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The past cialis online in canada week has seen an explosion of media commentary about whether children in the UK should go back to school. Since ‘lockdown’ (23 March 2020) began schools have been open to vulnerable children and young people, and to the children of cialis online in canada ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools. Viner et al1 cialis online in canada produced a rapid systematic review that concludes that school closures have less impact on rate and mortality than other social distancing measures. Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’.

This was conveyed cialis online in canada to the population of the UK on 10 May by the UK prime minister, Boris Johnson. He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken cialis online in canada by various groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson announced that there would be a phased return (in England) of some children to school from 1 June. There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools. In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a vital cialis online in canada part of restarting the UK economy, but they have concerns about the safety and welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision.

Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there cialis online in canada are children out there that have not spoken or played with another child their own age for the last two months. They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest cialis online in canada children will be the ones who fall further behind if we keep school gates closed. This phased return is in line with cialis online in canada what other European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets and news articles identifying problems in enacting the government plan and the illogical nature of Williamson’s statement.

The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school. This has caused concern about the attainment gap, but as cialis online in canada Quinn6 points out fewer children from disadvantaged backgrounds are likely to return to school than those from more affluent backgrounds.Government ministers and spokespeople reiterated that scientific evidence and observation of other European countries where schools had reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit. Is that cialis online in canada correct?. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’.

This provoked a cialis online in canada great deal of disquiet. Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the risk to cialis online in canada children of developing erectile dysfunction disease. The second is the risk to others of children transmitting erectile dysfunction disease, either while being symptomatic or asymptomatic. Here are some of the available evidence.Morbidity and mortality in children from erectile dysfunction diseaseChildren appear to be less likely to acquire erectile dysfunction disease in various nations.9–11 Barton et cialis online in canada al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications).

Of these 8113 paediatric cases, 14% required hospital admission. The admission rate to critical care was 2.2% cialis online in canada of confirmed cases (7.2% of admitted children). Death was cialis online in canada reported in 15 cases (0.18%). This adds to other evidence suggesting that children are at a relatively low risk from the cialis, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the cialis.15There are concerns that children who have been infected with the cialis can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for erectile dysfunction treatment, and in the absence of effective community testing it will be impossible to know if they are carrying the cialis. Children also can have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In short, it is difficult to determine without much more extensive testing if a child can transmit the .Arav cialis online in canada et al18 found that the contact route was much more important than the airborne route, which they concluded had a negligible contribution.

They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and cialis online in canada Child Health that explored family clusters of suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is a case for reopening schools to limited numbers of pupils—the risk to pupils and the adults they come into contact with seems to be small, and the potential gains for children may outweigh them. There is a big proviso with this however, and that is that the overall incidence of erectile dysfunction treatment has fallen below specified threshold. This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure cialis online in canada the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of decreasing to manageable levels.Ensuring that personal protective equipment supply can meet demand.Being confident that any adjustments would not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy.

Decisions about whether to reopen schools are taken on a national level with a cialis online in canada distance from personal concerns and fears. Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is cialis online in canada a difficult path to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation. Parents were being asked cialis online in canada to believe that MMR was a safe treatment in the face of a massive and emotive campaign that promoted the ‘risk’ of having the treatment above all else.

This situation is even more complex than that as we have increased access to opinion and cialis online in canada difficulty in understanding if or how much that information is biased. It is no wonder that decision-making is difficult. It is likely that evidence will cialis online in canada continue to emerge and gradually the choice will become easier to make. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach. By working to identify a consensus position, researchers can report findings on a specific question (or set of questions) that are based on the knowledge and experience of experts in their cialis online in canada field.However, there are challenges to this approach.

For example, what should be done when consensus cannot be reached?. How can experts be engaged in a way that allows them to consider objectively the views of others and—where appropriate—change their own opinions in response? cialis online in canada. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus. Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, so that the methods employed “…appear to be more conducive to independent thought on the part of the experts and to cialis online in canada aid them in the gradual formation of a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline.

First, the overarching approach is based on a series of ‘rounds’, where a cialis online in canada set of experts are asked their opinions on a particular issue. The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses. Finally, the cialis online in canada findings of each round are always shared with the broader group anonymously. This avoids any bias that might result from participants being concerned about their own views being viewed negatively cialis online in canada or from their own opinions being biased by personal factors. This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged.

For example, a study of human factors that contributed to nursing errors cialis online in canada used only two rounds. The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could. Analysis of responses resulted in a list of 28 potential reasons—this list was sent back to the same group of experts cialis online in canada for the second round, asking them to score each one for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round cialis online in canada 1, draft competencies were developed from the findings of a survey of NP beliefs, knowledge and level of implementation of advance care planning.

Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made based on the original feedback, and a third round was conducted where 15 of the original NP participants confirmed their consensus with the cialis online in canada final document. The final document includes four competencies, each with several elements. Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses of Delphi studiesThe Delphi technique offers a flexible approach to gathering the views of experts cialis online in canada on an area of interest. The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups.

The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from dominant or high-profile members of the group are given extra cialis online in canada credence.5However, Delphi studies can—by their very nature—be complex and time consuming. The need for participants to complete multiple rounds can lead to high drop-out rates which impacts on validity of the cialis online in canada study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword. It provides those taking part with the opportunity to reflect and reconsider their position in response to additional information, which is an important part of nursing practice cialis online in canada. Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’.

Even with the level of flexibility and reflexivity present in Delphi studies, cialis online in canada it is still unlikely that a group of experts will demonstrate 100% agreement on issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached. This is where there is inconsistency across studies and authors, with the suggested level of consensus ranging from 51% to 100%.2 In addition, it has been identified that in some areas, consensus is not predefined as part cialis online in canada of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore related to cialis online in canada the quality of evidence, with expert opinion viewed as providing a poor basis for making judgements on healthcare interventions.7 This does not mean that the findings of Delphi studies are intrinsically unreliable or invalid.

It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts. It allows for reflection among participants, who are able to nuance and reconsider their opinion based on the anonymised cialis online in canada opinions of others. However, researchers must take steps to enhance robustness of the studies. It is important to try cialis online in canada and prevent participants from simply resorting to agreeing with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

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No Supplementary Data.No Article MediaNo cialis every day MetricsDocument Type http://deecarrollphoto.com/blog/. Research ArticleAffiliations:1. Center for Clinical Microbiology, Division of and Immunity, University College London, Royal Free Hospital Campus, London, UK 2. Marie Bashir Institute for Emerging cialis every day Infectious Diseases and Biosecurity, University of Sydney, Sydney NSW, Australia.

3. Immunotherapy Programme, Champalimaud Centre for the Unknown, Lisbon, Portugal, I Med Clinic, University of Mainz, Mainz, Germany 4. Barts and The London School of cialis every day Medicine and Dentistry, Queen Mary University of London, London, UK 5. Zambia National Public Health Institute, Ministry of Health, Lusaka, Zambia 6.

Foundation Congolaise pour la Recherche Médicale/University Marien Ngouabi Brazzaville, Congo, Institute http://heidimyworld.com/?page_id=2 for Tropical Medicine/University of Tübingen, Germany 7. Ministry of Health, Lusaka, Zambia 8. National Institute of cialis every day Medical Research, Dar es Salaam, Tanzania 9. Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Varese, 10.

Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy 11. Institute cialis every day for Clinical Medicine, Faculty of Health Sciences, University of Aarhus, Denmark, Department of Melecular Medicine, University of Pavia, Italy 12. Department of Medicine &. Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China 13.

Lazzaro Spallanzani, National Institute for Infectious Diseases IRCCS, Rome, Italy 14.

Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, cialis online in canada Hong Kong, China 13. Lazzaro Spallanzani, National Institute for Infectious Diseases IRCCS, Rome, Italy 14. Hong Kong Tuberculosis, Chest and Heart Diseases Association, Hong Kong, China 15. Blizard Institute, cialis online in canada Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, Division of , Royal London Hospital, Barts Health NHS Trust, London, UK, , Email.

[email protected]Publication date:01 August 2020More about this publication?. The International Journal of Tuberculosis and Lung Disease publishes articles on all aspects of lung health, including public health-related issues such as training programmes, cost-benefit analysis, legislation, epidemiology, intervention studies and health systems research. The IJTLD is dedicated to the continuing education of physicians and health personnel and the dissemination cialis online in canada of information on lung health world-wide. To share scientific research of immediate concern as rapidly as possible, The Union is fast-tracking the publication of certain articles from the IJTLD and publishing them on The Union website, prior to their publication in the Journal.

Read fast-track articles.Certain IJTLD articles are also selected for translation into French, Spanish, Chinese or Russian. These are available on the Union website.Editorial BoardInformation for AuthorsSubscribe to this TitleInternational Journal of Tuberculosis and Lung DiseasePublic Health ActionIngenta Connect is not responsible for the content or availability of external websitesDownload Article. Download (PDF 46 kb) No AbstractNo Reference information cialis online in canada available - sign in for access. No Supplementary Data.No Article MediaNo MetricsDocument Type.

Research ArticleAffiliations:1. Division of Pulmonary Rehabilitation, cialis online in canada Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy, Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Tradate, Varese-Como 2. Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy 3. Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Mexico City, Mexico 4.

