received at least one hypertension medications treatment dose (39%) was roughly 1.5 times higher than the rates for Black (25%) and Hispanic people (27%). (KHN is an editorially independent program of KFF.) It’s also important to note that data on race and ethnicity information has not been gathered for many people who have been vaccinated.

As of May 3, the CDC reported that race and ethnicity were known for only 55% of all people who low cost lasix had received at least one treatment dose. And three states, Montana, New Hampshire and Wyoming, don’t report race/ethnicity data at all. How to Approach treatment Equity, Experts Say Nneka Sederstrom, chief health equity officer at Hennepin Healthcare in Minneapolis, said that her state has done an “excellent job” vaccinating the 65-and-older population but that there’s still a lot of work to be done to reach communities of color. We “will need more direct tactics to reach” those who haven’t yet low cost lasix been vaccinated, “and help address any issues of hesitancy due to lack of knowledge or systemic barriers,” Sederstrom wrote in an email.

Ensuring that treatments are available at primary care providers is also important, said Dr. Georges Benjamin, low cost lasix executive director of the American Public Health Association. €œThe truth of the matter is, the more vaccinators that we can get that are placed where people are every day, where it becomes a routine part of your life, such as going … into your doctor’s office for a regular visit, that’s a winner,” said Benjamin. But, Dr.

Uché Blackstock, founder of Advancing Health Equity, an organization that advocates to end bias and racism in health care, said she would set low cost lasix the bar for treatment equity success higher than just an equally proportionate share of a certain racial/ethnic population receiving their treatment doses. €œWhat success in treatment equity would look like would be if Black people or Hispanic people were overrepresented in terms of treatment received since they have been disproportionately impacted by the lasix,” said Blackstock. So even though Biden quotes these statistics that lack data behind them, if the evidence did support them, it would still not be enough, she said. In fact, the CDC does describe treatment low cost lasix equity in those terms.

€œpreferential access and administration to those who have been most affected by hypertension medications.” Our Ruling Biden has repeatedly claimed that vaccination rates among white people and people of color age 65 and older are virtually the same — or even higher among people of color. No public national data from the CDC or another database has been released to support this assertion. For the few states that do report data on age and race/ethnicity combined, the numbers suggest that, for the low cost lasix most part, obvious disparities persist in the vaccination rates for white seniors and seniors of color. In several states, treatment administration rates are more proportional to the percentage of the Black and Hispanic populations, but the data covers all age groups.

National data for all age groups also shows that rates of vaccinations for Black and Hispanic people lag behind that of white people. Existing data paints one story on treatment low cost lasix equity, while Biden’s words paint another. Without data to back it up, we rate Biden’s statement False. Sources:The Associated Press, “AP Fact low cost lasix check.

Biden overstates how many Americans immunized,” May 3, 2021Bloomberg News, hypertension medications Racial Gap Tracker, accessed May 5, 2021Centers for Disease Control and Prevention, “Demographic Characteristics of People Receiving hypertension medications Vaccinations in the United States,” accessed May 10, 2021Centers for Disease Control and Prevention, “County-Level hypertension medications Vaccination Coverage and Social Vulnerability — United States, December 14, 2020-March 1, 2021,” March 26, 2021Email exchange with Centers for Disease Control and Prevention spokesperson Chandra Zeikel, May 6, 2021Email exchange with White House administration official, May 6, 2021Email interview with Manuel Pastor, director of the University of Southern California Equity Research Institute, May 5, 2021Email interview with Nneka Sederstrom, chief health equity officer at Hennepin Healthcare in Minneapolis, May 5, 2021Email interview with Samantha Artiga, vice president and director of the racial equity and health policy program at KFF, May 5-6, 2021Kansas.gov, hypertension medications Demographics, accessed May 10, 2021KFF, Latest Data on hypertension medications Vaccinations Race/Ethnicity, May 5, 2021Michigan.gov, hypertension medications treatment dashboard, accessed May 10, 2021Minnesota.gov, “treatment Data,” accessed May 10, 2021NBC News, “Biden Hails Progress on treatment Equity, but Some Local Leaders Paint a Different Picture,” May 3, 2021Phone/email interview with Dayna Bowen Matthew, dean and Harold H. Greene Professor of Law at the George Washington University Law School, May 6-7, 2021Phone interview with Dr. Georges Benjamin, executive director of the American Public low cost lasix Health Association, May 6, 2021Phone interview with Dr. Uché Blackstock, founder of Advancing Health Equity, May 6, 2021Vermont.gov, hypertension medications treatment Dashboard, accessed May 10, 2021White House, “Remarks by President Biden on the American Families Plan,” May 3, 2021White House, “Remarks by President Biden on the hypertension medications Response,” April 27, 2021 Victoria Knight.

