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Publisher. American Political Science Review, vol. 114, issue 4 Nov 01, 2020 Authors Brian Gill, Emilyn Rubel Whitesell, Sean P.

Corcoran, Charles Tilley, Mariel Finucane and Liz Potamites Democracy Prep has large positive effects on civic participation, increasing its students’ voter-registration rates by about 16 percentage points and their voting rates by about 12 percentage points. Given the low registration and voting rates of young adults nationally, these are substantial impacts. They provide new evidence that an education focused on preparing students for citizenship can boost civic participation in adulthood.

This study examines the impact of Democracy Prep on voter registration and participation in the 2016 election.Publisher. PLOS ONE Oct 15, 2020 Authors Keith Kranker, Sarah Bardin, So O’Neil, and Dara Lee Luca ObjectivesUnintended (mistimed or unwanted) pregnancies occur frequently in the United States and have negative effects. When designing prevention programs and intervention strategies for the provision of comprehensive birth control methods, it is necessary to identify (1) populations at high risk of unintended pregnancy, and (2) geographic areas with a concentration of need.MethodsTo estimate the proportion and incidence of unintended births and pregnancies for regions in Missouri, two machine-learning prediction models were developed using data from the National Survey of Family Growth and the Missouri Pregnancy Risk Assessment Monitoring System.

Each model was applied to Missouri birth certificate data from 2014 to 2016 to estimate the number of unintended births and pregnancies across regions in Missouri. Population sizes from the American Community Survey were incorporated to estimate the incidence of unintended births and pregnancies.ResultsAbout 24,500 (34.0%) of the live births in Missouri each year were estimated to have resulted from unintended pregnancies. About 25 per 1,000 women (ages 15 to 45) annually.

Further, 40,000 pregnancies (39.7%) were unintended each year. About 41 per 1,000 women annually. Unintended pregnancy was concentrated in Missouri’s largest urban areas, and annual incidence varied substantially across regions.ConclusionsOur proposed methodology was feasible to implement.

Random forest modeling identified factors in the data that best predicted unintended birth and pregnancy and outperformed other approaches. Maternal age, marital status, health insurance status, parity, and month that prenatal care began predict unintended pregnancy among women with a recent live birth. Using this approach to estimate the rates of unintended births and pregnancies across regions within Missouri revealed substantial within-state variation in the proportion and incidence of unintended pregnancy.

States and other agencies could use this study’s results or methods to better target interventions to reduce unintended pregnancy or address other public health needs..

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Chemicals in the environment are making people sicker, fatter and poorer.As we learn more about the novel antibiotics and buy antibiotics, research is revealing ugly realities about social and environmental effects on health – including how the same chronic illnesses associated with exposure to endocrine-disrupting compounds also increase your risk of developing severe buy antibiotics.In the U.S. And abroad, the chronic disease epidemic that was already underway at the start of 2020 meant the population entered into the antibiotics cipro in a state will cipro cure a sinus of reduced health. Evidence is now emerging for the role that environmental quality plays in people’s susceptibility to buy antibiotics and their risk of dying from it.Why Endocrine Disruptors Are a ProblemEndocrine-disrupting compounds, or EDCs, are a broad group of chemicals that can interfere with natural hormones in people’s bodies in ways that harm human health. They include perfluoroalkyl and polyfluoroalkyl substances, better known as PFAS, flame retardants, plasticizers, pesticides, antimicrobial products and will cipro cure a sinus fragrances, among others.These chemicals are pervasive in modern life.

They are found in a wide range of consumer goods, food packaging, personal care products, cosmetics, industrial processes and agricultural settings. EDCs then will cipro cure a sinus make their way into our air, water, soil and food.(Credit. Pennsylvania Department of Environmental Protection)Research has shown that people who are exposed to EDCs are more likely than others to develop metabolic disorders, such as obesity, Type 2 diabetes and high cholesterol, and they tend to have poorer cardiovascular health.EDCs can also interfere with normal immune system function, which plays a critical role in fighting off . Poor immune function also will cipro cure a sinus contributes to pulmonary problems such as asthma and chronic obstructive pulmonary disease.

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Yet, hormones are responsible for maintaining virtually all essential bodily functions, including metabolism and healthy blood pressure, blood sugar and inflammation.The chemical shape or structure of EDCs resembles hormones in ways that cause the body to misinterpret an EDC for a natural signal from a hormone.A comparison of the structures of estradiol (left), a female sex hormone, and BPA (right), an endocrine disruptor found in plastics often used in containers for storing food and beverages. (Credit. NIST/Wikipedia)Because the human body is very sensitive to hormones, only small amounts of hormones are required to convey their intended signal. Therefore, very small exposures to EDCs can have dramatic, adverse affects on people’s health.Environmental Quality and buy antibioticsResearchers are only just beginning to paint a picture about how environmental quality contributes to buy antibiotics susceptibility, and there is much we still don’t know.

However, scientists suspect that EDCs can play a role based on clear scientific evidence that EDCs increase people’s risk of developing chronic disease that put people at greater risk from buy antibiotics.Public health organizations such as the U.S. Centers for Disease Control and Prevention and the World Heath Organization officially recognize underlying health conditions – including obesity, diabetes, hypertension, cardiovascular disease, immunosuppression, chronic respiratory disease and cancer – as risk factors for critical illness and mortality from buy antibiotics.Scientific evidence shows that EDC exposure increases people’s risk of developing all of these conditions. Scientists are thinking about these connections, and research efforts are underway to answer more questions about how EDCs may be influencing the cipro.Air Pollution and Other Environmental RisksIn addition to EDCs, other environmental conditions are also likely playing a role in the buy antibiotics cipro. For example, multiple studies have reported increased risk of buy antibiotics illness and deaths.

The findings are consistent with those reported in China following the SARS outbreak in 2002-2003.Recent evidence also shows that buy antibiotics can lead to lingering health conditions, including heart damage. Environmental conditions such as heat waves are particularly dangerous for individuals with heart disease or heart damage. In places like California that are currently experiencing wildfires and heat waves, we can clearly see how multiple environmental conditions can combine to further increase risk of deaths associated with buy antibiotics.In the U.S., regulations such as the Clean Water Act and Clean Air Act have improved environmental quality and human health since the 1970s. However, the Trump administration has been trying to weaken them.In the past three and a half years, about 35 environmental rules and regulations pertaining to air quality or toxic substances like EDCs were either rolled back or are in the process of being removed, despite unambiguous evidence showing how poor environmental quality harms human health.

Allowing more pollution threatens to exacerbate the trend toward a sicker, fatter and poorer America at a time when people’s overall health is necessary for our collective resilience to buy antibiotics and future global health challenges.Kathryn Crawford is an Assistant Professor of Environmental Health at Middlebury in Vermont. This article originally appeared on The Conversation under a Creative Commons license. Read the original here..

Nearly a year where to buy generic cipro before the novel How to buy viagra online antibiotics emerged, Dr. Leonardo Trasande published “Sicker, Fatter, Poorer,” a book about connections where to buy generic cipro between environmental pollutants and many of the most common chronic illnesses. The book describes decades of scientific research showing how endocrine-disrupting chemicals, present in our daily lives and now found in nearly all people, interfere with natural hormones in our bodies. The title sums up the where to buy generic cipro consequences. Chemicals in the environment are making people sicker, fatter and poorer.As we learn more about the novel antibiotics and buy antibiotics, research is revealing ugly realities about social and environmental effects on health – including how the same chronic illnesses associated with exposure to endocrine-disrupting compounds also increase your risk of developing severe buy antibiotics.In the U.S.

And abroad, the chronic disease epidemic that was already underway at the start of 2020 meant the population entered into the where to buy generic cipro antibiotics cipro in a state of reduced health. Evidence is now emerging for the role that environmental quality plays in people’s susceptibility to buy antibiotics and their risk of dying from it.Why Endocrine Disruptors Are a ProblemEndocrine-disrupting compounds, or EDCs, are a broad group of chemicals that can interfere with natural hormones in people’s bodies in ways that harm human health. They include where to buy generic cipro perfluoroalkyl and polyfluoroalkyl substances, better known as PFAS, flame retardants, plasticizers, pesticides, antimicrobial products and fragrances, among others.These chemicals are pervasive in modern life. They are found in a wide range of consumer goods, food packaging, personal care products, cosmetics, industrial processes and agricultural settings. EDCs then make their way into where to buy generic cipro our air, water, soil and food.(Credit.

Pennsylvania Department of Environmental Protection)Research has shown that people who are exposed to EDCs are more likely than others to develop metabolic disorders, such as obesity, Type 2 diabetes and high cholesterol, and they tend to have poorer cardiovascular health.EDCs can also interfere with normal immune system function, which plays a critical role in fighting off . Poor immune function where to buy generic cipro also contributes to pulmonary problems such as asthma and chronic obstructive pulmonary disease. Autoimmune diseases like rheumatoid arthritis and Crohn’s disease. And metabolic disorders where to buy generic cipro. Many EDCs are also associated with different cancers.EDCs Can Mimic Human HormonesEDCs affect human health by mimicking our natural hormones.Hormones are chemical signals that our cells use to communicate with one another.

You might be familiar where to buy generic cipro with reproductive hormones – testosterone and estrogen – which help distinguish male and female physiology and reproduction. Yet, hormones are responsible for maintaining virtually all essential bodily functions, including metabolism and healthy blood pressure, blood sugar and inflammation.The chemical shape or structure of EDCs resembles hormones in ways that cause the body to misinterpret an EDC for a natural signal from a hormone.A comparison of the structures of estradiol (left), a female sex hormone, and BPA (right), an endocrine disruptor found in plastics often used in containers for storing food and beverages. (Credit. NIST/Wikipedia)Because the human body is very sensitive to hormones, only small amounts of hormones are required to convey their intended signal. Therefore, very small exposures to EDCs can have dramatic, adverse affects on people’s health.Environmental Quality and buy antibioticsResearchers are only just beginning to paint a picture about how environmental quality contributes to buy antibiotics susceptibility, and there is much we still don’t know.

However, scientists suspect that EDCs can play a role based on clear scientific evidence that EDCs increase people’s risk of developing chronic disease that put people at greater risk from buy antibiotics.Public health organizations such as the U.S. Centers for Disease Control and Prevention and the World Heath Organization officially recognize underlying health conditions – including obesity, diabetes, hypertension, cardiovascular disease, immunosuppression, chronic respiratory disease and cancer – as risk factors for critical illness and mortality from buy antibiotics.Scientific evidence shows that EDC exposure increases people’s risk of developing all of these conditions. Scientists are thinking about these connections, and research efforts are underway to answer more questions about how EDCs may be influencing the cipro.Air Pollution and Other Environmental RisksIn addition to EDCs, other environmental conditions are also likely playing a role in the buy antibiotics cipro. For example, multiple studies have reported increased risk of buy antibiotics illness and deaths. The findings are consistent with those reported in China following the SARS outbreak in 2002-2003.Recent evidence also shows that buy antibiotics can lead to lingering health conditions, including heart damage.

Environmental conditions such as heat waves are particularly dangerous for individuals with heart disease or heart damage. In places like California that are currently experiencing wildfires and heat waves, we can clearly see how multiple environmental conditions can combine to further increase risk of deaths associated with buy antibiotics.In the U.S., regulations such as the Clean Water Act and Clean Air Act have improved environmental quality and human health since the 1970s. However, the Trump administration has been trying to weaken them.In the past three and a half years, about 35 environmental rules and regulations pertaining to air quality or toxic substances like EDCs were either rolled back or are in the process of being removed, despite unambiguous evidence showing how poor environmental quality harms human health. Allowing more pollution threatens to exacerbate the trend toward a sicker, fatter and poorer America at a time when people’s overall health is necessary for our collective resilience to buy antibiotics and future global health challenges.Kathryn Crawford is an Assistant Professor of Environmental Health at Middlebury in Vermont. This article originally appeared on The Conversation under a Creative Commons license.

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We provide estimates of the effectiveness of administration of cipro denk 500 tablets the CoronaVac treatment in a countrywide mass vaccination campaign for the prevention of laboratory-confirmed buy antibiotics and related hospitalization, admission to the ICU, and death. Among fully immunized persons, the adjusted treatment effectiveness was 65.9% for buy antibiotics and 87.5% for hospitalization, 90.3% for ICU cipro denk 500 tablets admission, and 86.3% for death. The treatment-effectiveness results were maintained in both age-subgroup analyses, notably among persons 60 years of age or older, independent of variation in testing and independent of various factors regarding treatment introduction in Chile. The treatment-effectiveness results in our study are similar to estimates that have been reported in cipro denk 500 tablets Brazil for the prevention of buy antibiotics (50.7%. 95% CI, 35.6 to 62.2), including estimates of cases that resulted in medical cipro denk 500 tablets treatment (83.7%.

95% CI, 58.0 to 93.7) and estimates of a composite end point of hospitalized, severe, or fatal cases (100%. 95% CI, 56.4 to 100).27 The large confidence intervals for the trial in Brazil reflect the relatively small sample (9823 participants) and the few cases detected (35 cases that led to cipro denk 500 tablets medical treatment and 10 that were severe). However, our estimates are lower than the efficacy reported in Turkey cipro denk 500 tablets (91.3%. 95% CI, 71.3 to 97.3),27 possibly owing to the small sample in that phase 3 clinical trial (1322 participants), differences in local transmission dynamics, and the predominance of older adults among the fully or partially immunized participants in our study. Overall, our results suggest that the CoronaVac treatment had high cipro denk 500 tablets effectiveness against severe disease, hospitalizations, and death, findings that underscore the potential of this treatment to save lives and substantially reduce demands on the health care system.

Our study cipro denk 500 tablets has at least three main strengths. First, we used a rich administrative health care data set, combining data from an integrated vaccination system for the total population and from the Ministry of Health FONASA, which covers approximately 80% of the Chilean population. These data include information on laboratory tests, hospitalization, mortality, onset cipro denk 500 tablets of symptoms, and clinical history in order to identify risk factors for severe disease. Information on region of residence also allowed us to control for differences in incidence across the country. We adjusted for income and nationality, which cipro denk 500 tablets correlate with socioeconomic status in Chile and are thus considered to be social determinants of health.

The large population sample allowed us to estimate treatment effectiveness both for one dose and for the cipro denk 500 tablets complete two-dose vaccination schedule. It also allowed for a subgroup analysis involving adults 60 years of age or older, a subgroup that is at higher risk for severe disease3 and that is underrepresented in clinical trials. Second, data were collected during a rapid vaccination campaign with high uptake and during a cipro denk 500 tablets period with one of the highest community transmission rates of the cipro, which allowed for a relatively short follow-up period and for estimation of the prevention of at least four essential outcomes. buy antibiotics cases and related hospitalization, ICU admission, and cipro denk 500 tablets death. Finally, Chile has the highest testing rates for buy antibiotics in Latin America, universal health care access, and a standardized, public reporting system for vital statistics, which limited the number of undetected or unascertained cases and deaths.14 Our study has several limitations.

First, as an observational study, it is subject cipro denk 500 tablets to confounding. To account for known confounders, we adjusted the analyses for relevant variables that could affect treatment effectiveness, cipro denk 500 tablets such as age, sex, underlying medical conditions, region of residence, and nationality. The risk of misclassification bias that would be due to the time-dependent performance of the antibiotics RT-PCR assay is relatively low, because the median time from symptom onset to testing in Chile is approximately 4 days (98.1% of the tests were RT-PCR assays). In this 4-day cipro denk 500 tablets period, the sensitivity and specificity of the molecular diagnosis of buy antibiotics are high.37 However, there may be a risk of selection bias. Systematic differences between the vaccinated and unvaccinated groups, such as health-seeking behavior or risk aversion, may affect the probability of exposure to the treatment and the risk of buy antibiotics and related outcomes.38,39 However, we cannot be sure about the direction of the effect.

Persons may be hesitant to get the treatment for various reasons, including fear of side effects, lack cipro denk 500 tablets of trust in the government or pharmaceutical companies, or an opinion that they do not need it, and they may be more or less risk-averse. Vaccinated persons may compensate by increasing their risky behavior (Peltzman effect).39 We addressed potential differences in health care access by restricting the analysis to persons who had undergone diagnostic testing, and we found cipro denk 500 tablets results that were consistent with those of our main analysis. Second, owing to the relatively short follow-up in this study, late outcomes may not have yet developed in persons who were infected near the end of the study, because the time from symptom onset to hospitalization or death can vary substantially.3,15 Therefore, effectiveness estimates regarding severe disease and death, in particular, should be interpreted with caution. Third, during the study period, ICUs in Chile were operating at 93.5% of their capacity on average (65.7% of the patients had buy antibiotics).31 If fewer persons were hospitalized than would be under regular ICU operation, our effectiveness estimates for protection against ICU admission might be biased downward, and our effectiveness estimates for protection against death might be biased upward (e.g., if patients cipro denk 500 tablets received care at a level lower than would usually be received during regular health system operation). Fourth, although the national genomic surveillance for antibiotics in Chile has reported the circulation of at least two viral lineages considered to be variants of concern, P.1 and B.1.1.7 (or cipro denk 500 tablets the gamma and alpha variants, respectively),40 we lack representative data to estimate their effect on treatment effectiveness (Table S2).