Department of Infectious Diseases, Galliera Hospital, Genoa, Italy, , Email.

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Trial Population can you buy cialis Table cialis precio 1. Table 1 cialis precio. Characteristics of the Participants in cialis precio the mRNA-1273 Trial at Enrollment. The 45 enrolled participants received their first vaccination between March 16 and April 14, 2020 (Fig. S1).

Three participants did not receive the second vaccination, including one in the 25-μg group who had urticaria on both legs, with onset 5 days after the first vaccination, and two (one in the 25-μg group and one in the 250-μg group) who missed the second vaccination window owing to isolation for suspected erectile dysfunction treatment while the test results, ultimately negative, were pending. All continued to attend scheduled trial visits. The demographic characteristics of participants at enrollment are provided in Table 1. treatment Safety No serious adverse events were noted, and no prespecified trial halting rules were met. As noted above, one participant in the 25-μg group was withdrawn because of an unsolicited adverse event, transient urticaria, judged to be related to the first vaccination.

Figure 1. Figure 1. Systemic and Local Adverse Events. The severity of solicited adverse events was graded as mild, moderate, or severe (see Table S1).After the first vaccination, solicited systemic adverse events were reported by 5 participants (33%) in the 25-μg group, 10 (67%) in the 100-μg group, and 8 (53%) in the 250-μg group. All were mild or moderate in severity (Figure 1 and Table S2).

Solicited systemic adverse events were more common after the second vaccination and occurred in 7 of 13 participants (54%) in the 25-μg group, all 15 in the 100-μg group, and all 14 in the 250-μg group, with 3 of those participants (21%) reporting one or more severe events. None of the participants had fever after the first vaccination. After the second vaccination, no participants in the 25-μg group, 6 (40%) in the 100-μg group, and 8 (57%) in the 250-μg group reported fever. One of the events (maximum temperature, 39.6°C) in the 250-μg group was graded severe. (Additional details regarding adverse events for that participant are provided in the Supplementary Appendix.) Local adverse events, when present, were nearly all mild or moderate, and pain at the injection site was common.

Across both vaccinations, solicited systemic and local adverse events that occurred in more than half the participants included fatigue, chills, headache, myalgia, and pain at the injection site. Evaluation of safety clinical laboratory values of grade 2 or higher and unsolicited adverse events revealed no patterns of concern (Supplementary Appendix and Table S3). erectile dysfunction Binding Antibody Responses Table 2. Table 2. Geometric Mean Humoral Immunogenicity Assay Responses to mRNA-1273 in Participants and in Convalescent Serum Specimens.

Figure 2. Figure 2. erectile dysfunction Antibody and Neutralization Responses. Shown are geometric mean reciprocal end-point enzyme-linked immunosorbent assay (ELISA) IgG titers to S-2P (Panel A) and receptor-binding domain (Panel B), PsVNA ID50 responses (Panel C), and live cialis PRNT80 responses (Panel D). In Panel A and Panel B, boxes and horizontal bars denote interquartile range (IQR) and median area under the curve (AUC), respectively.

Whisker endpoints are equal to the maximum and minimum values below or above the median ±1.5 times the IQR. The convalescent serum panel includes specimens from 41 participants. Red dots indicate the 3 specimens that were also tested in the PRNT assay. The other 38 specimens were used to calculate summary statistics for the box plot in the convalescent serum panel. In Panel C, boxes and horizontal bars denote IQR and median ID50, respectively.

Whisker end points are equal to the maximum and minimum values below or above the median ±1.5 times the IQR. In the convalescent serum panel, red dots indicate the 3 specimens that were also tested in the PRNT assay. The other 38 specimens were used to calculate summary statistics for the box plot in the convalescent panel. In Panel D, boxes and horizontal bars denote IQR and median PRNT80, respectively. Whisker end points are equal to the maximum and minimum values below or above the median ±1.5 times the IQR.

The three convalescent serum specimens were also tested in ELISA and PsVNA assays. Because of the time-intensive nature of the PRNT assay, for this preliminary report, PRNT results were available only for the 25-μg and 100-μg dose groups.Binding antibody IgG geometric mean titers (GMTs) to S-2P increased rapidly after the first vaccination, with seroconversion in all participants by day 15 (Table 2 and Figure 2A). Dose-dependent responses to the first and second vaccinations were evident. Receptor-binding domain–specific antibody responses were similar in pattern and magnitude (Figure 2B). For both assays, the median magnitude of antibody responses after the first vaccination in the 100-μg and 250-μg dose groups was similar to the median magnitude in convalescent serum specimens, and in all dose groups the median magnitude after the second vaccination was in the upper quartile of values in the convalescent serum specimens.

The S-2P ELISA GMTs at day 57 (299,751 [95% confidence interval {CI}, 206,071 to 436,020] in the 25-μg group, 782,719 [95% CI, 619,310 to 989,244] in the 100-μg group, and 1,192,154 [95% CI, 924,878 to 1,536,669] in the 250-μg group) exceeded that in the convalescent serum specimens (142,140 [95% CI, 81,543 to 247,768]). erectile dysfunction Neutralization Responses No participant had detectable PsVNA responses before vaccination. After the first vaccination, PsVNA responses were detected in less than half the participants, and a dose effect was seen (50% inhibitory dilution [ID50]. Figure 2C, Fig. S8, and Table 2.

80% inhibitory dilution [ID80]. Fig. S2 and Table S6). However, after the second vaccination, PsVNA responses were identified in serum samples from all participants. The lowest responses were in the 25-μg dose group, with a geometric mean ID50 of 112.3 (95% CI, 71.2 to 177.1) at day 43.

The higher responses in the 100-μg and 250-μg groups were similar in magnitude (geometric mean ID50, 343.8 [95% CI, 261.2 to 452.7] and 332.2 [95% CI, 266.3 to 414.5], respectively, at day 43). These responses were similar to values in the upper half of the distribution of values for convalescent serum specimens. Before vaccination, no participant had detectable 80% live-cialis neutralization at the highest serum concentration tested (1:8 dilution) in the PRNT assay. At day 43, wild-type cialis–neutralizing activity capable of reducing erectile dysfunction infectivity by 80% or more (PRNT80) was detected in all participants, with geometric mean PRNT80 responses of 339.7 (95% CI, 184.0 to 627.1) in the 25-μg group and 654.3 (95% CI, 460.1 to 930.5) in the 100-μg group (Figure 2D). Neutralizing PRNT80 average responses were generally at or above the values of the three convalescent serum specimens tested in this assay.

Good agreement was noted within and between the values from binding assays for S-2P and receptor-binding domain and neutralizing activity measured by PsVNA and PRNT (Figs. S3 through S7), which provides orthogonal support for each assay in characterizing the humoral response induced by mRNA-1273. erectile dysfunction T-Cell Responses The 25-μg and 100-μg doses elicited CD4 T-cell responses (Figs. S9 and S10) that on stimulation by S-specific peptide pools were strongly biased toward expression of Th1 cytokines (tumor necrosis factor α >. Interleukin 2 >.

Interferon γ), with minimal type 2 helper T-cell (Th2) cytokine expression (interleukin 4 and interleukin 13). CD8 T-cell responses to S-2P were detected at low levels after the second vaccination in the 100-μg dose group (Fig. S11).To the Editor. Rapid and accurate diagnostic tests are essential for controlling the ongoing erectile dysfunction treatment cialis. Although the current standard involves testing of nasopharyngeal swab specimens by quantitative reverse-transcriptase polymerase chain reaction (RT-qPCR) to detect erectile dysfunction, saliva specimens may be an alternative diagnostic sample.1-4 Rigorous evaluation is needed to determine how saliva specimens compare with nasopharyngeal swab specimens with respect to sensitivity in detection of erectile dysfunction during the course of .

A total of 70 inpatients with erectile dysfunction treatment provided written informed consent to participate in our study (see the Methods section in Supplementary Appendix 1, available with the full text of this letter at NEJM.org). After erectile dysfunction treatment was confirmed with a positive nasopharyngeal swab specimen at hospital admission, we obtained additional samples from the patients during hospitalization. We tested saliva specimens collected by the patients themselves and nasopharyngeal swabs collected from the patients at the same time point by health care workers. Figure 1. Figure 1.

erectile dysfunction RNA Titers in Saliva Specimens and Nasopharyngeal Swab Specimens. Samples were obtained from 70 hospital inpatients who had a diagnosis of erectile dysfunction treatment. Panel A shows erectile dysfunction RNA titers in the first available nasopharyngeal and saliva samples. The lines indicate samples from the same patient. Results were compared with the use of a Wilcoxon signed-rank test (P<0.001).

Panel B shows percentages of positivity for erectile dysfunction in tests of the first matched nasopharyngeal and saliva samples at 1 to 5 days, 6 to 10 days, and 11 or more days (maximum, 53 days) after the diagnosis of erectile dysfunction treatment. Panel C shows longitudinal erectile dysfunction RNA copies per milliliter in 97 saliva samples, according to days since symptom onset. Each circle represents a separate sample. Dashed lines indicate additional samples teva generic cialis price from the same patient. The red line indicates a negative saliva sample that was followed by a positive sample at the next collection of a specimen.

