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To mark how to get doxazosin without a doctor Breast Cancer Awareness Month, UC Davis Health is offering free mammogram screening exams to help meet the needs of uninsured members of our community. The mammography team at UC Davis Health is ready to provide free screening mammograms by appointment on October 17 and how to get doxazosin without a doctor 31. The screening mammograms are available for uninsured women aged 40 and over, who have no current symptoms. (Women with symptoms need a different mammogram, called a diagnostic mammogram.)Appointments how to get doxazosin without a doctor will be available on two Saturdays this month.

October 17 and 31, from 7:15 a.m. To 2:00 p.m.To schedule an appointment, please call (916) 734-6145 how to get doxazosin without a doctor and mention the free Breast Cancer Awareness Month (BCAM) screening mammogram. A Spanish-speaking representative is available. Appointments are required and available on a how to get doxazosin without a doctor first-come, first-served basis.

Patients needing follow-up care will be referred to their primary care provider or other health care provider.Para conmemorar el Mes de Concientización sobre el Cáncer de Mama, UC Davis Health está ofreciendo exámenes de mamografía para cumplir con las necesidades de miembros de la comunidad que no cuentan con seguro médico. UC Davis Health está ofreciendo mamografías sin costo alguno el 17 y 31 de how to get doxazosin without a doctor octubreLos exámenes sin costo son para mujeres mayores de los 40 años quienes no tienen seguro médico, y quienes no tienen síntomas presentes. (Mujeres con síntomas necesitan un diferente tipo de mamografía, el cual es conocido como una mamografía de diagnóstico.)Citas están disponibles para dos sábados durante el mes de octubre. El 17 y el 31, how to get doxazosin without a doctor desde las 7:15 a.m.

Hasta las 2 p.m.Para hacer cita, por favor llamar al (916) 734-6145, y mencione la mamografía sin costo por motivo del Mes de Concientización sobre el Cáncer de Mama. Le atenderán how to get doxazosin without a doctor en español. Se requieren citas y se programarán por orden de llegada.Pacientes que requieren seguimiento serán referidas a sus médicos de cabecera u otro proveedor de salud..

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Senior woman attending a telehealth appointment.Providers have 11 additional telehealth services that will be reimbursed by the Centers for Medicare and Medicaid Services during the COVID-19 public health emergency.CMS announced yesterday the addition of 11 new services to the Medicare telehealth services list.Medicare will begin paying eligible practitioners for doxazosin pharmacology these services immediately, and for the duration of the PHE. These new telehealth services include certain neurostimulator analysis and doxazosin pharmacology programming services and cardiac and pulmonary rehabilitation services. CMS is also providing additional support to state Medicaid and Children's Health Insurance Program agencies in their efforts to expand access to telehealth through the release of a new supplement to its State Medicaid &. CHIP Telehealth doxazosin pharmacology Toolkit.

Policy Considerations doxazosin pharmacology for States Expanding Use of Telehealth, COVID-19 Version. The updated supplemental information clarifies to states, providers and other stakeholders which telehealth policies are temporary or permanent. It also helps states identify services that can be accessed through telehealth, which providers may deliver those services and the circumstances under which telehealth can be reimbursed once the PHE expires.WHY THIS MATTERSThe use of telehealth has grown during the pandemic as CMS has allowed doxazosin pharmacology greater flexibility for its use.Reimbursement at parity for an in-person visit has been a main driver. CMS has made some temporary telehealth measures permanent but providers still await an announcement on whether payment parity will remain when the public health emergency ends.A preliminary Medicaid and CHIP data snapshot on doxazosin pharmacology telehealth utilization during the PHE shows there have been more than 34.5 million services delivered via telehealth to Medicaid and CHIP beneficiaries between March and June of this year, representing an increase of more than 2,600% when compared to the same period from the prior year.

The data also shows that adults ages 19-64 received the most services delivered via telehealth, although there was substantial variance across both age groups and states. THE LARGER TRENDSince the beginning of the public health emergency, CMS has added over 135 services to the Medicare telehealth services list – such as emergency doxazosin pharmacology department visits, initial inpatient and nursing facility visits, and discharge day management services. The additional services being added totals 144 services performed by telehealth that will be paid by Medicare. Between mid-March and mid-August 2020, over 12.1 million Medicare beneficiaries – more doxazosin pharmacology than 36% – of people with Medicare fee-for-service have care through telemedicine.The 11 new services being added to the Medicare telehealth services list are the first being done through an expedited process allowed under the May 1 COVID-19 Interim Final Rule with comment period.

CMS actions follow through on President Trump's doxazosin pharmacology Executive Order on Improving Rural Health and Telehealth Access.Twitter. @SusanJMorseEmail the writer. Susan.morse@himssmedia.comThe COVID-19 crisis has magnified and exacerbated inequities in healthcare, with communities of color disproportionately affected doxazosin pharmacology by the disease and its economic fallout. But such disparities date back to long before the pandemic began to spread across the country this spring."Structural racism," said American Medical Association Chief Health Equity doxazosin pharmacology Officer Dr.

Aletha Maybank, "permeates the healthcare system."Given that reality, "How do we combat bias that's decades-old in our country as we move forward today?. " she asked.Maybank was among the experts at the HLTH VRTL 2020 conference this week who weighed in on the best strategies to confront the ways racism in doxazosin pharmacology the healthcare industry. From medical education content to training, to research study designs, to technological responses."Technology doxazosin pharmacology in itself can be a great equalizer," said Doctor on Demand Chief Medical Officer Dr. Ian Tong.

However, he doxazosin pharmacology cautioned, technology can also replicate the bias of its creators. He noted, for example, that tools relying on artificial intelligence to flag potentially harmful skin lesions may misdiagnose or overlook signs of disease on darker skin tones.Still, he said, "I have that belief we can use technology in the right way."For instance, he said, AI could be used to alert doctors that some patients may be at higher risk for certain diagnoses, due to social determinants of health.Tong said that developers should understand that technology is akin to medication in that it can be helpful, but it can also be harmful when used inappropriately."We need the tools, and I would ask that developers know that and consult us or involve us in the process early," Tong said.Maybank noted that there remain enormous gaps in health data regarding people of color and the disparities they face."As COVID has highlighted, a lot of folks don't have systems set up to collect race and ethnicity data," she said. By not collecting information accurately, "we're not finding out what's happening to all folks in this country."We're not understanding what is impacting people that is creating those differences," she continued.It's also important, she noted, doxazosin pharmacology for researchers and clinicians to move beyond what she called "the deficit model.""What are the strengths of people?. What doxazosin pharmacology are the networks?.

" she asked. "Those are the things we doxazosin pharmacology have to consider as it relates to race."Other experts stressed that the pandemic has highlighted – and worsened – existing inequities. "It's not enough just to be not doxazosin pharmacology racist. We have to be anti-racist," said Dr.

Laurie Glimcher, president and CEO of the Dana-Farber doxazosin pharmacology Cancer Institute. "I think there's a nationwide recognition of how much we doxazosin pharmacology have left to do."Dr. Ivor B. Horn, who moderated the panel with Maybank and Tong, noted that "technology is moving much faster than policy or practice." So how, she doxazosin pharmacology asked, do we train a new group of leaders in asking critical questions about addressing racism in healthcare?.

"I want [leaders] to put their money where their mouth is," said Tong. "I want them to doxazosin pharmacology engage and fund and direct their business to companies that have true representation across the company and at the leadership level." Maybank agreed, but also noted that doing so is difficult for those who don't know the root causes of the problems. "My call to action is to learn doxazosin pharmacology more!. " she said."Be humble, and be willing to be a learner, and seek out others who do have knowledge and companies who are doing the work in the trenches, and support them," Horn agreed."Racism is a cultural issue – broadly in this country, and more specifically, in medicine.

It’s going to take more than talk to doxazosin pharmacology drive meaningful change. Change must start at the top – with leadership [members] who recognize the problem head-on, and commit to balancing doxazosin pharmacology the scales," Tong said in a statement to Healthcare IT News. Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichEmail.

Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.Keck Medicine of USC, a health system based in Los Angeles, had experienced a few years of dramatic growth in both patient volume and geographic footprint, with numerous ambulatory locations and partnerships with hospitals in Los Angeles, Orange, Kern and Tulare Counties.THE PROBLEMTo help optimize availability for a large patient population, many of whom require complex, specialized care, Keck needed to minimize appointment no-shows and late cancellations. At the time, its IT required staff to manually enter appointment details.This process did not integrate with the electronic health record and provided limited visibility into what was going on during patients’ real-time care journeys. On top of that, staff was looking for stronger levels of customer support.Further, Keck needed a solution that would be adaptable and scalable – something that would be capable of taking on expanded features and additional use-cases (beyond appointment reminders) over time, particularly as Keck’s 10-year-old health system continues its dramatic growth trajectory.PROPOSALPatient-engagement IT vendor Lumeon proposed a multi-layered solution. First, it offered an automation platform that would integrate with Keck’s EHR, and automate the patient journey, beginning with text message appointment reminders.Automation would alleviate the manual work staff was doing in scheduling appointments, following up with reminders and rescheduling no-shows, enabling staff to focus on other, higher-value tasks.“Over time, as we identified other processes that could improve with automation, Lumeon consolidated these services into a single technology platform,” said Laurie Johnson, chief ambulatory officer at Keck Medicine of USC."If you can automate engagement and the handling of manual tasks to reduce the burden on your staff while delivering the high caliber of experience that patients expect, everyone wins."Laurie Johnson, Keck Medicine of USC“For instance, to support physical distancing and reduce the risk of COVID-19 exposure at our facilities, we used Lumeon’s automation platform to create a virtual check-in process, which keeps patients waiting outside of the facility until their physician is ready to see them for their appointment.”MARKETPLACEThere are a variety of patient engagement and relationship management tools on the health IT market today.