Results from a test-negative design study of the effectiveness of the CoronaVac treatment in health care workers in Manaus, Brazil, where the gamma variant is now predominant, showed that the efficacy of at least one dose of the treatment against buy antibiotics was 49.6% (95% CI, 11.3 to 71.4).29 Although the treatment-effectiveness estimates in Brazil are not directly comparable with our estimates owing to differences in the target population, the vaccination schedule (a window of 14 to 28 days between doses is recommended in Brazil41), and immunization status, they highlight the importance of continued treatment-effectiveness monitoring. Overall, our study results suggest that the CoronaVac treatment was highly effective in protecting against severe disease and death, findings that are consistent with the results of phase 2 trials23,24 and with preliminary efficacy cipro denk 500 tablets data.27V-safe Surveillance. Local and Systemic Reactogenicity cipro denk 500 tablets in Pregnant Persons Table 1. Table 1. Characteristics of Persons Who Identified as Pregnant in the V-safe cipro denk 500 tablets Surveillance System and Received an mRNA buy antibiotics treatment.

Table 2 cipro denk 500 tablets. Table 2. Frequency of Local and Systemic Reactions Reported on the Day after cipro denk 500 tablets mRNA buy antibiotics Vaccination in Pregnant Persons. From December 14, 2020, to February 28, 2021, a total of 35,691 v-safe participants identified as pregnant. Age distributions were similar among the participants who received the Pfizer–BioNTech treatment and those who received the Moderna treatment, with the majority cipro denk 500 tablets of the participants being 25 to 34 years of age (61.9% and 60.6% for each treatment, respectively) and non-Hispanic White (76.2% and 75.4%, respectively).

Most participants (85.8% and cipro denk 500 tablets 87.4%, respectively) reported being pregnant at the time of vaccination (Table 1). Solicited reports of injection-site pain, fatigue, headache, and myalgia were the most frequent local and systemic reactions after either dose for both treatments (Table 2) and were reported more frequently after dose 2 for both treatments. Participant-measured temperature at or above 38°C was reported by less than 1% of the participants cipro denk 500 tablets on day 1 after dose 1 and by 8.0% after dose 2 for both treatments. Figure 1 cipro denk 500 tablets. Figure 1.

Most Frequent Local and Systemic Reactions Reported in the V-safe Surveillance System on the Day after mRNA buy antibiotics cipro denk 500 tablets Vaccination. Shown are solicited reactions in pregnant persons and nonpregnant women 16 to 54 years of age who received a messenger RNA (mRNA) antibiotics disease 2019 (buy antibiotics) treatment — BNT162b2 (Pfizer–BioNTech) cipro denk 500 tablets or mRNA-1273 (Moderna) — from December 14, 2020, to February 28, 2021. The percentage of respondents was calculated among those who completed a day 1 survey, with the top events shown of injection-site pain (pain), fatigue or tiredness (fatigue), headache, muscle or body aches (myalgia), chills, and fever or felt feverish (fever).These patterns of reporting, with respect to both most frequently reported solicited reactions and the higher reporting of reactogenicity after dose 2, were similar to patterns observed among nonpregnant women (Figure 1). Small differences in reporting frequency between pregnant persons and nonpregnant women were observed for specific reactions (injection-site pain was reported cipro denk 500 tablets more frequently among pregnant persons, and other systemic reactions were reported more frequently among nonpregnant women), but the overall reactogenicity profile was similar. Pregnant persons did not report having severe reactions more frequently than nonpregnant women, except for nausea and vomiting, which were reported slightly more frequently only after dose 2 (Table S3).

V-safe Pregnancy cipro denk 500 tablets Registry. Pregnancy Outcomes cipro denk 500 tablets and Neonatal Outcomes Table 3. Table 3. Characteristics of V-safe cipro denk 500 tablets Pregnancy Registry Participants. As of March 30, 2021, the v-safe pregnancy registry call center attempted to contact 5230 persons who were vaccinated through February cipro denk 500 tablets 28, 2021, and who identified during a v-safe survey as pregnant at or shortly after buy antibiotics vaccination.

Of these, 912 were unreachable, 86 declined to participate, and 274 did not meet inclusion criteria (e.g., were never pregnant, were pregnant but received vaccination more than 30 days before the last menstrual period, or did not provide enough information to determine eligibility). The registry enrolled 3958 participants with vaccination from December 14, 2020, to February 28, 2021, of whom 3719 (94.0%) identified as cipro denk 500 tablets health care personnel. Among enrolled participants, most were 25 to 44 years of age (98.8%), non-Hispanic White (79.0%), and, at the cipro denk 500 tablets time of interview, did not report a buy antibiotics diagnosis during pregnancy (97.6%) (Table 3). Receipt of a first dose of treatment meeting registry-eligibility criteria was reported by 92 participants (2.3%) during the periconception period, by 1132 (28.6%) in the first trimester of pregnancy, by 1714 (43.3%) in the second trimester, and by 1019 (25.7%) in the third trimester (1 participant was missing information to determine the timing of vaccination) (Table 3). Among 1040 cipro denk 500 tablets participants (91.9%) who received a treatment in the first trimester and 1700 (99.2%) who received a treatment in the second trimester, initial data had been collected and follow-up scheduled at designated time points approximately 10 to 12 weeks apart.

Limited follow-up calls had been made at the time of this analysis. Table 4 cipro denk 500 tablets. Table 4 cipro denk 500 tablets. Pregnancy Loss and Neonatal Outcomes in Published Studies and V-safe Pregnancy Registry Participants. Among 827 participants who had a completed pregnancy, the pregnancy resulted cipro denk 500 tablets in a live birth in 712 (86.1%), in a spontaneous abortion in 104 (12.6%), in stillbirth in 1 (0.1%), and in other outcomes (induced abortion and ectopic pregnancy) in 10 (1.2%).

A total of 96 of 104 spontaneous abortions (92.3%) occurred before 13 weeks of gestation (Table 4), and 700 of 712 pregnancies that cipro denk 500 tablets resulted in a live birth (98.3%) were among persons who received their first eligible treatment dose in the third trimester. Adverse outcomes among 724 live-born infants — including 12 sets of multiple gestation — were preterm birth (60 of 636 among those vaccinated before 37 weeks [9.4%]), small size for gestational age (23 of 724 [3.2%]), and major congenital anomalies (16 of 724 [2.2%]). No neonatal deaths were reported at the cipro denk 500 tablets time of interview. Among the cipro denk 500 tablets participants with completed pregnancies who reported congenital anomalies, none had received buy antibiotics treatment in the first trimester or periconception period, and no specific pattern of congenital anomalies was observed. Calculated proportions of pregnancy and neonatal outcomes appeared similar to incidences published in the peer-reviewed literature (Table 4).

Adverse-Event Findings cipro denk 500 tablets on the VAERS During the analysis period, the VAERS received and processed 221 reports involving buy antibiotics vaccination among pregnant persons. 155 (70.1%) involved cipro denk 500 tablets nonpregnancy-specific adverse events, and 66 (29.9%) involved pregnancy- or neonatal-specific adverse events (Table S4). The most frequently reported pregnancy-related adverse events were spontaneous abortion (46 cases. 37 in the first trimester, 2 cipro denk 500 tablets in the second trimester, and 7 in which the trimester was unknown or not reported), followed by stillbirth, premature rupture of membranes, and vaginal bleeding, with 3 reports for each. No congenital anomalies were reported to the VAERS, a requirement under the EUAs.Participants Figure 1.

Figure 1 cipro denk 500 tablets. Enrollment and cipro denk 500 tablets Outcomes. The full analysis set (safety population) included all the participants who had undergone randomization and received at least one dose of the NVX-CoV2373 treatment or placebo, regardless of protocol violations or missing data. The primary end point was analyzed in the per-protocol population, which included participants who were seronegative at baseline, had received both doses of trial treatment or placebo, had no major protocol deviations affecting the primary end point, and had no confirmed cases of cipro denk 500 tablets symptomatic antibiotics disease 2019 (buy antibiotics) during the period from the first dose until 6 days after the second dose.Of the 16,645 participants who were screened, 15,187 underwent randomization (Figure 1). A total of 15,139 participants received at least one dose of NVX-CoV2373 (7569 participants) cipro denk 500 tablets or placebo (7570 participants).

14,039 participants (7020 in the treatment group and 7019 in the placebo group) met the criteria for the per-protocol efficacy population. Table 1 cipro denk 500 tablets. Table 1 cipro denk 500 tablets. Demographic and Clinical Characteristics of the Participants at Baseline (Per-Protocol Efficacy Population). The demographic and clinical characteristics of cipro denk 500 tablets the participants at baseline were well balanced between the groups in the per-protocol efficacy population, in which 48.4% were women.

94.5% were White, 2.9% were Asian, and 0.4% were Black. A total of 44.6% of the participants had at least one coexisting condition that had been defined by the Centers for Disease Control and cipro denk 500 tablets Prevention as a risk factor for severe buy antibiotics. These conditions included chronic respiratory, cardiac, renal, neurologic, hepatic, and immunocompromising conditions as well as obesity.14 The median age was 56 years, and 27.9% of the cipro denk 500 tablets participants were 65 years of age or older (Table 1). Safety Figure 2. Figure 2 cipro denk 500 tablets.

Solicited Local and Systemic Adverse cipro denk 500 tablets Events. The percentage of participants who had solicited local and systemic adverse events during the 7 days after each injection of the NVX-CoV2373 treatment or placebo is plotted according to the maximum toxicity grade (mild, moderate, severe, or potentially life-threatening). Data are not included for the 400 trial participants who were also enrolled in the seasonal influenza treatment substudy.A total of 2310 participants were included in cipro denk 500 tablets the subgroup in which adverse events were solicited. Solicited local adverse events were reported more frequently in the treatment cipro denk 500 tablets group than in the placebo group after both the first dose (57.6% vs. 17.9%) and the second dose (79.6% vs.

16.4%) (Figure cipro denk 500 tablets 2). Among the treatment recipients, the most commonly reported local adverse events were injection-site tenderness or pain after both the first dose (with 53.3% reporting cipro denk 500 tablets tenderness and 29.3% reporting pain) and the second dose (76.4% and 51.2%, respectively), with most events being grade 1 (mild) or 2 (moderate) in severity and of a short mean duration (2.3 days of tenderness and 1.7 days of pain after the first dose and 2.8 and 2.2 days, respectively, after the second dose). Solicited local adverse events were reported more frequently among younger treatment recipients (18 to 64 years of age) than among older recipients (≥65 years). Solicited systemic adverse events were reportedly more frequently in the treatment group than in the placebo group after both cipro denk 500 tablets the first dose (45.7% vs. 36.3%) and the second dose (64.0% vs.

30.0%) (Figure cipro denk 500 tablets 2). Among the treatment recipients, the most commonly reported systemic adverse events were headache, cipro denk 500 tablets muscle pain, and fatigue after both the first dose (24.5%, 21.4%, and 19.4%, respectively) and the second dose (40.0%, 40.3%, and 40.3%, respectively), with most events being grade 1 or 2 in severity and of a short mean duration (1.6, 1.6, and 1.8 days, respectively, after the first dose and 2.0, 1.8, and 1.9 days, respectively, after the second dose). Grade 4 systemic adverse events were reported in 3 treatment recipients. Two participants reported a grade 4 fever cipro denk 500 tablets (>40 °C), one after the first dose and the other after the second dose. A third cipro denk 500 tablets participant was found to have had positive results for antibiotics on PCR assay at baseline.

Five days after dose 1, this participant was hospitalized for buy antibiotics symptoms and subsequently had six grade 4 events. Nausea, headache, fatigue, myalgia, malaise, and cipro denk 500 tablets joint pain. Systemic adverse events were reported more often by younger treatment cipro denk 500 tablets recipients than by older treatment recipients and more often after the second dose than after the first dose. Among the treatment recipients, fever (temperature, ≥38°C) was reported in 2.0% after the first dose and in 4.8% after the second dose. Grade 3 cipro denk 500 tablets fever (39°C to 40°C) was reported in 0.4% after the first dose and in 0.6% after the second dose.

Grade 4 fever (>40°C) was reported in 2 participants, with one event after the first dose and one after the second dose. All 15,139 participants who had received at least one dose of treatment or placebo through the data cutoff date of the cipro denk 500 tablets final efficacy analysis were assessed for unsolicited adverse events. The frequency of unsolicited adverse events was higher among treatment recipients cipro denk 500 tablets than among placebo recipients (25.3% vs. 20.5%), with similar frequencies of severe adverse events (1.0% vs. 0.8%), serious adverse events cipro denk 500 tablets (0.5% vs.

0.5%), medically attended cipro denk 500 tablets adverse events (3.8% vs. 3.9%), adverse events leading to discontinuation of dosing (0.3% vs. 0.3%) or participation in the trial cipro denk 500 tablets (0.2% vs. 0.2%), potential immune-mediated medical conditions cipro denk 500 tablets (<0.1% vs. <0.1%), and adverse events of special interest relevant to buy antibiotics (0.1% vs.

0.3%). One related serious adverse event (myocarditis) was reported in a treatment recipient, which occurred 3 days after the second dose and was considered to be a potentially immune-mediated condition. An independent safety monitoring committee considered the event most likely to be viral myocarditis. The participant had a full recovery after 2 days of hospitalization. No episodes of anaphylaxis or treatment-associated enhanced buy antibiotics were reported.

Two deaths related to buy antibiotics were reported, one in the treatment group and one in the placebo group. The death in the treatment group occurred in a 53-year-old man in whom buy antibiotics symptoms developed 7 days after the first dose. He was subsequently admitted to the ICU for treatment of respiratory failure from buy antibiotics pneumonia and died 15 days after treatment administration. The death in the placebo group occurred in a 61-year-old man who was hospitalized 24 days after the first dose. The participant died 4 weeks later after complications from buy antibiotics pneumonia and sepsis.

Efficacy Figure 3. Figure 3. Kaplan–Meier Plots of Efficacy of the NVX-CoV2373 treatment against Symptomatic buy antibiotics. Shown is the cumulative incidence of symptomatic buy antibiotics in the per-protocol population (Panel A), the intention-to-treat population (Panel B), and the per-protocol population with the B.1.1.7 variant (Panel C). The timing of surveillance for symptomatic buy antibiotics began after the first dose in the intention-to-treat population and at least 7 days after the administration of the second dose in the per-protocol population (i.e., on day 28) through approximately the first 3 months of follow-up.Figure 4.

Figure 4. treatment Efficacy of NVX-CoV2373 in Specific Subgroups. Shown is the efficacy of the NVX-CoV2373 treatment in preventing buy antibiotics in various subgroups within the per-protocol population. treatment efficacy and 95% confidence intervals were derived with the use of Poisson regression with robust error variance. In the intention-to-treat population, treatment efficacy was assessed after the administration of the first dose of treatment or placebo.

Participants who identified themselves as being non-White or belonging to multiple races were pooled in a category of “other” race to ensure that the subpopulations would be large enough for meaningful analyses. Data regarding coexisting conditions were based on the definition used by the Centers for Disease Control and Prevention for persons who are at increased risk for buy antibiotics.Among the 14,039 participants in the per-protocol efficacy population, cases of virologically confirmed, symptomatic mild, moderate, or severe buy antibiotics with an onset at least 7 days after the second dose occurred in 10 treatment recipients (6.53 per 1000 person-years. 95% confidence interval [CI], 3.32 to 12.85) and in 96 placebo recipients (63.43 per 1000 person-years. 95% CI, 45.19 to 89.03), for a treatment efficacy of 89.7% (95% CI, 80.2 to 94.6) (Figure 3). Of the 10 treatment breakthrough cases, 8 were caused by the B.1.1.7 variant, 1 was caused by a non-B.1.1.7 variant, and 1 viral strain could not be identified.

Ten cases of mild, moderate, or severe buy antibiotics (1 in the treatment group and 9 in the placebo group) were reported in participants who were 65 years of age or older (Figure 4). Severe buy antibiotics occurred in 5 participants, all in the placebo group. Among these cases, 1 patient was hospitalized and 3 visited the emergency department. A fifth participant was cared for at home. All 5 patients met additional criteria regarding abnormal vital signs, use of supplemental oxygen, and buy antibiotics complications that were used to define severity (Table S1).

No hospitalizations or deaths from buy antibiotics occurred among the treatment recipients in the per-protocol efficacy analysis. Additional efficacy analyses in subgroups (defined according to age, race, and presence or absence of coexisting conditions) are detailed in Figure 4. Among the participants who were 65 years of age or older, overall treatment efficacy was 88.9% (95% CI, 12.8 to 98.6). Efficacy among all the participants starting 14 days after the first dose was 83.4% (95% CI, 73.6 to 89.5). A post hoc analysis of the primary end point identified the B.1.1.7 variant in 66 participants and a non-B.1.1.7 variant in 29 participants.

In 11 participants, PCR testing had been performed at a local hospital laboratory in which the variant had not been identified. treatment efficacy was 86.3% (95% CI, 71.3 to 93.5) against the B.1.1.7 variant and 96.4% (95% CI, 73.8 to 99.4) against non-B.1.1.7 strains. Too few non-White participants were enrolled in the trial to draw meaningful conclusions about variations in efficacy on the basis of race or ethnic group..