Panel D shows longitudinal erectile dysfunction RNA copies per milliliter in 97 nasopharyngeal swab specimens, according to days since symptom onset. The red lines indicate negative nasopharyngeal swab specimens there were followed by a positive swab at the next collection of a specimen. The gray area in Panels C and D indicates samples that were below the lower limit of detection of 5610 cialis RNA copies per milliliter of sample, which is at cycle threshold 38 of our quantitative reverse-transcriptase polymerase chain reaction assay targeting the erectile dysfunction N1 sequence recommended by the Centers for Disease Control and Prevention. To analyze these data, we used a linear mixed-effects regression model (see Supplementary Appendix 1) that accounts for the correlation between samples collected from the same person at a single time point (i.e., multivariate response) and the correlation between samples collected across time from the same patient (i.e., repeated measures). All the data used to generate this figure, including the raw cycle thresholds, are provided in Supplementary Data 1 in Supplementary Appendix 2.Using primer sequences from the Centers for Disease Control and Prevention, we detected more erectile dysfunction RNA copies in the saliva specimens (mean log copies per milliliter, 5.58.

95% confidence interval [CI], 5.09 to 6.07) than in the nasopharyngeal swab specimens (mean log copies per milliliter, 4.93. 95% CI, 4.53 to 5.33) (Figure 1A, and Fig. S1 in Supplementary Appendix 1). In addition, a higher percentage of saliva samples than nasopharyngeal swab samples were positive up to 10 days after the erectile dysfunction treatment diagnosis (Figure 1B). At 1 to 5 days after diagnosis, 81% (95% CI, 71 to 96) of the saliva samples were positive, as compared with 71% (95% CI, 67 to 94) of the nasopharyngeal swab specimens.

These findings suggest that saliva specimens and nasopharyngeal swab specimens have at least similar sensitivity in the detection of erectile dysfunction during the course of hospitalization. Because the results of testing of nasopharyngeal swab specimens to detect erectile dysfunction may vary with repeated sampling in individual patients,5 we evaluated viral detection in matched samples over time. The level of erectile dysfunction RNA decreased after symptom onset in both saliva specimens (estimated slope, −0.11. 95% credible interval, −0.15 to −0.06) (Figure 1C) and nasopharyngeal swab specimens (estimated slope, −0.09. 95% credible interval, −0.13 to −0.05) (Figure 1D).

In three instances, a negative nasopharyngeal swab specimen was followed by a positive swab at the next collection of a specimen (Figure 1D). This phenomenon occurred only once with the saliva specimens (Figure 1C). During the clinical course, we observed less variation in levels of erectile dysfunction RNA in the saliva specimens (standard deviation, 0.98 cialis RNA copies per milliliter. 95% credible interval, 0.08 to 1.98) than in the nasopharyngeal swab specimens (standard deviation, 2.01 cialis RNA copies per milliliter. 95% credible interval, 1.29 to 2.70) (see Supplementary Appendix 1).

Recent studies have shown that erectile dysfunction can be detected in the saliva of asymptomatic persons and outpatients.1-3 We therefore screened 495 asymptomatic health care workers who provided written informed consent to participate in our prospective study, and we used RT-qPCR to test both saliva and nasopharyngeal samples obtained from these persons. We detected erectile dysfunction RNA in saliva specimens obtained from 13 persons who did not report any symptoms at or before the time of sample collection. Of these 13 health care workers, 9 had collected matched nasopharyngeal swab specimens by themselves on the same day, and 7 of these specimens tested negative (Fig. S2). The diagnosis in the 13 health care workers with positive saliva specimens was later confirmed in diagnostic testing of additional nasopharyngeal samples by a CLIA (Clinical Laboratory Improvement Amendments of 1988)–certified laboratory.

Variation in nasopharyngeal sampling may be an explanation for false negative results, so monitoring an internal control for proper sample collection may provide an alternative evaluation technique. In specimens collected from inpatients by health care workers, we found greater variation in human RNase P cycle threshold (Ct) values in nasopharyngeal swab specimens (standard deviation, 2.89 Ct. 95% CI, 26.53 to 27.69) than in saliva specimens (standard deviation, 2.49 Ct. 95% CI, 23.35 to 24.35). When health care workers collected their own specimens, we also found greater variation in RNase P Ct values in nasopharyngeal swab specimens (standard deviation, 2.26 Ct.

95% CI, 28.39 to 28.56) than in saliva specimens (standard deviation , 1.65 Ct. 95% CI, 24.14 to 24.26) (Fig. S3). Collection of saliva samples by patients themselves negates the need for direct interaction between health care workers and patients. This interaction is a source of major testing bottlenecks and presents a risk of nosocomial .

Collection of saliva samples by patients themselves also alleviates demands for supplies of swabs and personal protective equipment. Given the growing need for testing, our findings provide support for the potential of saliva specimens in the diagnosis of erectile dysfunction . Anne L. Wyllie, Ph.D.Yale School of Public Health, New Haven, CT [email protected]John Fournier, M.D.Yale School of Medicine, New Haven, CTArnau Casanovas-Massana, Ph.D.Yale School of Public Health, New Haven, CTMelissa Campbell, M.D.Maria Tokuyama, Ph.D.Pavithra Vijayakumar, B.A.Yale School of Medicine, New Haven, CTJoshua L. Warren, Ph.D.Yale School of Public Health, New Haven, CTBertie Geng, M.D.Yale School of Medicine, New Haven, CTM.

Catherine Muenker, M.S.Adam J. Moore, M.P.H.Chantal B.F. Vogels, Ph.D.Mary E. Petrone, B.S.Isabel M. Ott, B.S.Yale School of Public Health, New Haven, CTPeiwen Lu, Ph.D.Arvind Venkataraman, B.S.Alice Lu-Culligan, B.S.Jonathan Klein, B.S.Yale School of Medicine, New Haven, CTRebecca Earnest, M.P.H.Yale School of Public Health, New Haven, CTMichael Simonov, M.D.Rupak Datta, M.D., Ph.D.Ryan Handoko, M.D.Nida Naushad, B.S.Lorenzo R.

Sewanan, M.Phil.Jordan Valdez, B.S.Yale School of Medicine, New Haven, CTElizabeth B. White, A.B.Sarah Lapidus, M.S.Chaney C. Kalinich, M.P.H.Yale School of Public Health, New Haven, CTXiaodong Jiang, M.D., Ph.D.Daniel J. Kim, A.B.Eriko Kudo, Ph.D.Melissa Linehan, M.S.Tianyang Mao, B.S.Miyu Moriyama, Ph.D.Ji E. Oh, M.D., Ph.D.Annsea Park, B.A.Julio Silva, B.S.Eric Song, M.S.Takehiro Takahashi, M.D., Ph.D.Manabu Taura, Ph.D.Orr-El Weizman, B.A.Patrick Wong, M.S.Yexin Yang, B.S.Santos Bermejo, B.S.Yale School of Medicine, New Haven, CTCamila D.

Odio, M.D.Yale New Haven Health, New Haven, CTSaad B. Omer, M.B., B.S., Ph.D.Yale Institute for Global Health, New Haven, CTCharles S. Dela Cruz, M.D., Ph.D.Shelli Farhadian, M.D., Ph.D.Richard A. Martinello, M.D.Akiko Iwasaki, Ph.D.Yale School of Medicine, New Haven, CTNathan D. Grubaugh, Ph.D.Albert I.

Ko, M.D.Yale School of Public Health, New Haven, CT [email protected], [email protected] Supported by the Huffman Family Donor Advised Fund, a Fast Grant from Emergent Ventures at the Mercatus Center at George Mason University, the Yale Institute for Global Health, the Yale School of Medicine, a grant (U19 AI08992, to Dr. Ko) from the National Institute of Allergy and Infectious Diseases, the Beatrice Kleinberg Neuwirth Fund, and a grant (Rubicon 019.181EN.004, to Dr. Vogel) from the Dutch Research Council (NWO). Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on August 28, 2020, at NEJM.org.

Drs. Grubaugh and Ko contributed equally to this letter. 5 References1. Kojima N, Turner F, Slepnev V, et al. Self-collected oral fluid and nasal swabs demonstrate comparable sensitivity to clinician collected nasopharyngeal swabs for erectile dysfunction treatment detection.

April 15, 2020 (https://www.medrxiv.org/content/10.1101/2020.04.11.20062372v1). Preprint.Google Scholar2. Williams E, Bond K, Zhang B, Putland M, Williamson DA. Saliva as a non-invasive specimen for detection of erectile dysfunction. J Clin Microbiol 2020;58(8):e00776-20-e00776-20.3.

Pasomsub E, Watcharananan SP, Boonyawat K, et al. Saliva sample as a non-invasive specimen for the diagnosis of erectile dysfunction disease 2019. A cross-sectional study. Clin Microbiol Infect 2020 May 15 (Epub ahead of print).4. Vogels CBF, Brackney D, Wang J, et al.

