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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Guy A. Bogaert, MD, PhD
But because the price of water is heavily mediated by policy and regional economics erectile dysfunction circumcision purchase 40 mg cialis professional with mastercard, local scarcity or abundance does not tell us much about the attractiveness of water development all by themselves (Shaw erectile dysfunction caused by vasectomy cheap 20mg cialis professional amex, 2007) erectile dysfunction doctors near me discount 20 mg cialis professional amex. Midwestern Great Lakes states age related erectile dysfunction causes discount 40 mg cialis professional, because of their historical contributions to transportation equipment erectile dysfunction q and a purchase cialis professional 40mg without prescription, heavy manufacturing kratom impotence cialis professional 40 mg overnight delivery, energy production, and agriculture produce more than a quarter of national greenhouse gas emissions (Livingston et al. Total volume of water withdrawn from the Great Lakes for the period of 1988-2016 by the industrial sector. Data source: Great Lakes Regional Water Use Database There has long been speculation that the water itself would become a major commodity-bottled and shipped as bulk water or pumped out of the region via inter-basin transfers. This is unlikely as large interbasin transfer schemes to move water long distances from the lakes are economically impractical (Annin, 2018). A large portion of bottled water is packaged tap water, however, and is thus folded into public drinking water consumption (Hu et al. Existing industrial demands in a variety of sectors are very sensitive to changes in water availability and quality related to climate change. Agricultural consumption generally increases with higher temperatures and longer dry periods (Schoengold and Zilberman, 2007). If regulatory action is taken to control nutrient pollution flows from farm and livestock operations created by more intense rainfall, it will increase the cost of farm operations (Rathinasamy et al. The commercial fishing industry is directly impacted by climate related changes in water quality in particular. It is unclear whether regional diversion regulations will constrain future industrial uses. Lawrence River Basin Water Resources Compact ("Great Lakes Compact"), severely restricts the amount of water that can be diverted out of the Great Lakes Basin and puts environmental review conditions on large new consumptive uses within the basin. However, it was designed mainly to control the expansion of municipal uses beyond the basin line by regulating new consumption by utilities, rather than new large industrial uses. The most recent high-profile test of this by water intensive industry relocating to the Great Lakes Basin is the planned development of a Foxconn liquid crystal display factory in the Village of Mount Pleasant, Wisconsin. The Wisconsin Department of Natural Resources has granted the southwest portion of the City of Racine a diversion allowance of up to 7 mgd, much of which is expected to go to the Foxconn plant (Thomas, 2018). So far, this is an isolated case, but if it were to become a general trend in the region, it would create intense new demands on water resources given that individual factories can consume about the same amount of water every day as a small city. Fifteen Michigan beaches were either closed or are under advisories because of bacterial contamination during the 2018 Labor Day weekend. In June 2018, 24 Michigan beaches were closed because of elevated bacteria levels, just when a heat wave made it especially desirable for people to head to the beach. This is not an uncommon occurrence, especially during the summer months, on the coastlines of the Great Lakes. The increase in the frequency and intensity of extreme precipitation events are likely to exacerbate the issues associated with runoff and the associated effects on bacterial counts. Conclusions Allowing the vast, natural resource of the Great Lakes to be taken for granted and degraded through human activities, including the effects of climate change, is not an option. For economic, aesthetic, and ecological reasons, we need the Great Lakes to remain healthy, unpolluted, and productive. Climate change is already having an impact on the region, and there is evidence that such impacts may increase under expected future climate change. Responding to these stressors requires both adaptations to the impacts that cannot be avoided. Public support for protecting the Great Lakes is strong across the region, and despite differing concern about climate change as a threat, overall public support for action to address climate change is high. It is critical that we recognize the importance of this freshwater resource and ensure its protection for generations to come. Using cultural ecosystem services to inform restoration priorities in the Laurentian Great Lakes. The abiotic and biotic factors limiting establishment of predatory fishes at their expanding northern range boundaries in Ontario, Canada. Ontario freshwater fishes demonstrate differing range-boundary shifts in a warming climate. Heat waves in the United States: Mortality risk during heat waves and effect modification by heat wave characteristics in 43 U. The influence of water quality on the demand for residential development around Lake Erie (PhD Thesis). Recreational exposure to microcystins during algal blooms in two California lakes. A comparative examination of recent changes in nutrients and lower food web structure in Lake Michigan and Lake Huron. Projected compositional shifts and loss of ecosystem services in freshwater fish communities under climate change scenarios. The empirics of wetland valuation: a comprehensive summary and a meta-analysis of the literature. Changing ecosystem dynamics in the Laurentian Great Lakes: bottom-up and top-down regulation. Recreational fishing participation trends in Upper Great Lakes States: an age-period-cohort analysis. Increasing Great Lakeeffect snowfall during the Twentieth Century: A regional response to Global Warming? Changes in the abundance and diversity of coastal wetland fauna from the open water / macrophytes edge towards shore. The Business Case for Green Infrastructure: Resilient Stormwater Management in the Great Lakes Region. Sinha, Hydrologic impacts of projected future climate change in the Lake Michigan region, Journal of Great Lakes Research, doi: 10. Lee, Toxin-producing cyanobacteria in freshwater: A review of the problems, impact on drinking water safety, and efforts for protecting public health. Fraser, Hydrology influences generalistspecialist bird-based indices of biotic integrity in Great Lakes coastal wetlands. Cherkauer, Assessing potential winter weather response to climate change and implications for tourism in the U. Kim, Simulating streamflow response to climate scenarios in central Canada using a simple statistical downscaling method. Minns, Potential impacts of climate change on the distributions of several common and rare freshwater fishes in Canada. Barrick, Spatiotemporal Snowfall Variability in the Lake Michigan Region: How is Warming Affecting Wintertime Snowfall? Speiser, Mental health and our changing climate: impacts, implications, and guidance. Kitchell, Climate change expands the spatial extent and duration of preferred thermal habitat for Lake Superior fishes. Report prepared for the International Joint Commission, Upper