We provide where to buy generic cipro estimates of the effectiveness see it here of administration of the CoronaVac treatment in a countrywide mass vaccination campaign for the prevention of laboratory-confirmed buy antibiotics and related hospitalization, admission to the ICU, and death. Among fully immunized persons, the adjusted treatment effectiveness was 65.9% for buy antibiotics and 87.5% for hospitalization, 90.3% for ICU admission, where to buy generic cipro and 86.3% for death. The treatment-effectiveness results were maintained in both age-subgroup analyses, notably among persons 60 years of age or older, independent of variation in testing and independent of various factors regarding treatment introduction in Chile. The treatment-effectiveness results in our study are similar where to buy generic cipro to estimates that have been reported in Brazil for the prevention of buy antibiotics (50.7%. 95% CI, 35.6 to where to buy generic cipro 62.2), including estimates of cases that resulted in medical treatment (83.7%.

95% CI, 58.0 to 93.7) and estimates of a composite end point of hospitalized, severe, or fatal cases (100%. 95% CI, 56.4 to 100).27 The large confidence intervals for the trial in Brazil reflect where to buy generic cipro the relatively small sample (9823 participants) and the few cases detected (35 cases that led to medical treatment and 10 that were severe). However, our estimates are lower than the efficacy where to buy generic cipro reported in Turkey (91.3%. 95% CI, 71.3 to 97.3),27 possibly owing to the small sample in that phase 3 clinical trial (1322 participants), differences in local transmission dynamics, and the predominance of older adults among the fully or partially immunized participants in our study. Overall, our results suggest that the CoronaVac treatment had high effectiveness against severe disease, hospitalizations, and death, findings that where to buy generic cipro underscore the potential of this treatment to save lives and substantially reduce demands on the health care system.

Our study has at where to buy generic cipro least three main strengths. First, we used a rich administrative health care data set, combining data from an integrated vaccination system for the total population and from the Ministry of Health FONASA, which covers approximately 80% of the Chilean population. These data include information on laboratory tests, hospitalization, mortality, onset of symptoms, and clinical history in order to identify where to buy generic cipro risk factors for severe disease. Information on region of residence also allowed us to control for differences in incidence across the country. We adjusted for income and nationality, which correlate with socioeconomic status in Chile and are where to buy generic cipro thus considered to be social determinants of health.

The large population sample allowed us to estimate treatment effectiveness both for one dose and for the complete where to buy generic cipro two-dose vaccination schedule. It also allowed for a subgroup analysis involving adults 60 years of age or older, a subgroup that is at higher risk for severe disease3 and that is underrepresented in clinical trials. Second, data were collected during a rapid vaccination campaign with high uptake and where to buy generic cipro during a period with one of the highest community transmission rates of the cipro, which allowed for a relatively short follow-up period and for estimation of the prevention of at least four essential outcomes. buy antibiotics cases and related hospitalization, ICU admission, and death where to buy generic cipro. Finally, Chile has the highest testing rates for buy antibiotics in Latin America, universal health care access, and a standardized, public reporting system for vital statistics, which limited the number of undetected or unascertained cases and deaths.14 Our study has several limitations.

First, as an observational study, where to buy generic cipro it is subject to confounding. To account for known confounders, we adjusted the analyses for relevant variables that could affect treatment effectiveness, where to buy generic cipro such as age, sex, underlying medical conditions, region of residence, and nationality. The risk of misclassification bias that would be due to the time-dependent performance of the antibiotics RT-PCR assay is relatively low, because the median time from symptom onset to testing in Chile is approximately 4 days (98.1% of the tests were RT-PCR assays). In this 4-day period, the sensitivity and specificity of the molecular diagnosis where to buy generic cipro of buy antibiotics are high.37 However, there may be a risk of selection bias. Systematic differences between the vaccinated and unvaccinated groups, such as health-seeking behavior or risk aversion, may affect the probability of exposure to the treatment and the risk of buy antibiotics and related outcomes.38,39 However, we cannot be sure about the direction of the effect.

Persons may be hesitant to get the treatment for various reasons, where to buy generic cipro including fear of side effects, lack of trust in the government or pharmaceutical companies, or an opinion that they do not need it, and they may be more or less risk-averse. Vaccinated persons may compensate by increasing their risky behavior (Peltzman effect).39 We addressed potential differences in health care access by restricting the analysis to persons who had undergone diagnostic testing, and where to buy generic cipro we found results that were consistent with those of our main analysis. Second, owing to the relatively short follow-up in this study, late outcomes may not have yet developed in persons who were infected near the end of the study, because the time from symptom onset to hospitalization or death can vary substantially.3,15 Therefore, effectiveness estimates regarding severe disease and death, in particular, should be interpreted with caution. Third, during the study period, ICUs in Chile were operating at 93.5% of their capacity on average (65.7% of the patients had buy antibiotics).31 If fewer persons were where to buy generic cipro hospitalized than would be under regular ICU operation, our effectiveness estimates for protection against ICU admission might be biased downward, and our effectiveness estimates for protection against death might be biased upward (e.g., if patients received care at a level lower than would usually be received during regular health system operation). Fourth, although the national genomic surveillance for antibiotics in Chile has reported the circulation of at least two viral lineages considered to be variants of concern, P.1 and B.1.1.7 (or the gamma and alpha variants, respectively),40 we lack representative data to estimate their where to buy generic cipro effect on treatment effectiveness (Table S2).

Results from a test-negative design study of the effectiveness of the CoronaVac treatment in health care workers in Manaus, Brazil, where the gamma variant is now predominant, showed that the efficacy of at least one dose of the treatment against buy antibiotics was 49.6% (95% CI, 11.3 to 71.4).29 Although the treatment-effectiveness estimates in Brazil are not directly comparable with our estimates owing to differences in the target population, the vaccination schedule (a window of 14 to 28 days between doses is recommended in Brazil41), and immunization status, they highlight the importance of continued treatment-effectiveness monitoring. Overall, our study results suggest that the CoronaVac treatment was highly effective in protecting against severe disease and death, findings that are consistent with the results of phase 2 trials23,24 and with where to buy generic cipro preliminary efficacy data.27V-safe Surveillance. Local and where to buy generic cipro Systemic Reactogenicity in Pregnant Persons Table 1. Table 1. Characteristics of where to buy generic cipro Persons Who Identified as Pregnant in the V-safe Surveillance System and Received an mRNA buy antibiotics treatment.

Table 2 where to buy generic cipro. Table 2. Frequency of Local and Systemic Reactions Reported on the Day after where to buy generic cipro mRNA buy antibiotics Vaccination in Pregnant Persons. From December 14, 2020, to February 28, 2021, a total of 35,691 v-safe participants identified as pregnant. Age distributions were similar among the participants who received the Pfizer–BioNTech treatment and those who received the Moderna treatment, with the majority of the participants where to buy generic cipro being 25 to 34 years of age (61.9% and 60.6% for each treatment, respectively) and non-Hispanic White (76.2% and 75.4%, respectively).

Most participants (85.8% and 87.4%, respectively) reported being pregnant at the time of vaccination (Table where to buy generic cipro 1). Solicited reports of injection-site pain, fatigue, headache, and myalgia were the most frequent local and systemic reactions after either dose for both treatments (Table 2) and were reported more frequently after dose 2 for both treatments. Participant-measured temperature at or above 38°C was reported by less than 1% of the participants on day 1 after dose 1 and by 8.0% after dose 2 for both treatments where to buy generic cipro. Figure 1 where to buy generic cipro. Figure 1.

Most Frequent Local and Systemic Reactions Reported in the V-safe where to buy generic cipro Surveillance System on the Day after mRNA buy antibiotics Vaccination. Shown are solicited reactions in pregnant persons and nonpregnant women where to buy generic cipro 16 to 54 years of age who received a messenger RNA (mRNA) antibiotics disease 2019 (buy antibiotics) treatment — BNT162b2 (Pfizer–BioNTech) or mRNA-1273 (Moderna) — from December 14, 2020, to February 28, 2021. The percentage of respondents was calculated among those who completed a day 1 survey, with the top events shown of injection-site pain (pain), fatigue or tiredness (fatigue), headache, muscle or body aches (myalgia), chills, and fever or felt feverish (fever).These patterns of reporting, with respect to both most frequently reported solicited reactions and the higher reporting of reactogenicity after dose 2, were similar to patterns observed among nonpregnant women (Figure 1). Small differences in reporting frequency between pregnant persons and nonpregnant women were observed for specific reactions where to buy generic cipro (injection-site pain was reported more frequently among pregnant persons, and other systemic reactions were reported more frequently among nonpregnant women), but the overall reactogenicity profile was similar. Pregnant persons did not report having severe reactions more frequently than nonpregnant women, except for nausea and vomiting, which were reported slightly more frequently only after dose 2 (Table S3).

V-safe Pregnancy where to buy generic cipro Registry. Pregnancy Outcomes where to buy generic cipro and Neonatal Outcomes Table 3. Table 3. Characteristics of where to buy generic cipro V-safe Pregnancy Registry Participants. As of March where to buy generic cipro 30, 2021, the v-safe pregnancy registry call center attempted to contact 5230 persons who were vaccinated through February 28, 2021, and who identified during a v-safe survey as pregnant at or shortly after buy antibiotics vaccination.

Of these, 912 were unreachable, 86 declined to participate, and 274 did not meet inclusion criteria (e.g., were never pregnant, were pregnant but received vaccination more than 30 days before the last menstrual period, or did not provide enough information to determine eligibility). The registry enrolled 3958 participants with vaccination from December 14, 2020, to February 28, 2021, of where to buy generic cipro whom 3719 (94.0%) identified as health care personnel. Among enrolled participants, most were 25 to 44 years of age (98.8%), non-Hispanic White (79.0%), and, at the time of interview, did not report a buy antibiotics where to buy generic cipro diagnosis during pregnancy (97.6%) (Table 3). Receipt of a first dose of treatment meeting registry-eligibility criteria was reported by 92 participants (2.3%) during the periconception period, by 1132 (28.6%) in the first trimester of pregnancy, by 1714 (43.3%) in the second trimester, and by 1019 (25.7%) in the third trimester (1 participant was missing information to determine the timing of vaccination) (Table 3). Among 1040 participants (91.9%) who received a treatment in the first trimester and 1700 (99.2%) who received a treatment where to buy generic cipro in the second trimester, initial data had been collected and follow-up scheduled at designated time points approximately 10 to 12 weeks apart.

Limited follow-up calls had been made at the time of this analysis. Table 4 where to buy generic cipro. Table 4 where to buy generic cipro. Pregnancy Loss and Neonatal Outcomes in Published Studies and V-safe Pregnancy Registry Participants. Among 827 participants who had a completed pregnancy, the pregnancy resulted in a live birth in 712 (86.1%), in a spontaneous abortion in 104 (12.6%), in stillbirth in 1 (0.1%), and in other outcomes (induced abortion and where to buy generic cipro ectopic pregnancy) in 10 (1.2%).

A total of 96 of 104 spontaneous abortions (92.3%) occurred before 13 weeks of gestation (Table 4), and 700 of 712 pregnancies that resulted in a live birth (98.3%) were among persons who received their first eligible treatment dose in where to buy generic cipro the third trimester. Adverse outcomes among 724 live-born infants — including 12 sets of multiple gestation — were preterm birth (60 of 636 among those vaccinated before 37 weeks [9.4%]), small size for gestational age (23 of 724 [3.2%]), and major congenital anomalies (16 of 724 [2.2%]). No neonatal deaths where to buy generic cipro were reported at the time of interview. Among the participants with completed pregnancies who reported congenital anomalies, none had received buy antibiotics treatment in the first trimester or periconception period, and no specific pattern of congenital where to buy generic cipro anomalies was observed. Calculated proportions of pregnancy and neonatal outcomes appeared similar to incidences published in the peer-reviewed literature (Table 4).

Adverse-Event Findings on the VAERS where to buy generic cipro During the analysis period, the VAERS received and processed 221 reports involving buy antibiotics vaccination among pregnant persons. 155 (70.1%) involved nonpregnancy-specific adverse events, and 66 (29.9%) involved pregnancy- or where to buy generic cipro neonatal-specific adverse events (Table S4). The most frequently reported pregnancy-related adverse events were spontaneous abortion (46 cases. 37 in the first trimester, 2 in the where to buy generic cipro second trimester, and 7 in which the trimester was unknown or not reported), followed by stillbirth, premature rupture of membranes, and vaginal bleeding, with 3 reports for each. No congenital anomalies were reported to the VAERS, a requirement under the EUAs.Participants Figure 1.

Figure 1 where to buy generic cipro. Enrollment and Outcomes where to buy generic cipro. The full analysis set (safety population) included all the participants who had undergone randomization and received at least one dose of the NVX-CoV2373 treatment or placebo, regardless of protocol violations or missing data. The primary end point was analyzed in the per-protocol population, where to buy generic cipro which included participants who were seronegative at baseline, had received both doses of trial treatment or placebo, had no major protocol deviations affecting the primary end point, and had no confirmed cases of symptomatic antibiotics disease 2019 (buy antibiotics) during the period from the first dose until 6 days after the second dose.Of the 16,645 participants who were screened, 15,187 underwent randomization (Figure 1). A total of 15,139 participants received at least one dose of NVX-CoV2373 (7569 participants) or placebo (7570 participants) where to buy generic cipro.

14,039 participants (7020 in the treatment group and 7019 in the placebo group) met the criteria for the per-protocol efficacy population. Table 1 where to buy generic cipro. Table 1 where to buy generic cipro. Demographic and Clinical Characteristics of the Participants at Baseline (Per-Protocol Efficacy Population). The demographic and clinical characteristics of the participants at baseline were well balanced between where to buy generic cipro the groups in the per-protocol efficacy population, in which 48.4% were women.

94.5% were White, 2.9% were Asian, and 0.4% were Black. A total of 44.6% of the participants had at least one coexisting condition that had been defined by where to buy generic cipro the Centers for Disease Control and Prevention as a risk factor for severe buy antibiotics. These conditions included chronic respiratory, cardiac, renal, neurologic, hepatic, and immunocompromising conditions as well as obesity.14 The median age was 56 years, and 27.9% where to buy generic cipro of the participants were 65 years of age or older (Table 1). Safety Figure 2. Figure 2 where to buy generic cipro.

Solicited Local and Systemic where to buy generic cipro Adverse Events. The percentage of participants who had solicited local and systemic adverse events during the 7 days after each injection of the NVX-CoV2373 treatment or placebo is plotted according to the maximum toxicity grade (mild, moderate, severe, or potentially life-threatening). Data are not included for the 400 trial participants who were also enrolled where to buy generic cipro in the seasonal influenza treatment substudy.A total of 2310 participants were included in the subgroup in which adverse events were solicited. Solicited local adverse events were reported more frequently in the treatment group than in the placebo group after both the first where to buy generic cipro dose (57.6% vs. 17.9%) and the second dose (79.6% vs.

16.4%) (Figure 2) where to buy generic cipro. Among the treatment recipients, the most commonly reported local adverse events were injection-site tenderness where to buy generic cipro or pain after both the first dose (with 53.3% reporting tenderness and 29.3% reporting pain) and the second dose (76.4% and 51.2%, respectively), with most events being grade 1 (mild) or 2 (moderate) in severity and of a short mean duration (2.3 days of tenderness and 1.7 days of pain after the first dose and 2.8 and 2.2 days, respectively, after the second dose). Solicited local adverse events were reported more frequently among younger treatment recipients (18 to 64 years of age) than among older recipients (≥65 years). Solicited systemic adverse events were reportedly more frequently in the treatment group than in the placebo group after both the where to buy generic cipro first dose (45.7% vs. 36.3%) and the second dose (64.0% vs.

30.0%) (Figure 2) where to buy generic cipro. Among the treatment recipients, the most commonly reported systemic adverse events were headache, muscle pain, and fatigue after both the first dose (24.5%, 21.4%, and where to buy generic cipro 19.4%, respectively) and the second dose (40.0%, 40.3%, and 40.3%, respectively), with most events being grade 1 or 2 in severity and of a short mean duration (1.6, 1.6, and 1.8 days, respectively, after the first dose and 2.0, 1.8, and 1.9 days, respectively, after the second dose). Grade 4 systemic adverse events were reported in 3 treatment recipients. Two participants reported a grade 4 fever where to buy generic cipro (>40 °C), one after the first dose and the other after the second dose. A third participant was found to have had positive results for where to buy generic cipro antibiotics on PCR assay at baseline.

Five days after dose 1, this participant was hospitalized for buy antibiotics symptoms and subsequently had six grade 4 events. Nausea, headache, where to buy generic cipro fatigue, myalgia, malaise, and joint pain. Systemic adverse events were reported more often by younger treatment recipients than by older treatment recipients and more often after the where to buy generic cipro second dose than after the first dose. Among the treatment recipients, fever (temperature, ≥38°C) was reported in 2.0% after the first dose and in 4.8% after the second dose. Grade 3 fever (39°C to 40°C) was reported in 0.4% after the first dose and in where to buy generic cipro 0.6% after the second dose.

Grade 4 fever (>40°C) was reported in 2 participants, with one event after the first dose and one after the second dose. All 15,139 participants who had received at least one dose of treatment or placebo through where to buy generic cipro the data cutoff date of the final efficacy analysis were assessed for unsolicited adverse events. The frequency of unsolicited adverse events was higher among treatment recipients where to buy generic cipro than among placebo recipients (25.3% vs. 20.5%), with similar frequencies of severe adverse events (1.0% vs. 0.8%), serious adverse events where to buy generic cipro (0.5% vs.