SalivaDirect. Simple and sensitive molecular diagnostic test for erectile dysfunction surveillance. August 4, 2020 (https://www.medrxiv.org/content/10.1101/2020.08.03.20167791v1). Preprint.Google Scholar5. Zou L, Ruan F, Huang M, et al.

erectile dysfunction viral load in upper respiratory specimens of infected patients. N Engl J Med 2020;382:1177-1179..

Trial Population Table cialis online in canada more 1. Table 1 cialis online in canada. Characteristics of the Participants cialis online in canada in the mRNA-1273 Trial at Enrollment.

The 45 enrolled participants received their first vaccination between March 16 and April 14, 2020 (Fig. S1). Three participants did not receive the second vaccination, including one in the 25-μg group who had urticaria on both legs, with onset 5 days after the first vaccination, and two (one in the 25-μg group and one in the 250-μg group) who missed the second vaccination window owing to isolation for suspected erectile dysfunction treatment while the test results, ultimately negative, were pending.

All continued to attend scheduled trial visits. The demographic characteristics of participants at enrollment are provided in Table 1. treatment Safety No serious adverse events were noted, and no prespecified trial halting rules were met.

As noted above, one participant in the 25-μg group was withdrawn because of an unsolicited adverse event, transient urticaria, judged to be related to the first vaccination. Figure 1. Figure 1.

Systemic and Local Adverse Events. The severity of solicited adverse events was graded as mild, moderate, or severe (see Table S1).After the first vaccination, solicited systemic adverse events were reported by 5 participants (33%) in the 25-μg group, 10 (67%) in the 100-μg group, and 8 (53%) in the 250-μg group. All were mild or moderate in severity (Figure 1 and Table S2).

Solicited systemic adverse events were more common after the second vaccination and occurred in 7 of 13 participants (54%) in the 25-μg group, all 15 in the 100-μg group, and all 14 in the 250-μg group, with 3 of those participants (21%) reporting one or more severe events. None of the participants had fever after the first vaccination. After the second vaccination, no participants in the 25-μg group, 6 (40%) in the 100-μg group, and 8 (57%) in the 250-μg group reported fever.

One of the events (maximum temperature, 39.6°C) in the 250-μg group was graded severe. (Additional details regarding adverse events for that participant are provided in the Supplementary Appendix.) Local adverse events, when present, were nearly all mild or moderate, and pain at the injection site was common. Across both vaccinations, solicited systemic and local adverse events that occurred in more than half the participants included fatigue, chills, headache, myalgia, and pain at the injection site.

Evaluation of safety clinical laboratory values of grade 2 or higher and unsolicited adverse events revealed no patterns of concern (Supplementary Appendix and Table S3). erectile dysfunction Binding Antibody Responses Table 2. Table 2.

Geometric Mean Humoral Immunogenicity Assay Responses to mRNA-1273 in Participants and in Convalescent Serum Specimens. Figure 2. Figure 2.

erectile dysfunction Antibody and Neutralization Responses. Shown are geometric mean reciprocal end-point enzyme-linked immunosorbent assay (ELISA) IgG titers to S-2P (Panel A) and receptor-binding domain (Panel B), PsVNA ID50 responses (Panel C), and live cialis PRNT80 responses (Panel D). In Panel A and Panel B, boxes and horizontal bars denote interquartile range (IQR) and median area under the curve (AUC), respectively.

Whisker endpoints are equal to the maximum and minimum values below or above the median ±1.5 times the IQR. The convalescent serum panel includes specimens from 41 participants. Red dots indicate the 3 specimens that were also tested in the PRNT assay.

The other 38 specimens were used to calculate summary statistics for the box plot in the convalescent serum panel. In Panel C, boxes and horizontal bars denote IQR and median ID50, respectively. Whisker end points are equal to the maximum and minimum values below or above the median ±1.5 times the IQR.

In the convalescent serum panel, red dots indicate the 3 specimens that were also tested in the PRNT assay. The other 38 specimens were used to calculate summary statistics for the box plot in the convalescent panel. In Panel D, boxes and horizontal bars denote IQR and median PRNT80, respectively.

Whisker end points are equal to the maximum and minimum values below or above the median ±1.5 times the IQR. The three convalescent serum specimens were also tested in ELISA and PsVNA assays. Because of the time-intensive nature of the PRNT assay, for this preliminary report, PRNT results were available only for the 25-μg and 100-μg dose groups.Binding antibody IgG geometric mean titers (GMTs) to S-2P increased rapidly after the first vaccination, with seroconversion in all participants by day 15 (Table 2 and Figure 2A).

Dose-dependent responses to the first and second vaccinations were evident. Receptor-binding domain–specific antibody responses were similar in pattern and magnitude (Figure 2B). For both assays, the median magnitude of antibody responses after the first vaccination in the 100-μg and 250-μg dose groups was similar to the median magnitude in convalescent serum specimens, and in all dose groups the median magnitude after the second vaccination was in the upper quartile of values in the convalescent serum specimens.

The S-2P ELISA GMTs at day 57 (299,751 [95% confidence interval {CI}, 206,071 to 436,020] in the 25-μg group, 782,719 [95% CI, 619,310 to 989,244] in the 100-μg group, and 1,192,154 [95% CI, 924,878 to 1,536,669] in the 250-μg group) exceeded that in the convalescent serum specimens (142,140 [95% CI, 81,543 to 247,768]). erectile dysfunction Neutralization Responses No participant had detectable PsVNA responses before vaccination. After the first vaccination, PsVNA responses were detected in less than half the participants, and a dose effect was seen (50% inhibitory dilution [ID50].

Figure 2C, Fig. S8, and Table 2. 80% inhibitory dilution [ID80].

Fig. S2 and Table S6). However, after the second vaccination, PsVNA responses were identified in serum samples from all participants.

The lowest responses were in the 25-μg dose group, with a geometric mean ID50 of 112.3 (95% CI, 71.2 to 177.1) at day 43. The higher responses in the 100-μg and 250-μg groups were similar in magnitude (geometric mean ID50, 343.8 [95% CI, 261.2 to 452.7] and 332.2 [95% CI, 266.3 to 414.5], respectively, at day 43). These responses were similar to values in the upper half of the distribution of values for convalescent serum specimens.

Before vaccination, no participant had detectable 80% live-cialis neutralization at the highest serum concentration tested (1:8 dilution) in the PRNT assay. At day 43, wild-type cialis–neutralizing activity capable of reducing erectile dysfunction infectivity by 80% or more (PRNT80) was detected in all participants, with geometric mean PRNT80 responses of 339.7 (95% CI, 184.0 to 627.1) in the 25-μg group and 654.3 (95% CI, 460.1 to 930.5) in the 100-μg group (Figure 2D). Neutralizing PRNT80 average responses were generally at or above the values of the three convalescent serum specimens tested in this assay.

Good agreement was noted within and between the values from binding assays for S-2P and receptor-binding domain and neutralizing activity measured by PsVNA and PRNT (Figs. S3 through S7), which provides orthogonal support for each assay in characterizing the humoral response induced by mRNA-1273. erectile dysfunction T-Cell Responses The 25-μg and 100-μg doses elicited CD4 T-cell responses (Figs.

S9 and S10) that on stimulation by S-specific peptide pools were strongly biased toward expression of Th1 cytokines (tumor necrosis factor α >. Interleukin 2 >. Interferon γ), with minimal type 2 helper T-cell (Th2) cytokine expression (interleukin 4 and interleukin 13).

CD8 T-cell responses to S-2P were detected at low levels after the second vaccination in the 100-μg dose group (Fig. S11).To the Editor. Rapid and accurate diagnostic tests are essential for controlling the ongoing erectile dysfunction treatment cialis.

Although the current standard involves testing of nasopharyngeal swab specimens by quantitative reverse-transcriptase polymerase chain reaction (RT-qPCR) to detect erectile dysfunction, saliva specimens may be an alternative diagnostic sample.1-4 Rigorous evaluation is needed to determine how saliva specimens compare with nasopharyngeal swab specimens with respect to sensitivity in detection of erectile dysfunction during the course of . A total of 70 inpatients with erectile dysfunction treatment provided written informed consent to participate in our study (see the Methods section in Supplementary Appendix 1, available with the full text of this letter at NEJM.org). After erectile dysfunction treatment was confirmed with a positive nasopharyngeal swab specimen at hospital admission, we obtained additional samples from the patients during hospitalization.

We tested saliva specimens collected by the patients themselves and nasopharyngeal swabs collected from the patients at the same time point by health care workers. Figure 1. Figure 1.

erectile dysfunction RNA Titers in Saliva Specimens and Nasopharyngeal Swab Specimens. Samples were obtained from 70 hospital inpatients who had a diagnosis of erectile dysfunction treatment. Panel A shows erectile dysfunction RNA titers in the first available nasopharyngeal and saliva samples.

The lines indicate samples from the same patient. Results were compared with the use of a Wilcoxon signed-rank test (P<0.001). Panel B shows percentages of positivity for erectile dysfunction in tests of the first matched nasopharyngeal and saliva samples at 1 to 5 days, 6 to 10 days, and 11 or more days (maximum, 53 days) after the diagnosis of erectile dysfunction treatment.