Some of the vendors of these tools include Luma Health, Lumeon, Nimblr, RevenueWell, Salesforce, Solutionreach, Weave, WebPT and WELL.MEETING THE CHALLENGELumeon’s platform automates appointment reminder activities and processes. Patients receive three reminders for each appointment – via voice, e-mail or text – and in their preferred language, without manual intervention from staff. The system also is programmed to avoid calling patients during inconvenient hours.“Care teams only need to engage with the system to follow up with a patient due to noncompliance, a no-show for an appointment or if the patient has requested help from their care team,” Johnson explained. €œStaff also have access to a centralized, self-service library of pathways so they can make changes as and when needed.”Because the technology is integrated with Keck’s Cerner EHR, all reminders are in sync with the latest patient information.

For example, if a patient cancels an appointment, the reminder automatically is canceled. Or, if a patient has multiple appointments on the same day, then the system only sends one reminder to cover all of them.“This level of automation improves efficiency and lowers the burden on our staff, reducing the likelihood of errors as a result,” Johnson said. €œIt also cuts costs by ensuring more patients come to their appointments, or cancel or reschedule with sufficient notice so the system can then fill those empty slots.”The virtual check-in solution, deployed recently during the COVID-19 pandemic, sends patients automated text message reminders ahead of their upcoming appointments that include instructions to remain in their car and simply text “READY” upon arrival.“After texting ‘READY,’ the patient is registered as having checked in and is asked to continue to wait in their car or near the clinic until further notice,” Johnson explained. €œWhen the care team is ready to receive them, a text message is sent to notify the patient to come in, along with directions to the appropriate location.

Upon arrival, they can be escorted directly to their exam room.”RESULTSWith the appointment reminders solution, Keck was able to reduce its no-show rate from 7% to 5%. Managing approximately 100,000 appointment reminders per month, this reduction resulted in immense revenue savings.“The patients, staff and physicians at Keck Medicine also noted a significant change during the initial adoption of Lumeon’s automation platform,” Johnson noted. €œThey witnessed huge benefits to their patients, experiencing care in a more efficient and convenient manner.”With regard to the virtual check-in solution, Keck currently is in the pilot phase. During the first 10 days that the system was live, 67% of eligible patients used the system to check in virtually for their appointments, avoiding congestion in the outpatient facility during COVID-19.“Once we fully deploy the virtual check-in solution across the health system, we can safely manage check-ins for more than 80,000 patients per month,” Johnson said.“Keck Medicine of USC has an enduring commitment to the healthcare needs of our community.

Patient safety is always our highest priority, and during times like this, it’s even more important to create an environment where our patients feel safe and at ease during their visit and continue to seek the care they need.”ADVICE FOR OTHERS“Patient engagement is incredibly important, but it’s not the sole consideration,” Johnson advised. €œThink about how it impacts your care team. If you can automate engagement and the handling of manual tasks to reduce the burden on your staff while delivering the high caliber of experience that patients expect, everyone wins.”Twitter. @SiwickiHealthITEmail the writer.

Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication.At the Cerner Health Conference on Wednesday, two representatives from the Office of the National Coordinator for Health IT offered some updates on the compliance requirements of its 21st Century Cures information blocking rules published in March.First, Deputy National Coordinator for Health IT Steven Posnack noted that, with an interim final rule under review at the U.S. Office of Management and Budget, those covered should keep their eyes peeled for some potential reshuffling of compliance dates due to the demands of the ongoing COVID-19 pandemic."We do have an interim final rule under review [at OMB] that will adjust certain timelines associated with the certification program and information blocking, so please be on the lookout for that," said Posnack. "You can expect certain adjustments to our timing and compliance requirements." HIMSS20 Digital Learn on-demand, earn credit, find products and solutions. Get Started >>.

As of now, the start date for requiring adherence to the info blocking rules is November 2.Wherever the new date might be moved, it will eventually arrive. In the meantime, those covered by the rules – healthcare providers, developers of certified health IT, health information networks and health information exchanges – should continue to prepare, he said.The obligations under the law for each group may be unique, and "each of these actors are uniquely and individually accountable for their own conduct," he said.But the ability of each to maintain compliance will have impact on other organizations across the ecosystem when it comes to information blocking. For instance, vendors such as Cerner are no longer just judged by ONC on the ability of their software to meet rigorous certification requirements.With the 21st Century Cures Act, "Congress said, 'Not only do you need to look at the software itself, but you also need to evaluate the business practices and overall corporate compliance of health IT developers,'" said Posnack."And under our statutory requirements now, ONC would have to pursue oversight-related activities to correct that health IT developer's behavior."Likewise, "if you're a healthcare provider and you're engaged in something that ultimately our Office of the Inspector General, who does enforcement on information blocking, sees that you have been inappropriately restricting information exchange, that could be subject to information blocking-related enforcement in the future."At the same time, ONC has built in significant leeway with its rulemaking, establishing eight exceptions meant to offer covered entities "certainty that, when their practices with respect to accessing, exchanging, or using electronic health information meet the conditions of one or more exceptions, such practices will not be considered information blocking."Five of them involve reasons for not fulfilling requests to access, exchange or use electronic health information:Preventing harm exception.Privacy exception.Security exception.Infeasibility exception.Health IT performance exception.Three of them have to do with procedures around fulfilling requests to access, exchange or use EHI:Content and manner exception.Fees exception.Licensing exception.At the Cerner conference, Rachel Nelson, branch chief for policy analysis and implementation in ONC's Regulatory Affairs Division, spent some time unpacking the content and manner exception, which has caused some confusion among various stakeholders."The content and manner exception is available where, let's say, an actor receives a request for electronic health information that they can legally and appropriately share – but they don't have the technical capability to facilitate this exchange or use of that electronic health information in the manner requested," said Nelson.The exception's two main conditions, the content ("which I like to think of as the 'what,'" she explained) and the manner (the "how") must both be met to satisfy the exception, according to ONC.Content, for these purposes – the "what" – is defined by ONC's United States Core Data for Interoperability, or USCDI, as a defined set of shareable health data classes and elements. Whereas for IT developers USCDI is simply a standard that must be met for certification, Nelson emphasized, for providers it "describes what information is within the scope of information blocking definition and is the scope of required content – what you would have to share."As for the "how," the manner exception, it "offers a framework for working through alternative manners for sharing electronic health information when perhaps you can't meet the exact manner that was originally requested," she explained.

"It offers a fairly wide array of options for how to make the electronic health information available and still be covered by this exception."The exception "can be met even if you do not have all of the requested electronic health information," said Nelson. "And even if, for whatever reason that is appropriate, you cannot share all of the electronic health information that you do have."Perhaps a particular few pieces of information are covered by a state law that would prohibit you disclosing it in response to a particular request. You can still meet content and matter exception in that sort of a circumstance, as long as you meet the full conditions of the exception," she explained"We encourage people to take advantage of the certainty they offer, that if your practices in responding to requests for access, exchange and use of electronic health information are consistent with the conditions of one or more exceptions, that those practices are not information blocking."As Posnack explained earlier this year, the goal of the Content and Manner Exception is to "give stakeholders ... An opportunity to negotiate, in the open market, the ability to make available or electronic health information or access, exchange or use."So if I'm a requester and you happen to be one of those information blocking-covered actors, you and I would be able to engage in an open market negotiation and come to terms," he explained.

"If we're able to do that, then both parties, it's a win-win for both parties. If we're unable to do that, per the statute, we still have an obligation to make sure that electronic health information is made available."[Note. This article has been updated to include comments from TeleTracking representatives.]Earlier this month, the Centers for Medicare and Medicaid Services announced that hospitals that were not in compliance with reporting requirements from the U.S. Department of Health and Human Services could find their participation in the federal programs put at risk.Starting October 7, CMS Administrator Seema Verma said that hospitals would have 14 weeks to come into compliance.

She described "ample opportunity" to do so, with multiple enforcement letters and technological support available before termination.Hospitals would also be required to report influenza data along with COVID-19 patient information, said HHS. Around the country, hospital associations expressed their continued commitment to sharing data, along with concern that systems unable to do so may not receive reimbursement from Medicare and Medicaid. "Tying data reporting to participation in the Medicare program remains an overly heavy-handed approach that could jeopardize access to hospital care for all Americans," said American Hospital Association President and CEO Rick Pollack in a statement. "We would echo what was shared by the American Hospital Association – that hospitals are committed to providing timely and accurate information in a transparent manner," said Cara Welch, director of communications at the Colorado Hospital Association, to Healthcare IT News.

"However, this should be done through partnership between hospitals and the federal and state agencies, not through mandates." Welch said the CHA "is working closely with member hospitals and health systems who are working to be in compliance with this regulation."This has been a challenging process because of the accelerated timeline, the changing expectations and the manual data entry process that many of our hospitals have had to use."A Mississippi Hospital Association spokesperson said, "MHA believes that it is important for all healthcare providers, not just hospitals, to report critical data which may be useful in responding to the COVID pandemic." Though they said "the reporting requirements need to be focused and not overly burdensome," they said it was too soon to tell whether the current requirements could be classified as such. In July, HHS triggered alarm among public health advocates when it directed hospitals to bypass the Centers for Disease Control and Prevention in reporting about COVID-19 patients. Health systems, some only given a few days' notice of the change, were thrown into "chaos," with some saying they faced technical difficulties and others pointing to the fact that closed hospitals were being listed as "non-reporting." Some of these issues, say associations, are ongoing – making the threat of a crackdown even more fraught. "We have noticed discrepancies between the data submitted by hospitals to the federal government and what is appearing in its data reporting platform," said Katy Peterson, vice president of communications and member engagement for the Montana Hospital Association.