vknight@kff.org, @victoriaregisk Related Topics Contact Us Submit a Story TipEAST LOS ANGELES — For the past year, 13-year-old twins Ariel Jr. And Abraham Osorio have logged on to their online classes low cost lasix from their parents’ flower shop. Ariel nestles in a corner among flowers, bows and stuffed animals. Abraham sets up on a small table in the back, where his dad used to work trimming flowers and keeping the books.

It’s not ideal for low cost lasix learning. It’s loud. It’s cramped. It’s bustling low cost lasix with people.

Still, when the twins’ mother, Graciela Osorio, recently had the chance to send her kids back to Brightwood Elementary in Monterey Park, California, she decided against it. €œAfter what we went through with their father, I’d rather keep them at low cost lasix home where I know they are safe,” said Graciela, 51. €œThere’s only a month left. It doesn’t make sense that they return for such a short time.” The boys’ father, Ariel Osorio Sr., 51, died of hypertension medications in January, four weeks after a trip to Mexico to visit his mother.

He fell ill quickly and wasn’t able to say goodbye to low cost lasix his children. Graciela Osorio is mourning the loss of her husband, Ariel Osorio, who died of hypertension medications in January. (Heidi de Marco/KHN) “I miss his presence,” Abraham said. €œI’m used to seeing him sit in his low cost lasix chair working, but not anymore.” Latinos have been hit disproportionately hard by hypertension medications, and many families are opting out of in-person learning.

In California, Latinos make up 39% of the state’s population but account for 47% of hypertension medications deaths, according to the state Department of Public Health. Nationally, their risk of death from hypertension medications is 2.3 times higher than that of whites. Latinos are low cost lasix vulnerable to the highly transmissible hypertension because they are more likely than non-Hispanic whites to work essential jobs that expose them to the public, said David Hayes-Bautista, a professor of public health and medicine at UCLA and co-author of a January study on this topic. They are more likely to lack health insurance, which may make them less likely to seek medical care, he said.

And they are more likely to live in multigenerational households, which means the lasix can spread quickly and easily within families. €œMany of them are essential workers and the breadwinners for their families and don’t have the luxury of telework, of physical distancing and self-isolation,” said low cost lasix Alberto González, a senior health strategist at UnidosUS, a Latino advocacy group in Washington, D.C. The Osorio family has lived in a multigenerational household since Ariel died, and Graciela had to keep other family members in mind when deciding whether to send her boys back into the classroom. In February, Graciela and low cost lasix the twins moved in with her 74-year-old mother, Cleotilde Servin, in East Los Angeles.

Ten people now share the roughly 1,000-square-foot home, squeezing by one another in the kitchen every morning. Cleotilde Servin makes lunch for the family members who live with her, including two daughters, a son and several grandchildren. (Heidi de Marco/KHN) Graciela’s mother and low cost lasix the other adults in the home have been vaccinated, but the children haven’t. Even though she instructs her sons to wear their masks and doesn’t allow them to visit friends, she’s terrified of what could happen if her kids caught the lasix at school and brought it home.

€œMy mother is active and takes vitamins, but it still worries me,” Graciela said. She got hypertension medications from her husband and gave it low cost lasix to her sister and niece. €œI don’t want anyone else to get sick,” she said. State and local education officials don’t have recent data on in-person attendance by race, but an EdSource analysis of California Public Health Department data from February shows that white students were more likely to attend school in person than other students.

The analysis showed that 12% of Latinos were attending in-person classes at least some of the time, compared with 32% of whites and 18% of all low cost lasix students. The Los Angeles Unified School District, the second-largest in the country, serves more than 600,000 students and reopened for in-person learning in mid-April. Only some campuses are open, mostly elementary schools, and are running on hybrid schedules, combining on-campus classes with distance learning. €œWe’ve upgraded the air fiation systems in every classroom, reconfigured low cost lasix school facilities to keep all at a school appropriately distanced, doubled the custodial staff, and we’ll provide weekly hypertension medications testing at school for every student and staff member,” district superintendent Austin Beutner said in his weekly recorded video update on March 22.

