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Start Preamble important link Census where to buy lasix for horses Bureau, Commerce. Notice of information collection. Request for where to buy lasix for horses comment. The Department of Commerce, in accordance with the Paperwork Reduction Act (PRA) of 1995, invites the general public and other Federal agencies to comment on proposed, and continuing information collections, which helps us assess the impact of our information collection requirements and minimize the public's reporting burden. The purpose of this notice is to allow for an additional 60 days of public comment on a proposed new information collection, the Management and where to buy lasix for horses Organizational Practices Survey—Hospitals (MOPS-HP).

An information collection request (ICR) for the MOPS-HP was submitted to OMB for approval on July 7, 2020 and is currently pending OMB review. To ensure consideration, comments regarding this proposed information collection must be received on or before January 19, 2021. Interested persons are invited to submit written comments where to buy lasix for horses by email to Thomas.J.Smith@census.gov. Please reference Management and Organizational Practices Survey—Hospitals (MOPS-HP) in the subject line of your comments. You may also submit comments, identified by Docket where to buy lasix for horses Number USBC-2020-0029, to the Federal e-Rulemaking Portal.

Http://www.regulations.gov. All comments received are part of the public record. No comments will be posted to http://www.regulations.gov for public viewing until after the comment period has closed where to buy lasix for horses. Comments will generally be posted without change. All Personally Identifiable Information (for example, name and address) voluntarily submitted by the commenter may where to buy lasix for horses be publicly accessible.

Do not submit Confidential Business Information or otherwise sensitive or protected information. You may submit attachments to electronic comments in Microsoft Word, Excel, or Adobe PDF file formats. Start Further Info where to buy lasix for horses Requests for additional information or specific questions related to collection activities should be directed to Edward Watkins at edward.e.watkins.iii@census.gov or 301-763-4750. End Further Info End Preamble Start Supplemental Information I. Abstract The U.S where to buy lasix for horses.

Census Bureau plans to conduct the Management and Organizational Practices Survey-Hospitals (MOPS-HP) for survey year 2020 as a joint project with Harvard Business School. The MOPS-HP will utilize a subset of the Service Annual Survey mail-out sample and will collect data on management practices from Chief Nursing Officers (CNOs) at general medical and surgical hospitals to assist in studying their relationship to clinical where to buy lasix for horses and financial performance. A notice seeking public comment on our plans to conduct this survey was previously published in the Federal Register on February 12, 2020, on pages 4623-4624. That notice proposed collecting data for survey years 2019 and 2014, but collection has been adjusted due to the ongoing hypertension lasix. The lasix has further highlighted the relevance of hospital management practices, especially as they relate to hospitals' abilities to respond to shocks to their organization and the health care where to buy lasix for horses system.

In light of this, the Census Bureau has modified the survey proposal to collect data for reference years 2020 and 2019. This change seeks to directly measure management practices and protocols before and where to buy lasix for horses during the lasix to obtain a better understanding of how hospitals have had to adjust and pivot operations during this public health emergency. The Census Bureau also plans to include two additional questions in the MOPS-HP content to help improve measurement of hospital preparedness. These questions will provide information on two elements of responsiveness, hospitals' coordinated deployment of frontline clinical workers and hospitals' ability to quickly respond to needed changes in standardized clinical protocols. In an effort to limit respondent where to buy lasix for horses burden while adding this content, adjustments were made to keep the total number of questions and estimated burden per response unchanged.

The project plan, schedule, and collection strategy are being actively monitored, and adjustments will be made as necessary, as the Census Bureau is cognizant and respectful of the time, resources, and burden placed on CNOs during the lasix. After the close of this second where to buy lasix for horses comment period, the Census Bureau will submit these planned changes as an amendment to the ICR, which is currently pending review at OMB. Any comments received by the close of the comment period will be summarized and included in the amendment. Currently, no official statistics on management practices in hospitals exist. Past research shows these practices are where to buy lasix for horses related to health care providers' clinical and financial outcomes.

This suggests that providing measures on management practices may potentially help the United States health care system, which is challenged by rising health care costs, increased demand from an aging society, and quality objectives. These data would permit users to examine relationships between management practices and financial outcomes using Census Bureau data (e.g., revenues) and relationships where to buy lasix for horses with clinical outcomes using external data sources. Additionally, these data would provide hospital administrators and managers information to evaluate their practices in comparison to other hospitals at an aggregate level. The MOPS-HP content was proposed by external researchers with past experience in surveying where to buy lasix for horses hospitals on management practices. Some questions are adapted from the Management and Organizational Practices Survey (MOPS), conducted in the manufacturing sector, allowing for inter-sectoral comparisons.

Content for the MOPS-HP includes performance monitoring, financial and clinical targets, and incentives. The 39 questions are grouped where to buy lasix for horses into the following sections. Tenure, Management Practices, Management Training, Management of Team Interactions, Staffing and Allocation of Human Resources, Standardized Clinical Protocols, Documentation of Patients' Medical Records, and Organizational Characteristics.Start Printed Page 73674 II. Method of Collection where to buy lasix for horses The MOPS-HP sample will consist of approximately 3,200 hospital locations for enterprises classified under General Medical and Surgical Hospitals (NAICS 6221) and sampled in the Service Annual Survey (SAS). The survey will be mailed separately from the 2020 SAS and collected electronically through the Census Bureau's Centurion online reporting system.

Respondents will be sent an initial letter with instructions detailing how to log into the instrument and report their information. These letters will be addressed where to buy lasix for horses to the location's CNO. In instances where the CNO is not identifiable, the letter will be addressed to the hospital's administrative office with attention to the CNO. Collection is scheduled where to buy lasix for horses to begin in the initial months of 2021. III.

Data OMB Control Number. 0607-XXXX. Form Number(s). MP-2000. Type of Review.

Regular submission, New Information Collection Request. Affected Public. General medical and surgical hospitals. Estimated Number of Respondents. Approximately 3,200.

Estimated Time per Response. 45 minutes. Estimated Total Annual Burden Hours. 2,400. Estimated Total Annual Cost to Public.

$0. (This is not the cost of respondents' time, but the indirect costs respondents may incur for such things as purchases of specialized software or hardware needed to report, or expenditures for accounting or records maintenance services required specifically by the collection.) Respondent's Obligation. Mandatory. Legal Authority. Title 13 U.S.C., Sections 131 and 182.

IV. Request for Comments We are soliciting public comments to permit the Department/Bureau to. (a) Evaluate whether the proposed information collection is necessary for the proper functions of the Department, including whether the information will have practical utility. (b) Evaluate the accuracy of our estimate of the time and cost burden for this proposed collection, including the validity of the methodology and assumptions used. (c) Evaluate ways to enhance the quality, utility, and clarity of the information to be collected.

And (d) Minimize the reporting burden on those who are to respond, including the use of automated collection techniques or other forms of information technology. Comments that you submit in response to this notice are a matter of public record. We will include, or summarize, each comment in our request to OMB to approve this ICR. Before including your address, phone number, email address, or other personal identifying information in your comment, you should be aware that your entire comment—including your personal identifying information—may be made publicly available at any time. While you may ask us in your comment to withhold your personal identifying information from public review, we cannot guarantee that we will be able to do so.

Start Signature Sheleen Dumas, Department PRA Clearance Officer, Office of the Chief Information Officer, Commerce Department. End Signature End Supplemental Information [FR Doc. 2020-25580 Filed 11-18-20. 8:45 am]BILLING CODE 3510-07-PStart Preamble Department of Veterans Affairs. Interim final rule.

The Department of Veterans Affairs (VA) is issuing this interim final rule to confirm that its health care professionals may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. Specifically, this rulemaking confirms VA's current practice of allowing VA health care professionals to deliver health care services in a State other than the health care professional's State of licensure, registration, certification, or other State requirement, thereby enhancing beneficiaries' access to critical VA health care services. This rulemaking also confirms VA's authority to establish national standards of practice for health care professionals which will standardize a health care professional's practice in all VA medical facilities. Effective Date. This rule is effective on November 12, 2020.

Comments. Comments must be received on or before January 11, 2021. Comments may be submitted through www.Regulations.gov or mailed to, Beth Taylor, 10A1, 810 Vermont Avenue NW, Washington, DC 20420. Comments should indicate that they are submitted in response to [“RIN 2900-AQ94—Authority of VA Professionals to Practice Health Care.”] Comments received will be available at regulations.gov for public viewing, inspection, or copies. Start Further Info Beth Taylor, Chief Nursing Officer, Veterans Health Administration.

810 Vermont Avenue NW, Washington, DC 20420, (202) 461-7250. (This is not a toll-free number.) End Further Info End Preamble Start Supplemental Information On January 30, 2020, the World Health Organization (WHO) declared the hypertension medications outbreak to be a Public Health Emergency of International Concern. On January 31, 2020, the Secretary of the Department of Health and Human Services declared a Public Health Emergency pursuant to 42 United States Code (U.S.C.) 247d, for the entire United States to aid in the nation's health care community response to the hypertension medications outbreak. On March 11, 2020, in light of new data and the rapid spread in Europe, WHO declared hypertension medications to be a lasix. On March 13, 2020, the President declared a National Emergency due to hypertension medications under sections 201 and 301 of the National Emergencies Act (50 U.S.C.

1601 et seq.) and consistent with section 1135 of the Social Security Act (SSA), as amended (42 U.S.C. 1320b-5). As a result of responding to the needs of our veteran population and other non-veteran beneficiaries during the hypertension medications National Emergency, where VA has had to shift health care Start Printed Page 71839professionals to other locations or duties to assist in the care of those affected by this lasix, VA has become acutely aware of the need to promulgate this rule to clarify the policies governing VA's provision of health care. This rule is intended to confirm that VA health care professionals may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. In particular, it will confirm (1) VA's continuing practice of authorizing VA health care professionals to deliver health care services in a State other than the health care professional's State of licensure, registration, certification, or other requirement.

And (2) VA's authority to establish national standards of practice for health care professions via policy, which will govern their employment, subject only to State laws where the health care professional is licensed, credentialed, registered, or subject to some other State requirements that do not unduly interfere with those duties. We note that the term State as it applies to this rule means each of the several States, Territories, and possessions of the United States, the District of Columbia, and the Commonwealth of Puerto Rico, or a political subdivision of such State. This definition is consistent with the term State as it is defined in 38 U.S.C. 101(20). A conflicting State law is one that would unduly interfere with the fulfillment of a VA health care professional's Federal duties.

We note that the policies and practices confirmed in this rule only apply to VA health care professionals appointed under 38 U.S.C. 7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code, which does not include contractors working in VA medical facilities or those working in the community. VA has long understood its governing statutory authorities to permit VA to engage in these practices. Section 7301(b) of title 38 the U.S.

Code establishes that the primary function of the Veterans Health Administration (VHA) within VA is to provide a complete medical and hospital service for the medical care and treatment of veterans. To allow VHA to carry out its medical care mission, Congress established a comprehensive personnel system for certain VA health care professionals, independent of the civil service rules. See Chapters 73-74 of title 38 of the U.S. Code. Congress granted the Secretary express statutory authority to establish the qualifications for VA's health care professionals, determine the hours and conditions of employment, take disciplinary action against employees, and otherwise regulate the professional activities of those individuals.

38 U.S.C. 7401-7464. Section 7402 of 38 U.S.C. Establishes the qualifications of appointees. To be eligible for appointment as a VA employee in a health care profession covered by section 7402(b) (other than a medical facility Director appointed under section 7402(b)(4)), most individuals, after appointment, must, among other requirements, be licensed, registered, or certified to practice their profession in a State, or satisfy some other State requirement.

However, the standards prescribed in section 7402(b) establish only the basic qualifications for VA health care professionals and do not limit the Secretary from establishing other qualifications or rules for health care professionals. In addition, the Secretary is responsible for the control, direction, and management of the Department, including agency personnel and management matters. See 38 U.S.C. 303. Such authorities permit the Secretary to further regulate the health care professions to make certain that VA's health care system provides safe and effective health care by qualified health care professionals to ensure the well-being of those veterans who have borne the battle.

In this rulemaking, VA is detailing its authority to manage its health care professionals by stating that they may practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other State requirements that unduly interfere with their practice. VA believes that this is necessary in order to provide additional protection for VA health care professionals against adverse State actions proposed or taken against them when they are practicing within the scope of their VA employment, particularly when they are practicing across State lines or when they are performing duties consistent with a VA national standard of practice for their health care profession. Practice Across State Lines Historically, VA has operated as a national health care system that authorizes VA health care professionals to practice in any State as long as they have a valid license, registration, certification, or fulfill other State requirements in at least one State. In doing so, VA health care professionals have been practicing within the scope of their VA employment regardless of any unduly burdensome State requirements that would restrict practice across State lines. We note, however, that VA may only hire health care professionals who are licensed, registered, certified, or satisfy some other requirement in a State, unless the statute requires or provides otherwise (e.g., 38 U.S.C.

7402(b)(14)). The hypertension medications lasix has highlighted VA's acute need to exercise its statutory authority of allowing VA health care professionals to practice across State lines. In response to the lasix, VA needed to and continues to need to move health care professionals quickly across the country to care for veterans and other beneficiaries and not have State licensure, registration, certification, or other State requirements hinder such actions. Put simply, it is crucial for VA to be able to determine the location and practice of its VA health care professionals to carry out its mission without any unduly burdensome restrictions imposed by State licensure, registration, certification, or other requirements. This rulemaking will support VA's authority to do so and will provide an increased level of protection against any adverse State action being proposed or taken against VA health care professionals who practice within the scope of their VA employment.

Since the start of the lasix, in furtherance of VA's Fourth Mission, VA has rapidly utilized its resources to assist parts of the country that are undergoing serious and critical shortages of health care resources. VA's Fourth Mission is to improve the Nation's preparedness for response to war, terrorism, national emergencies, and natural disasters by developing plans and taking actions to ensure continued service to veterans, as well as to support national, State, and local emergency management, public health, safety and homeland security efforts. VA has deployed personnel to support other VA medical facilities that have been impacted by hypertension medications as well as provided support to State and community nursing homes. As of July 2020, VA has deployed personnel to more than 45 States. VA utilized the Disaster Emergency Medical Personnel System (DEMPS), VA's main deployment program, for VA health care professionals to travel to locations deemed as national emergency or disaster areas, to help provide health care services in places such as New Orleans, Louisiana, and New York City, New York.