"Specifically, hospitals have submitted data using methods and channels approved by HHS, and the submitted data is not posting to the appropriate fields within the [HHS Protect] system. This is not the fault of the hospitals," Peterson continued.Peterson said these discrepancies have been acknowledged and confirmed by officials from Teletracking (which collects data on behalf of HHS for its HHS Protect system), the Montana Department of Health and Human Services and Juvare, the health IT vendor that runs the approved platform used to report the data."Other state hospital associations are reporting similar issues," said Peterson. TeleTracking representatives said after publication that Montana does not report data through TeleTracking. Though TeleTracking is aware of issues related to Montana's data accuracy, said the spokesperson, "it is not related to us at all." Though system bugs are to be expected, especially during rapid scale-ups, Peterson called it "patently unfair" to penalize hospitals as a result of them.

"Until there is a sound and reliable data reporting system in place, it is reckless to hold hostage the contracts between CMS and hospitals," she continued. "In Montana, this will penalize many hospitals that are properly submitting the required data. In a state where there may be only one hospital for 200 miles, it could also wipe out access to local healthcare when and where it is needed most." Even without technical issues, said Peterson, some hospitals – particularly the state's smallest, frontier hospitals – still struggle to meet reporting requirements on a regular basis. "The data requirements are particularly burdensome for facilities with extremely limited staff, but we are confident we can support them in meeting the government’s data reporting requirements in the time outlined under the new policy," said Peterson.As the COVID-19 pandemic continues to ravage rural areas, some hospital associations expressed concern about the extra work incurred by the requirements.

The financial fallout from the pandemic also makes the prospect of losing Medicare funding loom large."This is a lift, and couldn’t come at a worse time," said Dave Dillon, spokesperson for the Missouri Hospital Association. "Our rural hospitals are feeling the pinch as the virus is pushing throughout rural Missouri. Generally, rural hospitals have the fewest staff resources to dedicate to this. And, it is at a time where hospitals are experiencing significant surge and many also are experiencing workforce challenges."Dillon said that building toward 100 percent participation is the goal, and that the association is making "great progress" where compliance is concerned in terms of working with those who aren't there yet."We realize that transparency is important.

But using Medicare participation as a lever is beyond the pale," Dillon said. "Hopefully we’ll get to where CMS is satisfied, or 100 percent – whichever comes first." Hospital associations resolved to continue working with existing tools to ensure they would be in compliance. "OHA and Ohio hospitals are committed to supporting the state and national efforts of effectively managing the COVID-19 pandemic by making sure data is shared consistently," said John Palmer, director of media and public relations for the Ohio Hospital Association."Hospitals and health systems are working closely with the state and federal agencies to help facilitate the collection of this data while caring for our patients and communities on the front lines." Upon receipt of the CMS memo outlining the reporting changes, said Palmer, OHA Data Services released a new app allowing member hospitals to comply through the OHA Hospital Resource Tracker. "OHA is reviewing the changes in the latest HHS guidance and will provide an update to members regarding how the HHS data reporting changes will affect reporting to OHA.

OHA is committed to adjusting our data submission application so that our members can meet HHS and/or CMS requirements and remain compliant," said Palmer. Kat Jercich is senior editor of Healthcare IT News.Twitter. @kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication..

Senior woman attending a telehealth appointment.Providers have 11 additional telehealth services that will be reimbursed by the Centers for Medicare and Medicaid Services during the COVID-19 public health emergency.CMS announced yesterday the addition of 11 new services to the Medicare telehealth services list.Medicare will begin paying eligible practitioners for these services immediately, how to get doxazosin without a doctor and for the duration of the PHE. These new how to get doxazosin without a doctor telehealth services include certain neurostimulator analysis and programming services and cardiac and pulmonary rehabilitation services. CMS is also providing additional support to state Medicaid and Children's Health Insurance Program agencies in their efforts to expand access to telehealth through the release of a new supplement to its State Medicaid &.

CHIP Telehealth how to get doxazosin without a doctor Toolkit. Policy Considerations for States Expanding Use of Telehealth, how to get doxazosin without a doctor COVID-19 Version. The updated supplemental information clarifies to states, providers and other stakeholders which telehealth policies are temporary or permanent.

It also helps states identify services that can be accessed through telehealth, which providers may deliver those services and the circumstances under which telehealth can be reimbursed once the PHE expires.WHY THIS MATTERSThe use of telehealth has grown during the pandemic as CMS how to get doxazosin without a doctor has allowed greater flexibility for its use.Reimbursement at parity for an in-person visit has been a main driver. CMS has made some temporary telehealth measures permanent but providers still await an announcement on whether payment parity will remain when the public health emergency ends.A preliminary Medicaid and CHIP data snapshot on telehealth utilization during the PHE shows there have been more than 34.5 million services delivered via telehealth to Medicaid and CHIP beneficiaries between March and how to get doxazosin without a doctor June of this year, representing an increase of more than 2,600% when compared to the same period from the prior year. The data also shows that adults ages 19-64 received the most services delivered via telehealth, although there was substantial variance across both age groups and states.

THE LARGER TRENDSince the beginning of the public health emergency, CMS has added over 135 services to the Medicare telehealth services list – such as emergency department visits, initial inpatient and nursing facility how to get doxazosin without a doctor visits, and discharge day management services. The additional services being added totals 144 services performed by telehealth that will be paid by Medicare. Between mid-March and mid-August 2020, over 12.1 million Medicare beneficiaries – more than 36% – of people with Medicare fee-for-service have care through telemedicine.The 11 new services being added to the Medicare how to get doxazosin without a doctor telehealth services list are the first being done through an expedited process allowed under the May 1 COVID-19 Interim Final Rule with comment period.

CMS actions follow through on President Trump's Executive Order on Improving Rural how to get doxazosin without a doctor Health and Telehealth Access.Twitter. @SusanJMorseEmail the writer. Susan.morse@himssmedia.comThe COVID-19 crisis has magnified and exacerbated inequities how to get doxazosin without a doctor in healthcare, with communities of color disproportionately affected by the disease and its economic fallout.

But such disparities date back to long before the pandemic began to spread across the country this spring."Structural racism," how to get doxazosin without a doctor said American Medical Association Chief Health Equity Officer Dr. Aletha Maybank, "permeates the healthcare system."Given that reality, "How do we combat bias that's decades-old in our country as we move forward today?. " she asked.Maybank was among the experts at the how to get doxazosin without a doctor HLTH VRTL 2020 conference this week who weighed in on the best strategies to confront the ways racism in the healthcare industry.

From medical education content to training, to research study designs, how to get doxazosin without a doctor to technological responses."Technology in itself can be a great equalizer," said Doctor on Demand Chief Medical Officer Dr. Ian Tong. However, he how to get doxazosin without a doctor cautioned, technology can also replicate the bias of its creators.

He noted, for example, that tools relying on artificial intelligence to flag potentially harmful skin lesions may misdiagnose or overlook signs of disease on darker skin tones.Still, he said, "I have that belief we can use technology in the right way."For instance, he said, AI could be used to alert doctors that some patients may be at higher risk for certain diagnoses, due to social determinants of health.Tong said that developers should understand that technology is akin to medication in that it can be helpful, but it can also be harmful when used inappropriately."We need the tools, and I would ask that developers know that and consult us or involve us in the process early," Tong said.Maybank noted that there remain enormous gaps in health data regarding people of color and the disparities they face."As COVID has highlighted, a lot of folks don't have systems set up to collect race and ethnicity data," she said. By not collecting information accurately, "we're not finding out what's happening to all folks in this country."We're not understanding what is impacting people that is creating those differences," she continued.It's also important, she noted, for researchers and clinicians to move beyond what she called "the how to get doxazosin without a doctor deficit model.""What are the strengths of people?. What how to get doxazosin without a doctor are the networks?.

" she asked. "Those are the things we have to consider as it relates to race."Other experts stressed that the pandemic has highlighted how to get doxazosin without a doctor – and worsened – existing inequities. "It's not enough just to how to get doxazosin without a doctor be not racist.

We have to be anti-racist," said Dr. Laurie Glimcher, president and CEO how to get doxazosin without a doctor of the Dana-Farber Cancer Institute. "I think there's a nationwide recognition of how to get doxazosin without a doctor how much we have left to do."Dr.

Ivor B. Horn, who moderated the panel with Maybank and how to get doxazosin without a doctor Tong, noted that "technology is moving much faster than policy or practice." So how, she asked, do we train a new group of leaders in asking critical questions about addressing racism in healthcare?. "I want [leaders] to put their money where their mouth is," said Tong.

"I want them to engage and fund and direct their business to companies that have true representation across the how to get doxazosin without a doctor company and at the leadership level." Maybank agreed, but also noted that doing so is difficult for those who don't know the root causes of the problems. "My call how to get doxazosin without a doctor to action is to learn more!. " she said."Be humble, and be willing to be a learner, and seek out others who do have knowledge and companies who are doing the work in the trenches, and support them," Horn agreed."Racism is a cultural issue – broadly in this country, and more specifically, in medicine.

It’s going to take more than how to get doxazosin without a doctor talk to drive meaningful change. Change must how to get doxazosin without a doctor start at the top – with leadership [members] who recognize the problem head-on, and commit to balancing the scales," Tong said in a statement to Healthcare IT News. Kat Jercich is senior editor of Healthcare IT News.Twitter.

@kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication.Keck Medicine of USC, a health system based in Los Angeles, had experienced a few years of dramatic growth in both patient volume and geographic footprint, with numerous ambulatory locations and partnerships with hospitals in Los Angeles, Orange, Kern and Tulare Counties.THE PROBLEMTo help optimize availability for a large patient population, many of whom require complex, specialized care, Keck needed to minimize appointment no-shows and late cancellations. At the time, its IT required staff to manually enter appointment details.This process did not integrate with the electronic health record and provided limited visibility into what was going on during patients’ real-time care journeys.