In a statement released May 4, Beutner said 40% to 50% of elementary school students are now back in schools in “more affluent” communities compared with roughly 20% in low-income communities. €œWe see the greatest reluctance for children to be back in schools from families who live in some of the highest-needs communities low cost lasix we serve,” he said. Brightwood Elementary is a K-8 school with 870 students, about half of whom are Asian American and 40% Latino, said principal Robby Jung. Just 15% of students are back on campus, he said, and, of those, about one-third are Latino.

Ariel low cost lasix Osorio Jr. Works on his school homework at the back of the flower shop. (Heidi de Marco/KHN) Graciela Osorio owns Gracy’s Flower Shop in East Los Angeles, California, which she used to run with her husband. (Heidi de Marco/KHN) For the Osorio family, the overriding reason the eighth grade twins are not back at Brightwood low cost lasix is fear.

Like so many other Latino families — roughly 28,000 Latinos have died of hypertension medications in California — they are reeling from the grief and trauma that the disease has already wrought, and the fear of what it could do if it struck again. €œThe boys are seeing a therapist to deal with their dad’s death,” Graciela said. €œI know I should probably talk to someone, too.” With the memory of her husband’s death still so fresh that she can’t speak of him without crying, Graciela low cost lasix is still adjusting to the emotional toll, and to the day-to-day realities of running a flower shop by herself. Originally from Guerrero, Mexico, she started Gracy’s Flower Shop with her husband in 1997.

Ariel took care of the finances at home and at the shop and was the better English speaker of the two. €œNow being alone with the boys, it’s more difficult to low cost lasix keep up,” she said. After losing her husband to hypertension medications, Graciela Osorio decided not to let her sons return to in-person learning out of fear they might contract the lasix at school. €œI tell them they have to stay focused now that their dad isn’t around to push low cost lasix them,” she says.

(Heidi de Marco/KHN) During the hypertension medications lockdowns, the boys joined the couple at the shop. Her husband sat next to their children while they attended school online, helping with their homework and acting as the main contact for the school. €œThey were low cost lasix always with us,” Graciela said. €œThey grew up in the flower shop, so they didn’t have a problem setting up their school stations there.” Brightwood reopened its doors April 12, offering in-person learning two days a week for a few hours a day, with the rest of the sessions online.

Graciela said the limited schedule doesn’t work with her role as the family breadwinner. €œI would have to take them to low cost lasix school, pick them up for lunch and then bring them back,” she said. €œI can’t do that. I have to work.” But mostly she’s keeping them off campus because she doesn’t want to lose another family member.

She said she knows online classes aren’t the same low cost lasix as in-person instruction “but they have been keeping their grades up,” she said. €œI thank God I have good boys. They listen. They understand why I kept them home.” Abraham low cost lasix Osorio and Ariel Osorio Jr.

Outside their mother’s flower shop. (Heidi de low cost lasix Marco/KHN) The last day of school is May 28. Ariel and Abraham said they’re looking forward to high school in the fall. Still dealing with their father’s death, the boys, who are shy and reserved by nature, are torn between returning to school in person or continuing their classes online.

€œWe might go back,” Abraham said low cost lasix. €œFor now, we keep each other company.” This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Heidi de Marco. heidid@kff.org, @Heidi_deMarco Related Topics low cost lasix Contact Us Submit a Story TipAn exclusive Montana resort wants to turn sewage into snow so that its rich and famous members can ski its slopes in a winter season that’s shrinking because of climate change.

The Yellowstone Club — a ski and golf resort just north of Yellowstone National Park that counts Bill Gates, Justin Timberlake and Jessica Biel among its members — has asked the Montana Department of Environmental Quality for a permit to allow it to use wastewater for snowmaking operations on its ski slopes. About a dozen other ski areas across the U.S. Have used wastewater to make artificial snow low cost lasix before, but the Yellowstone Club would be the first in Montana. The technique has also been used in Europe and Australia.

Officials at the club say the program would not only ensure the slopes can open on time, usually in late November and early December, but also replenish the area’s watershed and keep streams running longer into the season. And it low cost lasix would allow the growing Big Sky resort area to handle its increasing wastewater volumes. €œIt’s an outside-the-box-idea,” said Rich Chandler, environmental manager for the club. €œBut it also checks a lot of boxes.” Is it a safe plan for the rich and famous who will occasionally ingest it when they wipe out on the slopes? low cost lasix.