Great Lakes Study, 96 pp. Ludsin, Climate change as a long-term stressor for the fisheries of the Laurentian Great Lakes of North America. Congressional Budget Office, Public Spending on Transportation and Water Infrastructure, 1956 to 2014. Grenouillet, Climate induced changes in the distribution of freshwater fish: observed and predicted trends. Modeling the effects of climate change on water, sediment, and nutrient yields from the Maumee River watershed. Marra, Full annual cycle climate change vulnerability assessment for migratory birds. Lele, the association between extreme precipitation and waterborne disease outbreaks in the United States, 19481994. Askin, Factors controlling erosion of the nearshore profile in overconsolidated till, Grimsby, Lake Ontario. Proceedings Canadian Coastal Conference, National Research Council of Canada, Ottawa, Canada, pp. Fisher, Spatial and temporal controls on overwash occurrence on a Great Lakes barrier spit. McKinley, Stronger winds over a large lake in response to a weakening air to lake temperature gradient. Greenstone, the economic impacts of climate change: evidence from agricultural output and random fluctuations in weather. Prieto, Hydro-climatic shifts driven by human water use for food and energy production. Chapra, Long-term trends of nutrients and trophic response variables for the Great Lakes Limnol. Interacting effects of change in climate, human population, land use, and water use on biodiversity and ecosystem services. Effects of Pesticide Use and Farming Practices on Water Treatment Costs in Maumee River Basin Communities. Managing Climate Change and Variability Risks in the Great Lakes Region, 2010-2016, Phase 1 Final Report. The value of disappearing beaches: a hedonic pricing model with endogenous beach width. Climate variability and change in the United States: potential impacts on vector-and rodent-borne diseases. Confirmation of the extinction of the Bramble Cay melomys Melomys rubicola on Bramble Cay, Torres Strait: results and conclusions from a comprehensive survey in August September 2014. Climate change impacts on terrestrial ecosystems in metropolitan Chicago and its surrounding, multi-state region. Projecting coldwater fish habitat in lakes of the glacial lakes region under changing land use and climate regimes. Hatch dates, growth, survival, and overwinter mortality of age-0 alewives in Lake Michigan: Implications for habitat-specific recruitment success. Green Infrastructure for Stormwater Control: Gauging Its Effectiveness with Community Partners. The effects of adjacent land use on wetland amphibian species richness and community composition. Changing climate, changing wildlife: A vulnerability assessment of 400 species of greatest conservation need and game species in Michigan. Climate warming is associated with smaller body size and shorter lifespans in moose near their southern range limit. Development and application of a North American Great Lakes hydrometeorological database - Part I: Precipitation, evaporation, runoff, and air temperature. A report prepared by the International Joint Commission Great Lakes Water Quality Board Public Engagement Work Group. Changing fish biodiversity: Predicting the loss of cyprinid biodiversity due to global climate change. The effects of climate change and eutrophication on cisco Coregonus artedi abundance in Minnesota lakes. Restoring aquatic ecosystem connectivity requires expanding inventories of both dams and road crossings. Hydrological responses to climate change conditioned by historic alterations of land-use and water-use. Size-dependent winter mortality of young-of-the-year white perch: climate warming and invasion of the Laurentian Great Lakes. Effects of climate and land management change on streamflow in the driftless area of Wisconsin. Temperature effects induced by climate change on the growth and consumption by salmonines in Lakes Michigan and Huron. Zebra versus quagga mussels: a review of their spread, population dynamics, and ecosystem impacts. Secular trends of precipitation amount, frequency, and intensity in the United States. Increase in forest water-use efficiency as atmospheric carbon dioxide concentrations rise. Living on the coast - protecting investments in shore property on the Great Lakes. Human amplified changes in precipitationrunoff patterns in large river basins of the Midwestern United States. Twenty years of invasion: a review of round goby Neogobius melanostomus biology, spread and ecological implications. Variable effects of climate and density on the juvenile ecology of two salmonids in an Alaskan lake. A climate model projection weighting scheme accounting for performance and interdependence. Morphometry and average temperature affect lake stratification responses to climate change. Temporal variations of extreme precipitation events in the United States: 18952000. Meteorological causes of the secular variations in observed extreme precipitation events for the conterminous United States. The importance of considering shifts in seasonal changes in discharges when predicting future phosphorus loads in streams. Links between type E botulism outbreaks, lake levels, and surface water temperatures in Lake Michigan, 19632008. Cyanobacterial Toxins in Freshwater and Food: Important Sources of Exposure to Humans. Fresh produce and their soils accumulate cyanotoxins from irrigation water: Implications for public health and food security.
While duration recording focuses on the length of time a behavior actually occurs erectile dysfunction age 25 buy cialis professional 20mg visa, latency recording focuses on the length of time that passes between when the instruction is delivered and a target behavior occurs erectile dysfunction san antonio purchase cialis professional 40 mg free shipping. In order for most people to be successful erectile dysfunction medication options order cialis professional 40mg without a prescription, they need to be able to quickly respond to demands in their environment erectile dysfunction song cheap cialis professional 40mg online. Many students (including those on the autism spectrum) do not jump to complete an activity the moment they receive an instruction erectile dysfunction drugs uk discount cialis professional 20 mg on-line. Some students spend a lot of time looking at materials instead of getting started with a project erectile dysfunction doctor calgary buy generic cialis professional 40 mg on-line, or delay turning to the right page until a minute or two after the other students do. These students are more likely to miss out on instructional time and be unable to keep up when they do initiate the task. National Autism Center { 88 Additional Data Collection Considerations the data collection procedures we have addressed to this point are extremely versatile. An often overlooked way of collecting data is to monitor permanent products such as completed worksheets or homework assignments. Permanent products are ideal for the classroom setting because a good deal of academic work lends itself to these measures. Like the other data collection procedures we have described, these permanent products can be used both as baseline and intervention data. Self-monitoring is another data collection method that is not used frequently enough. Self-monitoring systems require the student to record the occurrence of his own target behaviors. This data collection method can be applied with behavioral reduction and behavioral acceleration interventions. There are many studies