As of June 2020, a total of 1,893 staff have been mobilized to meet the needs of our facilities and Fourth Start Printed Page 71840Mission requests during the lasix. VA deployed 877 staff to meet Federal Emergency Management Agency (FEMA) Mission requests, 420 health care professionals were deployed as DEMPS response, 414 employees were mobilized to cross level staffing needs within their Veterans Integrated Service Networks (VISN), 69 employees were mobilized to support needs in another VISN, and 113 Travel Nurse Corps staff responded specifically for hypertension medications staffing support. In light of the rapidly changing landscape of the lasix, it is crucial for VA to be able to move its health care professionals quickly across the country to assist when a new hot spot emerges without fear of any adverse action from a State be proposed or taken against a VA health care professional. We note that, in addition to providing in person health care across State lines during the lasix, VA also provides telehealth across State lines. VA's video to home services have been heavily leveraged during the lasix to deliver safe, quality VA health care while adhering to Centers for Disease Control and Prevention (CDC) physical distancing guidelines.

Video visits to veterans' homes or other offsite location have increased from 41,425 in February 2020 to 657,423 in July of 2020. This represents a 1,478 percent utilization increase. VA has specific statutory authority under 38 U.S.C. 1730C to allow health care professionals to practice telehealth in any State regardless of where they are licensed, registered, certified, or satisfy some other State requirement. This rulemaking is consistent with Congressional intent under Public Law 115-185, sec.

151, June 6, 2018, codified at 38 U.S.C. 1730C for all VA health care professionals to practice across State lines regardless of the location of where they provide health care. This rulemaking will ensure that VA professionals are protected regardless of how they provide health care, whether it be via telehealth or in-person. Beyond the current need to mobilize health care resources quickly to different parts of the country, this practice of allowing VA health care professionals to practice across State lines optimizes the VA health care workforce to meet the needs of all VA beneficiaries year-round. It is common practice within the VA health care system to have primary and specialty health care professionals routinely travel to smaller VA medical facilities or rural locations in nearby States to provide care that may be difficult to obtain or unavailable in that community.

As of January 14, 2020, out of 182,100 licensed health care professionals who are employed by VA, 25,313 or 14 percent do not hold a State license, registration, or certification in the same State as their main VA medical facility. This number does not include the VA health care professionals who practice at a main VA medical facility in one State where they are licensed, registered, certified, or hold some other State requirement, but also practice at a nearby Community Based Outpatient Clinic (CBOC) in a neighboring State where they do not hold such credentials. Indeed, 49 out of the 140 VA medical facilities nationwide have one or more sites of care in a different State than the main VA medical facility. Also, VA has rural mobile health units that provide health care services to veterans who have difficulty accessing VA health care facilities. These mobile units are a vital source of health care to veterans who live in rural and medically underserved communities.

Some of the services provided by the mobile units include, but are not limited to, health care screening, mental health outreach, influenza and pneumonia vaccinations, and routine primary care. The rural mobile health units are an integral part of VA's goal of encouraging healthier communities and support VA's preventative health programs. Health care professionals who provide health care in these mobile units may provide services in various States where they may not hold a license, registration, or certification, or satisfy some other State requirement. It is critical that these health care professionals are protected from any adverse State action proposed or taken when performing these crucial services. In addition, the practice of health care professionals of providing health care across State lines also gives VA the flexibility to hire qualified health care professionals from any State to meet the staffing needs of a VA health care facility where recruitment or retention is difficult.

As of December 31, 2019, VA had approximately 13,000 vacancies for health care professions across the country. As a national health care system, it is imperative for VA to be able to recruit and retain health care professionals, where recruitment and retention is difficult, to ensure there is access to health care regardless of where the VA beneficiary resides. Permitting VA health care professionals to practice across State lines is an important incentive when trying to recruit for these vacancies, particularly during a lasix, where private health care facilities have greater flexibility to offer more competitive pay and benefits. This is also especially beneficial in recruiting spouses of active service members who frequently move across the country. National Standard of Practice This rulemaking also confirms VA's authority to establish national standards of practice for health care professions.

We note that this rulemaking does not create any such national standards. All national standards of practice will be created via policy. For the purposes of this rulemaking, a national standard of practice describes the tasks and duties that a VA health care professional practicing in the health care profession may perform and may be permitted to undertake. Having a national standard of practice means that individuals from the same VA health care profession may provide the same type of tasks and duties regardless of the VA medical facility where they are located or the State license, registration, certification, or other State requirement they hold. We emphasize that VA will determine, on an individual basis, that a health care professional has the necessary education, training, and skills to perform the tasks and duties detailed in the national standard of practice.

The need for national standards of practice have been highlighted by VA's large-scale initiative regarding the new electronic health record (EHR). VA's health care system is currently undergoing a transformational initiative to modernize the system by replacing its current EHR with a joint EHR with Department of Defense (DoD) to promote interoperability of medical data between VA and DoD. VA's new EHR system will provide VA and DoD health care professionals with quick and efficient access to the complete picture of a veteran's health information, improving VA's delivery of health care to our nation's veterans. For this endeavor, DoD and VA established a joint governance over the EHR system. In order to be successful, VA must standardize clinical processes with DoD.

This means that all health care professionals in DoD and VA who practice in a certain health care profession must be able to carry out the same duties and tasks irrespective of State requirements. The reason why this is important is because each health care profession is designated a role in the EHR system that sets forth specific privileges within the EHR that dictate allowed tasks for such profession. These tasks include, but are not limited to, dispensing and administrating medications. Prescriptive practices. Ordering of procedures and diagnostic imaging.

And required level of oversight. VA has the ability to modify these privileges within EHR, however, VA Start Printed Page 71841cannot do so on an individual user level, but rather at the role level for each health care profession. In other words, VA cannot modify the privileges for all health care professionals in one State to be consistent with that State's requirements. Instead, the privileges can only be modified for every health care professional in that role across all States. Therefore, the privileges established within EHR cannot be made facility or State specific.

In order to achieve standardized clinical processes, VA and DoD must create the uniform standards of practice for each health care specialty. Currently, DoD has specific authority from Congress to create national standards of practice for their health care professionals under 10 U.S.C. 1094. While VA lacks a similarly specific statute, VA has the general statutory authority, as explained above, to regulate its health care professionals and authorize health care practices that preempt conflicting State law. This regulation will confirm VA's authority to do so.

Absent such standardized practices, it will be incredibly difficult for VA to achieve its goal of being an active participant in EHR modernization because either some VA health care professionals would fear potential adverse State actions or DoD and VA would need to agree upon roles that are consistent with the most restrictive States' requirements to ensure that all health care professionals are acting within the scope of their State requirements. VA believes that agreement upon roles that are consistent with the most restrictive State is not an acceptable option because it will lead to delayed care and consequently decreased access and level of health care for VA beneficiaries. One example that impacts multiple health care professions throughout the VA system is the ability to administer medication without a provider (physician or advanced practice nurse practitioner) co-signature. As it pertains to nursing, almost all States permit nurses to follow a protocol. However, some States, such as New York, North Carolina, and South Carolina, do not permit nurses to follow a protocol without a provider co-signature.

A protocol is a standing order that has been approved by medical and clinical leadership if a certain sequence of health care events occur. For instance, if a patient is exhibiting certain signs of a heart attack, there is a protocol in place to administer potentially life-saving medication. If the nurse is the first person to see the signs, the nurse will follow the approved protocol and immediately administer the medication. However, if the nurse cannot follow the protocol and requires a provider co-signature, administration of the medication will be delayed until a provider is able to co-sign the order, which may lead to the deterioration of the patient's condition. This also increases the provider's workload and decreases the amount of time the provider can spend with patients.

Historically, VA physical therapists (PTs), occupational therapists, and speech therapists were routinely able to determine the need to administer topical medications during therapy sessions and were able to administer the topical without a provider co-signature. However, in order to accommodate the new EHR system and variance in State requirements, these therapists would need to place an order for all medications, including topicals, which would leave these therapists waiting for a provider co-signature in the middle of a therapy session, thus delaying care. Furthermore, these therapists also routinely ordered imaging to better assess the clinical needs of the patient, but would also have to wait for a provider co-signature, which will further delay care and increase provider workload. In addition to requiring provider co-signatures, there will also be a significant decrease in access to care due to other variances in State requirements. For instance, direct access to PTs will be limited in order to ensure that the role is consistent with all State requirements.

Direct access means that a beneficiary may request PT services without a provider's referral. However, while almost half of the States allow unrestricted direct access to PTs, over half of the States have some limitations on requesting PT services. For instance, in Alabama, a licensed PT may perform an initial evaluation and may only provide other services as delineated in specific subdivisions of the Alabama Physical Therapy Practice Act. Furthermore, in New York, PT treatment may be rendered by a licensed PT for 10 visits or 30 days, whichever shall occur first, without a referral from a physician, dentist, podiatrist, nurse practitioner, or licensed midwife. This is problematic as VA will not be able to allow for direct access due to these variances and direct access has been shown to be beneficial for patient care.

Currently, VISN 23 is completing a two-year strategic initiative to implement direct access and have PTs embedded into patient aligned care teams (PACT). Outcomes thus far include decreased wait times, improved veteran satisfaction, improved provider satisfaction, and improved functional outcomes. Therefore, VA will confirm its authority to ensure that health care professionals are protected against State action when they adhere to VA's national standards of practice. We reiterate that this rulemaking does not establish national standards of practice for each health care profession, but merely confirms VA's authority to do so, thereby preempting any State restrictions that unduly interfere with those practices. The actual national standards of practice will be developed in subregulatory policy for each health care profession.

As such, VA will make a concerted effort to engage appropriate stakeholders when developing the national standards of practice. Preemption As previously explained, in this rulemaking, VA is confirming its authority to manage its health care professionals. Specifically, this rulemaking will confirm VA's long-standing practice of allowing its health care professionals to practice in a State where they do not hold a license, registration, certification, or satisfy some other State requirement. The rule will also confirm that VA health care professionals must adhere to VA's national standards of practice, as determined by VA policy, irrespective of conflicting State licensing, registration, certification, or other State requirements that unduly burden that practice. We do note that VA health care professionals will only be required to perform tasks and duties to the extent of their education, skill, and training.

For instance, VA would not require a registered nurse to perform a task that the individual nurse was not trained to perform. Currently, practice in accordance with VA employment, including practice across State lines or adhering to a VA standard of practice, may jeopardize VA health care professionals' credentials or result in fines and imprisonment for unauthorized health care practice. This is because most States have restrictions that limit health care professionals' practice or have rules that prohibit health care professionals from furnishing health care services within that State without a license, registration, certification, or other requirement from that State. We note that, some States, for example Rhode Island, Utah, and Michigan, have enacted legislation or regulations that specifically allow certain VA health care professionals to practice in those States when they do not hold a State license. Several VA health care professionals have already had actions proposed or taken against them by various States Start Printed Page 71842while practicing health care within the scope of their VA employment, while they either practiced in a State where they do not hold a license, registration, certification, or other State requirement that unduly interfered with their VA employment.

In one instance, a VA psychologist was licensed in California but was employed and providing supervision of a trainee at the VA Medical Center (VAMC) in Nashville, Tennessee. California psychology licensing laws require supervisors to hold a license from the State where they are practicing and do not allow for California licensed psychologists to provide supervision to trainees or unlicensed psychologists outside the State of California. The California State Psychology Licensing Board proposed sanctions and fines of $1,000 for violating section 1387.4(a) of the CA Code of Regulations (CCR). The VA system did not qualify for the exemption of out of State supervision requirements listed in CCR section 1387.4. In addition, a VA physician who was licensed in Oregon, but was practicing at a VAMC in Biloxi, Mississippi had the status of their license changed from active to inactive because the Oregon Medical Board determined the professional did not reside in Oregon, in violation of Oregon's requirement that a physician physically reside in the State in order to maintain an active license.

This rulemaking serves to preempt State requirements, such as the ones discussed above, that were or can be used to take an action against VA health care professionals for practicing within the scope of their VA employment. State licensure, registration, certification, and other State requirements are preempted to the extent such State laws unduly interfere with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment. As explained above, Congress provided general statutory provisions that permit the VA Secretary to authorize health care practices by health care professionals at VA, which serve to preempt conflicting State laws that unduly interfere with the exercise of health care by VA health care professionals pursuant to that authorization. Although some VA health care professionals are required by Federal statute to have a State license, see, e.g., 38 U.S.C. 7402(b)(1)(C) (providing that, to be eligible to be appointed to a physician position at the VA, a physician must be licensed to practice medicine, surgery, or osteopathy in a State), a State may not attach a condition to the license that is unduly burdensome to or unduly interferes with the practice of health care within the scope of VA employment.

Under well-established interpretations of the Supremacy Clause, Federal laws and policies authorizing VA health care professionals to practice according to VA standards preempt conflicting State law. That is, a State law that prevents or unreasonably interferes with the performance of VA duties. See, e.g., Hancock v. Train, 426 U.S. 167, 178-81 (1976).

Sperry v. Florida, 373 U.S. 379, 385 (1963). Miller v. Arkansas, 352 U.S.

187 (1956). Ohio v. Thomas, 173 U.S. 276, 282-84 (1899). State Bar Disciplinary Rules as Applied to Federal Government Attorneys, 9 Op.

O.L.C. 71, 72-73 (1985). When a State law does not conflict with the performance of Federal duties in these ways, VA health care professionals are required to abide by the State law. Therefore, VA's policies and regulations will preempt State licensure, registration, and certification laws, rules, or other requirements only to the extent they conflict with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment. We emphasize that, in instances where there is no conflict with State requirements, VA health care professionals should abide by the State requirement.

For example, if a State license requires a health care professional to have a certain number of hours of continuing professional education per year to maintain their license, the health care professional must adhere to this State requirement if it does not prevent or unduly interfere with the exercise of VA employment. To determine whether a State requirement is conflicting, VA would assess whether the State law unduly interferes on a case-by-case basis. For instance, if Oregon requires all licensed physicians to reside in Oregon, VA would likely find that it unduly interferes with already licensed VA physicians who reside and work for VA in the State of Mississippi. We emphasize that the intent of the regulation is to only preempt State requirements that are unduly burdensome and interfere with a VA health care professionals' practice for the VA. For instance, it would not require a State to issue a license to an individual who does not meet the education requirements to receive a license in that State.

We note that this rulemaking also does not affect VA's existing requirement that all VA health care professionals adhere to restrictions imposed by the Controlled Substances Act, 21 U.S.C. 801 et seq. And implementing regulations at 21 CFR 1300, et seq., to prescribe or administer controlled substances. Any preemption of conflicting State requirements will be the minimum necessary for VA to effectively furnish health care services. It would be costly and time-consuming for VA to lobby each State board for each health care profession specialty to remove restrictions that impair VA's ability to furnish health care services to beneficiaries and then wait for the State to implement appropriate changes.

Doing so would not guarantee a successful result. Regulation For these reasons, VA is establishing a new regulation titled Health care professionals' practice in VA, which will be located at 38 CFR 17.419. This rule will confirm the ability of VA health care professionals to practice their health care profession consistent with the scope and requirements of their VA employment, notwithstanding any State license, registration, certification, or other requirements that unduly interfere with their practice. Subsection (a) of § 17.419 contains the definitions that will apply to the new section. Subsection (a)(1) contains the definition for beneficiary.