The short answer from state officials is yes. The method is safe for people and the environment as long as there is close monitoring to ensure contamination levels stay within standards, according to an environmental analysis. But, the state officials said, that analysis did not study potential pollutants for which there are low cost lasix no environmental standards in wastewater, such as traces of prescription drugs. A similar effort to turn wastewater into snow was controversial at the Arizona Snowbowl ski resort near Flagstaff.

To combat snowless winters there, the resort in the early 2000s purchased wastewater from Flagstaff and pumped it from the treatment plant to the ski area, where it would be turned into snow and sprayed onto the San Francisco Peaks. That drew protests from the Hopi Tribe, which said the artificial snow posed risks to public health low cost lasix and the environment and would desecrate a mountain it considers sacred. The tribe lost a legal challenge to prevent the Arizona ski area from moving ahead with the plan. In December 2012, the ski area fired up its snow guns and started making powder.

During the legal fight, environmental groups, including the Center for Biological Diversity, raised specific concerns about how wastewater can reduce local aquatic populations and cause some male fish low cost lasix to take on female appearances and reproductive traits. Wastewater’s effect on human health also raises concerns. Although modern water treatment can eliminate many pollutants — and, in some instances, prepare that water for human consumption — some elements still escape the process, specifically pharmaceuticals. The research is in its infancy, but a 2017 study by the United Nations Educational, Scientific and Cultural Organization found that only half of the pharmaceutical compounds were low cost lasix removed in the water treatment process.

It noted that evidence suggests some of the chemicals could affect human reproductive systems, too, just as studies have shown on aquatic life. “Modern wastewater treatment plants mostly reduce solids and low cost lasix bacteria by oxidizing the water. They were not designed to deal with complex chemical compounds,” said Birguy Lamizana-Diallo, program management officer at the United Nations Environment Program and an expert on wastewater treatment. Officials in Montana are quick to point out differences between their plan and what happened in Arizona.

For one, the ski area near Flagstaff often makes all its snow from treated wastewater, whereas the Yellowstone Club will low cost lasix use it, at least initially, on only about 10% of the 2,700 acres of skiable terrain and usually only in October and November to create a base layer for its ski runs. Come December, most of the snow people would be skiing and riding on would be natural. But perhaps the biggest difference between the two projects is the level of support the Yellowstone Club has for its plan, which is backed by environmental and conservation groups including the Gallatin River Task Force, the Association of Gallatin Agricultural Irrigators and Trout Unlimited. The idea low cost lasix to turn Big Sky’s wastewater into snow has been brewing for more than a decade and emerged from a collaboration between the Yellowstone Club and other local groups concerned about depleted snowpack due to climate change, which could starve area creeks and streams of water later in the season.

Yellowstone already uses treated wastewater to hydrate its golf courses, and in 2011 it teamed up with the Montana DEQ and the Gallatin River Task Force to see if they could safely turn the same water into snow. Chandler, the club’s environmental manager, said they successfully turned a half-million gallons of wastewater into 2 acres of snow about 18 inches deep. Kristin Gardner, executive director of the Gallatin River Task Force, said the snowmaking process effectively re-treats the wastewater by blasting it out of a filtered snowmaking gun that atomizes low cost lasix the water. €œIt’s an added layer of security for the human health side of things,” Chandler said.

Chandler said the information gathered from the pilot study forms the core of the ski club’s application with the Montana DEQ low cost lasix. A draft permit tentatively approving the project has been issued by the state agency, and a final decision is expected later this year. Officials at DEQ said that the wastewater used to make snow will be treated to the highest standards possible and that they can issue permits only to projects that will not pollute state waters. But the effect of pharmaceuticals remains uncharted territory low cost lasix.

Amy Steinmetz, public water supply bureau chief, said that neither the DEQ nor the U.S. Environmental Protection Agency has standards to specifically treat wastewater for pharmaceuticals. €œThe science low cost lasix is still emerging on that,” she said. If the DEQ does issue its final permit this year, the Yellowstone Club will most likely begin turning wastewater into snow in late 2022.