On top of that, staff was looking for stronger levels of customer support.Further, Keck needed a solution that would be adaptable and scalable – something that would be capable of taking on expanded features and additional use-cases (beyond appointment reminders) over time, particularly as Keck’s 10-year-old health system continues its dramatic growth trajectory.PROPOSALPatient-engagement IT vendor Lumeon proposed a multi-layered solution. First, it offered an automation platform that would integrate with Keck’s EHR, and automate the patient journey, beginning with text message appointment reminders.Automation would alleviate the manual work staff was doing in scheduling appointments, following up with reminders and rescheduling no-shows, enabling staff to focus on other, higher-value tasks.“Over time, as we identified other processes that could improve with automation, Lumeon consolidated these services into a single technology platform,” said Laurie Johnson, chief ambulatory officer at Keck Medicine of USC."If you can automate engagement and the handling of manual tasks to reduce the burden on your staff while delivering the high caliber of experience that patients expect, everyone wins."Laurie Johnson, Keck Medicine of USC“For instance, to support physical distancing and reduce the risk of COVID-19 exposure at our facilities, we used Lumeon’s automation platform to create a virtual check-in process, which keeps patients waiting outside of the facility until their physician is ready to see them for their appointment.”MARKETPLACEThere are a variety of patient engagement and relationship management tools on the health IT market today. Some of the vendors of these tools include Luma Health, Lumeon, Nimblr, RevenueWell, Salesforce, Solutionreach, Weave, WebPT and WELL.MEETING THE CHALLENGELumeon’s platform automates appointment reminder activities and processes.

Patients receive three reminders for each appointment – via voice, e-mail or text – and in their preferred language, without manual intervention from staff. The system also is programmed to avoid calling patients during inconvenient hours.“Care teams only need to engage with the system to follow up with a patient due to noncompliance, a no-show for an appointment or if the patient has requested help from their care team,” Johnson explained. €œStaff also have access to a centralized, self-service library of pathways so they can make changes as and when needed.”Because the technology is integrated with Keck’s Cerner EHR, all reminders are in sync with the latest patient information.

For example, if a patient cancels an appointment, the reminder automatically is canceled. Or, if a patient has multiple appointments on the same day, then the system only sends one reminder to cover all of them.“This level of automation improves efficiency and lowers the burden on our staff, reducing the likelihood of errors as a result,” Johnson said. €œIt also cuts costs by ensuring more patients come to their appointments, or cancel or reschedule with sufficient notice so the system can then fill those empty slots.”The virtual check-in solution, deployed recently during the COVID-19 pandemic, sends patients automated text message reminders ahead of their upcoming appointments that include instructions to remain in their car and simply text “READY” upon arrival.“After texting ‘READY,’ the patient is registered as having checked in and is asked to continue to wait in their car or near the clinic until further notice,” Johnson explained.

€œWhen the care team is ready to receive them, a text message is sent to notify the patient to come in, along with directions to the appropriate location. Upon arrival, they can be escorted directly to their exam room.”RESULTSWith the appointment reminders solution, Keck was able to reduce its no-show rate from 7% to 5%. Managing approximately 100,000 appointment reminders per month, this reduction resulted in immense revenue savings.“The patients, staff and physicians at Keck Medicine also noted a significant change during the initial adoption of Lumeon’s automation platform,” Johnson noted.

€œThey witnessed huge benefits to their patients, experiencing care in a more efficient and convenient manner.”With regard to the virtual check-in solution, Keck currently is in the pilot phase. During the first 10 days that the system was live, 67% of eligible patients used the system to check in virtually for their appointments, avoiding congestion in the outpatient facility during COVID-19.“Once we fully deploy the virtual check-in solution across the health system, we can safely manage check-ins for more than 80,000 patients per month,” Johnson said.“Keck Medicine of USC has an enduring commitment to the healthcare needs of our community. Patient safety is always our highest priority, and during times like this, it’s even more important to create an environment where our patients feel safe and at ease during their visit and continue to seek the care they need.”ADVICE FOR OTHERS“Patient engagement is incredibly important, but it’s not the sole consideration,” Johnson advised.

€œThink about how it impacts your care team. If you can automate engagement and the handling of manual tasks to reduce the burden on your staff while delivering the high caliber of experience that patients expect, everyone wins.”Twitter. @SiwickiHealthITEmail the writer.

Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication.At the Cerner Health Conference on Wednesday, two representatives from the Office of the National Coordinator for Health IT offered some updates on the compliance requirements of its 21st Century Cures information blocking rules published in March.First, Deputy National Coordinator for Health IT Steven Posnack noted that, with an interim final rule under review at the U.S. Office of Management and Budget, those covered should keep their eyes peeled for some potential reshuffling of compliance dates due to the demands of the ongoing COVID-19 pandemic."We do have an interim final rule under review [at OMB] that will adjust certain timelines associated with the certification program and information blocking, so please be on the lookout for that," said Posnack. "You can expect certain adjustments to our timing and compliance requirements." HIMSS20 Digital Learn on-demand, earn credit, find products and solutions.

Get Started >>. As of now, the start date for requiring adherence to the info blocking rules is November 2.Wherever the new date might be moved, it will eventually arrive. In the meantime, those covered by the rules – healthcare providers, developers of certified health IT, health information networks and health information exchanges – should continue to prepare, he said.The obligations under the law for each group may be unique, and "each of these actors are uniquely and individually accountable for their own conduct," he said.But the ability of each to maintain compliance will have impact on other organizations across the ecosystem when it comes to information blocking.

For instance, vendors such as Cerner are no longer just judged by ONC on the ability of their software to meet rigorous certification requirements.With the 21st Century Cures Act, "Congress said, 'Not only do you need to look at the software itself, but you also need to evaluate the business practices and overall corporate compliance of health IT developers,'" said Posnack."And under our statutory requirements now, ONC would have to pursue oversight-related activities to correct that health IT developer's behavior."Likewise, "if you're a healthcare provider and you're engaged in something that ultimately our Office of the Inspector General, who does enforcement on information blocking, sees that you have been inappropriately restricting information exchange, that could be subject to information blocking-related enforcement in the future."At the same time, ONC has built in significant leeway with its rulemaking, establishing eight exceptions meant to offer covered entities "certainty that, when their practices with respect to accessing, exchanging, or using electronic health information meet the conditions of one or more exceptions, such practices will not be considered information blocking."Five of them involve reasons for not fulfilling requests to access, exchange or use electronic health information:Preventing harm exception.Privacy exception.Security exception.Infeasibility exception.Health IT performance exception.Three of them have to do with procedures around fulfilling requests to access, exchange or use EHI:Content and manner exception.Fees exception.Licensing exception.At the Cerner conference, Rachel Nelson, branch chief for policy analysis and implementation in ONC's Regulatory Affairs Division, spent some time unpacking the content and manner exception, which has caused some confusion among various stakeholders."The content and manner exception is available where, let's say, an actor receives a request for electronic health information that they can legally and appropriately share – but they don't have the technical capability to facilitate this exchange or use of that electronic health information in the manner requested," said Nelson.The exception's two main conditions, the content ("which I like to think of as the 'what,'" she explained) and the manner (the "how") must both be met to satisfy the exception, according to ONC.Content, for these purposes – the "what" – is defined by ONC's United States Core Data for Interoperability, or USCDI, as a defined set of shareable health data classes and elements. Whereas for IT developers USCDI is simply a standard that must be met for certification, Nelson emphasized, for providers it "describes what information is within the scope of information blocking definition and is the scope of required content – what you would have to share."As for the "how," the manner exception, it "offers a framework for working through alternative manners for sharing electronic health information when perhaps you can't meet the exact manner that was originally requested," she explained. "It offers a fairly wide array of options for how to make the electronic health information available and still be covered by this exception."The exception "can be met even if you do not have all of the requested electronic health information," said Nelson.

"And even if, for whatever reason that is appropriate, you cannot share all of the electronic health information that you do have."Perhaps a particular few pieces of information are covered by a state law that would prohibit you disclosing it in response to a particular request. You can still meet content and matter exception in that sort of a circumstance, as long as you meet the full conditions of the exception," she explained"We encourage people to take advantage of the certainty they offer, that if your practices in responding to requests for access, exchange and use of electronic health information are consistent with the conditions of one or more exceptions, that those practices are not information blocking."As Posnack explained earlier this year, the goal of the Content and Manner Exception is to "give stakeholders ... An opportunity to negotiate, in the open market, the ability to make available or electronic health information or access, exchange or use."So if I'm a requester and you happen to be one of those information blocking-covered actors, you and I would be able to engage in an open market negotiation and come to terms," he explained.

"If we're able to do that, then both parties, it's a win-win for both parties. If we're unable to do that, per the statute, we still have an obligation to make sure that electronic health information is made available."[Note. This article has been updated to include comments from TeleTracking representatives.]Earlier this month, the Centers for Medicare and Medicaid Services announced that hospitals that were not in compliance with reporting requirements from the U.S.

Department of Health and Human Services could find their participation in the federal programs put at risk.Starting October 7, CMS Administrator Seema Verma said that hospitals would have 14 weeks to come into compliance. She described "ample opportunity" to do so, with multiple enforcement letters and technological support available before termination.Hospitals would also be required to report influenza data along with COVID-19 patient information, said HHS. Around the country, hospital associations expressed their continued commitment to sharing data, along with concern that systems unable to do so may not receive reimbursement from Medicare and Medicaid.

"Tying data reporting to participation in the Medicare program remains an overly heavy-handed approach that could jeopardize access to hospital care for all Americans," said American Hospital Association President and CEO Rick Pollack in a statement. "We would echo what was shared by the American Hospital Association – that hospitals are committed to providing timely and accurate information in a transparent manner," said Cara Welch, director of communications at the Colorado Hospital Association, to Healthcare IT News. "However, this should be done through partnership between hospitals and the federal and state agencies, not through mandates." Welch said the CHA "is working closely with member hospitals and health systems who are working to be in compliance with this regulation."This has been a challenging process because of the accelerated timeline, the changing expectations and the manual data entry process that many of our hospitals have had to use."A Mississippi Hospital Association spokesperson said, "MHA believes that it is important for all healthcare providers, not just hospitals, to report critical data which may be useful in responding to the COVID pandemic." Though they said "the reporting requirements need to be focused and not overly burdensome," they said it was too soon to tell whether the current requirements could be classified as such.