Panel C shows longitudinal erectile dysfunction RNA copies per milliliter in 97 saliva samples, according to days since symptom onset. Each circle represents a separate sample. Dashed lines indicate additional Related Site samples from the same patient.

The red line indicates a negative saliva sample that was followed by a positive sample at the next collection of a specimen. Panel D shows longitudinal erectile dysfunction RNA copies per milliliter in 97 nasopharyngeal swab specimens, according to days since symptom onset. The red lines indicate negative nasopharyngeal swab specimens there were followed by a positive swab at the next collection of a specimen.

The gray area in Panels C and D indicates samples that were below the lower limit of detection of 5610 cialis RNA copies per milliliter of sample, which is at cycle threshold 38 of our quantitative reverse-transcriptase polymerase chain reaction assay targeting the erectile dysfunction N1 sequence recommended by the Centers for Disease Control and Prevention. To analyze these data, we used a linear mixed-effects regression model (see Supplementary Appendix 1) that accounts for the correlation between samples collected from the same person at a single time point (i.e., multivariate response) and the correlation between samples collected across time from the same patient (i.e., repeated measures). All the data used to generate this figure, including the raw cycle thresholds, are provided in Supplementary Data 1 in Supplementary Appendix 2.Using primer sequences from the Centers for Disease Control and Prevention, we detected more erectile dysfunction RNA copies in the saliva specimens (mean log copies per milliliter, 5.58.

95% confidence interval [CI], 5.09 to 6.07) than in the nasopharyngeal swab specimens (mean log copies per milliliter, 4.93. 95% CI, 4.53 to 5.33) (Figure 1A, and Fig. S1 in Supplementary Appendix 1).

In addition, a higher percentage of saliva samples than nasopharyngeal swab samples were positive up to 10 days after the erectile dysfunction treatment diagnosis (Figure 1B). At 1 to 5 days after diagnosis, 81% (95% CI, 71 to 96) of the saliva samples were positive, as compared with 71% (95% CI, 67 to 94) of the nasopharyngeal swab specimens. These findings suggest that saliva specimens and nasopharyngeal swab specimens have at least similar sensitivity in the detection of erectile dysfunction during the course of hospitalization.

Because the results of testing of nasopharyngeal swab specimens to detect erectile dysfunction may vary with repeated sampling in individual patients,5 we evaluated viral detection in matched samples over time. The level of erectile dysfunction RNA decreased after symptom onset in both saliva specimens (estimated slope, −0.11. 95% credible interval, −0.15 to −0.06) (Figure 1C) and nasopharyngeal swab specimens (estimated slope, −0.09.

95% credible interval, −0.13 to −0.05) (Figure 1D). In three instances, a negative nasopharyngeal swab specimen was followed by a positive swab at the next collection of a specimen (Figure 1D). This phenomenon occurred only once with the saliva specimens (Figure 1C).

During the clinical course, we observed less variation in levels of erectile dysfunction RNA in the saliva specimens (standard deviation, 0.98 cialis RNA copies per milliliter. 95% credible interval, 0.08 to 1.98) than in the nasopharyngeal swab specimens (standard deviation, 2.01 cialis RNA copies per milliliter. 95% credible interval, 1.29 to 2.70) (see Supplementary Appendix 1).

Recent studies have shown that erectile dysfunction can be detected in the saliva of asymptomatic persons and outpatients.1-3 We therefore screened 495 asymptomatic health care workers who provided written informed consent to participate in our prospective study, and we used RT-qPCR to test both saliva and nasopharyngeal samples obtained from these persons. We detected erectile dysfunction RNA in saliva specimens obtained from 13 persons who did not report any symptoms at or before the time of sample collection. Of these 13 health care workers, 9 had collected matched nasopharyngeal swab specimens by themselves on the same day, and 7 of these specimens tested negative (Fig.

S2). The diagnosis in the 13 health care workers with positive saliva specimens was later confirmed in diagnostic testing of additional nasopharyngeal samples by a CLIA (Clinical Laboratory Improvement Amendments of 1988)–certified laboratory. Variation in nasopharyngeal sampling may be an explanation for false negative results, so monitoring an internal control for proper sample collection may provide an alternative evaluation technique.

In specimens collected from inpatients by health care workers, we found greater variation in human RNase P cycle threshold (Ct) values in nasopharyngeal swab specimens (standard deviation, 2.89 Ct. 95% CI, 26.53 to 27.69) than in saliva specimens (standard deviation, 2.49 Ct. 95% CI, 23.35 to 24.35).

When health care workers collected their own specimens, we also found greater variation in RNase P Ct values in nasopharyngeal swab specimens (standard deviation, 2.26 Ct. 95% CI, 28.39 to 28.56) than in saliva specimens (standard deviation , 1.65 Ct. 95% CI, 24.14 to 24.26) (Fig.

S3). Collection of saliva samples by patients themselves negates the need for direct interaction between health care workers and patients. This interaction is a source of major testing bottlenecks and presents a risk of nosocomial .

Collection of saliva samples by patients themselves also alleviates demands for supplies of swabs and personal protective equipment. Given the growing need for testing, our findings provide support for the potential of saliva specimens in the diagnosis of erectile dysfunction . Anne L.

Wyllie, Ph.D.Yale School of Public Health, New Haven, CT [email protected]John Fournier, M.D.Yale School of Medicine, New Haven, CTArnau Casanovas-Massana, Ph.D.Yale School of Public Health, New Haven, CTMelissa Campbell, M.D.Maria Tokuyama, Ph.D.Pavithra Vijayakumar, B.A.Yale School of Medicine, New Haven, CTJoshua L. Warren, Ph.D.Yale School of Public Health, New Haven, CTBertie Geng, M.D.Yale School of Medicine, New Haven, CTM. Catherine Muenker, M.S.Adam J.

Moore, M.P.H.Chantal B.F. Vogels, Ph.D.Mary E. Petrone, B.S.Isabel M.

Ott, B.S.Yale School of Public Health, New Haven, CTPeiwen Lu, Ph.D.Arvind Venkataraman, B.S.Alice Lu-Culligan, B.S.Jonathan Klein, B.S.Yale School of Medicine, New Haven, CTRebecca Earnest, M.P.H.Yale School of Public Health, New Haven, CTMichael Simonov, M.D.Rupak Datta, M.D., Ph.D.Ryan Handoko, M.D.Nida Naushad, B.S.Lorenzo R. Sewanan, M.Phil.Jordan Valdez, B.S.Yale School of Medicine, New Haven, CTElizabeth B. White, A.B.Sarah Lapidus, M.S.Chaney C.

Kalinich, M.P.H.Yale School of Public Health, New Haven, CTXiaodong Jiang, M.D., Ph.D.Daniel J. Kim, A.B.Eriko Kudo, Ph.D.Melissa Linehan, M.S.Tianyang Mao, B.S.Miyu Moriyama, Ph.D.Ji E. Oh, M.D., Ph.D.Annsea Park, B.A.Julio Silva, B.S.Eric Song, M.S.Takehiro Takahashi, M.D., Ph.D.Manabu Taura, Ph.D.Orr-El Weizman, B.A.Patrick Wong, M.S.Yexin Yang, B.S.Santos Bermejo, B.S.Yale School of Medicine, New Haven, CTCamila D.

Odio, M.D.Yale New Haven Health, New Haven, CTSaad B. Omer, M.B., B.S., Ph.D.Yale Institute for Global Health, New Haven, CTCharles S. Dela Cruz, M.D., Ph.D.Shelli Farhadian, M.D., Ph.D.Richard A.

Martinello, M.D.Akiko Iwasaki, Ph.D.Yale School of Medicine, New Haven, CTNathan D. Grubaugh, Ph.D.Albert I. Ko, M.D.Yale School of Public Health, New Haven, CT [email protected], [email protected] Supported by the Huffman Family Donor Advised Fund, a Fast Grant from Emergent Ventures at the Mercatus Center at George Mason University, the Yale Institute for Global Health, the Yale School of Medicine, a grant (U19 AI08992, to Dr.

Ko) from the National Institute of Allergy and Infectious Diseases, the Beatrice Kleinberg Neuwirth Fund, and a grant (Rubicon 019.181EN.004, to Dr. Vogel) from the Dutch Research Council (NWO). Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

This letter was published on August 28, 2020, at NEJM.org. Drs. Grubaugh and Ko contributed equally to this letter.

5 References1. Kojima N, Turner F, Slepnev V, et al. Self-collected oral fluid and nasal swabs demonstrate comparable sensitivity to clinician collected nasopharyngeal swabs for erectile dysfunction treatment detection.

April 15, 2020 (https://www.medrxiv.org/content/10.1101/2020.04.11.20062372v1). Preprint.Google Scholar2. Williams E, Bond K, Zhang B, Putland M, Williamson DA.

Saliva as a non-invasive specimen for detection of erectile dysfunction. J Clin Microbiol 2020;58(8):e00776-20-e00776-20.3. Pasomsub E, Watcharananan SP, Boonyawat K, et al.

Saliva sample as a non-invasive specimen for the diagnosis of erectile dysfunction disease 2019. A cross-sectional study. Clin Microbiol Infect 2020 May 15 (Epub ahead of print).4.