It would then be required to post signage advising skiers not to consume the snow. Similar signage can be found at Arizona low cost lasix Snowbowl. Chandler said that the Yellowstone Club is proud of the collaborative work and that, ultimately, the process will benefit the community and watershed. Making more snow and increasing the snowpack during the winter, Chandler estimates, will increase the summer runoff in area creeks by about 19 days, a big win in the increasingly arid West.

It’s also low cost lasix better than the alternative, he said. Treating the wastewater and then just pushing it directly into the Gallatin River. €œIt’s not like the Earth is producing low cost lasix more water, so we have to use what we have effectively,” he said. Related Topics Contact Us Submit a Story Tip[Editor’s note.

If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado Crisis low cost lasix Services at 1-844-493-TALK (8255) or text TALK to 38255.] KIOWA, Colo. €” The yellow-and-green facade of Patty Ann’s Cafe stands out on the main street of this ranching community just 25 miles from the Denver suburbs. Before the lasix, the cafe was a place for ranchers to gather for meals and to swap stories.

“Some people would call it almost like a conference room,” said Lance Wheeler, a low cost lasix local rancher and regular at the cafe. €œThere are some guys that, if you drive by Patty Ann’s at a certain time of day, their car or truck will always be there on certain days.” When hypertension medications restrictions closed in-person dining across Colorado last year, Patty Ann’s opened a takeout window. Customers spread their food on the hoods of their trucks and ate there while sharing news and commiserating over the stresses of ranching during the lasix. Keeping that low cost lasix community hub operating has been vital for the ranchers around Kiowa as the lasix takes its toll on mental health in agricultural communities where health providers are scarce and a “pull yourself up by your own bootstraps” mentality is prevalent.

Wheeler heads into Patty Ann’s Cafe for lunch. Ranchers often come to the Kiowa, Colorado, cafe for breakfast or lunch, which Wheeler said is a way to connect with others experiencing similar stresses. €œThat’s your support group, because you have commonality, a common experience, low cost lasix common difficulty.” (Eli Imadali for KHN) Roberta Kusma (left) laughs with her old friend Betty Hood at Patty Ann’s Cafe. The two worked in the same building when it was a grocery store years ago.

(Eli Imadali for KHN) The lasix over low cost lasix the past year has been a surprising boon for many farms and ranches as higher consumer demand amid food shortages has boosted business. But coupled with everyday worries about weather and commodity prices, the lasix also has led to mental health challenges, including serious stress, anxiety and depression among farmers and ranchers, health officials said. The American Farm Bureau Federation found that about 3 in 5 rural adults reported that the lasix has affected mental health in their communities, while two-thirds of farmers and farmworkers said the lasix has impacted their mental health. Treatment for mental health problems caused or worsened by the stress and isolation of the lasix has obstacles low cost lasix particular to ranching and farming country.

The stigma of acknowledging the need for mental health care can prevent people from seeking it. For those who overcome that obstacle and look for help, they are likely to find underfunded, understaffed and underequipped health providers who often don’t have the bandwidth or expertise for sufficient mental health support. €œI guess low cost lasix my cows are my therapists,” joked Wheeler. The 54-year-old rancher said he has felt the stress of the added responsibility of providing meat to customers in a time of food shortages, particularly at the beginning of the lasix.

But he feels lucky to have a family that supports him. Because drought has impeded hay production in low cost lasix Colorado, Wheeler has had to have bales shipped in from South Dakota. Wheeler says the lack of rain has been his biggest stressor. (Eli Imadali for KHN) Similar to other Rocky Mountain states, Colorado has one of the highest suicide rates in the country.

The rates low cost lasix are often worse in the state’s rural communities, a factor consistent with rural Americans’ risks nationwide. A Centers for Disease Control and Prevention report examining 2001-15 data found the suicide rate in rural counties was more than 17 per 100,000 people, compared with about 15 per 100,000 in small and medium-sized metro counties and about 12 per 100,000 in large metro counties. Kiowa is in Elbert County, whose 1,850 square miles of mostly low cost lasix dusty, flat plains start where the affluent bedroom communities of Denver end. The county has no urgent care center or hospital like its suburban neighbors, just four clinics to serve a population of 27,000.

A health care center in Elizabeth, Colorado, offers counseling, among other services. The few physical and mental health resources available in Elbert County are concentrated in the west, closer to low cost lasix Denver. (Eli Imadali for KHN) Dwayne Smith, Elbert County’s public health director, said that to help solve the problem residents need to talk with their health providers as candidly about their mental health challenges as about skin cancer or heart disease. €œIn a more conservative community, where historically mental health issues may not have been talked about as openly and as comfortably as in the [Denver] area, you have to work diligently to increase people’s comfort level,” Smith said.