In July, HHS triggered alarm among public health advocates when it directed hospitals to bypass the Centers for Disease Control and Prevention in reporting about COVID-19 patients. Health systems, some only given a few days' notice of the change, were thrown into "chaos," with some saying they faced technical difficulties and others pointing to the fact that closed hospitals were being listed as "non-reporting." Some of these issues, say associations, are ongoing – making the threat of a crackdown even more fraught. "We have noticed discrepancies between the data submitted by hospitals to the federal government and what is appearing in its data reporting platform," said Katy Peterson, vice president of communications and member engagement for the Montana Hospital Association.

"Specifically, hospitals have submitted data using methods and channels approved by HHS, and the submitted data is not posting to the appropriate fields within the [HHS Protect] system. This is not the fault of the hospitals," Peterson continued.Peterson said these discrepancies have been acknowledged and confirmed by officials from Teletracking (which collects data on behalf of HHS for its HHS Protect system), the Montana Department of Health and Human Services and Juvare, the health IT vendor that runs the approved platform used to report the data."Other state hospital associations are reporting similar issues," said Peterson. TeleTracking representatives said after publication that Montana does not report data through TeleTracking.

Though TeleTracking is aware of issues related to Montana's data accuracy, said the spokesperson, "it is not related to us at all." Though system bugs are to be expected, especially during rapid scale-ups, Peterson called it "patently unfair" to penalize hospitals as a result of them. "Until there is a sound and reliable data reporting system in place, it is reckless to hold hostage the contracts between CMS and hospitals," she continued. "In Montana, this will penalize many hospitals that are properly submitting the required data.

In a state where there may be only one hospital for 200 miles, it could also wipe out access to local healthcare when and where it is needed most." Even without technical issues, said Peterson, some hospitals – particularly the state's smallest, frontier hospitals – still struggle to meet reporting requirements on a regular basis. "The data requirements are particularly burdensome for facilities with extremely limited staff, but we are confident we can support them in meeting the government’s data reporting requirements in the time outlined under the new policy," said Peterson.As the COVID-19 pandemic continues to ravage rural areas, some hospital associations expressed concern about the extra work incurred by the requirements. The financial fallout from the pandemic also makes the prospect of losing Medicare funding loom large."This is a lift, and couldn’t come at a worse time," said Dave Dillon, spokesperson for the Missouri Hospital Association.

"Our rural hospitals are feeling the pinch as the virus is pushing throughout rural Missouri. Generally, rural hospitals have the fewest staff resources to dedicate to this. And, it is at a time where hospitals are experiencing significant surge and many also are experiencing workforce challenges."Dillon said that building toward 100 percent participation is the goal, and that the association is making "great progress" where compliance is concerned in terms of working with those who aren't there yet."We realize that transparency is important.

But using Medicare participation as a lever is beyond the pale," Dillon said. "Hopefully we’ll get to where CMS is satisfied, or 100 percent – whichever comes first." Hospital associations resolved to continue working with existing tools to ensure they would be in compliance. "OHA and Ohio hospitals are committed to supporting the state and national efforts of effectively managing the COVID-19 pandemic by making sure data is shared consistently," said John Palmer, director of media and public relations for the Ohio Hospital Association."Hospitals and health systems are working closely with the state and federal agencies to help facilitate the collection of this data while caring for our patients and communities on the front lines." Upon receipt of the CMS memo outlining the reporting changes, said Palmer, OHA Data Services released a new app allowing member hospitals to comply through the OHA Hospital Resource Tracker.

"OHA is reviewing the changes in the latest HHS guidance and will provide an update to members regarding how the HHS data reporting changes will affect reporting to OHA. OHA is committed to adjusting our data submission application so that our members can meet HHS and/or CMS requirements and remain compliant," said Palmer. Kat Jercich is senior editor of Healthcare IT News.Twitter.

@kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication..

Doxazosin and alcohol

€‹15 full-time equivalent specialist counsellors will be deployed across rural NSW to help prevent doxazosin and alcohol suicide, with the first two counsellors starting in the Eurobodalla and Snowy Mountains regions.NSW Mental Health Minister Bronnie Taylor said the relatively high rates of suicide in rural areas are devastating families and communities, and the $6.75 million investment will add another layer of help.“Many factors can contribute to suicide, from domestic violence, to relationship issues or unemployment, to stress and hardship,” Mrs Taylor said. €œThese specialist mental health counsellors are there on the ground to support people thinking of suicide or impacted by suicide, and I encourage communities across the state to lean on them for support.”Director Mental Health Drug and Alcohol for Southern NSW Local Health District Damien Eggleton said he wants more people to ask for help when they need it. €œOur rural communities have proven doxazosin and alcohol beyond a doubt they’re resilient and fearless when faced with adversity, whether that be geographic isolation, searing drought or the impact of the current pandemic – but they don’t need to go it alone,” Mr Eggleton said.

€œThe support provided by these counsellors will complement the peer work and drought support provided by our Farm Gate Counsellors and Drought Counsellors.”Rural counsellor Samara Byrne said she wants young people to know there are people you can turn to when feeling overwhelmed with life or feeling like a burden on others. €œWe are here for you and here to listen if you are feeling distressed, anxious or a burden doxazosin and alcohol to loved ones. The service is easily accessible through the Mental Health Line.

Just ask for the Rural Counsellor.”“Having moved from Sydney in 2016 to our beautiful farm in doxazosin and alcohol SNSW, I am so pleased to be able to do what I am most passionate about, supporting people’s wellbeing in Rural Australia and building on the natural local community resilience”.Minister Taylor urges people in the bush to get help by contacting these rural counsellors. €œSupport is available, all you need to do is pick up the phone and make an appointment by calling the NSW Mental Health Line on 1800 011 511.”The 15 rural counselling positions are part of the Towards Zero Suicides. A $87 doxazosin and alcohol million investment over three years in new suicide prevention initiatives.

A NSW Premier’s Priority, this is a whole-of-government commitment to transforming the way we identify and support anyone impacted by suicide.If you, or someone you know, is thinking about suicide or experiencing a personal crisis or distress, please seek help immediately in a life-threatening situation by calling 000 or seek support though one of these services:Lifeline 13 11 14Suicide Call Back Service 1300 659 467NSW Mental Health Line 1800 011 511Minister for Mental Health Bronnie Taylor and Minister for Police and Emergency Services David Elliott today announced the expansion of the Police Ambulance and Clinical Early Response (PACER) pilot program.“This ground breaking collaboration embeds mental health experts with first responders to support them to appropriately recognise, assess, and respond to mental health emergencies live at the scene,” Mrs Taylor said. €œThe pilot program doxazosin and alcohol has had incredible results with significant reductions in emergency department presentations, police and ambulance time on scene. €œThis approach has enormous potential to change lives, with the community getting more appropriate care at the time when they need it most.” Mr Elliott welcomed the support for the police officers who are deeply committed to serving and protecting the people of NSW “During the pilot program, police time-on-scene was reduced by an average of 45 minutes, not only supporting first responders to appropriately recognise and respond to psychiatric incidents in the community, but also freeing up officers to serve thecommunity in other areas,” Mr Elliott said.

€œThe presence and availability of a PACER clinician in a police station increases the knowledge doxazosin and alcohol and understanding of mental health issues amongst officers This initiative is crucial, now more than ever, following the devastating ‘Black Summer’ bushfires and the COVID-19 pandemic, which have affected us all.” NSW Police Force Deputy Commissioner, Malcolm Lanyon APM, said the PACER model has been a success at the trial site in St George Police Area Command. €œDuring the trial we saw a significant reduction in time taken for police to respond to these matters. It translated to a better outcome for both our officers and the doxazosin and alcohol individuals in need of assistance,” Mr Lanyon said.

The PACER program will expand to Campbelltown, Nepean, Northern Beaches, Sutherland Shire, Blacktown, Eastern Beaches, Kuring-gai, Metro Combined consisting of Kings Cross/Surry Hills/City of Sydney, South Sydney and Bankstown Police Area Commands with recruitment underway for the specialist mental health clinicians from July 2020. This investment is part of the $73 doxazosin and alcohol million suite of mental health measures recently announced by the NSW Government. This includes 216 new mental health staff, additional funding for the NSW Mental Health Line, extra support for Telehealth, funding for extra therapeutic programs to aid recovery in mental health units and a $6 million investment in Lifeline to expand their invaluable service..

€‹15 full-time equivalent specialist counsellors will be deployed across rural NSW to help prevent suicide, with the first two counsellors starting in the Eurobodalla and Snowy Mountains regions.NSW Mental Health Minister Bronnie Taylor said the relatively high rates of suicide in rural areas are devastating families and communities, and the $6.75 million investment will add another layer of help.“Many factors can contribute to suicide, from domestic violence, how to get doxazosin without a doctor to relationship issues or unemployment, to stress and hardship,” Mrs Taylor said. €œThese specialist mental health counsellors are there on the ground to support people thinking of suicide or impacted by suicide, and I encourage communities across the state to lean on them for support.”Director Mental Health Drug and Alcohol for Southern NSW Local Health District Damien Eggleton said he wants more people to ask for help when they need it. €œOur rural communities have proven beyond a doubt they’re resilient and fearless when faced with adversity, whether that be geographic isolation, searing drought or the impact of the current pandemic how to get doxazosin without a doctor – but they don’t need to go it alone,” Mr Eggleton said. €œThe support provided by these counsellors will complement the peer work and drought support provided by our Farm Gate Counsellors and Drought Counsellors.”Rural counsellor Samara Byrne said she wants young people to know there are people you can turn to when feeling overwhelmed with life or feeling like a burden on others.