We are defining the term beneficiary to mean a veteran or any other individual receiving health care under title 38 of the U.S. Code. We are using this definition because VA provides health care to veterans, certain family members of veterans, servicemembers, and others. This is VA's standard use of this term. Subsection (a)(2) contains the definition for health care professional.

We are defining the term health care professional to be an individual who meets specific criteria that is listed below. Subsection (a)(2)(i) will require that a health care professional be appointed to an occupation in VHA that is listed or authorized under 38 U.S.C. 7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code. Subsection (a)(2)(ii) requires that the individual is not a VA-contracted health care professional.

A health care professional does not include a contractor or a community health care professional because they are not considered VA employees nor appointed under 38 U.S.C. 7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code. Subsection (a)(2)(iii) lists the required qualifications for a health care professional. We note that these qualifications do not include all general Start Printed Page 71843qualifications for appointment, such as to hold a degree of doctor of medicine.

These qualifications are related to licensure, registration, certification, or other State requirements. Subsection (a)(2)(iii)(A) states that the health care professional must have an active, current, full, and unrestricted license, registration, certification, or satisfies another State requirement in a State to practice the health care specialty identified under 38 U.S.C. 7402(b). This standard ensures that VA health care professionals are qualified to practice their individual health care specialty if the specialty requires such credential. Subsection (a)(2)(iii)(B) states that the individual has other qualifications as prescribed by the Secretary for one of the health care professions listed under 38 U.S.C.

7402(b). Some health care professionals appointed under 38 U.S.C. 7401(3) whose qualifications are listed in 38 U.S.C. 7402(b) are not required to meet State license, registration, certification, or other requirements and rely on the qualifications prescribed by the Secretary. Therefore, these individuals would be included in this subsection and required to have the qualifications prescribed by the Secretary for their health care profession.

Subsection (a)(2)(iii)(C) states that the individual is otherwise authorized by the Secretary to provide health care services. This would include those individuals who practice a health care profession that does not require a State license, registration, certification, or other requirement and is also not listed in 38 U.S.C. 7402(b), but is authorized by the Secretary to provide health care services. Subsection (a)(2)(iii)(D) includes individuals who are trainees or may have a time limited appointment to finish clinicals or other requirements prior to being fully licensed. Therefore, the regulation will state that the individual is under the clinical supervision of a health care professional that meets the requirements listed in subsection (a)(2)(iii)(A)-(C) and the individual must meet the requirements in subsection (a)(2)(iii)(D)(i) or (a)(2)(iii)(D)(ii).

Subsection (a)(2)(iii)(D)(i) states that the individual is a health professions trainee appointed under 38 U.S.C. 7405 or 7406 participating in clinical or research training under supervision to satisfy program or degree requirements. Subsection (a)(2)(iii)(D)(ii) states that the individual is a health care employee, appointed under title 5 of the U.S. Code, 38 U.S.C. 7401(1) or (3), or 38 U.S.C.

7405 for any category of personnel described in 38 U.S.C. 7401(1) or (3) who must obtain an active, current, full and unrestricted licensure, registration, or certification or meet the qualification standards as defined by the Secretary within the specified time frame. These individuals have a time-limited appointment to obtain credentials. For example, marriage and family therapists require a certain number of supervised clinical post-graduate hours prior to receiving their license. Lastly, as we previously discussed in this rulemaking, we are defining the term State in subsection (a)(3) as the term is defined in 38 U.S.C.

101(20), and also including political subdivisions of such States. This is consistent with the definition of State in 38 U.S.C. 1730C(f) which is VA's statutory authority to preempt State law when the covered health care professional is using telehealth to provide treatment to an individual under this title. We believe that it is important to define the term in the same way as it is defined for health care professionals practicing via telehealth so that way it is consistent regardless of whether the health care professional is practicing in-person or via telehealth. Moreover, as subdivisions of a State are granted legal authority from the State itself, it makes sense to subject entities created by a State, or authorized by a State to create themselves, to be subject to the same limitations and restrictions as the State itself.

Section 17.419(b) details that VA health care professionals must practice within the scope of their Federal employment irrespective of conflicting State requirements that would prevent or unduly interfere with the exercise of Federal duties. This provision confirms that VA health care professionals may furnish health care consistent with their VA employment obligations without fear of adverse action proposed or taken by any State. In order to clarify and make transparent how VA utilizes or intends to utilize our current statutory authority, we are providing a non-exhaustive list of examples. The first example is listed in subsection (b)(1)(i). It states that a health care professional may practice their VA health care profession in any State irrespective of the State where they hold a valid license, registration, certification, or other qualification.

The second example is listed in subsection (b)(1)(ii). It states that a health care professional may practice their VA health care profession consistent with the VA national standard of practice as determined by VA. As previously explained, VA intends to establish national standards of practice via VA policy. A health care professional's practice within VA will continue to be subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C. 801, et seq.

And implementing regulations at 21 CFR 1300, et seq., on the authority to prescribe or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law and policy. This will ensure that professionals are still in compliance with critical laws concerning the prescribing and administering of controlled substances. This requirement is stated in subsection (b)(2). Subsection (c) expressly states the intended preemptive effect of § 17.419, to ensure that conflicting State and local laws, rules, regulations, and requirements related to health care professionals' practice will have no force or effect when such professionals are practicing health care while working within the scope of their VA employment. In circumstances where there is a conflict between Federal and State law, Federal law would prevail in accordance with Article VI, clause 2, of the U.S.

Constitution. Executive Order 13132 establishes principles for preemption of State law when it is implicated in rulemaking or proposed legislation. Where a Federal statute does not expressly preempt State law, agencies shall construe any authorization in the statute for the issuance of regulations as authorizing preemption of State law by rulemaking only when the exercise of State authority directly conflicts with the exercise of Federal authority or there is clear evidence to conclude that the Congress intended the agency to have the authority to preempt State law. In this situation, the Federal statutes do not expressly preempt State laws. However, VA construes the authorization established in 38 U.S.C.

303, 501, and 7401-7464 as authorizing preemption because the exercise of State authority directly conflicts with the exercise of Federal authority under these statutes. Congress granted the Secretary express statutory authority to establish the qualifications for VA's health care professionals, determine the hours and conditions of employment, take disciplinary action against employees, and otherwise regulate the professional activities of those individuals. 38 U.S.C. 7401-7464. Specifically, section 7402(b) states that most health care professionals, after appointment by VA, must, among other Start Printed Page 71844requirements, be licensed, registered, or certified to practice their profession in a State.

To that end, VA's regulations and policies will preempt any State law or action that conflicts with the exercise of Federal duties in providing health care at VA. In addition, any regulatory preemption of State law must be restricted to the minimum level necessary to achieve the objectives of the statute pursuant to the regulations that are promulgated. In this rulemaking, State licensure, registration, and certification laws, rules, regulations, or other requirements are preempted only to the extent such State laws unduly interfere with the ability of VA health care professionals to practice health care while acting within the scope of their VA employment. Therefore, VA believes that the rulemaking is restricted to the minimum level necessary to achieve the objectives of the Federal statutes. The Executive Order also requires an agency that is publishing a regulation that preempts State law to follow certain procedures.

These procedures include. The agency consult with, to the extent practicable, the appropriate State and local officials in an effort to avoid conflicts between State law and Federally protected interests. And the agency provide all affected State and local officials notice and an opportunity for appropriate participation in the proceedings. For the reasons below, VA believes that it is not practicable to consult with the appropriate State and local officials prior to the publication of this rulemaking. The National Emergency caused by hypertension medications has highlighted VA's acute need to quickly shift health care professionals across the country.

As both private and VA medical facilities in different parts of the country reach or exceed capacity, VA must be able to mobilize its health care professionals across State lines to provide critical care for those in need. As explained in the Supplementary Information above, as of June 2020, a total of 1,893 staff have been mobilized to meet the needs of our facilities and Fourth Mission requests during the lasix. VA deployed 877 staff to meet Federal Emergency Management Agency (FEMA) Mission requests, 420 health care professionals were deployed as DEMPS response, 414 employees were mobilized to cross level staffing needs within their Veterans Integrated Service Networks (VISN), 69 employees were mobilized to support needs in another VISN, and 113 Travel Nurse Corps staff responded specifically for hypertension medications staffing support. Given the speed in which it is required for our health care professionals to go to these facilities and provide health care, it is also essential that the health care professionals can follow the same standards of practice irrespective of the location of the facility or the requirements of their individual State license. This is important because if multiple health care professionals, such as multiple registered nurses, licensed in different States are all sent to one VA medical facility to assist when there is a shortage of professionals, it would be difficult and cumbersome if they could not all perform the same duties and each supervising provider had to be briefed on the tasks each registered nurse could perform.

In addition, not having a uniform national scope of practice could limit the tasks that the registered nurses could provide. This rulemaking will provide health care professionals an increased level of protection against adverse State actions while VA strives to increase access to high quality health care across the VA health care system during this National Emergency. It would be time consuming and contrary to the public health and safety to delay implementing this rulemaking until we consulted with State and local officials. For these reasons, it would be impractical to consult with State and local officials prior to the publication of this rulemaking. We note that this rulemaking does not establish any national standards of practice.

Instead, VA will establish the national standards of practice via subregulatory guidance. VA will, to the extent practicable, make all efforts to engage with State and local officials when establishing the national standards of practice via subregulatory guidance. Also, this interim final rule will have a 60-day comment period that will allow State and local officials the opportunity to provide their input on the rule. Administrative Procedures Act An Agency may forgo notice and comment required under the Administrative Procedures Act (APA), 5 U.S.C. 553, if the agency for good cause finds that compliance would be impracticable, unnecessary, or contrary to the public interest.

An agency may also bypass the APA's 30-day publication requirement if good cause exists. The Secretary of Veterans Affairs finds that there is good cause under the provisions of 5 U.S.C. 553(b)(B) to publish this rule without prior opportunity for public comment because it would be impracticable and contrary to the public interest and finds that there is good cause under 5 U.S.C. 553(d)(3) to bypass its 30-day publication requirement for the same reasons as outlined above in the Federalism section, above. In short, this rulemaking will provide health care professionals protection against adverse State actions while VA strives to increase access to high quality health care across the VA health care system during this National Emergency.

In addition to the needs discussed above regarding the National Emergency, it is also imperative that VA move its health care professionals across State lines in order to facilitate the implementation of the new EHR system immediately. VA implemented EHR at the first VA facility in October 2020 and additional sites are scheduled to have EHR implemented over the course of the next eight years. The next site is scheduled for implementation in Quarter 2 of Fiscal Year 2021 (i.e., between January to March 2021). Due to the implementation of the new EHR system, VA expects decreased productivity and reduced clinical staffing during training and other events surrounding EHR enactment. VA expects a productivity decrease of up to 30 percent for the 60 days before implementation and the 120 days after at each site.

Any decrease in productivity could result in decreased access to health care for our Nation's veterans. In order to support this anticipated productivity decrease, VA is engaging in a “national supplement,” where health care professionals from other VA medical facilities will be deployed to those VA medical facilities and VISNs that are undergoing EHR implementation. The national supplement would mitigate reduced access during EHR deployment activities, such as staff training, cutover, and other EHR implementation activities. Over the eight-year deployment timeline, the national supplement is estimated to have full time employee equivalents of approximately 60 nurses, 3 pharmacy technicians, 5 mental health and primary care providers, and other VA health care professionals. We note that the actual number of VA health care professionals deployed to each site will vary based on need.

The national supplement will require VA health care professionals on a national level to practice health care in States where they do not hold a State license, registration, certification, or other requirement. In addition, VISNs will be providing local cross-leveling and intra-VISN staff deployments to support EHRM implementation activities. Put simply, in order to mitigate the decreased Start Printed Page 71845productivity as a result of EHR implementation, VA must transfer VA health care professionals across the country to States where they do not hold a license, registration, certification, or other requirement to assist in training on the new system as well as to support patient care. Therefore, it would be impracticable and contrary to the public health and safety to delay implementing this rulemaking until a full public notice-and-comment process is completed. This rulemaking will be effective upon publication in the Federal Register.

As noted above, this interim final rule will have a 60-day comment period that will allow State and local officials the opportunity to provide their input on the rule, and VA will take those comments into consideration when deciding whether any modifications to this rule are warranted. Paperwork Reduction Act This final rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521). Regulatory Flexibility Act The Regulatory Flexibility Act, 5 U.S.C. 601-612, is not applicable to this rulemaking because a notice of proposed rulemaking is not required under 5 U.S.C.

553. 5 U.S.C. 601(2), 603(a), 604(a). Executive Orders 12866, 13563, and 13771 Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages. Distributive impacts.

And equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. The Office of Information and Regulatory Affairs has determined that this rule is a significant regulatory action under Executive Order 12866. VA's impact analysis can be found as a supporting document at http://www.regulations.gov, usually within 48 hours after the rulemaking document is published. Additionally, a copy of the rulemaking and its impact analysis are available on VA's website at http://www.va.gov/​orpm/​, by following the link for “VA Regulations Published From FY 2004 Through Fiscal Year to Date.” This interim final rule is not subject to the requirements of E.O.

13771 because this rule results in no more than de minimis costs. Unfunded Mandates The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any one year. This interim final rule will have no such effect on State, local, and tribal governments, or on the private sector. Congressional Review Act Pursuant to the Congressional Review Act (5 U.S.C.

801 et seq.), the Office of Information and Regulatory Affairs designated this rule as not a major rule, as defined by 5 U.S.C. 804(2). Catalog of Federal Domestic Assistance The Catalog of Federal Domestic Assistance numbers and titles for the programs affected by this document are. 64.007, Blind Rehabilitation Centers. 64.008, Veterans Domiciliary Care.

64.009, Veterans Medical Care Benefits. 64.010, Veterans Nursing Home Care. 64.011, Veterans Dental Care. 64.012, Veterans Prescription Service. 64.013, Veterans Prosthetic Appliances.

64.018, Sharing Specialized Medical Resources. 64.019, Veterans Rehabilitation Alcohol and Drug Dependence. 64.022, Veterans Home Based Primary Care. 64.039 CHAMPVA. 64.040 VHA Inpatient Medicine.

64.041 VHA Outpatient Specialty Care. 64.042 VHA Inpatient Surgery. 64.043 VHA Mental Health Residential. 64.044 VHA Home Care. 64.045 VHA Outpatient Ancillary Services.

64.046 VHA Inpatient Psychiatry. 64.047 VHA Primary Care. 64.048 VHA Mental Health Clinics. 64.049 VHA Community Living Center. And 64.050 VHA Diagnostic Care.