suggesting that self-monitoring systems can be effectively implemented in the classroom setting. For example, self-monitoring is efficient for the smooth running of the classroom. Further, learning to monitor their own activities is an important skill for all students. Please see the Self-management section in Chapter 2 for a more detailed description of self-monitoring procedures and the process of teaching students selfmanagement skills. Hint: You might need to collect your own baseline data because students are not very accurate when they first learn to record their own behavior! Without collecting baseline data, it will be impossible to clearly show that the intervention you put in place have led to student improvement. Baseline data collection need not be tedious or time-consuming once you have a system in place. Second, decide the time of day or the type of activity for which you will collect data. At least three data points are required to identify a trend (see data analysis section for details). Educators can access a number of examples of data collection sheets online or in various textbooks and manuals. You will have selected the intervention based on research findings (see Chapter 2), the professional judgment of staff involved (this chapter), family input (see Chapter 4), and the capacity to correctly implement the intervention at this time (see Chapter 5). You will need to collect data during the intervention phase so you can determine whether the treatment you are implementing is working. There is no doubt that it takes time and energy to accurately implement an intervention. If you do not collect data during the intervention phase, it might be hard to know if the treatment is working. More importantly, you do not want to continue using an ineffective intervention for the students in your care. For the student who talks out an average of 100 times per day, what are the odds you will notice if it drops to 90 or increases to 112 unless you collect data? You must analyze and compare data between baseline and intervention conditions to determine what to do next. You may decide to continue with the intervention if you see improvements based on the comparison of baseline and intervention data. Or you may decide to revise the current intervention or implement an entirely new intervention if it becomes clear things are not improving or are getting worse! Ongoing data collection helps you to determine how changes in the intervention affect the targeted behavior. It is important to use the same data collection procedure during both baseline and intervention phases. Graphing is a useful tool that can help you make decisions and use your professional judgment (Alberto & Troutman, 2003; Cooper, Heron, & Heward, 2007). All data points in the same phase are connected by a line, but data points are not connected across phases (see Figure 3). Phase lines can also be drawn at various points to indicate where a change in the intervention occurred. For example, if you learned that a student started on a new medication while you were implementing a new intervention, you would draw another phase change to show the new intervention phase (intervention 2: school intervention + medication). You will want to inspect the line graph to determine whether the behavior is changing and, if so, whether the change occurred in the desired direction. Ideally, the change from baseline to intervention is so fast and dramatic that the improvement will just jump out at you. Interpreting the graphed data is easier if you account for stability and trends in the data. Also, the percentage of overlapping data points aids in the interpretation of data. The school principal completes five-minute observations during social studies for a week because she does not want data collection to interfere with your teaching. High variability may indicate an unidentified environmental variable that affects the target behavior on some days but not others. You see that Kelly was highly on-task on Tuesday and Friday during the baseline condition. You remember that she asked to use the restroom before class began on each of these days. Armed with that information, you develop an intervention in which you give Kelly the opportunity to use the restroom each day before social studies. If you based your decision exclusively on stability, you might interpret the data to mean that the intervention was not effective (because there is still not a perfectly stable pattern of responding). But you realize there are more indicators that aid in interpretation of visually presented data. You also see that she spends more time on-task at the end of the first week of intervention. You decide to consider one of the other key indicators of intervention effectiveness - trends - before interpreting these data. The easiest way is to visually determine what line best "describes" all of the data. If you would rather use a mathematical approach to calculating the trend line, we recommend the chapter on single-subject designs in Applied Behavior Analysis for Teachers (Alberto & Troutman, 2003). Analyzing trends in the data will help determine if behavior change is moving in the desired direction. Ideally, when implementing a behavior reduction intervention, the desired effect would be a decreasing (or descending) trend relative to baseline. As mentioned earlier, you will need to collect at least three data points per condition. Identification of a trend requires at least three data points and often may require five or more. It can be difficult to identify a trend when the increase or decrease in behavior is gradual over time. If you were to draw a line that best represents all of the data in the intervention phase, you would see a descending trend. Because our goal is to decrease off-task behavior, the descending trend tells us our intervention is leading to favorable outcomes. More effective intervention data will generally produce lower percentages of overlapping data points. Lower percentages of overlapping data points indicate that the difference between baseline and intervention phases are so robust that there is an easily noticeable difference between baseline and intervention. That is, the difference is large enough that almost none of the data points overlap. In the end, you are only trying to figure out what percentage of the data points in baseline overlaps with the data points in your intervention condition. See Figure 7 to help illustrate the following narrative description: Step 1: Identify the range of data points for condition 1. You determine the range by identifying the lowest and highest numbers in the condition. The fewest number of times Jacob initiates with peers in baseline is three; the greatest number of times Jacob initiates with peers is five. Step 3: Identify the number of data points in condition 2 that fall within the range of condition 1. You compare each data point to the range of social initiations Jacob demonstrated during baseline. That is, you compare each data point in intervention to the range you calculated in step 1. If a data point falls within the range for baseline (which you calculated to be 3-5), you count that as an overlapping data point. If a data point falls outside the range for baseline, you do not count that data point. Step 4: Divide the number of data points identified in step 3 by the number of data points established in step 2. You determined that there was only one data point in intervention that overlapped with the range you calculated in baseline. You