€œWe are here for you and here to listen if you are feeling distressed, anxious or a burden to loved ones how to get doxazosin without a doctor. The service is easily accessible through the Mental Health Line. Just ask for the Rural Counsellor.”“Having moved from Sydney in 2016 to our beautiful farm in SNSW, I am so pleased to be able to do what I am most passionate about, supporting people’s wellbeing in Rural Australia and building on the natural local community resilience”.Minister how to get doxazosin without a doctor Taylor urges people in the bush to get help by contacting these rural counsellors. €œSupport is available, all you need to do is pick up the phone and make an appointment by calling the NSW Mental Health Line on 1800 011 511.”The 15 rural counselling positions are part of the Towards Zero Suicides.

A $87 million investment over three years in new suicide prevention initiatives how to get doxazosin without a doctor. A NSW Premier’s Priority, this is a whole-of-government commitment to transforming the way we identify and support anyone impacted by suicide.If you, or someone you know, is thinking about suicide or experiencing a personal crisis or distress, please seek help immediately in a life-threatening situation by calling 000 or seek support though one of these services:Lifeline 13 11 14Suicide Call Back Service 1300 659 467NSW Mental Health Line 1800 011 511Minister for Mental Health Bronnie Taylor and Minister for Police and Emergency Services David Elliott today announced the expansion of the Police Ambulance and Clinical Early Response (PACER) pilot program.“This ground breaking collaboration embeds mental health experts with first responders to support them to appropriately recognise, assess, and respond to mental health emergencies live at the scene,” Mrs Taylor said. €œThe pilot program how to get doxazosin without a doctor has had incredible results with significant reductions in emergency department presentations, police and ambulance time on scene. €œThis approach has enormous potential to change lives, with the community getting more appropriate care at the time when they need it most.” Mr Elliott welcomed the support for the police officers who are deeply committed to serving and protecting the people of NSW “During the pilot program, police time-on-scene was reduced by an average of 45 minutes, not only supporting first responders to appropriately recognise and respond to psychiatric incidents in the community, but also freeing up officers to serve thecommunity in other areas,” Mr Elliott said.

€œThe presence and availability of a PACER clinician in a police station increases the how to get doxazosin without a doctor knowledge and understanding of mental health issues amongst officers This initiative is crucial, now more than ever, following the devastating ‘Black Summer’ bushfires and the COVID-19 pandemic, which have affected us all.” NSW Police Force Deputy Commissioner, Malcolm Lanyon APM, said the PACER model has been a success at the trial site in St George Police Area Command. €œDuring the trial we saw a significant reduction in time taken for police to respond to these matters. It translated to a better outcome for both how to get doxazosin without a doctor our officers and the individuals in need of assistance,” Mr Lanyon said. The PACER program will expand to Campbelltown, Nepean, Northern Beaches, Sutherland Shire, Blacktown, Eastern Beaches, Kuring-gai, Metro Combined consisting of Kings Cross/Surry Hills/City of Sydney, South Sydney and Bankstown Police Area Commands with recruitment underway for the specialist mental health clinicians from July 2020.

This investment is part of how to get doxazosin without a doctor the $73 million suite of mental health measures recently announced by the NSW Government. This includes 216 new mental health staff, additional funding for the NSW Mental Health Line, extra support for Telehealth, funding for extra therapeutic programs to aid recovery in mental health units and a $6 million investment in Lifeline to expand their invaluable service..

How to order doxazosin online

John Rawls begins a Theory of Justice with the observation that how to order doxazosin online 'Justice is the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override'1 (p.3). The COVID-19 pandemic has resulted in lock-downs, the restriction of liberties, debate about the right to refuse medical treatment and many other changes to the everyday behaviour of how to order doxazosin online persons. The justice issues it raises are diverse, profound and will demand our attention for some time. How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles how to order doxazosin online that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to COVID-19 triage situations.

Their argument seems to highlight instances of what is called the McNamara fallacy. US Secretary how to order doxazosin online of Defense Robert McNamara used enemy body counts as a measure of military success during the Vietnam war. So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so they draw a distinction between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew between the different forms of how to order doxazosin online procedural fairness.

While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p. 85) there how to order doxazosin online is little prospect of that. As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for COVID-19 is no exception. Instead, we should work toward a transparent and fair process, what Rawls would describe as imperfect procedural how to order doxazosin online justice (p.

85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85). Their proposal is to triage patients into three broad categories.

High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about COVID-19 triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for COVID-19 can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for COVID-19. They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for COVID-19 that means looking beyond access to ICU.

Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for COVID-19 in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to COVID-19 should broadened to include all the services a system might provide.Brown et al argue in favour of COVID-19 immunity passports and the following summarises one of the key arguments in their article.7COVID-19 immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from COVID-19 should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues. Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to COVID-19, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding.

Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the virus. Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the pandemic.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles. They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about COVID-19.

These include that information about COVID-19 is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests. They observe that COVID-19 has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for COVID-19 and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means.

They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other. These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The COVID-19 pandemic is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs COVID-19 spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly. In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access.

However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with COVID-19 who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020. Central to these disucssions were two assumptions.

First, that ICU admission was a valuable but scarce resource in the pandemic context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU. In this paper we explain how scarcity and value were conflated in the early ICU COVID-19 triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question.

Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a pandemic, such as masks or vaccines. ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient.

People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe COVID-19 pandemic generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission. The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups. The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups.

This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the pandemic with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are prognostically relevant in COVID-19 infection. Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears. Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it.

Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases. Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with COVID-19 are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the pandemic, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate. This has the potential to compromise important decisions with regard to care for patients with COVID-19.The emerging reality of ICUIn general, the majority of patients who are ventilated for COVID-19 in ICU will die.

Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation. Emerging data show case fatality rates of 50%–88% for ventilated patients with COVID-19. In China11 and Italy about half of those with COVID-19 who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in COVID-19 needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired infections such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage.

Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-pandemic) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of COVID-19, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with COVID-19 begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with COVID-19 admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds. First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits. For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups.

In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with COVID-19, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with COVID-19 in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas.

Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the COVID-19 pandemic response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to COVID-19 in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate infection preventon and control training when dealing with patients with COVID-19 or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation. Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from COVID-19. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with COVID-19 (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people).

There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat COVID-19 with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist COVID-19 communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the pandemic.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team. Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources.

These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the pandemic context. See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during COVID-19Despite the sometimes overwhelming pressure of the pandemic, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for SARS-CoV-2 are quarantined in health facilities until they receive two consecutive negative tests. Patients may be isolated in hospital for several weeks.

To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity. However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During COVID-19 the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers.

Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear. An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of COVID-19, given the unprecedented nature and scale of the pandemic and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis. This suggests the need for COVID-19-specific ACPs.

Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with COVID-19 is challenging and complex. Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients.

But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients. And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature.

Equity can be addressed more robustly if pandemic responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with COVID-19. Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the pandemic will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in infections but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the COVID-19 Chronicles strip..

John Rawls begins a Theory of how to get doxazosin without a doctor Justice with the observation that 'Justice is the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override'1 (p.3). The COVID-19 pandemic has resulted in lock-downs, the restriction of liberties, debate about the right to refuse medical treatment and many other changes to the everyday behaviour how to get doxazosin without a doctor of persons. The justice issues it raises are diverse, profound and will demand our attention for some time. How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow how to get doxazosin without a doctor conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to COVID-19 triage situations.

Their argument seems to highlight instances of what is called the McNamara fallacy. US Secretary of Defense Robert how to get doxazosin without a doctor McNamara used enemy body counts as a measure of military success during the Vietnam war. So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so they draw a distinction between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew between how to get doxazosin without a doctor the different forms of procedural fairness.

While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p. 85) there is little prospect of how to get doxazosin without a doctor that. As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for COVID-19 is no exception. Instead, we should work toward a transparent and fair process, how to get doxazosin without a doctor what Rawls would describe as imperfect procedural justice (p.

85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85). Their proposal is to triage patients into three broad categories.

High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about COVID-19 triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for COVID-19 can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for COVID-19. They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for COVID-19 that means looking beyond access to ICU.

Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for COVID-19 in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to COVID-19 should broadened to include all the services a system might provide.Brown et al argue in favour of COVID-19 immunity passports and the following summarises one of the key arguments in their article.7COVID-19 immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from COVID-19 should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues. Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to COVID-19, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding.

Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the virus. Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the pandemic.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles. They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about COVID-19.

These include that information about COVID-19 is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests. They observe that COVID-19 has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for COVID-19 and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means.

They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other. These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The COVID-19 pandemic is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs COVID-19 spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly. In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access.

However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with COVID-19 who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020. Central to these disucssions were two assumptions.

First, that ICU admission was a valuable but scarce resource in the pandemic context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU. In this paper we explain how scarcity and value were conflated in the early ICU COVID-19 triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question.

Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a pandemic, such as masks or vaccines. ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient.

People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe COVID-19 pandemic generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission. The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups. The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups.

This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the pandemic with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are prognostically relevant in COVID-19 infection. Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears. Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it.

Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases. Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with COVID-19 are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the pandemic, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate. This has the potential to compromise important decisions with regard to care for patients with COVID-19.The emerging reality of ICUIn general, the majority of patients who are ventilated for COVID-19 in ICU will die.

Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation. Emerging data show case fatality rates of 50%–88% for ventilated patients with COVID-19. In China11 and Italy about half of those with COVID-19 who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in COVID-19 needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired infections such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage.

Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-pandemic) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of COVID-19, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with COVID-19 begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with COVID-19 admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds. First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits. For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups.

In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with COVID-19, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with COVID-19 in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas.

Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the COVID-19 pandemic response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to COVID-19 in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate infection preventon and control training when dealing with patients with COVID-19 or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation. Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from COVID-19. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with COVID-19 (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people).

There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat COVID-19 with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist COVID-19 communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the pandemic.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team. Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources.

These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the pandemic context. See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during COVID-19Despite the sometimes overwhelming pressure of the pandemic, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for SARS-CoV-2 are quarantined in health facilities until they receive two consecutive negative tests. Patients may be isolated in hospital for several weeks.

To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity. However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During COVID-19 the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers.

Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear. An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of COVID-19, given the unprecedented nature and scale of the pandemic and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis. This suggests the need for COVID-19-specific ACPs.

Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with COVID-19 is challenging and complex. Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients.

But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients. And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature.

Equity can be addressed more robustly if pandemic responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with COVID-19. Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the pandemic will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in infections but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the COVID-19 Chronicles strip..

Doxazosin 4

First-of-its-kind study, based on a mouse model, finds living in a doxazosin 4 polluted environment could be comparable to eating a high-fat diet, leading to a pre-diabetic state CLEVELAND—Air pollution is the world’s leading environmental risk factor, and causes more than nine million deaths per year. New research published in the Journal of Clinical Investigation shows air pollution may play a role in the development of cardiometabolic diseases, such as diabetes. Importantly, the effects were reversible with cessation of exposure doxazosin 4.

Researchers found that air pollution was a “risk factor for a risk factor” that contributed to the common soil of other fatal problems like heart attack and stroke. Similar to how an unhealthy diet and lack of exercise can lead to disease, exposure to air pollution could be added to this risk factor list as well. “In this study, we doxazosin 4 created an environment that mimicked a polluted day in New Delhi or Beijing,” said Sanjay Rajagopalan, MD, first author on the study, Chief of Cardiovascular Medicine at University Hospitals Harrington Heart and Vascular Institute, and Director of the Case Western Reserve University Cardiovascular Research Institute.

€œWe concentrated fine particles of air pollution, called PM2.5 (particulate matter component <. 2.5 microns) doxazosin 4. Concentrated particles like this develop from human impact on the environment, such as automobile exhaust, power generation and other fossil fuels.” These particles have been strongly connected to risk factors for disease.

For example, cardiovascular effects of air pollution can lead to heart attack and stroke. The research team has shown exposure to air pollution can increase the likelihood of the same risk factors that lead to doxazosin 4 heart disease, such as insulin resistance and type 2 diabetes. In the mouse model study, three groups were observed.

A control group receiving clean filtered air, a group exposed to polluted air for 24 weeks, and a group fed a high-fat diet. Interestingly, the doxazosin 4 researchers found that being exposed to air pollution was comparable to eating a high-fat diet. Both the air pollution and high-fat diet groups showed insulin resistance and abnormal metabolism – just like one would see in a pre-diabetic state.

These changes were associated doxazosin 4 with changes in the epigenome, a layer of control that can masterfully turn on and turn off thousands of genes, representing a critical buffer in response to environmental factors. This study is the first-of-its-kind to compare genome-wide epigenetic changes in response to air pollution, compare and contrast these changes with that of eating an unhealthy diet, and examine the impact of air pollution cessation on these changes.“The good news is that these effects were reversible, at least in our experiments” added Dr. Rajagopalan.

€œOnce the air pollution was removed from the environment, the mice appeared healthier and the pre-diabetic state seemed to reverse.” doxazosin 4 Dr. Rajagopalan explains that if you live in a densely polluted environment, taking actions such as wearing an N95 mask, using portable indoor air cleaners, utilizing air conditioning, closing car windows while commuting, and changing car air filters frequently could all be helpful in staying healthy and limiting air pollution exposure.Next steps in this research involve meeting with a panel of experts, as well as the National Institutes of Health, to discuss conducting clinical trials that compare heart health and the level of air pollution in the environment. For example, if someone has a heart attack, should they be wearing an N95 mask or using a portable air filter at home during recovery?.

Dr doxazosin 4. Rajagopalan and his team believe that it is important to address the environment as a population health risk factor and continue to diligently research these issues. The authors also note that these findings should encourage policymakers to enact measures aimed at reducing air pollution.Shyam Biswal, PhD, Professor in the Department of Environmental Health and Engineering at Johns Hopkins University School of Public Health, is the joint doxazosin 4 senior author on the study.

Drs. Rajagopalan and Biswal are co-PIs on the NIH grant that supported this work.###Rajagopalan, S., Biswal, S., et al. €œMetabolic effects of air pollution doxazosin 4 exposure and reversibility.” Journal of Clinical Investigation.

DOI. 10.1172/JCI137315. This work was supported by the National Institute of Environmental Health Sciences TaRGET II Consortium grant U01ES026721, as well as grants R01ES015146 and R01ES019616.About one in five women experience some form of depression during pregnancy, with poorly understood effects on the fetus.

Prenatal depression is linked to behavioural and developmental issues in children as well as an increased risk for depression as young adults. But how prenatal depression leads to these changes remains unclear. UCalgary researcher Dr.

Catherine Lebel, PhD, is helping understand what may be happening in the developing brains of these children. The research team has shown that young children whose mothers experienced more numerous symptoms of depression in pregnancy have weakened connectivity in brain pathways involved in emotion. These structural changes can be related to increased hyperactivity and aggression in boys.

The research is based on diffusion magnetic resonance imaging, an imaging technique that probes the strength of structural connections between brain regions. The findings are published in The Journal of Neuroscience. Catherine Lebel, senior author and investigator.

Riley Brandt, University of Calgary “The results help us understand how depression can have multigenerational impacts, and speaks to the importance of helping mothers who may be experiencing depression during pregnancy,” says Lebel, an associate professor at the Cumming School of Medicine, and researcher in the Alberta Children’s Hospital Research Institute. She holds the Canada Research Chair in Paediatric Neuroimaging. Lebel and her team studied 54 Calgary mothers and their children.

They were enrolled from the ongoing, prospective study called the Alberta Pregnancy Outcomes and Nutrition study. Mothers answered a survey about their depression symptoms at several points during their pregnancy. Their children were followed after birth and undertook an MRI scan at the Alberta Children’s Hospital at around age four.

As well, the children’s behaviour was assessed within six months of their MRI scan. The team found a significant reduction in structural brain connectivity between the amygdala, a structure essential for emotional processing, and the frontal cortex. Weakened connectivity between the amygdala and frontal cortex is associated with disruptive behaviours and vulnerability to depression.

The first author on the study, Dr. Rebecca Hay, MD, stresses the importance of recognition of depression and intervention in prenatal health. €œThese results suggest complex associations between the prenatal environment and children’s brain development, and may help us to understand why children of depressed mothers are more vulnerable to depression themselves,” says Hay, a resident physician in paediatrics and recent Cumming School of Medicine graduate.

The main clinical takeaway from this is to emphasize the importance of recognizing, treating prenatal depression and supporting mothers, both for better maternal outcomes and to help future child development. Rebecca Hay, the study's first author. Courtesy Rebecca Hay Current study looks at stress during pandemic Lebel and her research team are currently trying to understand how stress and mental health are affecting pregnant women during the COVID-19 pandemic.

She is examining how factors such as social supports might mitigate stress, and how this may influence pregnancy and birth outcomes. If you are interested, you can get involved here in the Pregnancy During the COVID-19 Pandemic study at the University of Calgary. So far, approximately 7,500 women from across Canada are enrolled and supplying information through questionnaires.

€œIt is critical to appropriately recognize and treat prenatal maternal mental health problems, both for the mothers and to improve child outcomes,” says Lebel. €œNow more than ever, with increased stress, anxiety and depression during the COVID-19 pandemic, we should do more to support mothers to positively impact the health of their children.” Lebel is an associate professor in the Department of Radiology at the Cumming School of Medicine, adjunct associate professor in the Werklund School of Education and a member of The Mathison Centre for Mental Health Research &. Education, Owerko Centre at ACHRI, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute.

The study was funded by the Canadian Institute of Health Research, Alberta Innovates - Health Solutions, the Alberta Children's Hospital Foundation, the National Institute of Environmental Health Sciences, the Mach-Gaensslen Foundation, and an Eyes High University of Calgary Postdoctoral Scholar. Led by the Hotchkiss Brain Institute, Brain and Mental Health is one of six research strategies guiding the University of Calgary toward its Eyes High goals. The strategy provides a unifying direction for brain and mental health research at the university..

First-of-its-kind study, based on a mouse model, finds living in a how to get doxazosin without a doctor polluted environment could be comparable to eating a high-fat diet, leading to a pre-diabetic state CLEVELAND—Air pollution is the world’s leading environmental risk factor, and causes more than nine million deaths per year. New research published in the Journal of Clinical Investigation shows air pollution may play a role in the development of cardiometabolic diseases, such as diabetes. Importantly, the how to get doxazosin without a doctor effects were reversible with cessation of exposure. Researchers found that air pollution was a “risk factor for a risk factor” that contributed to the common soil of other fatal problems like heart attack and stroke.

Similar to how an unhealthy diet and lack of exercise can lead to disease, exposure to air pollution could be added to this risk factor list as well. “In this study, we created an environment that mimicked a polluted day in New Delhi or Beijing,” said Sanjay Rajagopalan, MD, first author on the study, Chief of Cardiovascular Medicine at University Hospitals Harrington Heart and Vascular Institute, and how to get doxazosin without a doctor Director of the Case Western Reserve University Cardiovascular Research Institute. €œWe concentrated fine particles of air pollution, called PM2.5 (particulate matter component <. 2.5 microns) how to get doxazosin without a doctor.