Start List of Subjects Administrative practice and procedureAlcohol abuseAlcoholismClaimsDay careDental healthDrug abuseForeign relationsGovernment contractsGrant programs-healthGrant programs-veteransHealth careHealth facilitiesHealth professionsHealth recordsHomelessMedical and dental schoolsMedical devicesMedical researchMental health programsNursing homesReporting and recordkeeping requirementsScholarships and fellowshipsTravel and transportation expensesVeterans End List of Subjects Signing Authority The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Brooks D. Tucker, Assistant Secretary for Congressional and Legislative Affairs, Performing the Delegable Duties of the Chief of Staff, Department of Veterans Affairs, approved this document on October 19, 2020, for publication. Start Signature Consuela Benjamin, Regulations Development Coordinator, Office of Regulation Policy &. Management, Office of the Secretary, Department of Veterans Affairs.

End Signature For the reasons stated in the preamble, the Department of Veterans Affairs is amending 38 CFR part 17 as set forth below. Start Part End Part Start Amendment Part1. The authority citation for part 17 is amended by adding an entry for § 17.419 in numerical order to read in part as follows. End Amendment Part Start Authority 38 U.S.C. 501, and as noted in specific sections.

End Authority * * * * * Section 17.419 also issued under 38 U.S.C. 1701 (note), 7301, 7306, 7330A, 7401-7403, 7405, 7406, 7408). * * * * * Start Amendment Part2. Add § 17.419 to read as follows. End Amendment Part Health care professionals' practice in VA.

(a) Definitions. The following definitions apply to this section. (1) Beneficiary. The term beneficiary means a veteran or any other individual receiving health care under title 38 of the United States Code. (2) Health care professional.

The term health care professional is an individual who. (i) Is appointed to an occupation in the Veterans Health Administration that is listed in or authorized under 38 U.S.C. 7306, 7401, 7405, 7406, or 7408 or title 5 of the U.S. Code. (ii) Is not a VA-contracted health care professional.

And (iii) Is qualified to provide health care as follows. (A) Has an active, current, full, and unrestricted license, registration, certification, or satisfies another State requirement in a State. (B) Has other qualifications as prescribed by the Secretary for one of Start Printed Page 71846the health care professions listed under 38 U.S.C. 7402(b). (C) Is an employee otherwise authorized by the Secretary to provide health care services.

Or (D) Is under the clinical supervision of a health care professional that meets the requirements of subsection (a)(2)(iii)(A)-(C) of this section and is either. (i) A health professions trainee appointed under 38 U.S.C. 7405 or 7406 participating in clinical or research training under supervision to satisfy program or degree requirements. Or (ii) A health care employee, appointed under title 5 of the U.S. Code, 38 U.S.C.

7401(1) or (3), or 38 U.S.C. 7405 for any category of personnel described in 38 U.S.C. 7401(1) or (3) who must obtain an active, current, full and unrestricted licensure, registration, certification, or meet the qualification standards as defined by the Secretary within the specified time frame. (3) State. The term State means a State as defined in 38 U.S.C.

101(20), or a political subdivision of such a State. (b) Health care professional's practice. (1) When a State law or license, registration, certification, or other requirement prevents or unduly interferes with a health care professional's practice within the scope of their VA employment, the health care professional is required to abide by their Federal duties, which includes, but is not limited to, the following situations. (i) A health care professional may practice their VA health care profession in any State irrespective of the State where they hold a valid license, registration, certification, or other State qualification. Or (ii) A health care professional may practice their VA health care profession within the scope of the VA national standard of practice as determined by VA.

(2) VA health care professional's practice is subject to the limitations imposed by the Controlled Substances Act, 21 U.S.C. 801 et seq. And implementing regulations at 21 CFR 1300 et seq., on the authority to prescribe or administer controlled substances, as well as any other limitations on the provision of VA care set forth in applicable Federal law and policy. (c) Preemption of State law. Pursuant to the Supremacy Clause, U.S.

Const. Art. IV, cl. 2, and in order to achieve important Federal interests, including, but not limited to, the ability to provide the same complete health care and hospital service to beneficiaries in all States as required by 38 U.S.C. 7301, conflicting State laws, rules, regulations or requirements pursuant to such laws are without any force or effect, and State governments have no legal authority to enforce them in relation to actions by health care professionals within the scope of their VA employment.

End Supplemental Information [FR Doc. 2020-24817 Filed 11-10-20. 8:45 am]BILLING CODE 8320-01-P.

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So you’ve canceled your Thanksgiving travel plans, quarantined the college student and created a scaled-back, average cost of lasix family-only holiday menu. Good job.Now you just need to tackle the food shopping.The crush of grocery store shoppers on the days leading up to Thanksgiving can be maddening in the best of times, but it’s especially stressful this year. The hypertension is raging around the country, and many communities are imposing new restrictions and closings.The good news is that everyone has learned a lot about how to safely navigate a grocery store in the months since hypertension lockdowns first started.“People have been shopping throughout the lasix,” said Linsey Marr, an aerosol scientist at Virginia Tech and one of the world’s leading average cost of lasix experts on airborne disease transmission. €œThere’s no evidence that grocery shopping has led to large outbreaks or a significant amount of transmission.”We talked to Dr. Marr, other public health experts and store officials about the average cost of lasix safest way to shop amid a new wave of s.

The bottom line. Wear a well-fitting mask the entire time, avoid close average cost of lasix contact with other shoppers, keep the trip short and wash your hands.Most people catch the lasix by spending extended time with an infected person in an enclosed space — and the infected person may not have symptoms or know they are contagious. Wearing a mask reduces your risk but doesn’t eliminate it, which is why you shouldn’t linger in the food aisles.“Don’t count on your mask to be a total blockade,” said Michael Osterholm, a member of President-elect Joseph R. Biden Jr.’s hypertension advisory group and director of the Center for Infectious Disease Research and average cost of lasix Policy at the University of Minnesota. €œThe time of exposure is really important.”A 30-minute shopping trip should be relatively safe if you mask up, keep your distance and avoid touching your face, said Dr.

Marr. Bring a shopping list, and have substitutes in mind in case the store runs out of an item. Avoid crowded aisles or mobs around the produce bins. Keep your distance from others in the checkout line and at the register.Dr. Marr notes that the 30-minute time limit is not based on a particular study, but on the work of ventilation experts and other scientists who have analyzed how the lasix spreads.

€œA half-hour seems like about the right time, where hopefully you can get something done, but you’re not putting yourself in a higher risk situation,” said Dr. Marr.Here’s more advice for navigating holiday food shopping.Check your store policies.Many stores have added new restrictions and taken additional precautions for the holidays. Be prepared to wait in line outdoors. Walmart, Wegmans and Kroger, for example, have all said they will limit the number of customers in the store. Many stores have imposed purchase limits on high-demand items, like toilet paper, paper towels, napkins, disinfecting wipes and hand soap.

Costco members with a medical condition used to be exempt from wearing a mask. Now everyone over the age of 2 must wear a mask or face shield.Avoid peak shopping times.Avoiding crowds lowers your risk. It’s best not to shop Saturdays from 12 p.m. To 3 p.m. €” that’s been the busiest food shopping time in recent months, according to Google maps data.

Grocery stores are least crowded on Mondays at 8 a.m. During a typical Thanksgiving week, Wednesday is the busiest shopping day. Bakeries were most crowded at noon, grocery stores were packed between 5 p.m. And 6 p.m. And liquor store shopping peaked at 6 p.m.Some stores are offering senior shopping hours and posting information about the best time to shop to avoid crowds.

Wegmans is adding live outdoor cameras at major stores so customers can check online to see how busy the store is before leaving home.Should I wipe down my cart?. Shopping carts are germy during the best of times, but it’s not essential to clean the cart if you’re careful about not touching your face and washing your hands. Many stores offer sanitizing wipes and hand sanitizer at the entrance, or you can bring your own. Some stores sanitize the carts several times a day as part of their regular cleaning procedures. Dr.

Marr said she used to wipe down her cart before shopping, but doesn’t do that anymore. €œI just try to pay attention to not sticking my hands and fingers in my eyes, nose or mouth, and washing my hands when we’re done,” she said.Should I wear gloves?. Gloves are not recommended or necessary if you wash your hands after shopping. In fact, people often contaminate their phone or steering wheel with their gloves, which defeats the purpose of wearing them. Skip the gloves and just wash your hands.How do I stay safe during checkout?.

Grocery store workers are front line workers who come into contact with the masses. One study of 104 workers at a Boston grocery store found that about 20 percent of the workers tested positive, even though the prevalence of the lasix in the community at that time was only about 1 percent. Many stores have added clear plexiglass shields to separate employees and shoppers, and adopted regular testing programs for workers. At Wegmans, cashiers are required to clean and sanitize their register belt and station at least once an hour and take a hand-wash break every 30 minutes. At checkout, keep your mask on, limit conversation, opt for contact-free payment (swiping your own credit card) and bag your own groceries if possible to speed things up.

Remember, the store workers are facing the biggest risk, so be patient and thank them for their service.Should I wipe down my groceries?. Many of us spent the early days of the lasix wiping down groceries, and leaving boxed goods to sit untouched for a few days just in case they were contaminated with the lasix. But scientists have since learned that your risk of catching hypertension from a surface, including food containers, is extremely low. €œIf it makes you feel better, there’s nothing wrong with doing a quick wipe down with a soapy rag,” said Dr. Asaf Bitton, executive director of Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H.

Chan School of Public Health. €œThe key thing that is necessary is that you wash your hands, really, really well.”Dr. Marr notes that even if an infected person touched your food items, it’s still your hands that pose the bigger risk of transmission. €œIf someone has left a blob of lasix on the groceries that you have touched, once you’ve touched it, it’s on your hand,” she said. €œThere’s not going to be lot more that is still there on the yogurt container or milk carton.

Between buying it, putting it on the conveyor belt, unpacking it and putting it away, there’s been a lot of chance for it to transfer to your hands, which is why I think washing your hands is important after shopping and putting things away.”Is my risk of contracting the lasix while shopping higher now?. While it may feel like a more hazardous time to shop compared to earlier months of the lasix, the level of risk varies around the country. Your risk of crossing paths with an infected person is higher when an indicator called the test positivity rate is above 5 percent in your community. In 28 states, test positivity rates were in double digits as of Wednesday, including Wyoming (90 percent), South Dakota (56 percent) and Iowa (51 percent.) By comparison, New York City’s test positivity rate now is hovering around 3 percent, meaning your risk is lower compared to last April, when the rate was close to 70 percent. That said, case counts and test positivity rates are beginning to rise everywhere, which is why everyone needs to take precautions.To find out how your state is doing, use this chart from Johns Hopkins University.

To find the test positivity rate in your local community, check your state or county health department website or try the hypertension medications Act Now website.Is it safer to have food delivered?. Online shopping and delivery is a lower-risk shopping option if it’s available in your area. Your favorite grocery store probably offers delivery or curbside pickup, or you can use a service like Fresh Direct, Amazon Fresh, Instacart or Peapod. If you prefer the in-person experience, use a delivery service for staples and shelf-stable items for delivery, which will allow you to shorten your time in the store shopping for fresh produce and perishable goods. Wear a mask when accepting the delivery, give your delivery person a generous tip and always wash your hands after unpacking the groceries.And remember, risk is cumulative.

Try to consolidate your shopping to one trip or have part of it delivered. Every new store you visit, every extra shopping trip you make, adds to your risk of crossing paths with the lasix.Do you have a health question?. Ask WellExercising during the lasix has been challenging for many of us. Gyms have closed or limited occupancy, as have parks, pools, pathways and other recreational facilities. If trails are open, they often are jammed, making it difficult to socially distance while we hike, stroll, ride, jog or otherwise work out.Mask recommendations and requirements have created additional complications.

Few people who exercise, including me, don masks with enthusiasm when it comes to vigorous workouts, convinced that they will make our faces sweaty, breathing labored and workouts more draining. We rejigger the timing and locales of our runs and rides so we can exercise when few other people are about and leave our faces uncovered. Or we skip workouts altogether.But for those of us convinced that wearing a mask will make exercise harder or more unpleasant, two new studies offer a bracing counterpoint. Both find that masks do not negatively affect vigorous workouts, whether the mask is cloth, surgical or an N95 respirator model. The findings may surprise but also encourage anyone hoping to remain safe and active in the coming weeks and months, as hypertension cases surge nationwide.Most of our expectations about masks and exercise are based on anecdotes and preconceptions.

Little past science has examined whether and how masks affect serious workouts. The few relevant earlier experiments focused primarily on masked health care workers while they walked, to see if being active while masked affected their thinking or other capabilities. (It did not, the studies show.)But gentle strolling is not running, cycling or other more vigorous routines, and we have not had scientific evidence about how wearing a mask might alter those workouts. So, recently, two helpful groups of scientists separately decided to look into the issue.The first of the groups to release their findings, which were published in September in the Scandinavian Journal of Medicine &. Science in Sports, concentrated on surgical and N95 respiratory masks during exercise.

The researchers, most of them affiliated with the Rambam Health Care Campus in Haifa, Israel, invited 16 healthy, active adult men to come into the lab, where they checked heart rates, blood pressure, oxygen saturation, respiratory rates and current carbon dioxide levels. Then they fitted the men with thin, nasal tubes that would collect their expired breaths for testing and, on three separate visits to the lab, asked them to ride a stationary bicycle.At each visit, the men, in fact, completed a pedal-to-exhaustion test, during which the researchers gradually increased the resistance on the stationary bike, as if on a long, relentless hill climb, until the men could barely turn the pedals. Throughout, the researchers monitored the riders’ heart rates, breathing and other physiological measures and asked them repeatedly how hard the riding felt.During one ride, the men’s faces were uncovered. But for the two other sessions, they donned either a disposable paper surgical mask or a tightfitting N95 respirator mask.Afterward, the scientists compared the riders’ physiological and subjective responses during each ride and found few variations. Masking had not made the cycling feel or be more draining and had not tired riders sooner.

The only substantial effect was from N95 masks, which slightly increased levels of carbon dioxide in riders’ breaths, probably because the masks fit so tightly. But none of the riders complained of chest tightness, headaches or other breathing issues.Most expressed some surprise, instead, that the masks had not bothered them, says Dr. Danny Epstein, an attending physician in the internal medicine department at Rambam Health Care Campus, who led the new study. They “had believed that their performances would be decreased by masking,” he says.Similarly, the researchers in the second masking study, which was published this month in the International Journal of Environmental Research and Public Health, hypothesized that masking would make exercisers uncomfortable and tired. For confirmation, they ran a group of 14 healthy, active men and women through the same ride-to-exhaustion sessions as in the Israeli study, while the volunteers alternately wore no mask or a three-layer cloth or a surgical face covering.