Vogels CBF, Brackney D, Wang J, et al. SalivaDirect. Simple and sensitive molecular diagnostic test for erectile dysfunction surveillance.

August 4, 2020 (https://www.medrxiv.org/content/10.1101/2020.08.03.20167791v1). Preprint.Google Scholar5. Zou L, Ruan F, Huang M, et al.

erectile dysfunction viral load in upper respiratory specimens of infected patients. N Engl J Med 2020;382:1177-1179..

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The research is considered preliminary until published in a peer-reviewed journal."Right now, there are no limitations on what companies can do with this data," said Abdullah, a medical student at the University of Texas Medical Branch in Galveston. "As technology and health care become further intertwined and companies spend billions of dollars on health care-related apps, it's becoming more and more important to make sure where to get cialis pills we have checks and balances in place."That's because the data on health apps, he said, is not safeguarded by HIPAA, the 1996 law that protects health information gathered by doctors and health systems."Right now, it's like the Wild West, with zero protection," said Dr. David Grande, author of a study about health privacy in the digital age published in July in JAMA Network Open. "Health privacy concerns are growing at an astronomical pace, but we still have a where to get cialis pills very antiquated view of them."For example, Grande said many Americans are unaware that once their health data is collected, it's available online forever.

In Europe, "right to be forgotten" online privacy laws offer consumers where to get cialis pills some protection. But in the U.S., digital health info is "immortal," he said."People don't understand all the digital footprints they're leaving behind each time they interact with heath apps, and frankly, it's very hard to understand. Who on earth would want where to get cialis pills to read a long, complicated privacy agreement?. " said Grande, policy director at the University of Pennsylvania's Leonard Davis Institute of Health Economics in Philadelphia.As arduous as that task might seem, Abdullah urges people to take five minutes to read the agreements and find out what might happen to their data once they click "agree.""You have to weigh the risks and benefits," he said.

"The app where to get cialis pills might help patients track their blood sugar, but is it worth using if you know your data might possibly be shared?. "For consumers concerned with privacy, one red flag is the presence of ads on the health app."If you open the app and find ad services, you can be sure your data is being sent off to a third party in some way, shape or form," Abdullah said.Another tip is to check the app's automatic settings and make changes that will protect privacy, like turning off your location. But that, where to get cialis pills too, has a drawback, Grande said. "In some cases, turning off privacy settings makes an app harder to use."Like many internet-based services, health apps are usually free to download, with app-makers earning money through advertising or selling data to third parties, he said.However, that business model could change if lawmakers start enacting stricter guidelines and consumers become more willing to pay for health apps."Consumers put health very high on their list in terms of where they want privacy protection," Grande said.

"As they grow more uncomfortable with every aspect of their life being tracked, I think the thirst for regulation and where to get cialis pills privacy control will grow, too."American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position of where to get cialis pills the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved. If you have questions or comments about this story, please email [email protected]Copyright where to get cialis pills © 2020 HealthDay.

All rights reserved. SLIDESHOW where to get cialis pills Heart Disease. Causes of a Heart Attack See SlideshowLatest Mental Health News THURSDAY, Sept. 10, 2020 (American Heart Association News)With unemployment rates hovering at or near double digits, millions of people are at risk for eviction or where to get cialis pills foreclosure.

And a growing body of research suggests the effects go beyond financial, taking a toll on both physical and mental health.The CARES Act where to get cialis pills passed in late March included a moratorium on some evictions and an additional $600 per week in unemployment benefits. But those federal protections expired. A patchwork of temporary local, state and federal eviction moratoriums are in place, where to get cialis pills but the long-term picture is still uncertain.In fact, an analysis by Stout Risius Ross, a global consulting company, estimates more than 17 million U.S. Households – or more than 43% of rental households – are at risk for eviction over the coming months."The health impact is substantial, and it spans multiple realms," said Shakira Suglia, an associate professor and director of graduate studies in the department of epidemiology at Rollins School of Public Health at Emory University in Atlanta.For example, a 2015 study in the journal Social Forces showed mothers who were evicted were more likely to experience depression and higher parental stress than those in stable homes, and they also reported worse health.

A nationwide where to get cialis pills survey conducted by the Centers for Disease Control and Prevention in 2015 found that people with self-reported cardiovascular disease were more likely to face housing insecurity than those who didn't have heart problems. Research also shows people who face the threat of eviction are at greater risk for high blood pressure.Black and Latino communities are at even greater risk. Studies from cities throughout the country show that people of color, particularly Black and Latino people, make up about 80% of those facing eviction, according to a report last month from a group of nine academic groups and housing where to get cialis pills advocates.Matthew Desmond is a sociologist whose Eviction Lab at Princeton University was part of that report. He has conducted research showing that while Black women in Milwaukee neighborhoods made up less than 10% of the population, they accounted for 30% of evictions.

Desmond won a 2017 where to get cialis pills Pulitzer Prize for his book "Evicted. Poverty and Profit in the American where to get cialis pills City."Dr. Megan Sandel, an associate professor of pediatrics at Boston University School of Medicine, said the pattern of evictions often follow the historic trends of disinvestment in communities from redlining, the unequal treatment in lending faced by many communities of color. "You see this perpetuation of housing discrimination even to this day."Black and Hispanic households are almost twice as likely as white households to lack housing security, according to a 2014 where to get cialis pills report from the Joint Center for Housing Studies at Harvard University.Sandel, who also is an associate professor of environmental health at Boston University, said federal rental assistance and extending unemployment insurance could help families, but long-term solutions are needed."When families are able to move to areas with less concentrated poverty, their kids have higher lifetime earnings and are able to move up the economic ladder," she said.

"We talk about health so much in terms of pills or interventions, but a stable, decent, affordable home is the best intervention I can provide to my families. Right now, that's under threat for millions of Americans."Suglia, who co-authored an AHA scientific statement about housing and health, said an array of factors, such as stress, can impact health when a family is worried about paying their rent or being able to stay in their home.Under chronic stress, physiological systems may where to get cialis pills become dysregulated. Additionally, being in a constant state of worry may increase the likelihood that people turn to smoking, alcohol, and fat and sugar-laden foods, she said. That all can have physical effects."When your housing becomes unaffordable, you may neglect medication, health care, food and heat," she where to get cialis pills said.

"All these things only exacerbate or create additional health problems."While local and federal governments grapple with the where to get cialis pills issue, many nonprofit organizations are stepping in to help.For example, the American Heart Association and Enterprise Community Partners, a national affordable housing nonprofit, recently held a free webinar to help faith organizations learn strategies to convert unused property into affordable homes. Funded in part by the Kresge Foundation, the groups will hold additional workshops in late 2020 and early 2021. SLIDESHOW 17 Everyday Ways to Ease Depression See Slideshow In Chicago's Washington Heights, the Endeleo Institute, named for a where to get cialis pills Swahili term for growth and progress, is doing similar work to repurpose assets in that predominantly Black neighborhood's 95th Street corridor. The group also is working with the AHA, Northwestern University and other institutions to organize farmers markets and launch health education efforts.American Heart Association News covers heart and brain health.

Not all views expressed in this where to get cialis pills story reflect the official position of the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved. If you have questions or comments about where to get cialis pills this story, please email [email protected]Copyright © 2020 HealthDay. All rights reserved.

From Mental Health where to get cialis pills Resources Featured Centers Health Solutions From Our SponsorsLatest High Blood Pressure News THURSDAY, Sept. 10, 2020 (HealthDay News)Uncontrolled high where to get cialis pills blood pressure is becoming more common among Americans, putting them at increased risk for heart attack and stroke, a new study shows.Previous research showed that in 1999-2000, 32.2% of Americans maintained blood pressure less than 140/90 mm Hg, but the rate rose to 54.5% in 2013-2014. However, the rate fell to 48% in 2015-2016.Unfortunately, this new study found the proportion of adults aged 40-59 with successfully managed blood pressure fell nearly 10 percentage points from 2009 to 2018 (56.3% vs. 46.6%, respectively) where to get cialis pills.

Successful blood pressure management also fell among adults 60 and older by almost 6 percentage points from 2009 to 2018 (53.6% vs. 47.9%, respectively).The where to get cialis pills study will be presented at a virtual American Heart Association meeting, being held Sept. 10-13. Such research is considered preliminary until published in a peer-reviewed where to get cialis pills journal."We cannot assume improvement in blood pressure management will continue, even after 35 years of success.

High blood pressure is a serious health risk and deserves constant attention to prevent as many heart attacks and strokes as possible," said lead author Dr. Brent Egan, a professor at the University of South Carolina School of Medicine.The reasons why where to get cialis pills fewer Americans have successfully managed blood pressure varies by age and requires further study, according to the researchers."A closer look at our findings revealed the fall in blood pressure control in older adults was mainly due to less effective use of blood pressure medication and management, so we need to focus on making sure the level of treatment is adequate for this age group," Egan said in a meeting news release.The American Heart Association and American Medical Association have launched a national program called "Target. BP" in response to the high where to get cialis pills rate of uncontrolled blood pressure.-- Robert PreidtCopyright © 2020 HealthDay. All rights reserved.