0.5%), medically attended adverse events (3.8% where to buy generic cipro vs. 3.9%), adverse events leading to discontinuation of dosing (0.3% vs. 0.3%) or participation in where to buy generic cipro the trial (0.2% vs. 0.2%), potential immune-mediated medical conditions (<0.1% where to buy generic cipro vs. <0.1%), and adverse events of special interest relevant to buy antibiotics (0.1% vs.

0.3%). One related serious adverse event (myocarditis) was reported in a treatment recipient, which occurred 3 days after the second dose and was considered to be a potentially immune-mediated condition. An independent safety monitoring committee considered the event most likely to be viral myocarditis. The participant had a full recovery after 2 days of hospitalization. No episodes of anaphylaxis or treatment-associated enhanced buy antibiotics were reported.

Two deaths related to buy antibiotics were reported, one in the treatment group and one in the placebo group. The death in the treatment group occurred in a 53-year-old man in whom buy antibiotics symptoms developed 7 days after the first dose. He was subsequently admitted to the ICU for treatment of respiratory failure from buy antibiotics pneumonia and died 15 days after treatment administration. The death in the placebo group occurred in a 61-year-old man who was hospitalized 24 days after the first dose. The participant died 4 weeks later after complications from buy antibiotics pneumonia and sepsis.

Efficacy Figure 3. Figure 3. Kaplan–Meier Plots of Efficacy of the NVX-CoV2373 treatment against Symptomatic buy antibiotics. Shown is the cumulative incidence of symptomatic buy antibiotics in the per-protocol population (Panel A), the intention-to-treat population (Panel B), and the per-protocol population with the B.1.1.7 variant (Panel C). The timing of surveillance for symptomatic buy antibiotics began after the first dose in the intention-to-treat population and at least 7 days after the administration of the second dose in the per-protocol population (i.e., on day 28) through approximately the first 3 months of follow-up.Figure 4.

Figure 4. treatment Efficacy of NVX-CoV2373 in Specific Subgroups. Shown is the efficacy of the NVX-CoV2373 treatment in preventing buy antibiotics in various subgroups within the per-protocol population. treatment efficacy and 95% confidence intervals were derived with the use of Poisson regression with robust error variance. In the intention-to-treat population, treatment efficacy was assessed after the administration of the first dose of treatment or placebo.

Participants who identified themselves as being non-White or belonging to multiple races were pooled in a category of “other” race to ensure that the subpopulations would be large enough for meaningful analyses. Data regarding coexisting conditions were based on the definition used by the Centers for Disease Control and Prevention for persons who are at increased risk for buy antibiotics.Among the 14,039 participants in the per-protocol efficacy population, cases of virologically confirmed, symptomatic mild, moderate, or severe buy antibiotics with an onset at least 7 days after the second dose occurred in 10 treatment recipients (6.53 per 1000 person-years. 95% confidence interval [CI], 3.32 to 12.85) and in 96 placebo recipients (63.43 per 1000 person-years. 95% CI, 45.19 to 89.03), for a treatment efficacy of 89.7% (95% CI, 80.2 to 94.6) (Figure 3). Of the 10 treatment breakthrough cases, 8 were caused by the B.1.1.7 variant, 1 was caused by a non-B.1.1.7 variant, and 1 viral strain could not be identified.

Ten cases of mild, moderate, or severe buy antibiotics (1 in the treatment group and 9 in the placebo group) were reported in participants who were 65 years of age or older (Figure 4). Severe buy antibiotics occurred in 5 participants, all in the placebo group. Among these cases, 1 patient was hospitalized and 3 visited the emergency department. A fifth participant was cared for at home. All 5 patients met additional criteria regarding abnormal vital signs, use of supplemental oxygen, and buy antibiotics complications that were used to define severity (Table S1).

No hospitalizations or deaths from buy antibiotics occurred among the treatment recipients in the per-protocol efficacy analysis. Additional efficacy analyses in subgroups (defined according to age, race, and presence or absence of coexisting conditions) are detailed in Figure 4. Among the participants who were 65 years of age or older, overall treatment efficacy was 88.9% (95% CI, 12.8 to 98.6). Efficacy among all the participants starting 14 days after the first dose was 83.4% (95% CI, 73.6 to 89.5). A post hoc analysis of the primary end point identified the B.1.1.7 variant in 66 participants and a non-B.1.1.7 variant in 29 participants.

In 11 participants, PCR testing had been performed at a local hospital laboratory in which the variant had not been identified. treatment efficacy was 86.3% (95% CI, 71.3 to 93.5) against the B.1.1.7 variant and 96.4% (95% CI, 73.8 to 99.4) against non-B.1.1.7 strains. Too few non-White participants were enrolled in the trial to draw meaningful conclusions about variations in efficacy on the basis of race or ethnic group..

Cipro xr 1 gr

This investigation is cipro xr 1 gr a joint project of KHN, a national newsroom that produces in-depth journalism about health issues, and Spotlight PA, an independent, Cheap generic antabuse collaborative newsroom dedicated to producing investigative journalism for all of Pennsylvania. When Ian Kalinowski was at work, his mom usually texted him. So when he saw her number cipro xr 1 gr show up as an incoming call around lunchtime one Tuesday, he figured it had to be important. Now, more than seven years later, he remembers her screams, the shock and the questions she asked over and over again. €œWhy are they saying this to me?.

Why are they lying cipro xr 1 gr to me?. € Ian recalled his mom asking. €œThey’re telling me Adam’s dead. Why would they do this to cipro xr 1 gr me?. € Adam was Ian’s older brother.

Growing up, it seemed they spent every second together. Football, hockey and tag cipro xr 1 gr filled long days outside their Pittsburgh home. When Ian moved away for college, he and Adam turned to online poker to stay in touch. Adam served as best man at Ian’s wedding, and Ian admired his brother’s artistic streak. Adam could turn any piece cipro xr 1 gr of paper into an origami swan.

His mom’s home is still full of swans. Adam’s struggle with opioid and alcohol addiction was painful for Ian to watch. The problems began, it seemed to Ian, after Adam dropped out of college cipro xr 1 gr and used drugs to deal with his depression. Adam sought treatment, and he relied on methadone for many years, but his problems continued. When he was 32, he typically drank dozens of beers each day.

On Feb cipro xr 1 gr. 3, 2014, he entered a treatment center run by Addiction Specialists Inc., according to a lawsuit later filed by his family against the facility. The center, in a Fayette County strip mall, was about an hour’s cipro xr 1 gr drive south of Pittsburgh. Adam received a lighter engraved with his initials as a 30th birthday gift from his brother, Ian. After Adam’s death in 2014, Ian gave his son the middle name “Adam” as a tribute to his brother and best friend.

(Kristina Serafini / TribLIVE for Spotlight PA) Ian sits for a portrait at his home in Penn Township, cipro xr 1 gr Pennsylvania, on Wednesday, March 3, 2021. (Kristina Serafini / TribLIVE for Spotlight PA) Less than 24 hours after Adam made it to the facility, he was dead, according to expert reports from doctors in the family’s wrongful death lawsuit. Ian couldn’t understand what went wrong, and neither could his mom, still in denial on the other end of the phone call. What his family didn’t know was that Addiction Specialists, often known as ASI, had a history of violating state rules cipro xr 1 gr. In a later federal investigation into the facility’s billing and drug distribution practices, a grand jury concluded that a litany of problems occurred at the business many months before and after Adam’s arrival.

In the wrongful death suit, a lawyer for the Kalinowski family alleged Adam wasn’t evaluated by a physician when he arrived at ASI, didn’t receive the medication or treatment he needed, became increasingly uneasy and anxious throughout the night and killed himself. An Allegheny County judge in December 2019 said the business, two of its owners — Rosalind and Sean Sugarmann — and an ASI physician were negligent in cipro xr 1 gr caring for Adam. The judge ordered them to pay over $1.6 million in damages, although Ian doubts they ever will. ASI eventually shut down, two years after Adam died. In recent interviews with KHN-Spotlight PA, the Sugarmanns denied responsibility for cipro xr 1 gr Adam’s death and maintained that ASI was a good facility.

Rosalind said it helped a lot of people in a rural area with a high drug-overdose rate. Addiction treatment facilities in Pennsylvania, like ASI, are licensed and regulated by the state to ensure they follow certain rules and keep vulnerable people struggling with addiction safe. Oversight used to fall to the cipro xr 1 gr Department of Health. But in 2012, the state created the Department of Drug and Alcohol Programs, a $125 million agency set up to give substance use the attention lawmakers felt it deserved. At the time of Adam’s death in 2014, the department had taken few disciplinary actions against ASI.

It had issued citations and required the company to submit plans cipro xr 1 gr to correct them. But the Sugarmanns told KHN-Spotlight PA that, at the time, they didn’t fear the state would shut them down. Perhaps for cipro xr 1 gr good reason. A KHN-Spotlight PA investigation found that the department has allowed providers to continue operating despite repeated violations of state regulations and harm to clients. More than 80 interviews and a review of thousands of pages of state government and court records revealed that the department lacks resources and regulatory power, uses an inherently flawed oversight system that does little to ensure high-quality or effective care, and rarely takes strong disciplinary action against facilities when so many Pennsylvanians need services.

The department has no standard cipro xr 1 gr criteria for when it should force facilities to serve fewer patients and, as of early April, had revoked just one treatment provider’s license in nearly a decade. It doesn’t, as a regular practice, compare facilities to see if any stand out for an unusual number of violations or the most client deaths. And since state inspections focus heavily on records, they can be tricked with fraudulent paperwork, former employees in the treatment field said. This leaves Pennsylvanians — who suffer one cipro xr 1 gr of the highest drug overdose death rates in the nation — in the dark about which treatment facilities have troubling track records. Some advocates point out that overregulating or closing facilities could leave people suffering from addiction without options for care.

But in the current system, state and judicial records show, some patients have received inadequate treatment or even died. Certain facilities have fraudulently billed insurance cipro xr 1 gr companies. And owners rake in federal and state tax dollars, as well as private money from victims of the opioid crisis. €œMany of these rehab facilities are not properly run or supervised, and many are in it for the money,” said Peter Friday, an attorney who represented Adam’s family in their lawsuit. €œThese places cipro xr 1 gr have been unbridled.” Who Polices the Providers?.

Even though the Department of Drug and Alcohol Programs provides the licenses that allow addiction treatment facilities to operate, Jennifer Smith, secretary of the department, said it has limited responsibility for them. Law enforcement agencies are often better positioned to take action against troubled providers, she said, and insurance companies that pay for services also offer oversight. €œIt’s not our job to really cipro xr 1 gr police the providers,” Smith said in an interview. €œOur function is to really try to enable them to meet the [state’s] requirements, and by doing so, enabling them to provide quality services.” Jennifer Smith, secretary of the Pennsylvania Department of Drug and Alcohol Programs, said her agency has limited responsibility for treatment facilities, despite providing the licenses that allow them to operate. (Commonwealth Media Services) Yet, as the regulating body of these treatment facilities, the department collects some of the most critical information necessary to properly police them, including reports of client deaths and physical and sexual assaults.

Smith said most providers cipro xr 1 gr are trying to do good work. She said annual inspections ensure facilities meet safety standards, like having enough staff members and a building that’s up to code. But inspections cipro xr 1 gr are not meant to evaluate quality of care, she said. The KHN-Spotlight PA investigation found the department makes little of what it knows about troubling facilities accessible to the public. Its website shows if a facility currently has a provisional license — a designation indicating the provider failed to meet several state requirements and will be inspected more frequently until it resolves those concerns — but not whether it ever received such a sanction in the past, for what issues, nor how they were resolved.

The department does not post the reports it collects about deaths and assaults, which represent some of the most concerning events at treatment cipro xr 1 gr facilities. When KHN-Spotlight PA filed a public records request for those reports, the department shared only incidents that it decided did not warrant investigation. It said it could not provide the total number of such events at specific facilities since it doesn’t have aggregate data prior to September 2019, when it launched a new electronic reporting system. Even the available data from cipro xr 1 gr that new system provides an incomplete picture, as less than a quarter of treatment facilities had enrolled in the voluntary system as of March 2021. Smith said people should pick facilities the same way they do primary care doctors, based on publicly available information, personal recommendations and discussions with insurers.

One of the main public resources the department offers is a website with reports from its facility inspections. Inspectors write these reports after a site visit, listing any violations of state regulations they found cipro xr 1 gr. But these reports provide a limited window into the daily reality for clients, as there’s no indication of which violations are more severe than others, and many regulations focus on building conditions and completion of records. One regulation, for example, mandates the temperature at which refrigerated food must be maintained. In response cipro xr 1 gr to each violation inspectors find, the facility submits a plan to address it.

If the facility fails to provide a plan or follow through on it, the department has two primary options. Force the facility to reduce the number of clients it serves or issue a provisional license. If the cipro xr 1 gr department wants to permanently revoke a facility’s license, it must go through an administrative court process to get approval. In nearly a decade before December 2020, the state issued provisional licenses to fewer than 80 facilities — less than 10% of providers— and forced only three to reduce their capacity, according to data from the department. In ASI’s case, regulators said multiple times that the company failed to document that it provided required counseling and other services.

A department spokesperson said it didn’t force ASI to operate under provisional licenses before 2015 because the business submitted plans of correction the cipro xr 1 gr department found acceptable. Even if a facility has many violations, the department considers how cooperative it is in working to fix them, Smith said. After a recent reorganization, the department formed a quality improvement cipro xr 1 gr unit with three employees, Smith said. The unit may work directly with treatment facilities but is meant to address broader prevention efforts and other addiction-related programs as well. The department is also working with a national company to provide an online platform where clients can leave reviews of facilities, starting in spring 2022.

But many employees and clients in the treatment field are skeptical of cipro xr 1 gr any long-term improvement. For years, they’ve seen troubled facilities make fixes, only to have the same deficiencies arise in later inspections. The department’s own records show the cycle can persist for years. Years of Citations, Little Action At SOAR Corp methadone clinic in Philadelphia, inspectors from the state Department of Health first issued citations for unqualified employees in 2009, before the Department of Drug and Alcohol Programs was created and took cipro xr 1 gr over inspections in 2012. Inspectors at the time also found one counselor who was responsible for 40 clients — above the state-mandated maximum of 35.

SOAR Corp responded by saying it had demoted an unqualified counselor, had hired another counselor to lower caseloads and would ensure future hires met the state’s requirements. But state records show cipro xr 1 gr that within a year of those 2009 citations, the facility was cited three more times for similar issues. Hiring an unqualified project director, overloading counselor caseloads and lacking enough medical personnel. Year after year, state inspectors found the same problems. Yet the state approved SOAR to cipro xr 1 gr open additional locations in Lansdowne, Levittown and Warminster in 2010, 2016 and 2018, respectively.

In interviews with KHN-Spotlight PA, a dozen former employees and nearly a dozen current and former clients across multiple SOAR sites complained about poor hiring practices and chronic understaffing as just two symptoms of their much larger concerns. They believed the company relentlessly pursued profits by getting as many clients in the door as possible, with little care for the quality of treatment. The Philadelphia location has received three provisional licenses from the state, in 2012, 2019 and 2020, putting it among the 10 most frequent recipients of this sanction over nearly the past cipro xr 1 gr decade. The former counselors felt that expectations to maximize “billable hours” led to their burnout. And they saw high turnover among staffers.

The former and current clients said they sometimes went weeks without therapy or were switched from one overwhelmed counselor to another every few months cipro xr 1 gr. Nicole Tihansky was a client at SOAR’s Levittown location for about a year until last fall. She said she waited cipro xr 1 gr more than a month before getting her first counseling session, and then was assigned about five counselors, one after the other. €œIt makes you just want to get in and out of the session quickly, because you know you’ll get another counselor in a month,” she said. Understaffing is a problem across the treatment industry, according to employees in the field.

But former SOAR employees who have worked for multiple companies said SOAR stood out in their experiences for cipro xr 1 gr its high staff turnover and inadequate therapy. €œIt’s not about therapy or addressing the needs of clients,” said Esther Kirshenbaum, a counselor who worked at the Philadelphia location from 2017 to 2019. €œThe attitude is to just get clients in here and make sure we get paid.” In a statement, SOAR CEO Richard Mangano said the company “makes every effort to comply with local, State, and Federal regulations.” KHN-Spotlight PA shared with SOAR a detailed list of more than a dozen allegations from their reporting, including violations of state regulations and putting profits over patient care. Mangano did not cipro xr 1 gr address them specifically. €œSoar Corp categorically denies any allegation or suggestion of wrongdoing.

€¦ Soar Corp has and will continue to work with DDAP to improve the important services it provides,” Mangano wrote, referring to the Department of Drug and Alcohol Programs. In its responses to state citations in recent years, SOAR explained that clients didn’t show up to scheduled counseling sessions, and that services like drug tests and physician evaluations had been provided cipro xr 1 gr but simply not documented properly. The Department of Drug and Alcohol Programs has never forced SOAR to decrease its capacity, nor have state officials initiated the administrative court process to permanently revoke its license. Former clients and employees said state licensing inspections were announced ahead of time, causing a rush by SOAR employees in the days before a site visit to complete treatment plans, counseling notes and other required paperwork. Nicholas Cucchiaro was a SOAR cipro xr 1 gr counselor from 2017 to 2018.