The researchers monitored oxygen levels in the riders’ blood and muscles, heart rates, other physiological measures and the riders’ sense of how hard the exercise felt.Afterward, contrary to their hypothesis, they found no differences in the riders’ experience, whether they had worn a mask or not.“From the results of our study, I don’t think masks are likely to make workouts feel worse,” says Philip Chilibeck, a professor of kinesiology at the University of Saskatchewan in Canada, who oversaw the study.Of course, both of the new studies recruited healthy, active adults. We do not know if the results would be the same in people who are older, younger, in worse shape or have existing breathing problems. The studies also involved cycling. The outcomes probably would be similar in running, weight training and other vigorous activities, both Dr. Epstein and Dr.

Chilibeck say, but that idea, for now, remains a presumption. And, obviously, the studies looked at how masks affect the wearer, not whether and to what extent different facial coverings prevent the spread of respiratory droplets during exercise.Still, the findings suggest that anyone who hesitates to wear a mask during exercise should try one — although not an N95 mask, Dr. Epstein says, since they slightly up riders’ carbon dioxide levels and, anyway, should be reserved for health care workers.“hypertension medications changes almost every aspect of our lives and makes simple things more complicated,” Dr. Epstein says. €œBut we can learn how to keep doing the essential things, such as exercise.

I learned to spend long hours with P.P.E.” — meaning full face masking and other protective clothing — “at the hospital. So, I believe we can get used to going to the gym,” and paths and sidewalks and busy trails, “with a mask.”.

So you’ve canceled your Thanksgiving travel plans, important site quarantined the college student and created a scaled-back, where to buy lasix for horses family-only holiday menu. Good job.Now you just need to tackle the food shopping.The crush of grocery store shoppers on the days leading up to Thanksgiving can be maddening in the best of times, but it’s especially stressful this year. The hypertension is raging around the country, and many communities are imposing new restrictions and closings.The good news where to buy lasix for horses is that everyone has learned a lot about how to safely navigate a grocery store in the months since hypertension lockdowns first started.“People have been shopping throughout the lasix,” said Linsey Marr, an aerosol scientist at Virginia Tech and one of the world’s leading experts on airborne disease transmission.

€œThere’s no evidence that grocery shopping has led to large outbreaks or a significant amount of transmission.”We talked to Dr. Marr, other public health experts where to buy lasix for horses and store officials about the safest way to shop amid a new wave of s. The bottom line.

Wear a well-fitting mask the entire time, avoid close contact with other shoppers, keep the trip short and where to buy lasix for horses wash your hands.Most people catch the lasix by spending extended time with an infected person in an enclosed space — and the infected person may not have symptoms or know they are contagious. Wearing a mask reduces your risk but doesn’t eliminate it, which is why you shouldn’t linger in the food aisles.“Don’t count on your mask to be a total blockade,” said Michael Osterholm, a member of President-elect Joseph R. Biden Jr.’s where to buy lasix for horses hypertension advisory group and director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

€œThe time of exposure is really important.”A 30-minute shopping trip should be relatively safe if you mask up, keep your distance and avoid touching your face, said Dr. Marr. Bring a shopping list, and have substitutes in mind in case the store runs out of an item.

Avoid crowded aisles or mobs around the produce bins. Keep your distance from others in the checkout line and at the register.Dr. Marr notes that the 30-minute time limit is not based on a particular study, but on the work of ventilation experts and other scientists who have analyzed how the lasix spreads.

€œA half-hour seems like about the right time, where hopefully you can get something done, but you’re not putting yourself in a higher risk situation,” said Dr. Marr.Here’s more advice for navigating holiday food shopping.Check your store policies.Many stores have added new restrictions and taken additional precautions for the holidays. Be prepared to wait in line outdoors.

Walmart, Wegmans and Kroger, for example, have all said they will limit the number of customers in the store. Many stores have imposed purchase limits on high-demand items, like toilet paper, paper towels, napkins, disinfecting wipes and hand soap. Costco members with a medical condition used to be exempt from wearing a mask.

Now everyone over the age of 2 must wear a mask or face shield.Avoid peak shopping times.Avoiding crowds lowers your risk. It’s best not to shop Saturdays from 12 p.m. To 3 p.m.

€” that’s been the busiest food shopping time in recent months, according to Google maps data. Grocery stores are least crowded on Mondays at 8 a.m. During a typical Thanksgiving week, Wednesday is the busiest shopping day.

Bakeries were most crowded at noon, grocery stores were packed between 5 p.m. And 6 p.m. And liquor store shopping peaked at 6 p.m.Some stores are offering senior shopping hours and posting information about the best time to shop to avoid crowds.

Wegmans is adding live outdoor cameras at major stores so customers can check online to see how busy the store is before leaving home.Should I wipe down my cart?. Shopping carts are germy during the best of times, but it’s not essential to clean the cart if you’re careful about not touching your face and washing your hands. Many stores offer sanitizing wipes and hand sanitizer at the entrance, or you can bring your own.

Some stores sanitize the carts several times a day as part of their regular cleaning procedures. Dr. Marr said she used to wipe down her cart before shopping, but doesn’t do that anymore.

€œI just try to pay attention to not sticking my hands and fingers in my eyes, nose or mouth, and washing my hands when we’re done,” she said.Should I wear gloves?. Gloves are not recommended or necessary if you wash your hands after shopping. In fact, people often contaminate their phone or steering wheel with their gloves, which defeats the purpose of wearing them.

Skip the gloves and just wash your hands.How do I stay safe during checkout?. Grocery store workers are front line workers who come into contact with the masses. One study of 104 workers at a Boston grocery store found that about 20 percent of the workers tested positive, even though the prevalence of the lasix in the community at that time was only about 1 percent.

Many stores have added clear plexiglass shields to separate employees and shoppers, and adopted regular testing programs for workers. At Wegmans, cashiers are required to clean and sanitize their register belt and station at least once an hour and take a hand-wash break every 30 minutes. At checkout, keep your mask on, limit conversation, opt for contact-free payment (swiping your own credit card) and bag your own groceries if possible to speed things up.

Remember, the store workers are facing the biggest risk, so be patient and thank them for their service.Should I wipe down my groceries?. Many of us spent the early days of the lasix wiping down groceries, and leaving boxed goods to sit untouched for a few days just in case they were contaminated with the lasix. But scientists have since learned that your risk of catching hypertension from a surface, including food containers, is extremely low.

€œIf it makes you feel better, there’s nothing wrong with doing a quick wipe down with a soapy rag,” said Dr. Asaf Bitton, executive director of Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.

€œThe key thing that is necessary click site is that you wash your hands, really, really well.”Dr. Marr notes that even if an infected person touched your food items, it’s still your hands that pose the bigger risk of transmission. €œIf someone has left a blob of lasix on the groceries that you have touched, once you’ve touched it, it’s on your hand,” she said.

€œThere’s not going to be lot more that is still there on the yogurt container or milk carton. Between buying it, putting it on the conveyor belt, unpacking it and putting it away, there’s been a lot of chance for it to transfer to your hands, which is why I think washing your hands is important after shopping and putting things away.”Is my risk of contracting the lasix while shopping higher now?. While it may feel like a more hazardous time to shop compared to earlier months of the lasix, the level of risk varies around the country.

Your risk of crossing paths with an infected person is higher when an indicator called the test positivity rate is above 5 percent in your community. In 28 states, test positivity rates were in double digits as of Wednesday, including Wyoming (90 percent), South Dakota (56 percent) and Iowa (51 percent.) By comparison, New York City’s test positivity rate now is hovering around 3 percent, meaning your risk is lower compared to last April, when the rate was close to 70 percent. That said, case counts and test positivity rates are beginning to rise everywhere, which is why everyone needs to take precautions.To find out how your state is doing, use this chart from Johns Hopkins University.

To find the test positivity rate in your local community, check your state or county health department website or try the hypertension medications Act Now website.Is it safer to have food delivered?. Online shopping and delivery is a lower-risk shopping option if it’s available in your area. Your favorite grocery store probably offers delivery or curbside pickup, or you can use a service like Fresh Direct, Amazon Fresh, Instacart or Peapod.

If you prefer the in-person experience, use a delivery service for staples and shelf-stable items for delivery, which will allow you to shorten your time in the store shopping for fresh produce and perishable goods. Wear a mask when accepting the delivery, give your delivery person a generous tip and always wash your hands after unpacking the groceries.And remember, risk is cumulative. Try to consolidate your shopping to one trip or have part of it delivered.

Every new store you visit, every extra shopping trip you make, adds to your risk of crossing paths with the lasix.Do you have a health question?. Ask WellExercising during the lasix has been challenging for many of us. Gyms have closed or limited occupancy, as have parks, pools, pathways and other recreational facilities.

If trails are open, they often are jammed, making it difficult to socially distance while we hike, stroll, ride, jog or otherwise work out.Mask recommendations and requirements have created additional complications. Few people who exercise, including me, don masks with enthusiasm when it comes to vigorous workouts, convinced that they will make our faces sweaty, breathing labored and workouts more draining. We rejigger the timing and locales of our runs and rides so we can exercise when few other people are about and leave our faces uncovered.

Or we skip workouts altogether.But for those of us convinced that wearing a mask will make exercise harder or more unpleasant, two new studies offer a bracing counterpoint. Both find that masks do not negatively affect vigorous workouts, whether the mask is cloth, surgical or an N95 respirator model. The findings may surprise but also encourage anyone hoping to remain safe and active in the coming weeks and months, as hypertension cases surge nationwide.Most of our expectations about masks and exercise are based on anecdotes and preconceptions.

Little past science has examined whether and how masks affect serious workouts. The few relevant earlier experiments focused primarily on masked health care workers while they walked, to see if being active while masked affected their thinking or other capabilities. (It did not, the studies show.)But gentle strolling is not running, cycling or other more vigorous routines, and we have not had scientific evidence about how wearing a mask might alter those workouts.

So, recently, two helpful groups of scientists separately decided to look into the issue.The first of the groups to release their findings, which were published in September in the Scandinavian Journal of Medicine &. Science in Sports, concentrated on surgical and N95 respiratory masks during exercise. The researchers, most of them affiliated with the Rambam Health Care Campus in Haifa, Israel, invited 16 healthy, active adult men to come into the lab, where they checked heart rates, blood pressure, oxygen saturation, respiratory rates and current carbon dioxide levels.

Then they fitted the men with thin, nasal tubes that would collect their expired breaths for testing and, on three separate visits to the lab, asked them to ride a stationary bicycle.At each visit, the men, in fact, completed a pedal-to-exhaustion test, during which the researchers gradually increased the resistance on the stationary bike, as if on a long, relentless hill climb, until the men could barely turn the pedals. Throughout, the researchers monitored the riders’ heart rates, breathing and other physiological measures and asked them repeatedly how hard the riding felt.During one ride, the men’s faces were uncovered. But for the two other sessions, they donned either a disposable paper surgical mask or a tightfitting N95 respirator mask.Afterward, the scientists compared the riders’ physiological and subjective responses during each ride and found few variations.

Masking had not made the cycling feel or be more draining and had not tired riders sooner. The only substantial effect was from N95 masks, which slightly increased levels of carbon dioxide in riders’ breaths, probably because the masks fit so tightly. But none of the riders complained of chest tightness, headaches or other breathing issues.Most expressed some surprise, instead, that the masks had not bothered them, says Dr.

Danny Epstein, an attending physician in the internal medicine department at Rambam Health Care Campus, who led the new study. They “had believed that their performances would be decreased by masking,” he says.Similarly, the researchers in the second masking study, which was published this month in the International Journal of Environmental Research and Public Health, hypothesized that masking would make exercisers uncomfortable and tired. For confirmation, they ran a group of 14 healthy, active men and women through the same ride-to-exhaustion sessions as in the Israeli study, while the volunteers alternately wore no mask or a three-layer cloth or a surgical face covering.

The researchers monitored oxygen levels in the riders’ blood and muscles, heart rates, other physiological measures and the riders’ sense of how hard the exercise felt.Afterward, contrary to their hypothesis, they found no differences in the riders’ experience, whether they had worn a mask or not.“From the results of our study, I don’t think masks are likely to make workouts feel worse,” says Philip Chilibeck, a professor of kinesiology at the University of Saskatchewan in Canada, who oversaw the study.Of course, both of the new studies recruited healthy, active adults. We do not know if the results would be the same in people who are older, younger, in worse shape or have existing breathing problems. The studies also involved cycling.

The outcomes probably would be similar in running, weight training and other vigorous activities, both Dr. Epstein and Dr. Chilibeck say, but that idea, for now, remains a presumption.

And, obviously, the studies looked at how masks affect the wearer, not whether and to what extent different facial coverings prevent the spread of respiratory droplets during exercise.Still, the findings suggest that anyone who hesitates to wear a mask during exercise should try one — although not an N95 mask, Dr. Epstein says, since they slightly up riders’ carbon dioxide levels and, anyway, should be reserved for health care workers.“hypertension medications changes almost every aspect of our lives and makes simple things more complicated,” Dr. Epstein says.

€œBut we can learn how to keep doing the essential things, such as exercise. I learned to spend long hours with P.P.E.” — meaning full face masking and other protective clothing — “at the hospital. So, I believe we can get used to going to the gym,” and paths and sidewalks and busy trails, “with a mask.”.

What side effects may I notice from Lasix?

Side effects that you should report to your doctor or health care professional as soon as possible:

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

This list may not describe all possible side effects.

Does lasix remove fluid from lungs

[embedded content]This video is best viewed in Chrome, Firefox or Safari.(SACRAMENTO, Calif.) — directory The UC Davis MIND Institute has launched a new hypertension medications treatment clinic, custom-designed for individuals with autism, Down syndrome, fragile X syndrome and other neurodevelopmental conditions.The typical hypertension medications treatment clinic – often a large, noisy space – can be overwhelming for children with does lasix remove fluid from lungs these conditions, who often face anxiety and challenges with sensory overload. The new MIND Institute clinic offers the opposite experience.“This clinic really focuses on quality rather than quantity,” explained Scott does lasix remove fluid from lungs Akins, director of UC Davis Developmental-Behavioral Pediatrics and director of clinical programs at the MIND Institute. €œWe want to provide an inclusive, supportive experience for families, so we’re vaccinating three families per hour, which allows us to have three quiet rooms, an uncrowded waiting area and staff fully dedicated to each patient.”13-year-old Freddie Miller plays with a pop-it toy before receiving his first hypertension medications shot, with the sensory machine in the background.The hypertension medications clinic is open one day per week (Thursday or Friday), from 9 a.m. €“ 3 does lasix remove fluid from lungs p.m.