€œEven saying the words ‘anxiety,’ ‘depression,’ ‘mental health’ low cost lasix — all those things that in prior generations were very much a taboo subject.” Elbert County Public Health Director Dwayne Smith poses outside the Department of Health and Human Services, surrounded by prairie. (Eli Imadali for KHN) The public health crisis is just an added burden to the already high stress on people in the agricultural industry. €œFarmers and ranchers are absorbing a lot of the shocks to the system for us. Hailstorms, pest outbreaks, drought, markets — they’re adjusting low cost lasix for all that to keep food production moving,” said Colorado’s agriculture commissioner, Kate Greenberg.

Unpredictable weather, a volatile commodity market and a 700-acre grass fire cost Laura Negley, a rancher in the southeastern town of Eads, a lot of income around 2012. Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land. But she was low cost lasix devastated after those losses, followed by her youngest child’s departure for college. €œThat’s kind of when the wheels fell off for me.

And then I kind of low cost lasix spiraled down,” Negley said. The lasix exacerbated Laura Negley’s anxiety, isolating her from extended family and causing worry about her elderly parents.(Eli Imadali for KHN) Negley, now 59, said she initially didn’t recognize she needed help even though she was deep into her “dark place” of depression and anxiety, but her brother encouraged her to see a counselor near him in Greeley. So, when the cattle were done grazing for the season, Negley spent six winter weeks getting counseling 200 miles north. Those visits eventually transitioned to low cost lasix phone counseling and an anti-anxiety medication.

€œI do think you have to have a support group,” said Negley, who said her faith has helped her, too. Over the years, slashed budgets to local health departments have cut to the bone. In Elbert low cost lasix County, Smith is one of just three full-time employees in his department. About 15 years ago, it had at least six nurses.

It now has none. It is low cost lasix trying to hire one. €œWe have a lack of health providers” in rural America, Negley said. €œThe ones we do have are doing their best — but they’re trying to wear multiple hats.” Negley talks with son Jayce as he repairs a sweep plow on their family land in Eads, Colorado.

(Eli Imadali for KHN) Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land low cost lasix. (Eli Imadali for KHN) Stressors like severe drought and exhaustion from unrelenting hard work can lead to mental health struggles for farmers and ranchers. Negley will likely not have cattle this year because drought impeded grass growth.(Eli Imadali for KHN) Agencies in Colorado recognize the need to improve mental health services offered low cost lasix to rural residents. Colorado Crisis Services has a hotline and text-messaging number to refer people to free, confidential support.

And the state is working on tailored messaging campaigns to help farmers and ranchers understand those numbers are free and confidential to contact. These services can help low cost lasix. According to the CDC, for every adult death by suicide, about 230 people think seriously about suicide. A bill introduced in Colorado’s legislature would boost funding for rural rehabilitation specialists and help provide vouchers for rural Coloradans to get behavioral health services.

€œWe have to be low cost lasix flexible. What works in Denver does not work in La Junta” or the rest of rural Colorado, said Robert Werthwein, director of the state’s Office of Behavioral Health. But in tightknit small towns, ranchers say, even if the resources are there the stigma remains. €œThese are low cost lasix normal people with normal problems.

We’re just trying to, perhaps first and foremost, destigmatize mental health needs and resources,” Smith said. €œTimecards and schedules have had no meaning for the past year,” says Smith, one of three full-time employees in his department. €œIt’s just been never-ending.” (Eli Imadali for KHN) Stigmas are something 26-year-old Jacob Walter and his family want to low cost lasix help tackle. As Walter was growing up, a friend’s father and another friend’s mother died by suicide.

Before Walter left the family’s ranch in southeastern Colorado to start his sophomore year low cost lasix in college, he lost his own father, Rusty, to suicide in 2016. Walter said there were few local resources at the time to help people like his dad, and the nearest town was 45 minutes away. Rusty was involved in many community service organizations and gave a lot of his time to others, Walter said, but he suffered from depression. €œThe day before he committed suicide, we low cost lasix had been talking at the kitchen table, and he was just talking about [his depression], and he said.