He shared with KHN-Spotlight PA what he reported to the Department of Drug and Alcohol Programs and the Pennsylvania Office of Attorney General after he was fired. He told the agencies that a senior administrator at SOAR instructed him to make up counseling notes for clients who had gone weeks without an assigned therapist. €œThese are notes from therapy sessions that never happened,” he said, adding he knew it cipro xr 1 gr was wrong but feared losing his job if he didn’t comply. About a dozen other former employees and clients described to KHN-Spotlight PA their own experiences of similar practices, ranging from thrusting months’ worth of forms upon clients in the days before an inspection to backdating their paperwork. The Department of Drug and Alcohol Programs and the attorney general’s office both agreed to look into the allegations, Cucchiaro said, but he didn’t hear of any consequences for SOAR.

The attorney general’s office told KHN-Spotlight PA that it reviewed “a small number” of complaints regarding SOAR and referred the matter to the Department cipro xr 1 gr of Drug and Alcohol Programs. Smith, the department head, said that as a general matter it’s difficult to prevent facilities from falsifying paperwork, because state regulations require advance notice of licensing inspections. But if the department receives a complaint, it can conduct unannounced inspections, she said, and other facilities have been cipro xr 1 gr cited for fraudulent paperwork. Unannounced site visits were made in response to the complaints at SOAR, according to a department spokesperson, and citations were issued for violations that did not include fraudulent paperwork. SOAR’s Philadelphia location received provisional licenses in 2019 and 2020, but as of mid-April all the company’s sites were operating on full licenses after remedying the cited issues.

A Growing Industry One significant limitation on the department’s oversight is its inability to impose financial penalties cipro xr 1 gr on treatment facilities. In contrast, the state’s environmental protection and health departments can fine polluters and nursing homes for violations. A 2017 report from the state auditor general’s office urged lawmakers to allow the department to charge licensing fees and assess financial penalties, pointing to other states that do so. Smith told KHN-Spotlight cipro xr 1 gr PA that fining facilities would help weed out repeat violators. A bill introduced in the Pennsylvania legislature to allow the department to generate licensing fees went nowhere two years ago.

A similar measure was recently referred to the state Senate Health and Human Services Committee. €œI hope that it’s considered quickly as ensuring drug treatment facilities are given appropriate cipro xr 1 gr oversight is of utmost importance,” the bill’s sponsor, state Sen. Judy Schwank (D-Berks), said in a statement. Meanwhile, with millions of dollars on the line, the treatment industry is growing in Pennsylvania. Over the past four years, the state has seen a net gain of about 40 cipro xr 1 gr facilities, the department said, bringing the total to more than 800 treatment providers.

State budget documents suggest the industry’s client capacity has grown by about 5,000 over a similar period. The Department of Drug and Alcohol Programs employed 82 people, including two dozen who conduct facility inspections, as of April. That's about half the cipro xr 1 gr number of dog wardens employed by the state to inspect kennels. Smith said there is “adequate staff to perform our current licensing responsibilities.” In December 2018 — the same year the department said it received complaints from former SOAR employees and clients — it approved the company to open a location in Warminster. Inspection surveys at the facility since have found it violated state rules by providing a certain medication without state approval and failing to provide the required hours of therapy to some patients.

A former SOAR supervisor who is cipro xr 1 gr still working in the treatment industry and asked not to be named doubts the state will ever take stronger action against the company. €œThe state knows the demand for treatment and the demand for medication-assisted treatment,” the former supervisor said. €œIf you took SOAR’s license in Northeast Philadelphia cipro xr 1 gr and didn’t give them a provisional, you could be displacing 500 clients.” The Need for Treatment The urgency of the opioid crisis puts regulators in a tough position. If they shut down a facility, where will all the patients get treatment?. James McKay, a professor at the University of Pennsylvania’s medical school who researches the efficacy of addiction treatments, said facilities that are committing insurance fraud or actively harming patients should be penalized.

But the question becomes more complicated when judging how well cipro xr 1 gr a facility is serving its clients. In Philadelphia, where there are many treatment programs, it might make sense to close one that has ineffective interventions, untrained counselors and many clients dropping out, McKay said. €œBut if you’re out in the middle of the state and there’s only one treatment program in any reasonable distance, as long as they're not treating you badly, you’re at least going to get some support and meet others in recovery,” he said. €œSo much of this depends on what the other alternatives are.” In western Pennsylvania, an inpatient detox and rehab facility called cipro xr 1 gr Clear Day Treatment of Westmoreland has received multiple provisional licenses since it opened in 2018. State inspectors have noted at least six incidents that involved drugs on the premises and have cited the facility at least twice for understaffing, writing that the lack of sufficient staff fails to ensure “efficient and safe operation.” Despite these concerns, the facility is the only one in the county that provides detox services while allowing patients to stay on any of three medications for opioid use disorder.

Many patients in the area need that service, said Colleen Hughes, executive director of the Westmoreland Drug and Alcohol Commission. (The commission is one of more than 40 agencies across the cipro xr 1 gr state that the Department of Drug and Alcohol Programs contracts with to coordinate substance use services locally.) The commission determined in 2017 that a lack of residential rehabs in the county was one factor delaying people’s treatment. Clear Day responded to a request for proposals to meet that need from companies that manage Medicaid-paid behavioral health for the state in that region. Clear Day has been awarded nearly $750,000 in state Medicaid funds left over from previous years to help with startup costs, according to Southwest Behavioral Health Management, one of the companies that put out the request. Stephen Devlin, executive director of Clear Day, said in a statement that Southwest Behavioral Health Management closely cipro xr 1 gr monitored those funds, which helped the facility provide “much needed” addiction treatment services.

€œState auditors have been diligent in ensuring that Clear Day addressed all deficiencies that have been identified during audits,” Devlin wrote, “and, further, that Clear Day provides strong and effective treatment to the individuals in our care.” Hughes said her office has addressed the issues of understaffing and drugs on the premises with Clear Day through meetings and training sessions. Smith, head of the Department of Drug and Alcohol Programs, said. €œNone of us want to see cipro xr 1 gr providers closing. We want them to be successful. We want them to be able to deliver the services for their benefit and for ours.” Waiting for Consequences In Fayette County, ASI came under fire from state and federal authorities in 2015.

The FBI cipro xr 1 gr raided the facility that October. The following January, a federal grand jury indicted one of the owners, Rosalind Sugarmann, and an ASI doctor on multiple counts of illegally distributing a medication to treat opioid addiction. Nearly three months later, a counselor employed by ASI overdosed while staying at the facility, an attorney for the state cipro xr 1 gr later said in an administrative court filing against ASI. Ultimately, a bankruptcy case forced the business to close. In late 2016, Sugarmann pleaded guilty to illegal drug distribution and health care fraud.

But that hasn’t kept her and her family out of cipro xr 1 gr the recovery business. Less than a year after she was released from prison, Sugarmann — who has talked publicly about her own substance use decades ago — announced she was opening a recovery home. €œI’m not going to stop working with addicts ever. That’s my cipro xr 1 gr calling in life,” Sugarmann said in an interview with KHN-Spotlight PA. €œSomebody helped me, and I help somebody else.” But two families said Sugarmann failed their loved ones.

There’s Adam Kalinowski, who died at ASI in 2014, and there’s 37-year-old James Pschirer, who died of an overdose in a recovery home Sugarmann’s family operates. These homes offer peer support and often have cipro xr 1 gr curfews and rules designed to help people stay away from drugs after they’ve been discharged from inpatient treatment. In Kalinowski’s case, Sugarmann said ASI reported his death to everyone it was required to. There’s no indication from department records that the state cited ASI in connection with his suicide. (The Department of Drug and Alcohol Programs wouldn’t comment on Kalinowski’s case specifically but said it worked with the FBI to cipro xr 1 gr investigate problems at ASI.) Ian Kalinowski stands for a portrait outside his Penn Township, Pennsylvania, home on Wednesday, March 3, 2021.

Ian’s brother, Adam, died by suicide in 2014 while a client at a treatment center run by Addiction Specialists Inc., in Fayette County. (Kristina Serafini / TribLIVE for Spotlight PA) Neither Sugarmann nor her husband, Sean, mounted a defense against the Kalinowski family’s lawsuit in court. In a recent interview with KHN-Spotlight PA, Sean Sugarmann placed the blame for Kalinowski’s death elsewhere, saying that the facility was staffed correctly and that, given his eventual suicide, Kalinowski never should have been sent to ASI cipro xr 1 gr. Kalinowski’s family also sued UPMC Mercy, the Pittsburgh hospital where he was treated before going to ASI, and affiliated entities, but resolved the claims against them through a private settlement, according to a family attorney. UPMC denied responsibility for Kalinowski’s death.

In a pretrial court filing, an expert witness for UPMC directed blame at ASI, cipro xr 1 gr saying Kalinowski was well enough to be safely discharged to a residential treatment facility. That he wasn’t evaluated by a doctor, nurse or professional counselor when he arrived at ASI was a concern, the expert wrote, and “perhaps this tragedy could have been avoided” if ASI had provided a higher level of care. More recently, Rosalind Sugarmann has faced criticism for her involvement with cipro xr 1 gr recovery homes. In February 2019, while still under federal supervision, Sugarmann announced on a blog that she was “back in commission!. !.

€ and would open a men’s recovery home called The Second Act outside Pittsburgh cipro xr 1 gr. A 2017 law gave the Department of Drug and Alcohol Programs new power to regulate recovery homes in addition to treatment facilities. The state missed a June 2020 deadline to implement the voluntary licensing process but plans to roll out the program this year. James Pschirer turned to The Second Act for cipro xr 1 gr a place to stay in the fall of 2019. His mom, Andrea Zack, helped him with rent, writing out a $250 check to Sugarmann, according to a photocopy of the check the family provided.

Then, on Nov. 1, 2019, James died inside the home from a fentanyl and cocaine overdose, a photo of the death certificate provided by his family cipro xr 1 gr showed. Andrea Zack (left) and her daughter, Amanda Pschirer, are grieving the death of their son and brother, James Pschirer, who died in 2019 of an overdose at a recovery home in Allegheny County, Pennsylvania. Andrea says she usually avoids looking at pictures of him. €œIt hurts too much.” (Kristina Serafini / TribLIVE for Spotlight PA) Andrea and James’ sister, Amanda Pschirer, went to cipro xr 1 gr The Second Act to collect his clothes and personal items.

Andrea kept the coins in his pockets, knowing he had touched them. It wasn’t until after James’ death that his family found out about Sugarmann’s criminal conviction, they said. Amanda knows her brother chose to use drugs, but she thinks he could still be alive if he had stayed in another home with cipro xr 1 gr better oversight. And she’s angry that nothing stopped Sugarmann from being involved with one. €œI am worried that someone else will die under her care,” Amanda said.

When her son, James Pschirer, died, Andrea Zack kept the coins in his pockets, knowing cipro xr 1 gr he had touched them. (Kristina Serafini / TribLIVE for Spotlight PA) In interviews, Rosalind and Sean Sugarmann downplayed their involvement with The Second Act. €œMy kids cipro xr 1 gr are involved in the recovery homes,” Rosalind told KHN-Spotlight PA. €œI’m not an owner there.” The business is registered in their children’s names, and Rosalind said she’s lived in Los Angeles since early 2020. Still, Sean Sugarmann acknowledged helping his adult children manage the business, and said in March he was living in the men’s home at that time.

One of his daughters referred questions cipro xr 1 gr about The Second Act to Sean. Rosalind promotes the business on social media accounts, encouraging people to move in. She told KHN-Spotlight PA, “I’m not gonna deny that I’m a consultant.” Sean said an overdose death “could have happened anywhere, and I think it happens everywhere.” Last fall, Amanda Pschirer reached out to state officials with concerns about recovery homes. But she said she didn’t receive a cipro xr 1 gr response for four months. The department said a computer glitch with an online form, discovered in January, caused the delay in responding to her submission and about 260 others.

After her brother, James, died of an overdose at a recovery home, Amanda Pschirer reached out this past fall to state officials with concerns. But she says she didn’t receive a response for four cipro xr 1 gr months. (Kristina Serafini / TribLIVE for Spotlight PA) Ian Kalinowski, whose brother died at ASI seven years ago, has followed Rosalind’s posts online and saw that she’s still involved in the recovery business. He’s outraged. He and his cipro xr 1 gr family are still grieving Adam’s loss.

Ian wishes his young children had gotten to meet their uncle. He doubts the ASI defendants will ever provide the $1.6 million-plus that the judge said they owe. Ian recognizes that ASI’s leaders faced some consequences for problems at cipro xr 1 gr the business. €œBut there have still been no repercussions for what happened to my brother,” he said of the Sugarmanns. He’s not optimistic there ever will be.

Methodology. How We Investigated Pennsylvania’s Addiction Treatment Industry and Found Weak Oversight of ProvidersPennsylvania is at the epicenter of the nation’s opioid crisis, ranking among the top five states for overdose death rates and top 10 for number of adults suffering from substance use disorder in recent years, according to national data. And the addiction treatment industry there is growing.Federal grants, state initiatives and Medicaid pump millions of taxpayer dollars into the field annually. The state has seen a net gain of about 40 licensed treatment facilities over the past four years, bringing the total to more than 800.But an investigation by Spotlight PA and KHN found the Pennsylvania Department of Drug and Alcohol Programs — which licenses these facilities — provides weak oversight and lacks the resources and regulatory power to police them, allowing providers to continue operating despite repeated violations and harm to clients. The department has no standard criteria to determine when it should force facilities to serve fewer patients and, in nearly a decade, has revoked just one provider’s license.Spotlight PA, an independent, collaborative newsroom reporting on the Pennsylvania state government and statewide issues, began investigating the oversight of addiction treatment facilities shortly after its launch in late 2019.

The newsroom later partnered with KHN, a national organization that produces in-depth journalism about health issues.Our team began by scraping thousands of facility inspection reports from the Department of Drug and Alcohol Programs’ website. We then analyzed them to find the most egregious citations. Ones that mentioned a failure to report patient deaths and assault, that noted medication errors or that revealed unsafe staffing ratios.We also requested from the department historical data about which facilities had received provisional licenses — designations indicating that facilities have failed to meet several state requirements and will be inspected more frequently until they resolve those concerns. The department didn’t have an automated system to gather this data but agreed to compile it manually. It provided the information with the following caveat.

€œDue to incorrect data entered into the licensing database, the attached report may not include all provisional licenses since 2012. It is as close to accurate as we can determine base[d] on the available data.”Additionally, the team filed an open records request for reports of unusual incidents. These are certain serious events that the department requires facilities to report, including client deaths and incidents of physical and sexual abuse, among others. The department provided reports of only those incidents that it decided did not warrant investigation. It said it could not provide the total number of such events because it doesn’t have facility-specific aggregate data prior to September 2019, when it launched a new electronic reporting system.

Even available data from that new system provides an incomplete picture, as less than a quarter of treatment facilities had enrolled in the voluntary system as of March 2021.Reporters also reviewed the department’s administrative court history to see cases in which the state had initiated legal action against a facility.To further inform our reporting, Spotlight PA launched a public callout for readers to send in tips and concerns about facilities.Using a combination of these sources — facility inspection surveys, provisional license history, administrative court cases, limited reports of unusual incidents and tips from the public — we compiled a list of 34 facilities that appeared to have the most troubling track records.From the short list of facilities, Spotlight PA and KHN reporters then reached out to current and former employees and clients at various locations. The interviews helped establish whether people’s firsthand experiences matched the concerns that arose in the data.Our reporters also reviewed the licensing applications that these facilities had submitted to the state, as well as lawsuits filed by clients and employees against the facilities. We interviewed former employees of the Department of Drug and Alcohol Programs to understand the oversight system and challenges within the agency.The final story was based on interviews with more than 80 people and a review of thousands of pages of state government and court records. Daniel Simmons-Ritchie contributed data analysis to this story. Spotlight PA is powered by The Philadelphia Inquirer in partnership with PennLive/The Patriot-News, TribLIVE/Pittsburgh Tribune-Review, and WITF Public Media.

The independent, nonpartisan newsroom is funded by foundations and readers like you who are committed to accountability journalism that gets results. Spotlightpa.org/donate Aneri Pattani. apattani@kff.org, @aneripattani Related Topics Contact Us Submit a Story Tip“For #buy antibiotics treatments, shingles and even more dangerous and painful skin conditions may be the new thrombocytopenia” Alex Berenson in a Facebook post, April 19 Posts are showing up all over social media tying buy antibiotics vaccinations to shingles and other painful skin disorders. The source of one such post was Alex Berenson, an author and treatment critic whose posts are sometimes cited for misinformation. Berenson posted — first on Twitter, which then found its way to Facebook — a photo of a man covered in a severe rash.

The man, according to the post, blamed the skin outbreak on a buy antibiotics vaccination he had weeks earlier. The post also included unsubstantiated information purported to be from the man’s doctors, indicating a likely diagnosis of a type of rash usually triggered by medications or s, such as herpes simplex. It led Berenson to draw the conclusion that “for #buy antibiotics treatments, shingles and even more dangerous and painful skin conditions may be the new thrombocytopenia.” That is a reference to a low blood platelet condition reported among some people who experienced blood clots after getting the Johnson &. Johnson treatment. The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its news feed.

(Read more about PolitiFact’s partnership with Facebook.) Without more information, it’s impossible to know whether the picture was as described, or what might have led to the man’s condition. We reached out to Berenson by email, but he did not respond. However, in a related Twitter thread, Berenson went on to discuss a study conducted in Israel that looked at six shingles cases occurring post-vaccination in a group of about 500 people with immune disorders. The small Israeli study drew wide attention on social media and other outlets, and currently is the most-read article in the British Medical Journal’s Rheumatology. Some outlets, including the New York Post, ran stories on its findings, often with misleading headlines.