Concentrated particles like this develop from human impact on the environment, such as automobile exhaust, power generation and other fossil fuels.” These particles have been strongly connected to risk factors for disease. For example, cardiovascular effects of air pollution can lead to heart attack and stroke. The research team has shown how to get doxazosin without a doctor exposure to air pollution can increase the likelihood of the same risk factors that lead to heart disease, such as insulin resistance and type 2 diabetes. In the mouse model study, three groups were observed.

A control group receiving clean filtered air, a group exposed to polluted air for 24 weeks, and a group fed a high-fat diet. Interestingly, the researchers found that how to get doxazosin without a doctor being exposed to air pollution was comparable to eating a high-fat diet. Both the air pollution and high-fat diet groups showed insulin resistance and abnormal metabolism – just like one would see in a pre-diabetic state. These changes were associated with changes in the epigenome, a layer of how to get doxazosin without a doctor control that can masterfully turn on and turn off thousands of genes, representing a critical buffer in response to environmental factors.

This study is the first-of-its-kind to compare genome-wide epigenetic changes in response to air pollution, compare and contrast these changes with that of eating an unhealthy diet, and examine the impact of air pollution cessation on these changes.“The good news is that these effects were reversible, at least in our experiments” added Dr. Rajagopalan. €œOnce the air pollution was removed from the environment, the mice appeared healthier and the pre-diabetic state seemed how to get doxazosin without a doctor to reverse.” Dr. Rajagopalan explains that if you live in a densely polluted environment, taking actions such as wearing an N95 mask, using portable indoor air cleaners, utilizing air conditioning, closing car windows while commuting, and changing car air filters frequently could all be helpful in staying healthy and limiting air pollution exposure.Next steps in this research involve meeting with a panel of experts, as well as the National Institutes of Health, to discuss conducting clinical trials that compare heart health and the level of air pollution in the environment.

For example, if someone has a heart attack, should they be wearing an N95 mask or using a portable air filter at home during recovery?. Dr how to get doxazosin without a doctor. Rajagopalan and his team believe that it is important to address the environment as a population health risk factor and continue to diligently research these issues. The authors also note that these findings should encourage policymakers to enact measures aimed at reducing air pollution.Shyam Biswal, PhD, Professor in the Department of Environmental how to get doxazosin without a doctor Health and Engineering at Johns Hopkins University School of Public Health, is the joint senior author on the study.

Drs. Rajagopalan and Biswal are co-PIs on the NIH grant that supported this work.###Rajagopalan, S., Biswal, S., et al. €œMetabolic effects of air pollution exposure and reversibility.” Journal of how to get doxazosin without a doctor Clinical Investigation. DOI.

10.1172/JCI137315. This work was supported by the National Institute of Environmental Health Sciences TaRGET II Consortium grant U01ES026721, as well as grants R01ES015146 and R01ES019616.About one in five women experience some form of depression during pregnancy, with poorly understood effects on the fetus. Prenatal depression is linked to behavioural and developmental issues in children as well as an increased risk for depression as young adults. But how prenatal depression leads to these changes remains unclear.

UCalgary researcher Dr. Catherine Lebel, PhD, is helping understand what may be happening in the developing brains of these children. The research team has shown that young children whose mothers experienced more numerous symptoms of depression in pregnancy have weakened connectivity in brain pathways involved in emotion. These structural changes can be related to increased hyperactivity and aggression in boys.

The research is based on diffusion magnetic resonance imaging, an imaging technique that probes the strength of structural connections between brain regions. The findings are published in The Journal of Neuroscience. Catherine Lebel, senior author and investigator. Riley Brandt, University of Calgary “The results help us understand how depression can have multigenerational impacts, and speaks to the importance of helping mothers who may be experiencing depression during pregnancy,” says Lebel, an associate professor at the Cumming School of Medicine, and researcher in the Alberta Children’s Hospital Research Institute.

She holds the Canada Research Chair in Paediatric Neuroimaging. Lebel and her team studied 54 Calgary mothers and their children. They were enrolled from the ongoing, prospective study called the Alberta Pregnancy Outcomes and Nutrition study. Mothers answered a survey about their depression symptoms at several points during their pregnancy.

Their children were followed after birth and undertook an MRI scan at the Alberta Children’s Hospital at around age four. As well, the children’s behaviour was assessed within six months of their MRI scan. The team found a significant reduction in structural brain connectivity between the amygdala, a structure essential for emotional processing, and the frontal cortex. Weakened connectivity between the amygdala and frontal cortex is associated with disruptive behaviours and vulnerability to depression.

The first author on the study, Dr. Rebecca Hay, MD, stresses the importance of recognition of depression and intervention in prenatal health. €œThese results suggest complex associations between the prenatal environment and children’s brain development, and may help us to understand why children of depressed mothers are more vulnerable to depression themselves,” says Hay, a resident physician in paediatrics and recent Cumming School of Medicine graduate. The main clinical takeaway from this is to emphasize the importance of recognizing, treating prenatal depression and supporting mothers, both for better maternal outcomes and to help future child development.

Rebecca Hay, the study's first author. Courtesy Rebecca Hay Current study looks at stress during pandemic Lebel and her research team are currently trying to understand how stress and mental health are affecting pregnant women during the COVID-19 pandemic. She is examining how factors such as social supports might mitigate stress, and how this may influence pregnancy and birth outcomes. If you are interested, you can get involved here in the Pregnancy During the COVID-19 Pandemic study at the University of Calgary.

So far, approximately 7,500 women from across Canada are enrolled and supplying information through questionnaires. €œIt is critical to appropriately recognize and treat prenatal maternal mental health problems, both for the mothers and to improve child outcomes,” says Lebel. €œNow more than ever, with increased stress, anxiety and depression during the COVID-19 pandemic, we should do more to support mothers to positively impact the health of their children.” Lebel is an associate professor in the Department of Radiology at the Cumming School of Medicine, adjunct associate professor in the Werklund School of Education and a member of The Mathison Centre for Mental Health Research &. Education, Owerko Centre at ACHRI, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute.

The study was funded by the Canadian Institute of Health Research, Alberta Innovates - Health Solutions, the Alberta Children's Hospital Foundation, the National Institute of Environmental Health Sciences, the Mach-Gaensslen Foundation, and an Eyes High University of Calgary Postdoctoral Scholar. Led by the Hotchkiss Brain Institute, Brain and Mental Health is one of six research strategies guiding the University of Calgary toward its Eyes High goals. The strategy provides a unifying direction for brain and mental health research at the university..

Doxazosin increased heart rate

A man who was the manager of an area pharmacy doxazosin increased heart rate was convicted of stealing more than $100,000 in diabetic test strips over two years.Orange County resident Aatif Khan, of Newburgh, will be sentenced on Tuesday, Oct. 27, for stealing strips from throughout the country while doxazosin increased heart rate he worked at JNR Pharmacy in Brewster.In addition to the felony charge of second-degree grand larceny, which can be punished by a maximum of 15 years in prison, Khan was slapped with a fourth-degree criminal tax fraud charge, as he failed to report any of his stolen income. In total, Khan could face up to 19 years in prison.“Gathering the evidence needed to secure this conviction was challenging and it required locating witnesses from across the country -- but (Criminal Investigator Michael Benvie), and (Assistant District Attorney Nicholas LaStella) were simply relentless in their pursuit of justice and they put together an overwhelming case against Aatif Khan,” said Putnam County District Attorney Robert Tendy in a statement released on Friday, Aug. 28.Khan, then 32, was arrested by the Sheriff's Department Bureau of Criminal doxazosin increased heart rate Investigations on Feb. 28, 2019.

The theft reportedly came to light after the pharmacy's bookkeeper conducted an doxazosin increased heart rate inventory of the store.According to Tendy, this is the largest asset forfeiture case handled in the history of the Putnam County District Attorney's office. €œThe victim has been reimbursed for the loss his business suffered, and Mr. Khan has paid back all of the proceeds of doxazosin increased heart rate this crime, and then some," wrote Tendy. "In addition to the asset forfeiture we collected, he is on the hook for a significant sum of money in the form of unpaid taxes, penalties, and interest owed to the State of New York Department of Taxation and Finance for his felony tax fraud conviction.” Click here to sign up for Daily Voice's free daily emails and news alerts..

A man who how to get doxazosin without a doctor was the manager of an area pharmacy was convicted of stealing more than $100,000 in diabetic test strips over two years.Orange County resident Aatif Khan, of Newburgh, will be sentenced on Tuesday, Oct. 27, for stealing strips from throughout the country while he worked at JNR Pharmacy in Brewster.In addition to the felony charge of second-degree grand larceny, how to get doxazosin without a doctor which can be punished by a maximum of 15 years in prison, Khan was slapped with a fourth-degree criminal tax fraud charge, as he failed to report any of his stolen income. In total, Khan could face up to 19 years in prison.“Gathering the evidence needed to secure this conviction was challenging and it required locating witnesses from across the country -- but (Criminal Investigator Michael Benvie), and (Assistant District Attorney Nicholas LaStella) were simply relentless in their pursuit of justice and they put together an overwhelming case against Aatif Khan,” said Putnam County District Attorney Robert Tendy in a statement released on Friday, Aug. 28.Khan, then 32, was arrested by how to get doxazosin without a doctor the Sheriff's Department Bureau of Criminal Investigations on Feb.

28, 2019. The theft how to get doxazosin without a doctor reportedly came to light after the pharmacy's bookkeeper conducted an inventory of the store.According to Tendy, this is the largest asset forfeiture case handled in the history of the Putnam County District Attorney's office. €œThe victim has been reimbursed for the loss his business suffered, and Mr. Khan has paid back all how to get doxazosin without a doctor of the proceeds of this crime, and then some," wrote Tendy.

"In addition to the asset forfeiture we collected, he is on the hook for a significant sum of money in the form of unpaid taxes, penalties, and interest owed to the State of New York Department of Taxation and Finance for his felony tax fraud conviction.” Click here to sign up for Daily Voice's free daily emails and news alerts..