QUESTION Salt and sodium are the same where to get cialis pills. See Answer References SOURCE. American Heart Association, where to get cialis pills news release, Sept. 10, 2020Latest High Blood Pressure News By Serena GordonHealthDay ReporterFRIDAY, Sept.

11, 2020People with fatter legs appear where to get cialis pills less likely to have high blood pressure, new research suggests.The researchers suspect that measuring leg fat could help guide blood pressure prevention efforts. Those with bigger legs may not need to worry as much about high blood pressure -- a contributor to heart attack and stroke."Distribution where to get cialis pills of fat matters. Even though we think that fat is bad in all cases, it might be that leg fat is not as bad as we think," said the study's lead author, Aayush Visaria. He's a where to get cialis pills fourth year medical student at Rutgers New Jersey Medical School.Previous research has found that excess weight around the middle can increase the risk of heart disease and diabetes.

"Middle fat is really important because that's where all the organs are -- liver, pancreas, intestines -- and they're all affected by fat. Too much fat messes up the function of where to get cialis pills those organs," Visaria said.But that doesn't mean folks who gain more weight in their lower limbs don't need to maintain a healthy weight, too. "Regardless of where the fat is, a lot of fat isn't good. Having muscle where to get cialis pills is better than having fat.

Our study says, if you have fat, more fat in legs is better than having it in the abdomen," Visaria said.Dr. Vivek Bhalla is director of where to get cialis pills the Hypertension Center at Stanford University in California. "This study should not be interpreted to where to get cialis pills say that if a patient has higher leg fat that they will not develop high blood pressure. It is an important study to motivate further research into the factors as to why blood pressure would be lower," he explained.Bhalla said it's not yet clear how fat distribution might affect your high blood pressure risk.

He said it's possible that fat stored in different areas of the body may act in different ways.Visaria suggested that the difference may have something to do with triglyceride (a type of where to get cialis pills blood fat) levels. People in the study with more leg fat had decreased triglyceride levels, he noted.The new study included almost 6,000 adults participating in national health surveys between 2011 and 2016. Their average where to get cialis pills age was 37. About half were female.

Nearly one-quarter of the group had high blood pressure (defined in this study as blood pressure above 130/80 mm Hg).The researchers used special X-ray imaging to measure fat in the legs where to get cialis pills. These measurements were where to get cialis pills compared to overall body fat measurements. Men who had 34% fat in their legs were defined as having high leg fat. For women, the cutoff was 39%.Those with higher leg fat were 61% less likely to have high blood pressure than their where to get cialis pills slim-legged counterparts.

The findings held even after the researchers adjusted for factors such as age, sex, race/ethnicity, smoking, alcohol use, cholesterol levels and levels of waist fat.The researchers noted that this study wasn't designed to prove a cause-and-effect relationship. It could only show where to get cialis pills an association between higher leg fat and lower blood pressure. Visaria said more research is necessary, particularly in older people. He said the people in this study were between 20 and 59, so these findings may not be generalizable to people over 60.Bhalla pointed out that "obesity is a major where to get cialis pills epidemic in the United States and around the world, and like many things in medicine, it's not black or white, but rather there are shades of gray."In addition, Bhalla advised, "As we learn more about different types of fat, the distribution of fat, what factors are secreted by different types of fat and how that affects risk of common conditions -- [including] high blood pressure, heart disease and diabetes -- we need to keep in mind that we have to treat patients as individuals, measure their individual risk, and counsel patients appropriately." SLIDESHOW Low Blood Pressure (Hypotension).

Symptoms, Signs, Causes See Slideshow He also said it's important to remember the things people can do right now to lower their blood pressure, including:The findings were scheduled for presentation Thursday at a virtual meeting of the American Heart Association. Findings presented at meetings should be viewed as preliminary until they've been published in a peer-reviewed where to get cialis pills journal.Copyright © 2020 HealthDay. All rights where to get cialis pills reserved. From Heart Health Resources Featured Centers Health Solutions From Our Sponsors References SOURCES.

Aayush Visaria, MPH, 4th where to get cialis pills year medical student, Rutgers New Jersey Medical School, Newark, N.J.. Vivek Bhalla, MD, associate professor, medicine and nephrology, and director, Stanford Hypertension Center, AHA-Certified Comprehensive Hypertension Center, Stanford University School of Medicine, Calif.. Sept. 10, 2020, presentation, American Heart Association virtual hypertension meetingLatest HIV News By Alan MozesHealthDay ReporterTHURSDAY, Sept.

10, 2020 (HealthDay News)The daily drug regimen known as PrEP is a nearly foolproof way to prevent HIV . But a new study suggests that many high-risk Americans may be giving the medication a pass because of cost.The warning stems from a pricing analysis that tracked about 2.6 million PrEP prescriptions filled between 2014 and 2018.The researchers found that during that time frame, PrEP prices -- which were already high -- shot up an average of 5% per year."Pre-exposure prophylaxis, or PrEP, is when people at risk for HIV take a medication to prevent HIV," explained study author Dr. Nathan Furukawa. He is a medical officer in the division of HIV/AIDS prevention at the U.S.

Centers for Disease Control and Prevention.First introduced back in 2012, the regimen entails taking a single pill once a day (brand name Truvada), though the pill actually combines two antiretroviral drugs. According to the CDC, a second option -- Descovy -- is also approved for PrEP, though it is not yet clear whether it specifically protects women during vaginal intercourse.But the bottom line is that "PrEP is highly effective at preventing HIV from sex or injection drug use when taken consistently," stressed Furukawa. "If enough people at risk of HIV take PrEP, we can stop new HIV s and end the HIV epidemic."Furukawa and his colleagues describe the widespread adoption of PrEP as "a foundational pillar" of the effort to rein in HIV among those most vulnerable, including gay and bisexual men, and drug users.But only about 18% of Americans deemed at high-risk for HIV had embraced PrEP as of 2018. And the latest findings, said Furukawa, suggest that its prohibitive cost may be to blame.The conclusion follows an examination of PrEP orders and prices compiled by the IQVIA prescription database.

The database tracks more than nine in 10 medications dispensed by retail pharmacies in the United States, and between 60% and 86% of medications obtained online.The investigators found that between 2014 and 2018, the number of Americans who began taking PrEP increased significantly, rising from about 20,000 to nearly 205,000.Yet, at the same time, the cost of a month's supply of 30 tablets rose from $1,350 to $1,638, the study authors noted.But isn't PrEP covered by insurance?. Yes and no, Furukawa said."PrEP is covered by nearly all insurance plans, most state Medicaid plans and Medicare," he noted. "However, out-of-pocket costs for patients who have not met their deductible may still be prohibitive."Out-of-pocket costs shot up by nearly 15% a year during the study period. That translates to an average out-of-pocket rise from $54 a month in 2014 to $94 a month by 2018, the findings showed."Even though insurers cover about 94% of PrEP medication costs, patients may still have difficulties paying the remaining out-of-pocket costs, since the cost of the medication is large," Furukawa explained.As for those who are underinsured or lack insurance altogether, state medication assistance programs and the manufacturer of Truvada (Gilead) may offer subsidies.

(Furukawa directed those interested to the nonprofit PrEPcost.org website.)Furukawa also acknowledged that there are other impediments to PrEP acceptance beyond cost, including lack of awareness and insufficient access to health care.Still, he suggested that lowering the cost of the medication could be an important factor in getting more people on board.That thought was seconded by Dr. Michael Horberg, associate medical director and director of HIV/AIDS and STD at the Kaiser Permanente Care Management Institute in Rockville, Md.While drug assistance programs are available, "pharmacy costs are always a big concern in preventive medicine," said Horberg.But PrEP cost is likely to fall in the coming years, he said, as a cheaper generic version of Truvada comes to market. And PrEP is also now classified as a level "A" recommended drug by the U.S. Preventive Services Task Force.

That designation should drive out-of-pocket costs down to as low as zero, Horberg added."Nonetheless, the pharmaceutical industry should aim to lower costs, and make this readily available to all U.S. Citizens who would benefit from PrEP," Horberg said.The findings were published Sept. 8 in the Annals of Internal Medicine.Copyright © 2020 HealthDay. All rights reserved.

QUESTION What is HIV?. See Answer References SOURCES. Nathan Furukawa, MD, MPH, medical officer, division of HIV/AIDS prevention, U.S. Centers for Disease Control and Prevention, Atlanta.

Michael Horberg, MD, MAS, associate medical director and director, HIV/AIDS and STD, Kaiser Permanente Care Management Institute, Rockville, Md.. Annals of Internal Medicine, Sept. 8, 2020.

Latest Prevention cialis online in canada cialis online without prescription &. Wellness News THURSDAY, Sept cialis online in canada. 10, 2020 (American Heart Association News)Like ordering a ride or food delivery on your smartphone, keeping track of your heart rate, blood pressure or weight is just a few taps away thanks to thousands of free or inexpensive health apps.But with each click, you may be unwittingly handing over your health data to a third party.As health apps skyrocket in popularity, experts and medical organizations have begun warning consumers of the hidden dangers.