That got us wondering. How strong is the science behind this connection?. First, a Little Background Shingles, also called herpes zoster, occurs in people who had chickenpox, a cipro that causes itchy blisters. (Shingles can be prevented by the two-dose Shingrix treatment.) After a person recovers from chickenpox, the varicella-zoster cipro that causes it can lie dormant in the body, and then reactivate years or decades later in the form of shingles. Both are part of the herpes cipro family, which includes herpes simplex Types 1 and 2.

Type 1 commonly causes “cold” sores around the mouth and lips and is spread by kissing or sharing things like toothbrushes. Type 2 can cause genital herpes, which is spread via sexual contact. Among the things that can reactivate these dormant herpes ciproes are stress, drugs that suppress the immune system or simply aging. Now, Back to Those Social Media Posts Neither the picture of the man with a rash or the findings of the small study in Israel prove cause and effect. In other words, just because a rash follows a treatment by days or weeks does not mean the treatment caused the rash.

Dr. William Schaffner, a professor in the Division of Infectious Diseases at the Vanderbilt University School of Medicine, said it’s natural for people to link events that occur within a short span of time, but he stressed it doesn’t prove causality. €œJust because B follows A doesn’t mean A causes B,” he said. In considering whether there are links between a treatment and a side effect, researchers often follow two large groups of similar people, one group getting a particular medication or treatment, the other not. If the vaccinated or medicated individuals experience a side effect at a greater rate than those not treated, there may be a connection.

Safety is also monitored by tracking data on reported side effects. In the United States, the treatment Adverse Event Reporting System includes unverified reports from patients, doctors and others about possible illnesses or symptoms that occur following immunizations. The Centers for Disease Control and Prevention watches those reports. €œSo far, the data indicates that shingles and herpes are not occurring at an increased rate in the vaccinated population,” said Schaffner, who encourages people who get a rash of any kind — or shingles — following vaccination to report it through that system. But What About That Israeli Study?.

Even its authors said it was not designed to find a cause and effect. Instead, the study followed 491 people — all of whom were being treated for underlying autoimmune inflammatory conditions, such as rheumatoid arthritis, making them more susceptible to shingles in general. Out of those, six women ages 36 to 61 developed shingles in the days and weeks after they received the Pfizer vaccination, for a prevalence rate of 1.2%. The researchers noted in their article that treatment-related reactivation of shingles has been seen with other treatments, such as those for influenza, hepatitis A and rabies. But there were no reports of herpes-related rashes in the clinical trials for buy antibiotics treatments.

In the study, most of the cases were mild, five occurred after the first dose, and all five of those women went on to have their second dose with no additional adverse effects. The researchers said their observations cannot prove causality but should prompt “further vigilance and safety monitoring of buy antibiotics vaccination side effects.” Some media outlets, including the New York Post, ran headlines such as “Herpes Possibly Linked to buy antibiotics, Study Says.” That’s simply “clickbait,” said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. No one is getting infected with herpes from vaccinations, he said. €œWhat the anti-vax community is doing is giving the impression that vaccinations are giving people herpes, which is simply not true.” Adalja objects to the headline and effort to scare people, but he also said it is plausible, if yet unproven, that vaccination could reactivate an existing herpes zoster cipro.

Other types of rashes and injection-site redness have certainly been reported by people who have received a buy antibiotics treatment. Researchers at Massachusetts General Hospital, for example, reported on a group of 12 patients who had rashes that appeared four to 11 days after getting their first dose of the Moderna treatment. Ice and antihistamines were used to treat most of the patients, half of whom experienced a rash again after the second shot. And there have been reports on social media and in the press of people reporting similar rashes following vaccination. Still, experts say those rashes may simply be a sign that the immune system is working.

Such rashes are “pretty innocuous and easily treated,” said Adalja. Our Ruling An online post claims the buy antibiotics treatments cause shingles or other dangerous skin conditions. Although it contains a sliver of truth, it ignores important information. For instance, the evidence to date indicates this is an area to continue monitoring, but no direct link has been established between buy antibiotics vaccination and shingles or other serious skin conditions. The study cited was not intended to prove cause and effect, and it was looking at patients who already had suppressed immune systems that made them more likely to get shingles whether they had a vaccination or not.

We rate this statement Mostly False. Sources:Telephone interview with Dr. William Schaffner, professor of medicine, division of infectious diseases, Vanderbilt University School of Medicine, April 23, 2021Telephone interview with Dr. Amesh Adalja, senior scholar at Johns Hopkins Center for Health Security, April 23, 2021Rheumatology, “Herpes Zoster Following BNT162b2 mRNA buy antibiotics Vaccination in Patients With Autoimmune Inflammatory Rheumatic Diseases. A Case Study,” April 12, 2021The New England Journal of Medicine, “Delayed Large Local Reactions to mRNA-1273 treatment Against antibiotics,” April 1, 2021PolitiFact, “A Claim Comparing Adverse Events for buy antibiotics, Flu treatments Exaggerates Raw Data,” Jan.

15, 2021National Organization for Rare Disorders rare-disease database, “Erythema Multiforme,” accessed April 23, 2021Mayo Clinic, “Shingles,” accessed April 23, 2021Vanity Fair, “An Ex-New York Times Reporter Has Become the Right’s Go-To antibiotics Skeptic,” April 10, 2020 Julie Appleby. jappleby@kff.org, @Julie_Appleby Related Topics Contact Us Submit a Story TipIt was April, more than three months into the vaccination campaign against buy antibiotics, and Jim Freeman, 83, still had not gotten his first dose. Freeman had been eligible for months as part of the 75-and-older target group deemed most vulnerable to death and serious illness in the cipro. But he could not leave his home to make the journey to one of the mass-vaccination sites in San Mateo County. Freeman, who has Parkinson’s disease, has extremely limited mobility and no longer can walk.

€œHe watches TV at night and sees all these people in line getting treatments, but he couldn’t do it,” said his daughter Beth Freeman, 58. €œIt was really frustrating.” She contacted the county and state public health departments and even her local congresswoman for help, but none had a solution. Finally, after weeks of failed attempts to get someone to vaccinate her father at their home, Beth spent $700 to rent a special wheelchair-accessible van and, with the help of a home health aide, nervously drove her father to the county’s mass-vaccination site. Even as the nation has moved on to vaccinating everyone 16 and older, the vast majority of homebound people have not yet been vaccinated, said Kelly Buckland, executive director of the National Council on Independent Living. €œAs far as I can tell, no one’s really doing it.

Maybe a few places in the country, but not on the mass scale it needs to be.” Across the nation, an estimated 4 million Americans are homebound by age, disability or frailty, unable to easily leave their homes to receive a buy antibiotics treatment. Buckland noted that, while homebound people are not out in public where the cipro is circulating, they don’t live in a bubble. Most rely for care on family members or a rotating staff of home health aides who come and go and often have their own homes and families. €œFor people with disabilities, you can’t close yourself off. You don’t have the option.

People have to come into your home every day to give you services.” The Biden administration in late March dedicated $100 million to help vulnerable older adults and people with disabilities get vaccinations. But many caregivers and homebound people say they aren’t yet feeling the impact of that effort. California, where tens of thousands of residents like Jim Freeman are still waiting their turn for vaccination, offers a sharp lens on the challenges. Marta Green, a California official helping oversee treatment distribution, said during an April meeting of the state’s Community treatment Advisory Committee that California is “working on a partnership” to send ambulances to vaccinate homebound people where they live. In response to questions about how many homebound people had been vaccinated so far, a spokesperson for the California Department of Public Health said the effort was “just beginning” and estimates were not available.

As part of a $15 million no-bid contract with California to administer the state’s vaccination program, Blue Shield of California is obligated to provide treatment access to homebound people. The company, nonetheless, declined to provide responses to specific questions about such efforts. Spokesperson Erika Conner said the company has “diligently explored opportunities for this work” and recommended that homebound people contact their local public health departments or health care providers. The logistics of inoculating homebound people with a treatment that requires cold storage is not simple. Once thawed, a vial of Pfizer-BioNTech treatment contains six doses that must be delivered within six hours, while a Moderna treatment vial contains 10 to 15 doses to be used within 12 hours.

With each vaccination visit lasting about an hour plus the travel time, there isn’t much room for error, especially in rural areas where residents may live far apart. The one-dose Johnson &. Johnson treatment offers more flexibility, but the pause due to safety concerns resulted in delays. €œYeah, it’s not easy. If it were easy, we’d already have done it,” said Dr.

Mike Wasserman, a geriatrician and member of the California treatment advisory committee. €œBut that’s not an excuse. These are the folks who if they get the cipro they’re going to die. I don’t accept it.” Wasserman said he’d give the state a “D” for its efforts to reach the homebound for vaccination. For some, he added, it might already be too late.

€œIf you’re 80 years old and you live in a 1,000-square-foot home with 10 other people, you’re probably dead already.” In the absence of a coordinated state-driven effort, California counties are attempting a patchwork of approaches. In Los Angeles County, the public health department has partnered with the sheriff’s department and 15 fire departments to vaccinate homebound residents, with some success. Health officials projected that 50% of the county’s 10,000 homebound residents will have received one dose by the end of April. In Fresno County, with more than a million residents, health officials said they are compiling a list of homebound people who want help getting a treatment. So far, fewer than 20 people in that category have been contacted and received the treatment.

In San Mateo County, where Freeman lives, the health department has identified at least 1,000 individuals who are homebound and in need of the treatment. So far, 100 have been vaccinated. Before she resorted to renting the $700 mobility van for her father, Beth Freeman contacted county workers. They offered to send a bus to pick up her father and take him to a vaccination site, but she couldn’t imagine how that would work for him, both in terms of the physical logistics and the risk of exposure. She asked the nurses who visited her father twice a week through Sutter Health’s care-at-home program for help — after all, they had given him the flu shot.

But no luck. The nurses said they were not allowed to offer the buy antibiotics treatment. Finally, on April 6, Beth made the difficult decision to transport her father despite his limited mobility. €œI did not want to take him out of the house for this. It was risky for his health.

But at some point I realized it wasn’t going to happen any other way,” she said. €œHe wanted to see members of his family and time was ticking.” She said her father was up all night worrying, and his body was stiff. But with help from a home health aide, she used a special lift to hoist him into a wheelchair and wheeled him down two ramps and into the rented van, where she strapped him to the chair. They drove 20 minutes to the San Mateo County Event Center, her eyes darting from the road to the rearview mirror to check on her father, and then waited 40 minutes in the drive-thru line. €œWhen I rolled down the window, the nurses were like, What the hell?.

Why is he only coming to us now?. € she said. The experience was so stressful for her father, she added, that he slept on and off for the next two days. This week, they repeated the ordeal for his second dose — including laying out another $700 for the rental van. €œAll this, while he sees nurses at home twice a week?.

€ Beth Freeman said. €œWhat a missed opportunity.” Jenny Gold. jgold@kff.org, @JennyAGold Related Topics Contact Us Submit a Story Tip.

This investigation where to buy generic cipro is a joint project of KHN, Cheap generic antabuse a national newsroom that produces in-depth journalism about health issues, and Spotlight PA, an independent, collaborative newsroom dedicated to producing investigative journalism for all of Pennsylvania. When Ian Kalinowski was at work, his mom usually texted him. So when he saw her number show up as an incoming call around lunchtime one Tuesday, he figured where to buy generic cipro it had to be important. Now, more than seven years later, he remembers her screams, the shock and the questions she asked over and over again.

€œWhy are they saying this to me?. Why are where to buy generic cipro they lying to me?. € Ian recalled his mom asking. €œThey’re telling me Adam’s dead.

Why would where to buy generic cipro they do this to me?. € Adam was Ian’s older brother. Growing up, it seemed they spent every second together. Football, hockey and tag filled long days outside where to buy generic cipro their Pittsburgh home.

When Ian moved away for college, he and Adam turned to online poker to stay in touch. Adam served as best man at Ian’s wedding, and Ian admired his brother’s artistic streak. Adam could turn any where to buy generic cipro piece of paper into an origami swan. His mom’s home is still full of swans.

Adam’s struggle with opioid and alcohol addiction was painful for Ian to watch. The problems began, it seemed to Ian, after Adam dropped out of college and used drugs where to buy generic cipro to deal with his depression. Adam sought treatment, and he relied on methadone for many years, but his problems continued. When he was 32, he typically drank dozens of beers each day.

On Feb where to buy generic cipro. 3, 2014, he entered a treatment center run by Addiction Specialists Inc., according to a lawsuit later filed by his family against the facility. The center, in a Fayette County strip mall, was about an where to buy generic cipro hour’s drive south of Pittsburgh. Adam received a lighter engraved with his initials as a 30th birthday gift from his brother, Ian.

After Adam’s death in 2014, Ian gave his son the middle name “Adam” as a tribute to his brother and best friend. (Kristina Serafini / TribLIVE for Spotlight PA) Ian sits for a portrait at his home in Penn Township, Pennsylvania, on Wednesday, March where to buy generic cipro 3, 2021. (Kristina Serafini / TribLIVE for Spotlight PA) Less than 24 hours after Adam made it to the facility, he was dead, according to expert reports from doctors in the family’s wrongful death lawsuit. Ian couldn’t understand what went wrong, and neither could his mom, still in denial on the other end of the phone call.

What his family didn’t know was where to buy generic cipro that Addiction Specialists, often known as ASI, had a history of violating state rules. In a later federal investigation into the facility’s billing and drug distribution practices, a grand jury concluded that a litany of problems occurred at the business many months before and after Adam’s arrival. In the wrongful death suit, a lawyer for the Kalinowski family alleged Adam wasn’t evaluated by a physician when he arrived at ASI, didn’t receive the medication or treatment he needed, became increasingly uneasy and anxious throughout the night and killed himself. An Allegheny County judge in December 2019 said the business, two of its owners — Rosalind and Sean Sugarmann — and an ASI physician were negligent in caring for Adam where to buy generic cipro.

The judge ordered them to pay over $1.6 million in damages, although Ian doubts they ever will. ASI eventually shut down, two years after Adam died. In recent interviews with KHN-Spotlight PA, the Sugarmanns denied responsibility for Adam’s death and maintained that ASI was a where to buy generic cipro good facility. Rosalind said it helped a lot of people in a rural area with a high drug-overdose rate.

Addiction treatment facilities in Pennsylvania, like ASI, are licensed and regulated by the state to ensure they follow certain rules and keep vulnerable people struggling with addiction safe. Oversight used to fall to the Department of Health where to buy generic cipro. But in 2012, the state created the Department of Drug and Alcohol Programs, a $125 million agency set up to give substance use the attention lawmakers felt it deserved. At the time of Adam’s death in 2014, the department had taken few disciplinary actions against ASI.

It had issued citations and required the company to submit where to buy generic cipro plans to correct them. But the Sugarmanns told KHN-Spotlight PA that, at the time, they didn’t fear the state would shut them down. Perhaps for good reason where to buy generic cipro. A KHN-Spotlight PA investigation found that the department has allowed providers to continue operating despite repeated violations of state regulations and harm to clients.

More than 80 interviews and a review of thousands of pages of state government and court records revealed that the department lacks resources and regulatory power, uses an inherently flawed oversight system that does little to ensure high-quality or effective care, and rarely takes strong disciplinary action against facilities when so many Pennsylvanians need services. The department has no standard criteria for when it should force facilities to serve fewer patients and, as where to buy generic cipro of early April, had revoked just one treatment provider’s license in nearly a decade. It doesn’t, as a regular practice, compare facilities to see if any stand out for an unusual number of violations or the most client deaths. And since state inspections focus heavily on records, they can be tricked with fraudulent paperwork, former employees in the treatment field said.

This leaves Pennsylvanians — who suffer one of the highest drug overdose death rates in the nation — in the dark where to buy generic cipro about which treatment facilities have troubling track records. Some advocates point out that overregulating or closing facilities could leave people suffering from addiction without options for care. But in the current system, state and judicial records show, some patients have received inadequate treatment or even died. Certain facilities have fraudulently where to buy generic cipro billed insurance companies.

And owners rake in federal and state tax dollars, as well as private money from victims of the opioid crisis. €œMany of these rehab facilities are not properly run or supervised, and many are in it for the money,” said Peter Friday, an attorney who represented Adam’s family in their lawsuit. €œThese places have been where to buy generic cipro unbridled.” Who Polices the Providers?. Even though the Department of Drug and Alcohol Programs provides the licenses that allow addiction treatment facilities to operate, Jennifer Smith, secretary of the department, said it has limited responsibility for them.

Law enforcement agencies are often better positioned to take action against troubled providers, she said, and insurance companies that pay for services also offer oversight. €œIt’s not where to buy generic cipro our job to really police the providers,” Smith said in an interview. €œOur function is to really try to enable them to meet the [state’s] requirements, and by doing so, enabling them to provide quality services.” Jennifer Smith, secretary of the Pennsylvania Department of Drug and Alcohol Programs, said her agency has limited responsibility for treatment facilities, despite providing the licenses that allow them to operate. (Commonwealth Media Services) Yet, as the regulating body of these treatment facilities, the department collects some of the most critical information necessary to properly police them, including reports of client deaths and physical and sexual assaults.