already calculated the total number of data points in intervention to be 5 (see step 2). The intervention depicted in Figure 8 is not considered effective, in part, because of the high percentage of overlapping data points. Figure 8} Example of Ineffective Intervention: High Percentage of Overlapping Data Points Between Baseline and Intervention Aggression 14 12 10 Frequency 8 6 4 2 0 Baseline Intervention 1 2 3 4 5 6 7 8 School Days 101 } Evidence-based Practice and Autism in the Schools Challenges in Visual Analysis As we have stated previously, stability, trend, and overlapping data points are indicators of intervention effectiveness. However, visual analysis often requires that you give lesser importance to one or more of these indicators. But when you examine the data in the intervention phase, it is clear there is a descending trend. When all of these indicators are taken into consideration, you decide that you may need to collect additional data so that you can be certain about the effectiveness of the intervention (see next section on details). This exception is as follows: if you have nearly perfect trends in one direction for baseline phases. However, the nearly perfect trends suggest that the intervention is very effective. She has recently started making inappropriate vocalizations that interrupt the students around her. You begin collecting baseline data and find that the frequency of these inappropriate vocalizations seems to be increasing (see baseline phase of Figure 9). Shaliqua learns to correctly record the frequency of her vocalizations and to get access to reinforcers if she remains quiet. The frequency of inappropriate vocalizations quickly begins decreasing (see intervention phase of Figure 9). Despite the fact that there are 100% overlapping data points, you are thrilled with the results. You can see by examining the trend lines that impressive differences exist between baseline and intervention phases. That is, inappropriate vocalizations just kept becoming a bigger problem in baseline and they consistently became less problematic in intervention. A final challenge to visual data analysis relates to the length of time it takes for an intervention to produce a desirable outcome. The examples we have provided thus far reflect typical data for students who respond quickly to an intervention. She did not master multiplication and division of fractions during her fifth grade year so her sixth-grade teacher decides to begin with these skills at the beginning of the school 103 } Evidence-based Practice and Autism in the Schools year. Not surprisingly, Sami had not learned how to multiply or divide fractions over the summer! Eventually, there comes a point at which she really begins mastering these skills. Note that this did not happen the moment her teacher put the intervention into place. The teacher understood that Sami needed time to develop sufficient skills to show significant improvements. Because visual analysis can be very challenging, we recommend all school staff should consult with a professional. In order to really know if a treatment is effective, you need to compare two or more baseline conditions with two or more intervention conditions. This research design is used by scientists, but it is often used by practitioners as well. Practitioners like single-subject research design because it can be applied to one individual. It can also be applied to a small group of students or an entire classroom (although we do not cover these examples here). We encourage you to harness the strength of this research design to answer the questions you have about your students. This type of design demonstrates the relationship between the intervention and the target behavior.
See Section 5(e) for our coverage of mental health visits to Non-preferred providers and benefits for additional mental health services erectile dysfunction lipitor order 20 mg cialis professional free shipping. Note: Benefits for home nursing visits (skilled) related to covered maternity care are subject to the visit limitations described on page 59 erectile dysfunction drugs boots order 20mg cialis professional. Note: Maternity care benefits are not provided for prescription drugs required during pregnancy erectile dysfunction nutrition cialis professional 20 mg line, except as recommended under the Affordable Care Act erectile dysfunction 20 years old buy cialis professional 20mg with mastercard. Note: Here are some things to keep in mind: · You do not need to precertify your delivery; see page 26 for other circumstances impotence treatment natural purchase cialis professional 40 mg without prescription, such as extended stays for you or your newborn erectile dysfunction protocol download free cialis professional 40mg overnight delivery. You Pay Standard Option Continued from previous page: Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Note: You may request prior approval and receive specific benefit information in advance for the delivery itself and any other maternity-related surgical procedures to be provided by a Non-participating physician when the charge for that care will be $5,000 or more. Basic Option Continued from previous page: Participating/Non-participating: You pay all charges (except as noted below) Note: For services billed by Participating and Nonparticipating laboratories or radiologists, you are responsible only for any difference between our allowance and the billed amount. Maternity Care - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 47 Standard and Basic Option Section 5(a) Standard and Basic Option Benefit Description Maternity Care (cont. We cover other care of a newborn who requires professional services or non-routine treatment, only if we cover the newborn under a Self Plus One or Self and Family enrollment. Surgical benefits apply to circumcision when billed by a professional provider for a male newborn. Note: See page 156 for our payment for inpatient stays resulting from an emergency delivery at a hospital or other facility not contracted with your Local Plan. You may order Ameda milk storage bags, limited to 150 bags every 90 days, even if you own your own breast pump. Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility. Note: See below for a list of services not covered as treatments for infertility or as alternatives to conventional conception. You Pay Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Basic Option Preferred primary care provider or other healthcare professional: $30 copayment per visit Preferred specialist: $40 copayment per visit Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. You Pay Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Basic Option Preferred primary care provider or other healthcare professional: $30 copayment Preferred specialist: $40 copayment Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Preferred: Nothing Participating/Non-participating: You pay all charges · Preparation of each multi-dose vial of antigen Note: See page 39 for applicable office visit copayment. Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Preferred primary care provider or other healthcare professional: $30 copayment per multi-dose vial of antigen Preferred specialist: $40 copayment per multi-dose vial of antigen Participating/Non-participating: You pay all charges (except as noted below) Note: For services billed by Participating and Nonparticipating laboratories or radiologists, you pay any difference between our allowance and the billed amount. Not covered: Provocative food testing All charges All charges 2021 Blue Cross and Blue Shield Service Benefit Plan 51 Standard and Basic Option Section 5(a) Standard and Basic Option Benefit Description Treatment Therapies Outpatient treatment therapies: · Chemotherapy and radiation therapy Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also, Other services under You need prior Plan approval for certain services in Section 3 (pages 21-24). Note: See page 60 for our coverage of osteopathic and chiropractic manipulative treatment. Preferred: 10% of the Plan allowance (deductible applies) Member: 15% of the Plan allowance (deductible applies) Non-member: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and billed amount Preferred: 15% of the Plan allowance Member or Non-member: You pay all charges You Pay Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Basic Option Preferred primary care provider or other healthcare professional: $30 copayment per visit Preferred specialist: $40 copayment per visit Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. See also Other services under You need prior Plan approval for certain services in Section 3 (pages 21-24). Standard Option Basic Option Preferred primary care provider or other healthcare professional: $25 copayment per visit (no deductible) Preferred specialist: $35 copayment per visit (no deductible) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Note: Benefits are limited to 75 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three. Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above. Preferred primary care provider or other healthcare professional: $30 copayment per visit Preferred specialist: $40 copayment per visit Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. Participating/Non-participating: You pay all charges Note: See Section 5(c) for our payment levels for rehabilitative therapies billed for by the outpatient department of a hospital. Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 53 Standard and Basic Option Section 5(a) Standard and Basic Option Benefit Description Physical Therapy, Occupational Therapy, Speech Therapy, and Cognitive Rehabilitation Therapy (cont. Not covered: · Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay · Maintenance or palliative rehabilitative therapy · Exercise programs · Equine therapy and hippotherapy (exercise on horseback) · Massage therapy All charges All charges Hearing Services (Testing, Treatment, and Supplies) · Hearing tests related to illness or injury · Testing and examinations for prescribing hearing aids Note: For our coverage of hearing aids and related services, see page 57. Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Basic Option Preferred primary care provider or other healthcare professional: $30 copayment per visit Preferred specialist: $40 copayment per visit Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. Note: See Section 5(b), Surgical procedures, for coverage for surgical treatment of amblyopia and strabismus. Note: See pages 40-42 in this Section for our payment levels for Lab, X-ray, and other diagnostic tests performed or ordered by your provider. You Pay Standard Option Continued from previous page: Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Preferred primary care provider or other healthcare professional: $25 copayment (no deductible) Preferred specialist: $35 copayment (no deductible) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Preferred primary care provider or other healthcare professional: $30 copayment per visit Preferred specialist: $40 copayment per visit Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. You Pay Standard Option Preferred primary care provider or other healthcare professional: $25 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies) Preferred specialist: $35 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Basic Option Preferred primary care provider or other healthcare professional: $30 copayment per visit Preferred specialist: $40 copayment per visit Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Basic Option Preferred: 30% of the Plan allowance Participating/Non-participating: You pay all charges Orthopedic and Prosthetic Devices - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 56 Standard and Basic Option Section 5(a) Standard and Basic Option Benefit Description Orthopedic and Prosthetic Devices (cont. We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Preferred physicians, facilities, and pharmacies are not necessarily Preferred medical supply providers. You Pay Standard Option See previous page Basic Option See previous page Not covered: · Infant formulas used as a substitute for breastfeeding · Diabetic supplies, except as described in Section 5(f) or when Medicare Part B is primary · Medical foods administered orally, except as described in Section 5(f) All charges All charges Home Health Services Home nursing care (skilled) for two hours per day when: · A registered nurse (R. Note: Visits that you pay for while meeting your calendar year deductible count toward the annual visit limit. Basic Option Preferred: $30 copayment per visit Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. Standard Option Preferred: $25 copayment per visit (no deductible) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 12 visits per person, per calendar year. Note: Manipulation visits that you pay for while meeting your calendar year deductible count toward the treatment limit cited above. Basic Option Preferred: $30 copayment per visit Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 20 visits per person, per calendar year. Participating/Non-participating: You pay all charges Alternative Treatments Acupuncture Note: Acupuncture must be performed and billed by a healthcare provider who is licensed or certified to perform acupuncture by the state where the services are provided, and who is acting within the scope of that license or certification. Note: When billed by a facility such as the outpatient department of a hospital, you are limited to the number of visits per calendar year listed on this page. Note: See page 77 for our coverage of acupuncture when provided as anesthesia for covered surgery. Note: See page 46 for our coverage of acupuncture when provided as anesthesia for covered maternity care. Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Note: Benefits for acupuncture are limited to 24 visits per calendar year. Basic Option Preferred primary care provider or other healthcare professional: $30 copayment per visit Preferred specialist: $40 copayment per visit Note: Benefits for acupuncture are limited to 10 visits per calendar year. Participating/Non-participating: You pay all charges Alternative Treatments - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 60 Standard and Basic Option Section 5(a) Standard and Basic Option Benefit Description Alternative Treatments (cont. Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals Important things you should keep in mind about these benefits: · Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. This is because how they are paid depends on what type of provider bills for the service. Please refer to the prior approval and precertification information shown in Section 3 to be sure which services require prior approval or precertification. Prior to any gender reassignment surgery, your provider must submit a treatment plan including all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and your provider later modifies the plan (including changes to the procedures to be performed or the anticipated dates for the procedures). This benefit limitation does not apply if you have primary Medicare Part B coverage. See page 114 for information about Tier 4 and Tier 5 specialty drug fills from Preferred providers and Preferred pharmacies. Medications restricted under this benefit are available on our Specialty Drug List. Benefit Description You Pay Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. Surgical Procedures A comprehensive range of services, such as: · Operative procedures · Assistant surgeons/surgical assistance if required because of the complexity of the surgical procedures · Treatment of fractures and dislocations, including casting · Normal pre- and post-operative care by the surgeon · Correction of amblyopia and strabismus · Colonoscopy, with or without biopsy Note: Preventive care benefits apply to the professional charges for your first covered colonoscopy of the calendar year (see page 42). We provide benefits as described here for subsequent colonoscopy procedures performed by a professional provider in the same year. See Section 5(a), Orthopedic and Prosthetic Devices, and Section 5(c), Other Hospital Services and Supplies, for our coverage for the device. Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Note: You may request prior approval and receive specific benefit information in advance for surgeries to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. Note: Benefits for gender reassignment surgery are limited to once per covered procedure, per lifetime. Benefits are not available for repeat or revision procedures when benefits were provided for the initial procedure. Benefits are not available for gender reassignment surgery for any condition other than gender dysphoria. Benefits are available only for the following procedures: - Roux-en-Y - Gastric bypass - Laparoscopic adjustable gastric banding - Sleeve gastrectomy - Biliopancreatic bypass with duodenal switch Note: Benefits for the surgical treatment of morbid obesity are subject to the requirements listed on pages 62-63. Generally, we will allow a reduced amount for procedures other than the primary procedure. Note: We do not pay extra for "incidental" procedures (those that do not add time or complexity to patient care). Note: When unusual circumstances require the removal of casts or sutures by a physician other than the one who applied them, the Local Plan may determine that a separate allowance is payable. You Pay Standard Option See page 63 Basic Option See page 63 Not covered: · Reversal of voluntary sterilization · Services of a standby physician · Routine surgical treatment of conditions of the foot (see Section 5(a), Foot Care) · Cosmetic surgery All charges All charges Surgical Procedures - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 66 Standard and Basic Option Section 5(b) Standard and Basic Option Benefit Description Surgical Procedures (cont. Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. Prior approval is not required for kidney transplants or for transplants of corneal tissue. Benefits are subject to medical necessity and experimental/ investigational review, and to the prior approval requirements shown above. Organ transplants must be performed in a facility with a Medicare-Approved Transplant Program for the type of transplant anticipated. Physicians consider many features to determine how diseases will respond to different types of treatments. For the diagnoses listed on pages 71-75, the medical necessity limitation is considered satisfied if the patient meets the staging description. Not every facility provides transplant services for every type of transplant procedure or condition listed, or is designated or accredited for every covered transplant. Note: Coverage for the blood or marrow stem cell transplants described on pages 71-72 includes benefits for those transplants performed in an approved clinical trial to treat any of the conditions listed when prior approval is obtained. Refer to pages 73-74 for information about blood or marrow stem cell transplants covered only in clinical trials and the additional requirements that apply. Note: See pages 144-145 for our coverage of other costs associated with clinical trials. Note: We provide enhanced benefits for covered transplant services performed at Blue Distinction Centers for Transplants (see page 76 for more information). Benefit Description Organ/Tissue Transplants · Transplants of corneal tissue · Heart transplant · Heart-lung transplant · Kidney transplant · Liver transplant · Pancreas transplant · Simultaneous pancreas-kidney transplant · Simultaneous liver-kidney transplant · Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis · Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas · Single, double, or lobar lung transplant You Pay Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Note: You may request prior approval and receive specific benefit information in advance for kidney and cornea transplants to be performed by Nonparticipating physicians when the charge for the surgery will be $5,000 or more. Basic Option Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings Note: Your provider will document the place of service when filing your claim for the procedure(s). Organ/Tissue Transplants - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 70 Standard and Basic Option Section 5(b) Standard and Basic Option Benefit Description Organ/Tissue Transplants (cont. You Pay Standard Option See previous page Basic Option Continued from previous page: Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. Participating/Non-participating: You pay all charges Allogeneic blood or marrow stem cell transplants for the diagnoses as indicated below: · Acute lymphocytic or non-lymphocytic. Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. Organ/Tissue Transplants - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 71 Standard and Basic Option Section 5(b) Standard and Basic Option Benefit Description Organ/Tissue Transplants (cont. Note: Refer to pages 73-75 for information about blood or marrow stem cell transplants covered only in clinical trials. Autologous blood or marrow stem cell transplants for the diagnoses as indicated below: · Acute lymphocytic or non-lymphocytic. Participating/Non-participating: You pay all charges You Pay Standard Option See previous page Basic Option See previous page Organ/Tissue Transplants - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 72 Standard and Basic Option Section 5(b) Standard and Basic Option Benefit Description Organ/Tissue Transplants (cont. You Pay Standard Option Preferred: 15% of the Plan allowance (deductible applies) Participating: 35% of the Plan allowance (deductible applies) Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount Basic Option Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings Note: Your provider will document the place of service when filing your claim for the procedure(s). Participating/Non-participating: You pay all charges Organ/Tissue Transplants - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 73 Standard and Basic Option Section 5(b) Standard and Basic Option Benefit Description Organ/Tissue Transplants (cont. Note: Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the trial, and the beginning and end points of the trial. Participating/Non-participating: You pay all charges Organ/Tissue Transplants - continued on next page 2021 Blue Cross and Blue Shield Service Benefit Plan 74 Standard and Basic Option Section 5(b) Standard and Basic Option Benefit Description Organ/Tissue Transplants (cont.