It’s available for all individuals with neurodevelopmental conditions and their family members, ages 12 and older, regardless of health care provider or insurance status.Customized care for each patientThe clinic is being funded in part through a $68,000 grant from the Centers for Disease Control and Prevention to the MIND Institute’s Center for Excellence in Developmental Disabilities. It’s unique because child life specialists, trained in helping children with neurodevelopmental conditions cope with medical procedures, are involved at every step of the vaccination process.“It’s really important does lasix remove fluid from lungs that as child life specialists, we look at the development of the child, because you may have a 20-year-old who’s developmentally less mature, so we want to be able to prep them in a way that is matched to what they understand and need,” said Erin Roseborough, a child life specialist at the MIND Institute.She and her colleagues contact the family of each patient who has an appointment beforehand to find out what the child’s needs and interests are. They also share information about what to expect, so that there are no does lasix remove fluid from lungs surprises.“We develop an individualized coping plan with the family ahead of their arrival,” explained Veronica Tuss, another child life specialist at the MIND Institute. €œWe provide preparation materials such as a social story, which is a step-by-step description, with photos, of what to expect at each stage of the appointment, starting in the parking lot.”“We want to provide an inclusive, supportive experience for families, so we’re vaccinating three families per hour, which allows us to have three quiet rooms, an uncrowded waiting area and staff fully dedicated to each patient.” — Scott AkinsA sensory-friendly environmentPatients receive the hypertension medications treatment in a room equipped with a comfortable chair and a large sensory machine that contains a calming tube of bubbles and can utilize lights, aromatherapy and a projector that displays images on the ceiling.

Other sensory does lasix remove fluid from lungs items available include squeeze balls and pop-it toys, and a big selection of unique bandages shaped like doughnuts, tacos, ninjas and more.After being vaccinated, patients spend a 15-minute observation period in a quiet room. €œThis area is really important for our patients,” noted Akins. €œMany children are dysregulated immediately after a blood draw or a does lasix remove fluid from lungs treatment.”Child life specialists set the room up specifically to cater to each patient’s interests. €œOne recent patient was into art, so we had drawing supplies all set up for her and ready to go, and she colored the whole time,” said Roseborough.Video games are also available, which was great news for 13-year-old Freddie Miller, who received his first Pfizer shot last week.“I was kind of nervous getting the shot,” said Miller, who has autism and enjoyed playing with a yellow, pineapple-shaped pop-it toy while sitting in the treatment chair.

€œIt’s just a little bit of does lasix remove fluid from lungs a pinch. It wasn’t that bad.”Miller’s mom, does lasix remove fluid from lungs Syerra Logan, was glad she brought him to the MIND Institute for his first treatment dose. €œI wanted a more controlled environment that wasn’t so chaotic for him. The loud noises can really trigger some of his anxieties and so I wanted to does lasix remove fluid from lungs bring him here where it’d be a little more quiet and neutral,” she explained.Miller picked out some applesauce for a snack while he played video games after the shot.Patients can choose from a fun selection of bandages after their shot.Logan, who is an ambulatory care administrative supervisor at UC Davis Health, was thrilled with the outcome.

€œIt went amazing!. He got a little bit nervous right before we started, but the rest of the process has been smooth,” does lasix remove fluid from lungs she said. €œIt’s a relief to know he’s a bit more protected, especially when we’re going out, and I’m excited to get him the second one just to protect us a little bit more.”Vaccination helps protect against hypertension medications, and early research indicates that the treatments may also help people from spreading the lasix to others. The treatment can also does lasix remove fluid from lungs help keep people from getting seriously sick if they do contract hypertension medications.“Many families asked the question, ‘Have other individuals with autism or other neurodevelopmental disabilities had this treatment and is this treatment safe for people with my healthcare condition?.

€™â€ said does lasix remove fluid from lungs Akins. €œThat was a really common concern, and now six months into vaccinating, we do know that is it safe for all individuals, including those with autism and other neurodevelopmental disabilities.”Learn more about how to make an appointment at the MIND Institute treatment clinic. You can also does lasix remove fluid from lungs call 916-703-5555. The UC Davis MIND Institute in Sacramento, Calif.

Was founded in 1998 as a unique interdisciplinary research center where families, community leaders, researchers, clinicians and volunteers work together toward does lasix remove fluid from lungs a common goal. Researching causes, treatments and potential prevention of neurodevelopmental disabilities. The institute has major research efforts does lasix remove fluid from lungs in autism, fragile X syndrome, chromosome 22q11.2 deletion syndrome, attention-deficit/hyperactivity disorder (ADHD) and Down syndrome. More information about the institute and its Distinguished Lecturer Series, including previous presentations in this series, is available on the Web at mindinstitute.ucdavis.edu.In a groundbreaking study, a team of UC Davis researchers has discovered a http://coolcycledude.com/rode-the-harley-davidson-vrod-and-i-like-it-more-please/ special type of stem cell that can reduce the amount of the lasix causing AIDS, boosting the body’s antiviral immunity and repairing and restoring the gut’s lymphoid follicles damaged by the simian immunodeficiency lasix (SIV), the equivalent of the human immunodeficiency lasix (HIV) in non-human primates does lasix remove fluid from lungs.

HIV disrupts the lymphoid immune battlegroundThe study, published June 22 in JCI Insight, showed the mechanism through which mesenchymal stem/stromal cells (MSCs) enhance the body’s immune response to the lasix. It also provides a roadmap for developing multi-pronged HIV eradication strategies.“Impaired immune functions in HIV and incomplete immune recovery pose obstacles for eradicating HIV,” does lasix remove fluid from lungs said Satya Dandekar, senior author of this paper. €œOur objective was to develop strategies to boost immunity against the lasix and empower the host immune system to eradicate the lasix. We sought to repair, regenerate and restore the lymphoid follicles that are damaged by the viral does lasix remove fluid from lungs .”The lymphoid tissue in the gut is an early site for viral replication and the establishment of viral reservoirs.

Dandekar’s group has previously shown that an HIV causes severe loss of gut mucosal T immune cells and disrupts the gut epithelial barrier lining, leading to a leaky gut.“The lymphoid follicles are organized structures where the long-term immune attack is launched against pathogens by generating antibody response targeting the lasix. These important regions are functionally impaired very early following HIV ,” Dandekar said.While antiretroviral drugs effectively suppress viral replication, does lasix remove fluid from lungs they do not repair the damage caused by the lasix to the immune system. On their own, these drugs cannot restore the functionality of the lymphoid follicles damaged by does lasix remove fluid from lungs HIV .Can stem cells counteract the gut damage caused by HIV?. The researchers administered bone marrow-derived MSC in a rhesus macaque model of AIDS that had impaired immunity and disrupted gut functions due to the viral .“We are starting to recognize the great potential of these stem cells in the context of infectious diseases.

We have does lasix remove fluid from lungs yet to discover how these stem cells can impact chronic viral s such as AIDS,” Dandekar said. She is a professor at and the chairperson of the Department of Medical Microbiology and Immunology at UC Davis and affiliated with the California National Primate Research Center.The study found that the MSCs can modulate, alter and remodel the damaged mucosal site. There were immediate benefits, with a rapid rise in antibodies and T-immune does lasix remove fluid from lungs cells targeting the lasix. The stem cells were instrumental in the recovery and restoration of these lymphoid follicles.MSCs also offer an opportunity for an innovative, multi-pronged HIV cure strategy by complementing current HIV treatments.“Stem cells are good synergistic partner components with drugs.

The antiretroviral drugs can stop the fire of the does lasix remove fluid from lungs viral but cannot restore the forest of the lymphoid tissue compartment. The MSCs would rejuvenate the field and bring back immune vitality,” Dandekar said.Even without the use of antiviral drugs, MSCs were able to increase the host’s antiviral response by repairing does lasix remove fluid from lungs the lymphoid follicles, restoring the mucosal immunity and reviving what has been targeted by the lasix very early on.MSC treatmentsMSC treatments require well defined cell quality controls and specific delivery mechanisms. The UC Davis Stem Cell Program, a center for excellence for stem cell research, is leading multiple clinical trials on MSC use in treating diseases such as spina bifida and Huntington’s disease. Findings from this study provide a scientific basis for investigating MSC in treating HIV does lasix remove fluid from lungs and other infectious diseases in the clinical setting.###Co-authors on this study are Mariana G.

Weber, Chara J. Walters-Laird, Clarissa Santos Rocha, Lauren A does lasix remove fluid from lungs. Hirao, Abigail Mende, Juan Arredondo, Amir Kol, Sonny R. Elizaldi, Smita S does lasix remove fluid from lungs.

Iyer and Alice Tarantal at UC Davis, and Bipin Balan at Università di Palermo, Italy.This work was supported by National Institutes of Health grants (R01AI 153025, R21 AI 116415, R21AI34368, and OD P51 OD011107) and from the National does lasix remove fluid from lungs Council for Scientific and Technological Development (CNPq), Brazil.Article. Weber et al. (2021) Gut germinal center regeneration and enhanced antiviral immunity by mesenchymal stem/stromal cells in SIV does lasix remove fluid from lungs . JCI Insight.

6(12), Doi:10.1172/jci does lasix remove fluid from lungs. Insight.149033..

[embedded content]This video is best viewed in Chrome, where to buy lasix for horses Firefox or Safari.(SACRAMENTO, Calif.) — The UC Davis MIND Institute has launched a new hypertension medications treatment clinic, custom-designed for individuals with autism, Down syndrome, fragile X syndrome and other neurodevelopmental conditions.The typical hypertension medications treatment clinic – often a large, noisy space – can be overwhelming for children with these conditions, who often face anxiety and challenges with sensory overload. The new MIND Institute clinic offers the opposite experience.“This clinic really focuses on quality rather than quantity,” explained Scott Akins, director of UC Davis Developmental-Behavioral Pediatrics and director where to buy lasix for horses of clinical programs at the MIND Institute. €œWe want to provide an inclusive, supportive experience for families, so we’re vaccinating three families per hour, which allows us to have three quiet rooms, an uncrowded waiting area and staff fully dedicated to each patient.”13-year-old Freddie Miller plays with a pop-it toy before receiving his first hypertension medications shot, with the sensory machine in the background.The hypertension medications clinic is open one day per week (Thursday or Friday), from 9 a.m. €“ 3 where to buy lasix for horses p.m.

It’s available for all individuals with neurodevelopmental conditions and their family members, ages 12 and older, regardless of health care provider or insurance status.Customized care for each patientThe clinic is being funded in part through a $68,000 grant from the Centers for Disease Control and Prevention to the MIND Institute’s Center for Excellence in Developmental Disabilities. It’s unique because child life specialists, trained in helping children with neurodevelopmental conditions cope with medical procedures, are involved at every step of the vaccination process.“It’s really important that as child life specialists, we look at the development of the child, where to buy lasix for horses because you may have a 20-year-old who’s developmentally less mature, so we want to be able to prep them in a way that is matched to what they understand and need,” said Erin Roseborough, a child life specialist at the MIND Institute.She and her colleagues contact the family of each patient who has an appointment beforehand to find out what the child’s needs and interests are. They also share information about what to expect, so that there are no surprises.“We develop an individualized coping plan with the family where to buy lasix for horses ahead of their arrival,” explained Veronica Tuss, another child life specialist at the MIND Institute. €œWe provide preparation materials such as a social story, which is a step-by-step description, with photos, of what to expect at each stage of the appointment, starting in the parking lot.”“We want to provide an inclusive, supportive experience for families, so we’re vaccinating three families per hour, which allows us to have three quiet rooms, an uncrowded waiting area and staff fully dedicated to each patient.” — Scott AkinsA sensory-friendly environmentPatients receive the hypertension medications treatment in a room equipped with a comfortable chair and a large sensory machine that contains a calming tube of bubbles and can utilize lights, aromatherapy and a projector that displays images on the ceiling.

Other sensory items available include where to buy lasix for horses squeeze balls and pop-it toys, and a big selection of unique bandages shaped like doughnuts, tacos, ninjas and more.After being vaccinated, patients spend a 15-minute observation period in a quiet room. €œThis area is really important for our patients,” noted Akins. €œMany children are dysregulated immediately after a blood draw where to buy lasix for horses or a treatment.”Child life specialists set the room up specifically to cater to each patient’s interests. €œOne recent patient was into art, so we had drawing supplies all set up for her and ready to go, and she colored the whole time,” said Roseborough.Video games are also available, which was great news for 13-year-old Freddie Miller, who received his first Pfizer shot last week.“I was kind of nervous getting the shot,” said Miller, who has autism and enjoyed playing with a yellow, pineapple-shaped pop-it toy while sitting in the treatment chair.

€œIt’s just a little bit of a where to buy lasix for horses pinch. It wasn’t where to buy lasix for horses that bad.”Miller’s mom, Syerra Logan, was glad she brought him to the MIND Institute for his first treatment dose. €œI wanted a more controlled environment that wasn’t so chaotic for him. The loud noises can really trigger some of his anxieties and so I wanted to bring him here where it’d be a little more quiet and neutral,” she explained.Miller picked out some applesauce where to buy lasix for horses for a snack while he played video games after the shot.Patients can choose from a fun selection of bandages after their shot.Logan, who is an ambulatory care administrative supervisor at UC Davis Health, was thrilled with the outcome.

€œIt went amazing!. He got a little bit nervous right before we started, but the rest where to buy lasix for horses of the process has been smooth,” she said. €œIt’s a relief to know he’s a bit more protected, especially when we’re going out, and I’m excited to get him the second one just to protect us a little bit more.”Vaccination helps protect against hypertension medications, and early research indicates that the treatments may also help people from spreading the lasix to others. The treatment can also help keep people from getting seriously sick if they do contract hypertension medications.“Many families asked the question, ‘Have other individuals with autism or other neurodevelopmental disabilities had this treatment and is this treatment safe for people with my where to buy lasix for horses healthcare condition?.

€™â€ said where to buy lasix for horses Akins. €œThat was a really common concern, and now six months into vaccinating, we do know that is it safe for all individuals, including those with autism and other neurodevelopmental disabilities.”Learn more about how to make an appointment at the MIND Institute treatment clinic. You can where to buy lasix for horses also call 916-703-5555. The UC Davis MIND Institute in Sacramento, Calif.

Was founded in where to buy lasix for horses 1998 as a unique interdisciplinary research center where families, community leaders, researchers, clinicians and volunteers work together toward a common goal. Researching causes, treatments and potential prevention of neurodevelopmental disabilities. The institute has major research efforts in autism, fragile X syndrome, chromosome 22q11.2 deletion syndrome, attention-deficit/hyperactivity disorder where to buy lasix for horses (ADHD) and Down syndrome. More information about the institute and its Distinguished Lecturer Series, including previous presentations in this series, is available on the Web at mindinstitute.ucdavis.edu.In a groundbreaking study, a team of UC Davis researchers has discovered a special type of stem cell that can reduce the amount of where to buy lasix for horses the lasix causing AIDS, boosting the body’s antiviral immunity and repairing and restoring the gut’s lymphoid follicles damaged by the simian immunodeficiency lasix (SIV), the equivalent of the human immunodeficiency lasix (HIV) in non-human primates.