Smith said where to buy generic cipro most providers are trying to do good work. She said annual inspections ensure facilities meet safety standards, like having enough staff members and a building that’s up to code. But inspections are not meant to evaluate quality of where to buy generic cipro care, she said. The KHN-Spotlight PA investigation found the department makes little of what it knows about troubling facilities accessible to the public.

Its website shows if a facility currently has a provisional license — a designation indicating the provider failed to meet several state requirements and will be inspected more frequently until it resolves those concerns — but not whether it ever received such a sanction in the past, for what issues, nor how they were resolved. The department does not post the reports it collects about deaths and assaults, which represent some of the where to buy generic cipro most concerning events at treatment facilities. When KHN-Spotlight PA filed a public records request for those reports, the department shared only incidents that it decided did not warrant investigation. It said it could not provide the total number of such events at specific facilities since it doesn’t have aggregate data prior to September 2019, when it launched a new electronic reporting system.

Even the where to buy generic cipro available data from that new system provides an incomplete picture, as less than a quarter of treatment facilities had enrolled in the voluntary system as of March 2021. Smith said people should pick facilities the same way they do primary care doctors, based on publicly available information, personal recommendations and discussions with insurers. One of the main public resources the department offers is a website with reports from its facility inspections. Inspectors write these reports after a site visit, listing any violations of state regulations they where to buy generic cipro found.

But these reports provide a limited window into the daily reality for clients, as there’s no indication of which violations are more severe than others, and many regulations focus on building conditions and completion of records. One regulation, for example, mandates the temperature at which refrigerated food must be maintained. In response to each violation inspectors find, the facility submits a plan to where to buy generic cipro address it. If the facility fails to provide a plan or follow through on it, the department has two primary options.

Force the facility to reduce the number of clients it serves or issue a provisional license. If the department wants to permanently revoke a facility’s license, it must go through an administrative court process to get approval where to buy generic cipro. In nearly a decade before December 2020, the state issued provisional licenses to fewer than 80 facilities — less than 10% of providers— and forced only three to reduce their capacity, according to data from the department. In ASI’s case, regulators said multiple times that the company failed to document that it provided required counseling and other services.

A department spokesperson said it didn’t force ASI to operate under provisional licenses before 2015 because the business submitted plans of where to buy generic cipro correction the department found acceptable. Even if a facility has many violations, the department considers how cooperative it is in working to fix them, Smith said. After a recent reorganization, the department formed a quality improvement unit with three employees, Smith where to buy generic cipro said. The unit may work directly with treatment facilities but is meant to address broader prevention efforts and other addiction-related programs as well.

The department is also working with a national company to provide an online platform where clients can leave reviews of facilities, starting in spring 2022. But many employees and clients in the treatment field are where to buy generic cipro skeptical of any long-term improvement. For years, they’ve seen troubled facilities make fixes, only to have the same deficiencies arise in later inspections. The department’s own records show the cycle can persist for years.

Years of Citations, Little Action At SOAR Corp methadone clinic in Philadelphia, inspectors from the state Department of Health where to buy generic cipro first issued citations for unqualified employees in 2009, before the Department of Drug and Alcohol Programs was created and took over inspections in 2012. Inspectors at the time also found one counselor who was responsible for 40 clients — above the state-mandated maximum of 35. SOAR Corp responded by saying it had demoted an unqualified counselor, had hired another counselor to lower caseloads and would ensure future hires met the state’s requirements. But state records show that within a year of those 2009 citations, the facility was cited three more times where to buy generic cipro for similar issues.

Hiring an unqualified project director, overloading counselor caseloads and lacking enough medical personnel. Year after year, state inspectors found the same problems. Yet the state approved SOAR to open additional locations in Lansdowne, Levittown and Warminster in 2010, 2016 and 2018, respectively where to buy generic cipro. In interviews with KHN-Spotlight PA, a dozen former employees and nearly a dozen current and former clients across multiple SOAR sites complained about poor hiring practices and chronic understaffing as just two symptoms of their much larger concerns.

They believed the company relentlessly pursued profits by getting as many clients in the door as possible, with little care for the quality of treatment. The Philadelphia location has received where to buy generic cipro three provisional licenses from the state, in 2012, 2019 and 2020, putting it among the 10 most frequent recipients of this sanction over nearly the past decade. The former counselors felt that expectations to maximize “billable hours” led to their burnout. And they saw high turnover among staffers.

The former and current clients said they sometimes where to buy generic cipro went weeks without therapy or were switched from one overwhelmed counselor to another every few months. Nicole Tihansky was a client at SOAR’s Levittown location for about a year until last fall. She said she waited more than a month before getting her first counseling session, and then was where to buy generic cipro assigned about five counselors, one after the other. €œIt makes you just want to get in and out of the session quickly, because you know you’ll get another counselor in a month,” she said.

Understaffing is a problem across the treatment industry, according to employees in the field. But former SOAR employees who have worked for multiple companies where to buy generic cipro said SOAR stood out in their experiences for its high staff turnover and inadequate therapy. €œIt’s not about therapy or addressing the needs of clients,” said Esther Kirshenbaum, a counselor who worked at the Philadelphia location from 2017 to 2019. €œThe attitude is to just get clients in here and make sure we get paid.” In a statement, SOAR CEO Richard Mangano said the company “makes every effort to comply with local, State, and Federal regulations.” KHN-Spotlight PA shared with SOAR a detailed list of more than a dozen allegations from their reporting, including violations of state regulations and putting profits over patient care.

Mangano did where to buy generic cipro not address them specifically. €œSoar Corp categorically denies any allegation or suggestion of wrongdoing. €¦ Soar Corp has and will continue to work with DDAP to improve the important services it provides,” Mangano wrote, referring to the Department of Drug and Alcohol Programs. In its responses to state citations in recent where to buy generic cipro years, SOAR explained that clients didn’t show up to scheduled counseling sessions, and that services like drug tests and physician evaluations had been provided but simply not documented properly.

The Department of Drug and Alcohol Programs has never forced SOAR to decrease its capacity, nor have state officials initiated the administrative court process to permanently revoke its license. Former clients and employees said state licensing inspections were announced ahead of time, causing a rush by SOAR employees in the days before a site visit to complete treatment plans, counseling notes and other required paperwork. Nicholas Cucchiaro was a SOAR counselor from 2017 to where to buy generic cipro 2018. He shared with KHN-Spotlight PA what he reported to the Department of Drug and Alcohol Programs and the Pennsylvania Office of Attorney General after he was fired.

He told the agencies that a senior administrator at SOAR instructed him to make up counseling notes for clients who had gone weeks without an assigned therapist. €œThese are notes from where to buy generic cipro therapy sessions that never happened,” he said, adding he knew it was wrong but feared losing his job if he didn’t comply. About a dozen other former employees and clients described to KHN-Spotlight PA their own experiences of similar practices, ranging from thrusting months’ worth of forms upon clients in the days before an inspection to backdating their paperwork. The Department of Drug and Alcohol Programs and the attorney general’s office both agreed to look into the allegations, Cucchiaro said, but he didn’t hear of any consequences for SOAR.

The attorney where to buy generic cipro general’s office told KHN-Spotlight PA that it reviewed “a small number” of complaints regarding SOAR and referred the matter to the Department of Drug and Alcohol Programs. Smith, the department head, said that as a general matter it’s difficult to prevent facilities from falsifying paperwork, because state regulations require advance notice of licensing inspections. But if the department receives a complaint, it where to buy generic cipro can conduct unannounced inspections, she said, and other facilities have been cited for fraudulent paperwork. Unannounced site visits were made in response to the complaints at SOAR, according to a department spokesperson, and citations were issued for violations that did not include fraudulent paperwork.

SOAR’s Philadelphia location received provisional licenses in 2019 and 2020, but as of mid-April all the company’s sites were operating on full licenses after remedying the cited issues. A Growing where to buy generic cipro Industry One significant limitation on the department’s oversight is its inability to impose financial penalties on treatment facilities. In contrast, the state’s environmental protection and health departments can fine polluters and nursing homes for violations. A 2017 report from the state auditor general’s office urged lawmakers to allow the department to charge licensing fees and assess financial penalties, pointing to other states that do so.

Smith told KHN-Spotlight PA where to buy generic cipro that fining facilities would help weed out repeat violators. A bill introduced in the Pennsylvania legislature to allow the department to generate licensing fees went nowhere two years ago. A similar measure was recently referred to the state Senate Health and Human Services Committee. €œI hope that it’s considered quickly where to buy generic cipro as ensuring drug treatment facilities are given appropriate oversight is of utmost importance,” the bill’s sponsor, state Sen.

Judy Schwank (D-Berks), said in a statement. Meanwhile, with millions of dollars on the line, the treatment industry is growing in Pennsylvania. Over the past four years, the state has seen a net gain of about 40 facilities, the department said, bringing the total to more than 800 where to buy generic cipro treatment providers. State budget documents suggest the industry’s client capacity has grown by about 5,000 over a similar period.

The Department of Drug and Alcohol Programs employed 82 people, including two dozen who conduct facility inspections, as of April. That's about half the where to buy generic cipro number of dog wardens employed by the state to inspect kennels. Smith said there is “adequate staff to perform our current licensing responsibilities.” In December 2018 — the same year the department said it received complaints from former SOAR employees and clients — it approved the company to open a location in Warminster. Inspection surveys at the facility since have found it violated state rules by providing a certain medication without state approval and failing to provide the required hours of therapy to some patients.

A former SOAR supervisor who is still working in the treatment industry and asked not to be where to buy generic cipro named doubts the state will ever take stronger action against the company. €œThe state knows the demand for treatment and the demand for medication-assisted treatment,” the former supervisor said. €œIf you took SOAR’s license in Northeast Philadelphia and didn’t give them a provisional, you could be where to buy generic cipro displacing 500 clients.” The Need for Treatment The urgency of the opioid crisis puts regulators in a tough position. If they shut down a facility, where will all the patients get treatment?.

James McKay, a professor at the University of Pennsylvania’s medical school who researches the efficacy of addiction treatments, said facilities that are committing insurance fraud or actively harming patients should be penalized. But the where to buy generic cipro question becomes more complicated when judging how well a facility is serving its clients. In Philadelphia, where there are many treatment programs, it might make sense to close one that has ineffective interventions, untrained counselors and many clients dropping out, McKay said. €œBut if you’re out in the middle of the state and there’s only one treatment program in any reasonable distance, as long as they're not treating you badly, you’re at least going to get some support and meet others in recovery,” he said.

€œSo much of this depends on what the other alternatives are.” In western Pennsylvania, an inpatient detox where to buy generic cipro and rehab facility called Clear Day Treatment of Westmoreland has received multiple provisional licenses since it opened in 2018. State inspectors have noted at least six incidents that involved drugs on the premises and have cited the facility at least twice for understaffing, writing that the lack of sufficient staff fails to ensure “efficient and safe operation.” Despite these concerns, the facility is the only one in the county that provides detox services while allowing patients to stay on any of three medications for opioid use disorder. Many patients in the area need that service, said Colleen Hughes, executive director of the Westmoreland Drug and Alcohol Commission. (The commission is one of more than 40 agencies across the state that the Department of Drug and Alcohol Programs contracts with to coordinate substance use services locally.) The commission determined in 2017 that a lack of residential rehabs where to buy generic cipro in the county was one factor delaying people’s treatment.

Clear Day responded to a request for proposals to meet that need from companies that manage Medicaid-paid behavioral health for the state in that region. Clear Day has been awarded nearly $750,000 in state Medicaid funds left over from previous years to help with startup costs, according to Southwest Behavioral Health Management, one of the companies that put out the request. Stephen Devlin, executive director of Clear Day, said in a statement that Southwest Behavioral Health Management closely monitored those funds, which helped the facility provide “much needed” addiction treatment services where to buy generic cipro. €œState auditors have been diligent in ensuring that Clear Day addressed all deficiencies that have been identified during audits,” Devlin wrote, “and, further, that Clear Day provides strong and effective treatment to the individuals in our care.” Hughes said her office has addressed the issues of understaffing and drugs on the premises with Clear Day through meetings and training sessions.

Smith, head of the Department of Drug and Alcohol Programs, said. €œNone of where to buy generic cipro us want to see providers closing. We want them to be successful. We want them to be able to deliver the services for their benefit and for ours.” Waiting for Consequences In Fayette County, ASI came under fire from state and federal authorities in 2015.

The FBI where to buy generic cipro raided the facility that October. The following January, a federal grand jury indicted one of the owners, Rosalind Sugarmann, and an ASI doctor on multiple counts of illegally distributing a medication to treat opioid addiction. Nearly three months later, a counselor employed by ASI overdosed while staying at the facility, an attorney for the where to buy generic cipro state later said in an administrative court filing against ASI. Ultimately, a bankruptcy case forced the business to close.

In late 2016, Sugarmann pleaded guilty to illegal drug distribution and health care fraud. But that where to buy generic cipro hasn’t kept her and her family out of the recovery business. Less than a year after she was released from prison, Sugarmann — who has talked publicly about her own substance use decades ago — announced she was opening a recovery home. €œI’m not going to stop working with addicts ever.

That’s my where to buy generic cipro calling in life,” Sugarmann said in an interview with KHN-Spotlight PA. €œSomebody helped me, and I help somebody else.” But two families said Sugarmann failed their loved ones. There’s Adam Kalinowski, who died at ASI in 2014, and there’s 37-year-old James Pschirer, who died of an overdose in a recovery home Sugarmann’s family operates. These homes offer peer support and where to buy generic cipro often have curfews and rules designed to help people stay away from drugs after they’ve been discharged from inpatient treatment.

In Kalinowski’s case, Sugarmann said ASI reported his death to everyone it was required to. There’s no indication from department records that the state cited ASI in connection with his suicide. (The Department of Drug and Alcohol Programs wouldn’t comment on Kalinowski’s case specifically but said it worked with the FBI to investigate problems at ASI.) Ian Kalinowski stands for a portrait outside his Penn Township, Pennsylvania, home on Wednesday, March 3, 2021 where to buy generic cipro. Ian’s brother, Adam, died by suicide in 2014 while a client at a treatment center run by Addiction Specialists Inc., in Fayette County.

(Kristina Serafini / TribLIVE for Spotlight PA) Neither Sugarmann nor her husband, Sean, mounted a defense against the Kalinowski family’s lawsuit in court. In a where to buy generic cipro recent interview with KHN-Spotlight PA, Sean Sugarmann placed the blame for Kalinowski’s death elsewhere, saying that the facility was staffed correctly and that, given his eventual suicide, Kalinowski never should have been sent to ASI. Kalinowski’s family also sued UPMC Mercy, the Pittsburgh hospital where he was treated before going to ASI, and affiliated entities, but resolved the claims against them through a private settlement, according to a family attorney. UPMC denied responsibility for Kalinowski’s death.

In a pretrial court filing, an expert witness for UPMC directed blame at ASI, saying Kalinowski was well enough to be safely discharged where to buy generic cipro to a residential treatment facility. That he wasn’t evaluated by a doctor, nurse or professional counselor when he arrived at ASI was a concern, the expert wrote, and “perhaps this tragedy could have been avoided” if ASI had provided a higher level of care. More recently, where to buy generic cipro Rosalind Sugarmann has faced criticism for her involvement with recovery homes. In February 2019, while still under federal supervision, Sugarmann announced on a blog that she was “back in commission!.

!. € and would where to buy generic cipro open a men’s recovery home called The Second Act outside Pittsburgh. A 2017 law gave the Department of Drug and Alcohol Programs new power to regulate recovery homes in addition to treatment facilities. The state missed a June 2020 deadline to implement the voluntary licensing process but plans to roll out the program this year.

James Pschirer turned where to buy generic cipro to The Second Act for a place to stay in the fall of 2019. His mom, Andrea Zack, helped him with rent, writing out a $250 check to Sugarmann, according to a photocopy of the check the family provided. Then, on Nov. 1, 2019, James died inside the home from a fentanyl and cocaine overdose, a photo of the death where to buy generic cipro certificate provided by his family showed.

Andrea Zack (left) and her daughter, Amanda Pschirer, are grieving the death of their son and brother, James Pschirer, who died in 2019 of an overdose at a recovery home in Allegheny County, Pennsylvania. Andrea says she usually avoids looking at pictures of him. €œIt hurts too much.” (Kristina Serafini / TribLIVE for Spotlight PA) Andrea and James’ sister, Amanda Pschirer, where to buy generic cipro went to The Second Act to collect his clothes and personal items. Andrea kept the coins in his pockets, knowing he had touched them.

It wasn’t until after James’ death that his family found out about Sugarmann’s criminal conviction, they said. Amanda knows her brother chose where to buy generic cipro to use drugs, but she thinks he could still be alive if he had stayed in another home with better oversight. And she’s angry that nothing stopped Sugarmann from being involved with one. €œI am worried that someone else will die under her care,” Amanda said.

When her son, James Pschirer, died, Andrea Zack kept the coins in his pockets, knowing he had touched where to buy generic cipro them. (Kristina Serafini / TribLIVE for Spotlight PA) In interviews, Rosalind and Sean Sugarmann downplayed their involvement with The Second Act. €œMy kids are involved in the where to buy generic cipro recovery homes,” Rosalind told KHN-Spotlight PA. €œI’m not an owner there.” The business is registered in their children’s names, and Rosalind said she’s lived in Los Angeles since early 2020.