Syndromes
First impotence and depression cheap 40mg cialis professional free shipping, it is very difficult to recognize at the bedside without measurement of esophageal pressure or diaphragmatic electrical activity erectile dysfunction drugs kamagra cheap cialis professional 40 mg line, and these techniques are not routinely performed in a clinical setting erectile dysfunction walgreens purchase 40 mg cialis professional fast delivery. Third erectile dysfunction treatment in lucknow order 40mg cialis professional with amex, contrary to expectations erectile dysfunction drugs india buy cialis professional 20mg online, the incidence of reverse triggering increases with deeper sedation levels erectile dysfunction drugs and melanoma buy cialis professional 40 mg online. The intervention group was protected from this effect because cisatracurium prevented the diaphragmatic contraction that would have occurred in response to the reverse triggering mechanism. We would draw this conclusion regardless of whether the hypothesis of reverse triggering is correct. Mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of neuromechanical coupling. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Preclinical investigations have indicated potential synergistic interaction of their combination. Patients received ibrutinib monotherapy (420 mg once daily) for 3 cycles, followed by the addition of venetoclax (weekly dose escalation to 400 mg once daily). Response assessments were performed according to International Workshop on Chronic Lymphocytic Leukemia 2008 criteria. Minimal residual disease was assessed by means of multicolor flow cytometry in bone marrow (sensitivity, 10-4). With combined treatment, the proportions of patients who had complete remission (with or without normal blood count recovery) and remission with undetectable minimal residual disease increased over time. After 12 cycles of combined treatment, 88% of the patients had complete remission or complete remission with incomplete count recovery, and 61% had remission with undetectable minimal residual disease. The adverse-event profile was similar to what has been reported with ibrutinib and venetoclax. B-cell receptor signaling mainly occurs in lymphoid tissues and sends growth and survival signals to the leukemic cells. Oral ibrutinib is continued indefinitely, as limited by adverse events or until disease progression. Most responses to ibrutinib are partial, but with continuous therapy, they are quite durable. Gradual dose escalation, premedication, and frequent laboratory surveillance are used to safely initiate venetoclax therapy. First, every patient had a response, almost all had a complete response, and in most no residual disease was detected by means of flow cytometry. Third, initiation of venetoclax was facilitated by a period of administration of ibrutinib alone that reduced tumor bulk and the risk of tumor lysis syndrome. Finally, and most surprisingly, the published report does not include a KaplanMeier curve! As shown in Panel C, ibrutinib induced partial remission in most patients, and venetoclaxibrutinib induced complete remission in 96% of the patients. Targeting B cell receptor signalling in cancer: preclinical and clinical advances. Dose selection was guided by a preclinical model in mice and nonhuman primates that related dose level to reduction in the concentration of huntingtin. Nowhere are the manifestations more striking than around Lake Maracaibo in northwestern Venezuela, where the disease is almost epidemic. The mutant protein is toxic and prone to aggregation in cell culture, animal models, and human brains. Remarkably, disease manifestations are reversed when the mutant gene is turned off or suppressed in transgenic mice,5,6 which suggests that this approach could be effective in humans. This allows a nonallele-specific approach, in which the treatment would be suitable for all patients. Importantly, the levels of huntingtin protein can be assessed in the spinal fluid and correlate well with levels in the brain, thus providing a measure of the biologic effect of the treatment. The patients received four injections into the spinal fluid at 4-week intervals, with a 4-month followup. The trial agent was not associated with doselimiting adverse events; the most common adverse effects were related to the lumbar punctures. Remarkably, the reduction in the levels of mutant huntingtin was in a range that is expected to have therapeutic benefit on the basis of studies in animals. The current trial was of insufficient size and duration to show a significant difference in clinical measures between patients given the active agent and those who received placebo. However, an analysis after the trial showed a correlation of such measures with levels of the mutant protein in the spinal fluid, indicating that reducing the protein level could be beneficial. The phase 3 trial that has just begun is appropriately designed to determine whether this intervention has a clinically meaningful effect. For those in Venezuela who donated the samples that made this promising approach possible, the treatment should be free. Therefore, direct inhibition of HbS polymerization has potential to favorably modify disease outcomes. The primary end point was the percentage of participants who had a hemoglobin response, which was defined as an increase of more than 1. A total of 274 participants were randomly assigned in a 1:1:1 ratio to receive a once-daily oral dose of 1500 mg of voxelotor, 900 mg of voxelotor, or placebo. Most participants had sickle cell anemia (homozygous hemoglobin S or hemoglobin S0-thalassemia), and approximately two thirds were receiving hydroxyurea at baseline. Anemia worsened between baseline and week 24 in fewer participants in each voxelotor dose group than in those receiving placebo. At week 24, the 1500-mg voxelotor group had significantly greater reductions from baseline in the indirect bilirubin level and percentage of reticulocytes than the placebo group. The percentage of participants with an adverse event that occurred or worsened during the treatment period was similar across the trial groups. Adverse events of at least grade 3 occurred in 26% of the participants in the 1500-mg voxelotor group, 23% in the 900-mg voxelotor group, and 26% in the placebo group. Most adverse events were not related to the trial drug or placebo, as determined by the investigators. These findings are consistent with inhibition of HbS polymerization and indicate a disease-modifying potential. Affecting an estimated 100,000 Americans and millions worldwide, sickle cell disease is among the most common inherited blood disorders in humans and is associated with profound complications and premature death. HbS polymerization results in a very complex cascade of processes that include erythrocyte sickling, intravascular hemolysis with release of cell-free hemoglobin, increased adhesion of red cells to the endothelium of blood vessels, activation of platelets, production of inflammatory cytokines, and ultimately vascular occlusion. Although studies have shown that hydroxyurea is effective in reducing admissions for pain and acute chest syndrome, use of the agent remains low. As an inhibitor of HbS polymerization, voxelotor increases hemoglobinoxygen affinity and has been shown to reduce red-cell sickling, hemolysis, and anemia in murine models and earlystage clinical trials. The participants