HIV disrupts the lymphoid immune battlegroundThe study, published June 22 in JCI Insight, showed the mechanism through which mesenchymal stem/stromal cells (MSCs) enhance the body’s immune response to the lasix. It also provides a roadmap for developing multi-pronged HIV eradication strategies.“Impaired immune functions in HIV and incomplete immune recovery pose obstacles for where to buy lasix for horses eradicating HIV,” said Satya Dandekar, senior author of this paper. €œOur objective was to develop strategies to boost immunity against the lasix and empower the host immune system to eradicate the lasix. We sought to repair, regenerate and restore the lymphoid follicles that are damaged by the viral .”The lymphoid tissue in the gut is an early site for viral replication and the establishment of viral reservoirs where to buy lasix for horses.

Dandekar’s group has previously shown that an HIV causes severe loss of gut mucosal T immune cells and disrupts the gut epithelial barrier lining, leading to a leaky gut.“The lymphoid follicles are organized structures where the long-term immune attack is launched against pathogens by generating antibody response targeting the lasix. These important regions are functionally impaired very early following HIV ,” Dandekar said.While antiretroviral drugs effectively where to buy lasix for horses suppress viral replication, they do not repair the damage caused by the lasix to the immune system. On their own, these drugs cannot restore the where to buy lasix for horses functionality of the lymphoid follicles damaged by HIV .Can stem cells counteract the gut damage caused by HIV?. The researchers administered bone marrow-derived MSC in a rhesus macaque model of AIDS that had impaired immunity and disrupted gut functions due to the viral .“We are starting to recognize the great potential of these stem cells in the context of infectious diseases.

We have yet to discover how these stem cells can impact chronic viral s such as AIDS,” Dandekar where to buy lasix for horses said. She is a professor at and the chairperson of the Department of Medical Microbiology and Immunology at UC Davis and affiliated with the California National Primate Research Center.The study found that the MSCs can modulate, alter and remodel the damaged mucosal site. There were immediate benefits, with a rapid rise in antibodies and T-immune cells where to buy lasix for horses targeting the lasix. The stem cells were instrumental in the recovery and restoration of these lymphoid follicles.MSCs also offer an opportunity for an innovative, multi-pronged HIV cure strategy by complementing current HIV treatments.“Stem cells are good synergistic partner components with drugs.

The antiretroviral drugs can stop the fire of the where to buy lasix for horses viral but cannot restore the forest of the lymphoid tissue compartment. The MSCs would rejuvenate the field and bring back immune vitality,” Dandekar said.Even without the use of antiviral drugs, MSCs were able where to buy lasix for horses to increase the host’s antiviral response by repairing the lymphoid follicles, restoring the mucosal immunity and reviving what has been targeted by the lasix very early on.MSC treatmentsMSC treatments require well defined cell quality controls and specific delivery mechanisms. The UC Davis Stem Cell Program, a center for excellence for stem cell research, is leading multiple clinical trials on MSC use in treating diseases such as spina bifida and Huntington’s disease. Findings from this study provide a scientific basis for investigating MSC in treating HIV and other infectious diseases in the clinical setting.###Co-authors on this study are Mariana G where to buy lasix for horses.

Weber, Chara J. Walters-Laird, Clarissa where to buy lasix for horses Santos Rocha, Lauren A. Hirao, Abigail Mende, Juan Arredondo, Amir Kol, Sonny R. Elizaldi, Smita where to buy lasix for horses S.

Iyer and Alice Tarantal at UC Davis, where to buy lasix for horses and Bipin Balan at Università di Palermo, Italy.This work was supported by National Institutes of Health grants (R01AI 153025, R21 AI 116415, R21AI34368, and OD P51 OD011107) and from the National Council for Scientific and Technological Development (CNPq), Brazil.Article. Weber et al. (2021) Gut germinal center regeneration and enhanced antiviral immunity by mesenchymal stem/stromal cells in SIV where to buy lasix for horses. JCI Insight.

6(12), Doi:10.1172/jci where to buy lasix for horses. Insight.149033..

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All doctoral students strive for the day—after years can you take too much lasix of often all-consuming study—that their Recommended Reading thesis is ready to submit. For both doctoral students and supervisors there is often trepidation about whether the thesis will meet the criteria to merit the award of a can you take too much lasix Doctor of Philosophy (PhD). As anxieties increase, doctoral students often ask what makes a good PhD, something we explored in a recent ‘Research Made Simple’ article,1 but perhaps the more important question is ‘what makes a PhD student successful?. €™ In can you take too much lasix this article we outline the core criteria on which PhD theses are judged and offer suggestions for achieving success.How are PhDs assessedTraditionally, a PhD involves 3 to 4 years of full-time study (or a longer part-time programme), which is assessed by the student submitting the work they have undertaken as a thesis or—less commonly—a portfolio of published papers and an associated narrative (sometimes referred to as ‘PhD by publication’).

In addition, the student must undertake an oral defence of their work through a discussion (the ‘viva’) with examiners, who are deemed to be experts in the field of study or with related methodological expertise.2A thesis is a self-contained monograph written by the student which:Sets out the problem and context of the research, including theoretical perspectives.Outlines existing approaches that have addressed the problem or related issues before, typically by undertaking a thorough critical analysis of literature and identifying a gap in the evidence.Justifies and critically evaluates the research methodologies and methods chosen to address the problem.Presents the finding of the research and how they add to existing knowledge.Makes recommendations as to how the findings can advance the discipline and improve practice, and/or suggest further research directions.What criteria are used to assess a PhD thesis?. The core criteria for PhD success—ubiquitous to all disciplines and universities—are that the student;Has made an original and significant contribution to knowledge of the topic under investigation;Draws on a well-argued and cohesive conceptual/theoretical framework;Demonstrates the ability to critically evaluate and justify the research methodology and methods adopted;Can convey information (written and verbally) succinctly;Produces a thesis is of sufficient rigour that can you take too much lasix the work is evaluated as publishable in relevant discipline-specific journal(s).Table 1 highlights some of the key ingredients of PhD success, in terms of the study, thesis and viva.View this table:Table 1 Key principles to PhD study successJustifying methodsThe justification of methodological choices is usually presented in a distinct chapter that typically has two components. First, a ‘big picture’ description of the theoretical perspective and methodological justification (sometimes called the research approach), followed by an account of procedure (methods) of how the research was undertaken.Critical writingAn essential criterion expected from examiners is that students demonstrate criticality in the way can you take too much lasix they present and defend information. This can be a challenge, and many PhD students perceive that there is little guidance about how to develop effective arguments and few opportunities to develop critical writing skills.2 3 Similar to developing knowledge and understanding of research methods, students need the knowledge and skills for effective oral communication of ideas and writing.3The student must be able to write succinctly and critically to produce a robust and coherent thesis.2 4 A thesis should open with a clear outline of the problem, informing the reader what the thesis about and why the topic is important.

It should detail what contexts and perspectives are relevant and offer an outline to can you take too much lasix the layout of the thesis. In all chapters, students should consider the following:Use of ‘signposts’ to tell the reader where they are going to go, summarising afterwards and providing appropriate links throughout.Meaningful headings. The content of chapters and sections need to reflect the heading.Avoidance of can you take too much lasix vague terms or superfluous words, keeping sentences clear and focussed.Paragraphs that are distinct enough to explore and evaluate a clear issue but linked well enough to enhance the flow of the thesis. A general rule of thumb is that a paragraph can you take too much lasix should be about half a page.

Any less and there is limited criticality, any longer and there is a tendency http://karenlkaplan.com/jewish-broadcasiting-system-tv-national-network/ to ramble, lose focus and cause the reader to become disengaged.A PhD is not about how much the student can write. It is about how well they articulate can you take too much lasix and critically analyse information.Critical writing at Doctoral level is essential to establish the quality of the research and the credibility of the researcher. A good thesis creates a portrait of an authoritative and competent researcher, and critical writing is crucial for building the examiners’ confidence in the research undertaken.Publishable standard of the workPublishing in refereed journals and conferences is the traditional way in which the research community disseminates findings can you take too much lasix and builds knowledge, although there is increasing recognition of the role of social media platforms as a means of rapidly sharing knowledge. Refereed journals use recognised standards (such as the CONSORT (Consolidated Standards of Reporting Trials) guidelines for trials)5 and rigorous review processes to assess the quality of a research paper, which must be met for successful publication.

It is therefore unsurprising that many examiners view a thesis more favourably if a student provides evidence of having published elements of their work.6Summary of key considerationsUnlike undergraduate can you take too much lasix assessment, there is a paucity of research exploring the assessment of PhDs. However, a study that explored the process and judgements of experienced examiners,6 provided a valuable summary of the characteristics of a poor and excellent thesis (table 2).View this table:Table 2 Characteristics of a poor and excellent thesis6ConclusionThis article has outlined some of the steps that a PhD student should consider in order to produce a high-quality thesis and ensure a successful viva. We have considered how it is important that decision-making is transparent in the thesis, and defendable can you take too much lasix in the oral defence/viva. A PhD thesis should show evidence of originality and theoretical/conceptual cohesiveness, communicated via the student’s critical writing ability.

The thesis and defence provide students with the opportunity to share their can you take too much lasix knowledge and expertise in the field, offers them a methodological stage and gives the platform to share their critical perceptions, experiences and expertise.Commentary on. Carlton E, Kohne J, Shankar-Hari, can you take too much lasix et al. Readmission diagnoses after paediatric severe sepsis hospitalisation. Crit Care Med 2019;47:583–90.Implications for practice and researchChildren with coexisting can you take too much lasix comorbidities when discharged following severe sepsis have a higher rate of readmission as compared with matched hospitalisations for other acute medical conditions.There is a need for internationally agreed evidence-based guidelines/consensus paper to minimise post-sepsis readmissions through identification of potentially preventable factors, appropriate discharge criteria and parental education.More research is required into strategies towards prevention of readmissions following discharge after an episode of severe sepsis in children.ContextSepsis is a leading cause of avoidable death across all age groups.1 Attempts have been made to streamline the management pathways in the UK and elsewhere through publication of national guidelines.1 While robust guidelines exist for management of initial sepsis episodes, strategies to identify and prevent readmissions are necessary.

All doctoral students strive for the day—after years tab lasix 40mg price in canada of often all-consuming study—that their thesis is ready where to buy lasix for horses to submit. For both doctoral students and supervisors there is often trepidation about whether the thesis will meet where to buy lasix for horses the criteria to merit the award of a Doctor of Philosophy (PhD). As anxieties increase, doctoral students often ask what makes a good PhD, something we explored in a recent ‘Research Made Simple’ article,1 but perhaps the more important question is ‘what makes a PhD student successful?.

€™ In this article we outline the where to buy lasix for horses core criteria on which PhD theses are judged and offer suggestions for achieving success.How are PhDs assessedTraditionally, a PhD involves 3 to 4 years of full-time study (or a longer part-time programme), which is assessed by the student submitting the work they have undertaken as a thesis or—less commonly—a portfolio of published papers and an associated narrative (sometimes referred to as ‘PhD by publication’). In addition, the student must undertake an oral defence of their work through a discussion (the ‘viva’) with examiners, who are deemed to be experts in the field of study or with related methodological expertise.2A thesis is a self-contained monograph written by the student which:Sets out the problem and context of the research, including theoretical perspectives.Outlines existing approaches that have addressed the problem or related issues before, typically by undertaking a thorough critical analysis of literature and identifying a gap in the evidence.Justifies and critically evaluates the research methodologies and methods chosen to address the problem.Presents the finding of the research and how they add to existing knowledge.Makes recommendations as to how the findings can advance the discipline and improve practice, and/or suggest further research directions.What criteria are used to assess a PhD thesis?. The core criteria for PhD success—ubiquitous to all disciplines and universities—are that the student;Has made an original and significant contribution to knowledge of the topic under investigation;Draws on a well-argued and cohesive conceptual/theoretical framework;Demonstrates the ability to critically evaluate and justify the research methodology and methods adopted;Can convey information (written and verbally) succinctly;Produces a thesis is of sufficient rigour that where to buy lasix for horses the work is evaluated as publishable in relevant discipline-specific journal(s).Table 1 highlights some of the key ingredients of PhD success, in terms of the study, thesis and viva.View this table:Table 1 Key principles to PhD study successJustifying methodsThe justification of methodological choices is usually presented in a distinct chapter that typically has two components.

First, a ‘big picture’ description of the theoretical perspective and methodological justification (sometimes called the research approach), followed by an account of procedure (methods) of how the research was undertaken.Critical writingAn essential criterion expected from examiners is where to buy lasix for horses that students demonstrate criticality in the way they present and defend information. This can be a challenge, and many PhD students perceive that there is little guidance about how to develop effective arguments and few opportunities to develop critical writing skills.2 3 Similar to developing knowledge and understanding of research methods, students need the knowledge and skills for effective oral communication of ideas and writing.3The student must be able to write succinctly and critically to produce a robust and coherent thesis.2 4 A thesis should open with a clear outline of the problem, informing the reader what the thesis about and why the topic is important. It should detail what contexts and perspectives where to buy lasix for horses are relevant and offer an outline to the layout of the thesis.

In all chapters, students should consider the following:Use of ‘signposts’ to tell the reader where they are going to go, summarising afterwards and providing appropriate links throughout.Meaningful headings. The content of chapters and sections need to reflect the heading.Avoidance of vague terms or superfluous words, keeping sentences clear and focussed.Paragraphs that are distinct where to buy lasix for horses enough to explore and evaluate a clear issue but linked well enough to enhance the flow of the thesis. A general rule of thumb where to buy lasix for horses is that a paragraph should be about half a page.

Any less and there is limited criticality, any longer and there is a tendency to ramble, lose http://team-kennedy.com/mortgage/ focus and cause the reader to become disengaged.A PhD is not about how much the student can write. It is about how well they articulate and critically analyse information.Critical writing at Doctoral level where to buy lasix for horses is essential to establish the quality of the research and the credibility of the researcher. A good thesis creates a portrait of an authoritative and competent researcher, and critical writing is crucial for building the examiners’ confidence in the research undertaken.Publishable standard of the workPublishing in refereed journals and conferences is the traditional way in which the research community disseminates where to buy lasix for horses findings and builds knowledge, although there is increasing recognition of the role of social media platforms as a means of rapidly sharing knowledge.