Still, Sean Sugarmann acknowledged helping his adult children manage the business, and said in March he was living in the men’s home at that time. One of his daughters where to buy generic cipro referred questions about The Second Act to Sean. Rosalind promotes the business on social media accounts, encouraging people to move in. She told KHN-Spotlight PA, “I’m not gonna deny that I’m a consultant.” Sean said an overdose death “could have happened anywhere, and I think it happens everywhere.” Last fall, Amanda Pschirer reached out to state officials with concerns about recovery homes.

But she said she didn’t receive a response for four months where to buy generic cipro. The department said a computer glitch with an online form, discovered in January, caused the delay in responding to her submission and about 260 others. After her brother, James, died of an overdose at a recovery home, Amanda Pschirer reached out this past fall to state officials with concerns. But she says she didn’t receive a response for where to buy generic cipro four months.

(Kristina Serafini / TribLIVE for Spotlight PA) Ian Kalinowski, whose brother died at ASI seven years ago, has followed Rosalind’s posts online and saw that she’s still involved in the recovery business. He’s outraged. He and his family where to buy generic cipro are still grieving Adam’s loss. Ian wishes his young children had gotten to meet their uncle.

He doubts the ASI defendants will ever provide the $1.6 million-plus that the judge said they owe. Ian recognizes that ASI’s where to buy generic cipro leaders faced some consequences for problems at the business. €œBut there have still been no repercussions for what happened to my brother,” he said of the Sugarmanns. He’s not optimistic there ever will be.

Methodology. How We Investigated Pennsylvania’s Addiction Treatment Industry and Found Weak Oversight of ProvidersPennsylvania is at the epicenter of the nation’s opioid crisis, ranking among the top five states for overdose death rates and top 10 for number of adults suffering from substance use disorder in recent years, according to national data. And the addiction treatment industry there is growing.Federal grants, state initiatives and Medicaid pump millions of taxpayer dollars into the field annually. The state has seen a net gain of about 40 licensed treatment facilities over the past four years, bringing the total to more than 800.But an investigation by Spotlight PA and KHN found the Pennsylvania Department of Drug and Alcohol Programs — which licenses these facilities — provides weak oversight and lacks the resources and regulatory power to police them, allowing providers to continue operating despite repeated violations and harm to clients.

The department has no standard criteria to determine when it should force facilities to serve fewer patients and, in nearly a decade, has revoked just one provider’s license.Spotlight PA, an independent, collaborative newsroom reporting on the Pennsylvania state government and statewide issues, began investigating the oversight of addiction treatment facilities shortly after its launch in late 2019. The newsroom later partnered with KHN, a national organization that produces in-depth journalism about health issues.Our team began by scraping thousands of facility inspection reports from the Department of Drug and Alcohol Programs’ website. We then analyzed them to find the most egregious citations. Ones that mentioned a failure to report patient deaths and assault, that noted medication errors or that revealed unsafe staffing ratios.We also requested from the department historical data about which facilities had received provisional licenses — designations indicating that facilities have failed to meet several state requirements and will be inspected more frequently until they resolve those concerns.

The department didn’t have an automated system to gather this data but agreed to compile it manually. It provided the information with the following caveat. €œDue to incorrect data entered into the licensing database, the attached report may not include all provisional licenses since 2012. It is as close to accurate as we can determine base[d] on the available data.”Additionally, the team filed an open records request for reports of unusual incidents.

These are certain serious events that the department requires facilities to report, including client deaths and incidents of physical and sexual abuse, among others. The department provided reports of only those incidents that it decided did not warrant investigation. It said it could not provide the total number of such events because it doesn’t have facility-specific aggregate data prior to September 2019, when it launched a new electronic reporting system. Even available data from that new system provides an incomplete picture, as less than a quarter of treatment facilities had enrolled in the voluntary system as of March 2021.Reporters also reviewed the department’s administrative court history to see cases in which the state had initiated legal action against a facility.To further inform our reporting, Spotlight PA launched a public callout for readers to send in tips and concerns about facilities.Using a combination of these sources — facility inspection surveys, provisional license history, administrative court cases, limited reports of unusual incidents and tips from the public — we compiled a list of 34 facilities that appeared to have the most troubling track records.From the short list of facilities, Spotlight PA and KHN reporters then reached out to current and former employees and clients at various locations.

The interviews helped establish whether people’s firsthand experiences matched the concerns that arose in the data.Our reporters also reviewed the licensing applications that these facilities had submitted to the state, as well as lawsuits filed by clients and employees against the facilities. We interviewed former employees of the Department of Drug and Alcohol Programs to understand the oversight system and challenges within the agency.The final story was based on interviews with more than 80 people and a review of thousands of pages of state government and court records. Daniel Simmons-Ritchie contributed data analysis to this story. Spotlight PA is powered by The Philadelphia Inquirer in partnership with PennLive/The Patriot-News, TribLIVE/Pittsburgh Tribune-Review, and WITF Public Media.

The independent, nonpartisan newsroom is funded by foundations and readers like you who are committed to accountability journalism that gets results. Spotlightpa.org/donate Aneri Pattani. apattani@kff.org, @aneripattani Related Topics Contact Us Submit a Story Tip“For #buy antibiotics treatments, shingles and even more dangerous and painful skin conditions may be the new thrombocytopenia” Alex Berenson in a Facebook post, April 19 Posts are showing up all over social media tying buy antibiotics vaccinations to shingles and other painful skin disorders. The source of one such post was Alex Berenson, an author and treatment critic whose posts are sometimes cited for misinformation.

Berenson posted — first on Twitter, which then found its way to Facebook — a photo of a man covered in a severe rash. The man, according to the post, blamed the skin outbreak on a buy antibiotics vaccination he had weeks earlier. The post also included unsubstantiated information purported to be from the man’s doctors, indicating a likely diagnosis of a type of rash usually triggered by medications or s, such as herpes simplex. It led Berenson to draw the conclusion that “for #buy antibiotics treatments, shingles and even more dangerous and painful skin conditions may be the new thrombocytopenia.” That is a reference to a low blood platelet condition reported among some people who experienced blood clots after getting the Johnson &.

Johnson treatment. The post was flagged as part of Facebook’s efforts to combat false news and misinformation on its news feed. (Read more about PolitiFact’s partnership with Facebook.) Without more information, it’s impossible to know whether the picture was as described, or what might have led to the man’s condition. We reached out to Berenson by email, but he did not respond.

However, in a related Twitter thread, Berenson went on to discuss a study conducted in Israel that looked at six shingles cases occurring post-vaccination in a group of about 500 people with immune disorders. The small Israeli study drew wide attention on social media and other outlets, and currently is the most-read article in the British Medical Journal’s Rheumatology. Some outlets, including the New York Post, ran stories on its findings, often with misleading headlines. That got us wondering.

How strong is the science behind this connection?. First, a Little Background Shingles, also called herpes zoster, occurs in people who had chickenpox, a cipro that causes itchy blisters. (Shingles can be prevented by the two-dose Shingrix treatment.) After a person recovers from chickenpox, the varicella-zoster cipro that causes it can lie dormant in the body, and then reactivate years or decades later in the form of shingles. Both are part of the herpes cipro family, which includes herpes simplex Types 1 and 2.

Type 1 commonly causes “cold” sores around the mouth and lips and is spread by kissing or sharing things like toothbrushes. Type 2 can cause genital herpes, which is spread via sexual contact. Among the things that can reactivate these dormant herpes ciproes are stress, drugs that suppress the immune system or simply aging. Now, Back to Those Social Media Posts Neither the picture of the man with a rash or the findings of the small study in Israel prove cause and effect.

In other words, just because a rash follows a treatment by days or weeks does not mean the treatment caused the rash. Dr. William Schaffner, a professor in the Division of Infectious Diseases at the Vanderbilt University School of Medicine, said it’s natural for people to link events that occur within a short span of time, but he stressed it doesn’t prove causality. €œJust because B follows A doesn’t mean A causes B,” he said.

In considering whether there are links between a treatment and a side effect, researchers often follow two large groups of similar people, one group getting a particular medication or treatment, the other not. If the vaccinated or medicated individuals experience a side effect at a greater rate than those not treated, there may be a connection. Safety is also monitored by tracking data on reported side effects. In the United States, the treatment Adverse Event Reporting System includes unverified reports from patients, doctors and others about possible illnesses or symptoms that occur following immunizations.

The Centers for Disease Control and Prevention watches those reports. €œSo far, the data indicates that shingles and herpes are not occurring at an increased rate in the vaccinated population,” said Schaffner, who encourages people who get a rash of any kind — or shingles — following vaccination to report it through that system. But What About That Israeli Study?. Even its authors said it was not designed to find a cause and effect.

Instead, the study followed 491 people — all of whom were being treated for underlying autoimmune inflammatory conditions, such as rheumatoid arthritis, making them more susceptible to shingles in general. Out of those, six women ages 36 to 61 developed shingles in the days and weeks after they received the Pfizer vaccination, for a prevalence rate of 1.2%. The researchers noted in their article that treatment-related reactivation of shingles has been seen with other treatments, such as those for influenza, hepatitis A and rabies. But there were no reports of herpes-related rashes in the clinical trials for buy antibiotics treatments.

In the study, most of the cases were mild, five occurred after the first dose, and all five of those women went on to have their second dose with no additional adverse effects. The researchers said their observations cannot prove causality but should prompt “further vigilance and safety monitoring of buy antibiotics vaccination side effects.” Some media outlets, including the New York Post, ran headlines such as “Herpes Possibly Linked to buy antibiotics, Study Says.” That’s simply “clickbait,” said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. No one is getting infected with herpes from vaccinations, he said.

€œWhat the anti-vax community is doing is giving the impression that vaccinations are giving people herpes, which is simply not true.” Adalja objects to the headline and effort to scare people, but he also said it is plausible, if yet unproven, that vaccination could reactivate an existing herpes zoster cipro. Other types of rashes and injection-site redness have certainly been reported by people who have received a buy antibiotics treatment. Researchers at Massachusetts General Hospital, for example, reported on a group of 12 patients who had rashes that appeared four to 11 days after getting their first dose of the Moderna treatment. Ice and antihistamines were used to treat most of the patients, half of whom experienced a rash again after the second shot.

And there have been reports on social media and in the press of people reporting similar rashes following vaccination. Still, experts say those rashes may simply be a sign that the immune system is working. Such rashes are “pretty innocuous and easily treated,” said Adalja. Our Ruling An online post claims the buy antibiotics treatments cause shingles or other dangerous skin conditions.

Although it contains a sliver of truth, it ignores important information. For instance, the evidence to date indicates this is an area to continue monitoring, but no direct link has been established between buy antibiotics vaccination and shingles or other serious skin conditions. The study cited was not intended to prove cause and effect, and it was looking at patients who already had suppressed immune systems that made them more likely to get shingles whether they had a vaccination or not. We rate this statement Mostly False.

Sources:Telephone interview with Dr. William Schaffner, professor of medicine, division of infectious diseases, Vanderbilt University School of Medicine, April 23, 2021Telephone interview with Dr. Amesh Adalja, senior scholar at Johns Hopkins Center for Health Security, April 23, 2021Rheumatology, “Herpes Zoster Following BNT162b2 mRNA buy antibiotics Vaccination in Patients With Autoimmune Inflammatory Rheumatic Diseases. A Case Study,” April 12, 2021The New England Journal of Medicine, “Delayed Large Local Reactions to mRNA-1273 treatment Against antibiotics,” April 1, 2021PolitiFact, “A Claim Comparing Adverse Events for buy antibiotics, Flu treatments Exaggerates Raw Data,” Jan.

15, 2021National Organization for Rare Disorders rare-disease database, “Erythema Multiforme,” accessed April 23, 2021Mayo Clinic, “Shingles,” accessed April 23, 2021Vanity Fair, “An Ex-New York Times Reporter Has Become the Right’s Go-To antibiotics Skeptic,” April 10, 2020 Julie Appleby. jappleby@kff.org, @Julie_Appleby Related Topics Contact Us Submit a Story TipIt was April, more than three months into the vaccination campaign against buy antibiotics, and Jim Freeman, 83, still had not gotten his first dose. Freeman had been eligible for months as part of the 75-and-older target group deemed most vulnerable to death and serious illness in the cipro. But he could not leave his home to make the journey to one of the mass-vaccination sites in San Mateo County.

Freeman, who has Parkinson’s disease, has extremely limited mobility and no longer can walk. €œHe watches TV at night and sees all these people in line getting treatments, but he couldn’t do it,” said his daughter Beth Freeman, 58. €œIt was really frustrating.” She contacted the county and state public health departments and even her local congresswoman for help, but none had a solution. Finally, after weeks of failed attempts to get someone to vaccinate her father at their home, Beth spent $700 to rent a special wheelchair-accessible van and, with the help of a home health aide, nervously drove her father to the county’s mass-vaccination site.

Even as the nation has moved on to vaccinating everyone 16 and older, the vast majority of homebound people have not yet been vaccinated, said Kelly Buckland, executive director of the National Council on Independent Living. €œAs far as I can tell, no one’s really doing it. Maybe a few places in the country, but not on the mass scale it needs to be.” Across the nation, an estimated 4 million Americans are homebound by age, disability or frailty, unable to easily leave their homes to receive a buy antibiotics treatment. Buckland noted that, while homebound people are not out in public where the cipro is circulating, they don’t live in a bubble.

Most rely for care on family members or a rotating staff of home health aides who come and go and often have their own homes and families. €œFor people with disabilities, you can’t close yourself off. You don’t have the option. People have to come into your home every day to give you services.” The Biden administration in late March dedicated $100 million to help vulnerable older adults and people with disabilities get vaccinations.

But many caregivers and homebound people say they aren’t yet feeling the impact of that effort. California, where tens of thousands of residents like Jim Freeman are still waiting their turn for vaccination, offers a sharp lens on the challenges. Marta Green, a California official helping oversee treatment distribution, said during an April meeting of the state’s Community treatment Advisory Committee that California is “working on a partnership” to send ambulances to vaccinate homebound people where they live. In response to questions about how many homebound people had been vaccinated so far, a spokesperson for the California Department of Public Health said the effort was “just beginning” and estimates were not available.

As part of a $15 million no-bid contract with California to administer the state’s vaccination program, Blue Shield of California is obligated to provide treatment access to homebound people. The company, nonetheless, declined to provide responses to specific questions about such efforts. Spokesperson Erika Conner said the company has “diligently explored opportunities for this work” and recommended that homebound people contact their local public health departments or health care providers. The logistics of inoculating homebound people with a treatment that requires cold storage is not simple.

Once thawed, a vial of Pfizer-BioNTech treatment contains six doses that must be delivered within six hours, while a Moderna treatment vial contains 10 to 15 doses to be used within 12 hours. With each vaccination visit lasting about an hour plus the travel time, there isn’t much room for error, especially in rural areas where residents may live far apart. The one-dose Johnson &. Johnson treatment offers more flexibility, but the pause due to safety concerns resulted in delays.

€œYeah, it’s not easy. If it were easy, we’d already have done it,” said Dr. Mike Wasserman, a geriatrician and member of the California treatment advisory committee. €œBut that’s not an excuse.

These are the folks who if they get the cipro they’re going to die. I don’t accept it.” Wasserman said he’d give the state a “D” for its efforts to reach the homebound for vaccination. For some, he added, it might already be too late. €œIf you’re 80 years old and you live in a 1,000-square-foot home with 10 other people, you’re probably dead already.” In the absence of a coordinated state-driven effort, California counties are attempting a patchwork of approaches.

In Los Angeles County, the public health department has partnered with the sheriff’s department and 15 fire departments to vaccinate homebound residents, with some success. Health officials projected that 50% of the county’s 10,000 homebound residents will have received one dose by the end of April. In Fresno County, with more than a million residents, health officials said they are compiling a list of homebound people who want help getting a treatment. So far, fewer than 20 people in that category have been contacted and received the treatment.

In San Mateo County, where Freeman lives, the health department has identified at least 1,000 individuals who are homebound and in need of the treatment. So far, 100 have been vaccinated. Before she resorted to renting the $700 mobility van for her father, Beth Freeman contacted county workers. They offered to send a bus to pick up her father and take him to a vaccination site, but she couldn’t imagine how that would work for him, both in terms of the physical logistics and the risk of exposure.

She asked the nurses who visited her father twice a week through Sutter Health’s care-at-home program for help — after all, they had given him the flu shot. But no luck. The nurses said they were not allowed to offer the buy antibiotics treatment. Finally, on April 6, Beth made the difficult decision to transport her father despite his limited mobility.

€œI did not want to take him out of the house for this. It was risky for his health. But at some point I realized it wasn’t going to happen any other way,” she said. €œHe wanted to see members of his family and time was ticking.” She said her father was up all night worrying, and his body was stiff.

But with help from a home health aide, she used a special lift to hoist him into a wheelchair and wheeled him down two ramps and into the rented van, where she strapped him to the chair. They drove 20 minutes to the San Mateo County Event Center, her eyes darting from the road to the rearview mirror to check on her father, and then waited 40 minutes in the drive-thru line. €œWhen I rolled down the window, the nurses were like, What the hell?. Why is he only coming to us now?.

€ she said. The experience was so stressful for her father, she added, that he slept on and off for the next two days. This week, they repeated the ordeal for his second dose — including laying out another $700 for the rental van. €œAll this, while he sees nurses at home twice a week?.

€ Beth Freeman said. €œWhat a missed opportunity.” Jenny Gold. jgold@kff.org, @JennyAGold Related Topics Contact Us Submit a Story Tip.