€˜You know, you can always get help and stuff.’” That’s the message agricultural leaders like Ray Atkinson, communications director at the American Farm Bureau Federation, say should be conveyed most. It’s OK to acknowledge when you need help. €œIf your tractor needed maintenance … you would stop what you’re doing and you’d get it working right before you go try and go out in the low cost lasix field,” Atkinson said. €œYou are the most important piece of equipment on your farm.” Cattle eat hay on Rafter W Ranch near Simla, Colorado.

Drought hasn’t allowed grazing on grassy pastures. (Eli Imadali for KHN) low cost lasix [Editor’s note. If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado Crisis Services at 1-844-493-TALK (8255) or text TALK to 38255.] Related Topics Contact Us Submit a Story TipKALISPELL, Mont.

€” The low cost lasix hypertension medications vaccination operation at the Flathead County fairgrounds can dole out 1,000 doses in seven hours. But demand has plummeted recently, down to fewer than 70 requests for the shots a day. So, at the start of May, the northwestern Montana county dropped its mass vaccination offerings from three to two clinics a low cost lasix week. Though most of those eligible in the county haven’t yet gotten a dose, during the final Thursday clinic on April 29, few cars pulled up and nurses had time to chat between patients.

€œIt’s a trickle,” said Flathead City-County Health Officer Joe Russell. €œNot enough people will get vaccinated to reach herd immunity, not in Flathead low cost lasix County and maybe not in Montana.” Daily hypertension medications vaccination rates are falling nationwide. Gaps in treatment uptake are starting to show, especially in rural America. That leaves many communities grappling with an imperfect lasix endgame.

Flathead stands out as one of Montana’s most populated counties low cost lasix to fall behind. There, 25% of people had been fully vaccinated by May 10. To compare, nearly 33% of Montanans were fully vaccinated, and that figure is closer to 35% nationwide. Flathead County is a medical destination for the top corner of the state, a gateway to Glacier National Park and neighbor to two tribal nations low cost lasix.

It’s Montana’s fourth-largest county by population with more than 103,000 people, yet it’s rural — 18 people per square mile. It’s also conservative, with the majority of residents voting for former President Donald Trump last year. National polling has shown rural Americans and Republicans to be among the most low cost lasix resistant to getting treatments. Russell said he hopes at least 40% of Flathead County residents eventually get the shots.

That’s well low cost lasix below the 70% to 80% believed to be needed to create widespread protection from the pathogen that has stalled normal life. Public health experts worry about reservoirs of the lasix fueling outbreaks. That possibility further strains year-old tensions in places such as Flathead County, where strangers and family members alike can be split on whether the lasix is a threat and the decision to wear a mask marks where people stand. hypertension medications treatments are the latest phase of low cost lasix that divide.

Cameron Gibbons, who lives outside Kalispell, has worried about how hypertension medications could affect her 13-year-old son. He’s had coughs turn into lung s that landed him in the emergency room for trouble breathing, so the family has played it safe during the lasix. €œWe haven’t seen family in a long time because they haven’t chosen to be careful, which is OK, as long as when we get back to normal we can all set low cost lasix our differences aside,” Gibbons said. €œNow there’s this judgment of ‘Oh, you got the treatment.’” Some of Montana’s most vaccinated places overlap with tribal nations.

Chelsea Kleinmeyer, the health director of the Confederated Salish and Kootenai Tribes, said the tribes’ members seemed to largely accept treatments after the lasix disproportionately sickened and killed Native Americans. But the reservation crosses low cost lasix four counties, including Flathead. €œWe travel to those counties every single day,” Kleinmeyer said. €œIt goes back to.

Are we really protected against this lasix, these variants, if we low cost lasix don’t achieve herd immunity?. € States are shifting from mass clinics to bringing shots to where people are, but that strategy, too, can be unpredictable. The same day of the county’s final Thursday clinic, the low cost lasix local health system hosted a walk-in clinic in the middle of the Flathead Valley Community College campus in Kalispell. Most of the chairs for people to wait 15 minutes post-shot remained empty and, by early afternoon, the clinic had to send 200 doses to the county health department to avoid wastage.

Although organizers had hoped to vaccinate at least 100 people that day, Audra Saranto, a registered nurse who heads Kalispell Regional Healthcare’s vaccination team, said she counts the college event as a success — 50 people got treatments who might otherwise not have. As daily hypertension medications vaccination rates slow across the low cost lasix nation, states are shifting from mass clinics to bringing shots more directly to people. But results can be unpredictable. Organizers of a Flathead Valley Community College clinic on April 29 had hoped to vaccinate at least 100 people, but ended up giving out only half as many shots.