were stratified according to age, hydroxyurea use, and geographic region. More participants who received the 1500-mg daily dose of voxelotor had a hemoglobin response (defined as an increase in hemoglobin level of >1. Subgroup analyses suggested a potential benefit for voxelotor in both adults and adolescents, patients receiving voxelotor alone or in combination with hydroxyurea, and patients with few or frequent vasoocclusive episodes. The investigators concluded that the increase in hemoglobin level and reduction in hemolysis observed with voxelotor support its use as a new, potentially disease-modifying therapy for sickle cell disease. The difference between the 1500-mg oncedaily dose of voxelotor and placebo with respect to the primary efficacy end point in the trial, a modest increase in hemoglobin level, was statistically significant, and the increase tended to n engl j med 381;6 nejm. The clinical significance of this response was the associated reduction in hemolysis, a consequence of sickle cell disease that is associated with chronic organ injury. A trend toward a cumulative reduction in the incidence of vaso-occlusive pain episodes with voxelotor as compared with placebo may be emerging in an extended followup analysis out to 72 weeks. Follow-up studies are needed to examine this very important, clinically relevant end point. The occurrence of adverse events during the treatment period was common in this trial, but more serious grade 3 or greater events were balanced across all trial groups and included reports of gastrointestinal complications (diarrhea, nausea, and abdominal pain), headache, and rash. Relatively small numbers of patients discontinued the trial drug because of adverse events. Adverse events related to sickle cell disease were also fairly similar across the trial groups. As described in a thoughtful review by Eaton and Bunn,10 HbS polymerization is the root cause of sickle cell disease and its complications, and approaches to treating sickle cell disease that ultimately inhibit polymerization can and should have a therapeutic effect. But can increasing oxygen affinity of hemoglobin cause harm if it results in tissue hypoxia? The predicted benefit of antisickling agents does not require complete inhibition of HbS polymerization. This modest inhibition of polymerization should increase delay time without deleterious shifts in the oxygen-binding curve, allowing red cells to transit through the microcirculation with less sickling and therefore improved oxygen delivery. At the dose levels studied, voxelotor did not appear to impair tissue oxygenation, a finding that is supported by the maintenance of baseline serum erythropoietin levels, a surrogate end point in the trial. It is a phase 3, randomized, controlled trial of a rationally designed agent for sickle cell disease, a condition for which there have been limited disease-modifying therapies. A phase 1/2 ascending dose study and open-label extension study of voxelotor in patients with sickle cell disease. Daily data on mortality and air pollution were collected from 652 cities in 24 countries or regions. We used overdispersed generalized additive models with random-effects meta-analysis to investigate the associations. Concentrationresponse curves from each city were pooled to allow global estimates to be derived. The link between particulate pollution and mortality was originally recognized in the context of severe episodes of poor air quality in the 20th century, such as the London Fog of 1952. The policy response to the increasing evidence of the effects of air pollution on public health was for governments to develop air-quality regulations. The population serves as its own control, and confounding by population characteristics is negligible because these are stable over short time frames. Time-series studies can be confounded by time-varying factors such as influenza epidemics and temperature; however, statistical methods to reduce such confounding have been developed. Efforts have been made to include larger regions in time-series analyses to increase the generalizability of the reported associations. The strength of the associations was reduced but remained significant in two-pollutant models that addressed potential confounding by gaseous pollutants. This finding has profound policy implications, especially 774 n engl j med 381;8 nejm. Even work not only makes no sense, it would set a high-income countries, such as the United States, dangerous precedent for environmental policy. Francisco, and the School of Public Health, University of CaliThe Clean Air Act requires a periodic review fornia, Berkeley. Environ Health Perspect 2008; 9 inconvenient scientific evidence as anathema, 116:1480-6. Ambient particulate air pollution traditionally used to infer causation, Cox wants and daily mortality in 652 cities. Cardiovascular to rely on studies that use a theoretical approach mortality and exposure to airborne fine particulate matter and 10 called "manipulative causality. The first coprimary outcome was the composite of cardiovascular death or myocardial infarction; the second coprimary outcome was the composite of cardiovascular death, myocardial infarction, or ischemia-driven revascularization. Mehta at the Population Health Re search Institute, McMaster University and Hamilton Health Sciences, David Braley Research Bldg. At a median follow-up of 3 years, the first coprimary outcome had occurred in 158 of the 2016 patients (7. Treatment of nonculprit lesions could be performed during the index admission or after discharge, a choice that was made by investigators before randomization. Among patients who were randomly assigned to undergo complete revascularization, one third had the second procedure after hospital discharge. Subgroup analyses that were based on the intended timing of the second procedure showed no interaction with the primary outcomes, which indicates that complete revascularization may be safely postponed until after hospital discharge in selected patients. The risk of adverse events (including stroke, major bleeding, and acute kidney injury) was similar in the two groups, which supports the safety of an additional procedure. Investigators specified before randomization whether they intended to perform the second procedure during the index hospitalization or after hospital discharge. Among the patients who underwent complete revascularization, the intended timing of the second procedure was during the index hospitalization for 1285 patients and after hospital discharge for 596 patients. Patients participating in trials are different from sicker patients seen in the clinical setting, and extrapolation of the results to patients with a greater risk of complications may not be safe. Also, some patients may benefit more from firm adherence to high-potency dual antiplatelet therapy with either prasugrel or ticagrelor. We hope that the investigators will be able to obtain data from longer follow-up in order to evaluate whether the tendency toward a small reduction in all-cause mortality becomes significant over time. Better selection of high-risk patients may also refine the determination of who is most likely to benefit from complete revascularization. Regardless, in light of the results of the well-planned and well-executed trial by Mehta et al. From the Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of pulmonary disease associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation.
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