Refereed journals use recognised standards (such as the CONSORT (Consolidated Standards of Reporting Trials) guidelines for trials)5 and rigorous review processes to assess the quality of a research paper, which must be met for successful publication. It is therefore unsurprising that many examiners view a thesis more favourably if a student provides evidence of where to buy lasix for horses having published elements of their work.6Summary of key considerationsUnlike undergraduate assessment, there is a paucity of research exploring the assessment of PhDs. However, a study that explored the process and judgements of experienced examiners,6 provided a valuable summary of the characteristics of a poor and excellent thesis (table 2).View this table:Table 2 Characteristics of a poor and excellent thesis6ConclusionThis article has outlined some of the steps that a PhD student should consider in order to produce a high-quality thesis and ensure a successful viva.

We have considered how it is important that decision-making is transparent in the thesis, and defendable in where to buy lasix for horses the oral defence/viva. A PhD thesis should show evidence of originality and theoretical/conceptual cohesiveness, communicated via the student’s critical writing ability. The thesis and defence provide students with the opportunity to share their knowledge and expertise in the field, offers them a methodological stage and gives where to buy lasix for horses the platform to share their critical perceptions, experiences and expertise.Commentary on.

Carlton E, where to buy lasix for horses Kohne J, Shankar-Hari, et al. Readmission diagnoses after paediatric severe sepsis hospitalisation. Crit Care Med 2019;47:583–90.Implications for practice and researchChildren with coexisting comorbidities when discharged following severe sepsis have a higher rate of readmission as compared with matched hospitalisations for other acute medical conditions.There is a need for internationally agreed evidence-based guidelines/consensus paper to minimise post-sepsis readmissions through identification of potentially preventable factors, appropriate discharge criteria and parental education.More research is required into strategies towards prevention of readmissions following discharge after an episode of severe sepsis in children.ContextSepsis is a leading cause of avoidable death across all age groups.1 Attempts have been made to streamline the management pathways in the UK and elsewhere through publication of national guidelines.1 While robust guidelines where to buy lasix for horses exist for management of initial sepsis episodes, strategies to identify and prevent readmissions are necessary.

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What is the Notice of does lasix cause hyperkalemia Compliance (NOC) Data Extract?. The data extract is a series of compressed ASCII text files of the database. The uncompressed does lasix cause hyperkalemia size of the files is approximately 22.7 MB. In order to utilize the data, the file must be loaded into an existing database or information system.

The typical user is most likely a third party claims adjudicator, provincial formulary, insurance company, does lasix cause hyperkalemia etc. A casual user of this file must be familiar with database structure and capable of setting up queries. The "Read me" file contains the data structure required to download the zipped files.The NOC extract files have been updated. They contain does lasix cause hyperkalemia Health Canada authorization dates for all drugs dating back to 1994 that have received an NOC.

All NOCs issued between 1991 and 1993 can be found in the NOC listings.Please note any Portable Document Format (PDF) files visible on the NOC database are not part of the data extracts.For more information, please go to the Read Me File.Data Extracts - Last updated. 2021-05-14 CopyrightFor information on copyright does lasix cause hyperkalemia and who to contact, please visit the Notice of Compliance Online Database Terms and Conditions.Summary Basis of Decision (SBD) documents provide information related to the original authorization of a product. The SBD for is located below. Recent Activity for SBDs written for eligible drugs approved after September 1, 2012 will be updated to include post-authorization information.

This information will be compiled in a Post-Authorization does lasix cause hyperkalemia Activity Table (PAAT). The PAAT will include brief summaries of activities such as submissions for new uses of the product, and whether Health Canada's decisions were negative or positive. PAATs will be updated regularly with post-authorization does lasix cause hyperkalemia activity throughout the product's life cycle. Post-Authorization Activity Table (PAAT) for Post-Authorization Activity Table (PAAT) RowNum Activity/submission type, control number Date submitted Decision and date Summary of activities Summary Basis of Decision (SBD) for Date SBD issued.

The following information relates does lasix cause hyperkalemia to the new drug submission for. Drug Identification Number (DIN). 1 What was approved?. 2 does lasix cause hyperkalemia Why was approved?.

3 What steps led to the approval of ?. Submission does lasix cause hyperkalemia Milestones. Submission Milestone Date 4 What follow-up measures will the company take?. 5 What post-authorization activity has taken place for ?.

6 What does lasix cause hyperkalemia other information is available about drugs?. ICMRA1 and WHO call on the pharmaceutical industry to provide wide access to clinical data for all new medicines and treatments (whether full or conditional approval, under emergency use, or rejected). Clinical trial reports should be published does lasix cause hyperkalemia without redaction of confidential information for reasons of overriding public health interest.The hypertension medications lasix has brought into sharp focus the need for information and data to support academics, researchers and industry in developing treatments and therapeutics. To support regulators and health authorities in their decision-making.

To support healthcare professionals does lasix cause hyperkalemia in their treatment decisions. And to support public confidence in the treatments and therapeutics being deployed.While some initiatives have met with stakeholder support (e.g. WHO International Clinical Trials Registry Platform, US NIH ClinicalTrials.gov database, Health Canada Clinical Information Portal, EMA Clinical Trials Register and Japan Registry of Clinical Trials), not all past efforts have been successful. Often this was because they were unsustainable due to reliance on goodwill or lack of does lasix cause hyperkalemia appropriate resourcing.2The common aim of these initiatives is to ensure that results of research are accessible to all those involved in health care decision-making.

The priority should be for new innovative medicines and treatments. This improves transparency does lasix cause hyperkalemia and strengthens the validity and value of the scientific evidence base. To succeed, initiatives need multi-stakeholder engagement aimed at finding solutions that deliver benefits for public health.Regulators continue to spend considerable resources negotiating transparency with sponsors. Both positive and negative clinically relevant data should be made available, while only personal data and individual patient data should be redacted.

In any case, aggregated data are unlikely to lead to re-identification of personal data and techniques of anonymisation can be used.The first benefit is public trust does lasix cause hyperkalemia. Regulators are opening their decisions to public scrutiny demonstrating confidence in their work.Another benefit is the possible check of data integrity, a scientific necessity and an ethical must. Data must be robust, exhaustive and verifiable, through peer-review does lasix cause hyperkalemia. Data integrity is priceless.

Wrong regulatory decisions, made on selected or unreliable data, will affect the patients who receive that medicine.Lack of public access to negative trials has been identified as a source of bias, which weakens the conclusions of systematic reviews and provides a false sense does lasix cause hyperkalemia of reassurance on the safety or efficacy of the medicine.Publication of data allows science to advance faster, by avoiding repetition of unnecessary trials and waste of resources (human and financial). This also brings benefits by improving the efficiency of development programmes and reducing both development costs and time. Publication of data also allows secondary analyses (and meta-analysis) which have a different or complementary focus.Many public bodies have made open access a requirement as data are a common good. Providing access to data is also owed to trial participants who contributed physically and took the potential research does lasix cause hyperkalemia risks.Not all data are of high quality, and increased public scrutiny should eventually improve the overall quality of data.

Resources however are needed for data sharing, and systems for such access need to be established. Standardisation of data will allow better analyses but is not a requirement.While does lasix cause hyperkalemia there may be a small risk of misuse of data (piracy or data mining for unfair commercial purpose) and misinterpretation, trial data can be put in context when published with the regulatory review of such data.Data must be published at the time of finalisation of the regulatory review. It cannot be justified to keep confidential efficacy and safety data of a medicine available on the market, or which has been refused access to the market. Some regulators regularly publish the data that support positive approvals, but fewer do this for rejections, while this should avoid false expectations, misuse (accidental or not) and safety issues.

Many completed trials on publication platforms only disclose protocols while results remain partial, outdated or unpublished.ICMRA and WHO are conscious of concerns that some stakeholders may have as regulators move to greater levels of transparency, but we remain confident of the overwhelming positive public health benefits of doing so.Providing systematic public access to data supporting approvals and rejections of medicines reviewed by regulators, is long overdue despite existing initiatives, such as those from does lasix cause hyperkalemia the European Medicines Agency and Health Canada. The hypertension medications lasix has revealed how essential to public trust access to data is. ICMRA and WHO call on the pharmaceutical industry to commit, within short timelines, and without waiting for legal changes, to provide voluntary unrestricted access to trial results data for the benefit of public health.__________________________________________________________1 ICMRA is a voluntary coalition of leaders of medicines regulatory authorities that provides strategic directions for enhanced cooperation, improved communication and effective global crisis response mechanisms.2 E.g. Past declarations and private initiatives abandoned or not followed through include.

-- Walsh F (26 February 2013), "Drug firm Roche pledges greater access to trials data" -- Alials Campaign, https://www.alials.net/ (most recent data from March 2019) -- WHO and multi-party Joint statement on public disclosure of results from clinical trials, 18 May 2017 (accessed here, March 2021)..

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The "Read me" file contains the data structure required to download the zipped files.The NOC extract files have been updated. They contain Health Canada authorization dates for all drugs dating where to buy lasix for horses back to 1994 that have received an NOC. All NOCs issued between 1991 and 1993 can be found in the NOC listings.Please note any Portable Document Format (PDF) files visible on the NOC database are not part of the data extracts.For more information, please go to the Read Me File.Data Extracts - Last updated.

2021-05-14 CopyrightFor information on copyright and who to contact, please visit the Notice of Compliance Online Database Terms and Conditions.Summary Basis of Decision (SBD) documents provide information related to the original authorization of where to buy lasix for horses a product. The SBD for is located below. Recent Activity for SBDs written for eligible drugs approved after September 1, 2012 will be updated to include post-authorization information.

This information will be compiled in a Post-Authorization where to buy lasix for horses Activity Table (PAAT). The PAAT will include brief summaries of activities such as submissions for new uses of the product, and whether Health Canada's decisions were negative or positive. PAATs will where to buy lasix for horses be updated regularly with post-authorization activity throughout the product's life cycle.

Post-Authorization Activity Table (PAAT) for Post-Authorization Activity Table (PAAT) RowNum Activity/submission type, control number Date submitted Decision and date Summary of activities Summary Basis of Decision (SBD) for Date SBD issued. The following information relates to the new drug submission for where to buy lasix for horses. Drug Identification Number (DIN).

1 What was approved?. 2 Why was where to buy lasix for horses approved?. 3 What steps led to the approval of ?.

Submission where to buy lasix for horses Milestones. Submission Milestone Date 4 What follow-up measures will the company take?. 5 What post-authorization activity has taken place for ?.

6 What where to buy lasix for horses other information is available about drugs?. ICMRA1 and WHO call on the pharmaceutical industry to provide wide access to clinical data for all new medicines and treatments (whether full or conditional approval, under emergency use, or rejected). Clinical trial reports should be published without redaction of confidential information for reasons of overriding public health interest.The hypertension medications lasix has brought into sharp focus the need for information and data to support academics, researchers and industry where to buy lasix for horses in developing treatments and therapeutics.

To support regulators and health authorities in their decision-making. To support healthcare professionals in where to buy lasix for horses their treatment decisions. And to support public confidence in the treatments and therapeutics being deployed.While some initiatives have met with stakeholder support (e.g.

WHO International Clinical Trials Registry Platform, US NIH ClinicalTrials.gov database, Health Canada Clinical Information Portal, EMA Clinical Trials Register and Japan Registry of Clinical Trials), not all past efforts have been successful. Often this was because they were unsustainable due to reliance on goodwill or lack of appropriate resourcing.2The common aim of these initiatives is to ensure that results of research are accessible to all those involved in where to buy lasix for horses health care decision-making. The priority should be for new innovative medicines and treatments.

This improves transparency and strengthens the validity and value of the scientific evidence base where to buy lasix for horses. To succeed, initiatives need multi-stakeholder engagement aimed at finding solutions that deliver benefits for public health.Regulators continue to spend considerable resources negotiating transparency with sponsors. Both positive and negative clinically relevant data should be made available, while only personal data and individual patient data should be redacted.

In any case, aggregated data are unlikely to lead where to buy lasix for horses to re-identification of personal data and techniques of anonymisation can be used.The first benefit is public trust. Regulators are opening their decisions to public scrutiny demonstrating confidence in their work.Another benefit is the possible check of data integrity, a scientific necessity and an ethical must. Data must be where to buy lasix for horses robust, exhaustive and verifiable, through peer-review.

Data integrity is priceless. Wrong regulatory decisions, made on selected or unreliable where to buy lasix for horses data, will affect the patients who receive that medicine.Lack of public access to negative trials has been identified as a source of bias, which weakens the conclusions of systematic reviews and provides a false sense of reassurance on the safety or efficacy of the medicine.Publication of data allows science to advance faster, by avoiding repetition of unnecessary trials and waste of resources (human and financial). This also brings benefits by improving the efficiency of development programmes and reducing both development costs and time.

Publication of data also allows secondary analyses (and meta-analysis) which have a different or complementary focus.Many public bodies have made open access a requirement as data are a common good. Providing access to data is also owed to trial participants who contributed physically and where to buy lasix for horses took the potential research risks.Not all data are of high quality, and increased public scrutiny should eventually improve the overall quality of data. Resources however are needed for data sharing, and systems for such access need to be established.

Standardisation of data will allow better analyses but is not a where to buy lasix for horses requirement.While there may be a small risk of misuse of data (piracy or data mining for unfair commercial purpose) and misinterpretation, trial data can be put in context when published with the regulatory review of such data.Data must be published at the time of finalisation of the regulatory review. It cannot be justified to keep confidential efficacy and safety data of a medicine available on the market, or which has been refused access to the market. Some regulators regularly publish the data that support positive approvals, but fewer do this for rejections, while this should avoid false expectations, misuse (accidental or not) and safety issues.

Many completed trials on publication platforms only disclose protocols while results remain partial, outdated or unpublished.ICMRA and WHO are conscious of concerns that some stakeholders may have as regulators where to buy lasix for horses move to greater levels of transparency, but we remain confident of the overwhelming positive public health benefits of doing so.Providing systematic public access to data supporting approvals and rejections of medicines reviewed by regulators, is long overdue despite existing initiatives, such as those from the European Medicines Agency and Health Canada. The hypertension medications lasix has revealed how essential to public trust access to data is. ICMRA and WHO call on where to buy lasix for horses the pharmaceutical industry to commit, within short timelines, and without waiting for legal changes, to provide voluntary unrestricted access to trial results data for the benefit of public health.__________________________________________________________1 ICMRA is a voluntary coalition of leaders of medicines regulatory authorities that provides strategic directions for enhanced cooperation, improved communication and effective global crisis response mechanisms.2 E.g.

Past declarations and private initiatives abandoned or not followed through include. -- Walsh F (26 February 2013), "Drug firm Roche pledges greater access to trials data" -- Alials Campaign, https://www.alials.net/ (most recent data from March 2019) -- WHO and multi-party Joint statement on public disclosure of results from clinical trials, 18 May 2017 (accessed here, March 2021)..