(Katheryn Houghton / KHN) The health system may host similar clinics at major job sites, like for a lumber low cost lasix company. A mobile team will offer shots in busy places like farmers markets, even if it means risking people not following up for a second dose. It’s not surprising that hypertension medications vaccinations aren’t universally accepted yet in this divided county. Flathead’s board of health deadlocked over mask rules and crowd size limits low cost lasix amid the area’s worst hypertension medications outbreaks.

Two top county health officials resigned in the past year. Thousands of people have signed dueling petitions to remove or keep one board of health member who had stirred doubt over hypertension medications cases and opposed mask rules. And the city of Kalispell is low cost lasix home to state Sen. Keith Regier, a Republican who repeated false claims on the Senate floor last month that hypertension medications treatments may contain microchips to track people.

Regier said in an interview he was “offering caution in how we progress with this vaccination.” Meanwhile, Whitefish, roughly a 20-minute drive from Kalispell, has maintained a mask ordinance that has outlasted the statewide mandate. Banners downtown show local leaders asking people to mask up so people can pray together and keep schools open. Even so, the rule isn’t always followed there. At the county’s final Thursday clinic, John Calhoun, 67, undid his pearl snap shirt to get his second shot and joked with the nurse, “I’m doing this so Joe Biden doesn’t throw me in jail.” Calhoun said he hopes being vaccinated will help him ease tensions the next time someone tells him to wear a mask.

He believes hypertension medications is real but doesn’t think it’s as serious as health officials claim, even though he has diabetes, a risk factor for hypertension medications complications. €œNothing seems to bother me all that bad,” Calhoun said. €œI had a horse fall on me, broke my hip, and once stabbed myself with a hunting knife. All that caused me a bit of a problem, but other stuff just doesn’t bother me.” He decided to get the shot after an old high school friend with a degree in biochemistry told him it was important — an opinion Calhoun trusted over those of government-paid experts and liberal politicians who he said have used the lasix to grab more power.

John Calhoun doesn’t trust that hypertension medications is as dangerous as national leaders have said, but a friend talked him into getting a shot. He hopes being vaccinated will ease tensions the next time someone tells him to wear a mask.(Katheryn Houghton / KHN) Calhoun said he’s still trying to talk his wife, Lola, into getting vaccinated to play it safe. €œShe’s one of those ladies that you don’t talk her into much.” Lola Calhoun, 59, said she got her shingles treatment within the past year because she trusts the protection it offers. When it comes to hypertension medications, she said she’d rather risk the lasix than be injected with treatments that feel too new, despite decades of research underpinning their unprecedented development.

€œThe hypertension medications treatment to me is experimental and we are the case studies,” she said. €œMaybe a year from now, I’ll see what happens to these people who got the treatment.” On a recent evening, Ray Sederdahl, 63, sat on his girlfriend’s Kalispell porch while his grandkids picked dandelions. The Air Force veteran said even if he wasn’t skeptical of the treatments, he thinks of hypertension medications as an illness that’s much like the flu. €œThe VA keeps trying to get me to schedule an appointment and I just say, ‘At this time, I’ll pass,’” Sederdahl said.

€œA lot of the older vets I talk to, they didn’t get it either, and they’re not gonna get it.” To Sederdahl, things feel normal enough. Businesses are open and he doesn’t have to wear a mask most places. Erica Lengacher, an intensive care unit nurse in Kalispell who has worked hypertension medications units and treatment clinics, said she’s sad but not surprised that treatment rates are slowing. But, she said, the overall feeling at the county’s treatment clinics is hopefulness — people are still showing up, even if the crowds are smaller.

Lengacher said Flathead was hit so hard this winter, she hopes some natural immunity from those already infected, along with the growing vaccination levels, will be enough to hold off further outbreaks over the next few months. €œJust given our lifestyle — single-family homes, no public transportation, a few people per square mile — we may get away with it,” Lengacher said. €œBut there’s a big question mark of how variants show up here. There are just a lot of big question marks.” As of May 10, the county had 116 confirmed active cases of hypertension medications, up from 71 on April 23.

Katheryn Houghton. khoughton@kff.org, @K_Hought Related Topics Contact Us Submit a Story Tip.

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