In May, the American Medical Association called on lawmakers and the health care industry to install "regulatory guardrails" to protect all types of patient privacy in the digital age.Until that happens, health app users are largely unprotected from having their data passed along to tech giants and marketing companies that might target them with ads, said Mohammed Abdullah, senior author of a new study about privacy issues and apps.The study, being presented at the American Heart Association's virtual Hypertension Scientific Sessions that begins Thursday, examined 35 diabetes mobile apps and found that all of them gave data to a third party, even in cialis online in canada cases where the app's privacy policy said it wouldn't. The research is considered preliminary until published in a peer-reviewed journal."Right now, there are no limitations on what companies can do with this data," said Abdullah, a medical student at the University of Texas Medical Branch in Galveston. "As technology and health care become further intertwined and companies spend billions of dollars on health care-related apps, it's becoming more and more important to make sure we have checks and balances in place."That's because the data on health apps, he said, is not safeguarded by HIPAA, the cialis online in canada 1996 law that protects health information gathered by doctors and health systems."Right now, it's like the Wild West, with zero protection," said Dr.

David Grande, author of a study about health privacy in the digital age published in July in JAMA Network Open. "Health privacy concerns are growing at an astronomical pace, but we still have a very antiquated view of them."For example, Grande said cialis online in canada many Americans are unaware that once their health data is collected, it's available online forever. In Europe, "right to be forgotten" online privacy cialis online in canada laws offer consumers some protection.

But in the U.S., digital health info is "immortal," he said."People don't understand all the digital footprints they're leaving behind each time they interact with heath apps, and frankly, it's very hard to understand. Who on earth would want to cialis online in canada read a long, complicated privacy agreement?. " said Grande, policy director at the University of Pennsylvania's Leonard Davis Institute of Health Economics in Philadelphia.As arduous as that task might seem, Abdullah urges people to take five minutes to read the agreements and find out what might happen to their data once they click "agree.""You have to weigh the risks and benefits," he said.

"The app might help patients track their blood sugar, but is it worth using if you know cialis online in canada your data might possibly be shared?. "For consumers concerned with privacy, one red flag is the presence of ads on the health app."If you open the app and find ad services, you can be sure your data is being sent off to a third party in some way, shape or form," Abdullah said.Another tip is to check the app's automatic settings and make changes that will protect privacy, like turning off your location. But that, too, has a drawback, cialis online in canada Grande said.

"In some cases, turning off privacy settings makes an app harder to use."Like many internet-based services, health apps are usually free to download, with app-makers earning money through advertising or selling data to third parties, he said.However, that business model could change if lawmakers start enacting stricter guidelines and consumers become more willing to pay for health apps."Consumers put health very high on their list in terms of where they want privacy protection," Grande said. "As they grow more uncomfortable with every aspect of their life being tracked, cialis online in canada I think the thirst for regulation and privacy control will grow, too."American Heart Association News covers heart and brain health. Not all views cialis online in canada expressed in this story reflect the official position of the American Heart Association.

Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved. If you have questions or comments about this story, cialis online in canada please email [email protected]Copyright © 2020 HealthDay. All rights reserved.

SLIDESHOW Heart Disease cialis online in canada. Causes of a Heart Attack See SlideshowLatest Mental Health News THURSDAY, Sept. 10, 2020 (American Heart Association News)With unemployment rates hovering at or near double digits, millions of people are cialis online in canada at risk for eviction or foreclosure.

And a growing body of research suggests the effects go beyond financial, taking cialis online in canada a toll on both physical and mental health.The CARES Act passed in late March included a moratorium on some evictions and an additional $600 per week in unemployment benefits. But those federal protections expired. A patchwork of temporary local, state and federal cialis online in canada eviction moratoriums are in place, but the long-term picture is still uncertain.In fact, an analysis by Stout Risius Ross, a global consulting company, estimates more than 17 million U.S.

Households – or more than 43% of rental households – are at risk for eviction over the coming months."The health impact is substantial, and it spans multiple realms," said Shakira Suglia, an associate professor and director of graduate studies in the department of epidemiology at Rollins School of Public Health at Emory University in Atlanta.For example, a 2015 study in the journal Social Forces showed mothers who were evicted were more likely to experience depression and higher parental stress than those in stable homes, and they also reported worse health. A nationwide survey conducted by the Centers for Disease Control and Prevention in 2015 found that people with self-reported cardiovascular disease were more likely to face housing insecurity than those who didn't cialis online in canada have heart problems. Research also shows people who face the threat of eviction are at greater risk for high blood pressure.Black and Latino communities are at even greater risk.

Studies from cities throughout the country show that people of color, particularly Black and Latino people, make up about 80% of those facing eviction, according to cialis online in canada a report last month from a group of nine academic groups and housing advocates.Matthew Desmond is a sociologist whose Eviction Lab at Princeton University was part of that report. He has conducted research showing that while Black women in Milwaukee neighborhoods made up less than 10% of the population, they accounted for 30% of evictions. Desmond won a cialis online in canada 2017 Pulitzer Prize for his book "Evicted.

Poverty and cialis online in canada Profit in the American City."Dr. Megan Sandel, an associate professor of pediatrics at Boston University School of Medicine, said the pattern of evictions often follow the historic trends of disinvestment in communities from redlining, the unequal treatment in lending faced by many communities of color. "You see this perpetuation of housing discrimination even to this day."Black and Hispanic households are almost twice as likely as white households to lack housing security, according to a 2014 report from the Joint Center for Housing Studies at Harvard University.Sandel, who cialis online in canada also is an associate professor of environmental health at Boston University, said federal rental assistance and extending unemployment insurance could help families, but long-term solutions are needed."When families are able to move to areas with less concentrated poverty, their kids have higher lifetime earnings and are able to move up the economic ladder," she said.

"We talk about health so much in terms of pills or interventions, but a stable, decent, affordable home is the best intervention I can provide to my families. Right now, that's under threat for millions of Americans."Suglia, who co-authored an AHA scientific statement about housing and health, said an array of factors, such as stress, can impact health when a family cialis online in canada is worried about paying their rent or being able to stay in their home.Under chronic stress, physiological systems may become dysregulated. Additionally, being in a constant state of worry may increase the likelihood that people turn to smoking, alcohol, and fat and sugar-laden foods, she said.

That all can have cialis online in canada physical effects."When your housing becomes unaffordable, you may neglect medication, health care, food and heat," she said. "All these things only exacerbate or create additional health problems."While local and federal governments grapple with the issue, many nonprofit organizations are stepping in to help.For example, the cialis online in canada American Heart Association and Enterprise Community Partners, a national affordable housing nonprofit, recently held a free webinar to help faith organizations learn strategies to convert unused property into affordable homes. Funded in part by the Kresge Foundation, the groups will hold additional workshops in late 2020 and early 2021.

SLIDESHOW 17 Everyday Ways to Ease Depression See Slideshow In Chicago's Washington Heights, the Endeleo Institute, named for a Swahili term for growth and progress, is doing similar work to repurpose assets in that predominantly Black neighborhood's 95th cialis online in canada Street corridor. The group also is working with the AHA, Northwestern University and other institutions to organize farmers markets and launch health education efforts.American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position cialis online in canada of the American Heart Association.

Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved. If you have questions or comments about this story, please email [email protected]Copyright © 2020 HealthDay cialis online in canada. All rights reserved.

From Mental Health Resources Featured Centers Health Solutions From Our SponsorsLatest High Blood Pressure News THURSDAY, Sept cialis online in canada. 10, 2020 (HealthDay News)Uncontrolled high blood pressure is becoming more common among Americans, putting them at increased risk for heart attack and stroke, a new study shows.Previous research showed that in 1999-2000, 32.2% of Americans maintained blood pressure less than 140/90 mm Hg, but the rate rose to cialis online in canada 54.5% in 2013-2014. However, the rate fell to 48% in 2015-2016.Unfortunately, this new study found the proportion of adults aged 40-59 with successfully managed blood pressure fell nearly 10 percentage points from 2009 to 2018 (56.3% vs.

46.6%, respectively) cialis online in canada. Successful blood pressure management also fell among adults 60 and older by almost 6 percentage points from 2009 to 2018 (53.6% vs. 47.9%, respectively).The study will be presented at cialis online in canada a virtual American Heart Association meeting, being held Sept.

10-13. Such research is considered cialis online in canada preliminary until published in a peer-reviewed journal."We cannot assume improvement in blood pressure management will continue, even after 35 years of success. High blood pressure is a serious health risk and deserves constant attention to prevent as many heart attacks and strokes as possible," said lead author Dr.

Brent Egan, a professor at the University of South Carolina School of Medicine.The reasons why fewer Americans have successfully managed blood pressure varies by age and requires further study, according to the researchers."A closer look at our findings cialis online in canada revealed the fall in blood pressure control in older adults was mainly due to less effective use of blood pressure medication and management, so we need to focus on making sure the level of treatment is adequate for this age group," Egan said in a meeting news release.The American Heart Association and American Medical Association have launched a national program called "Target. BP" in response to the high rate of uncontrolled blood pressure.-- cialis online in canada Robert PreidtCopyright © 2020 HealthDay. All rights reserved.

QUESTION Salt and cialis online in canada sodium are the same. See Answer References SOURCE http://recoverymonologue.com/?p=330. American Heart cialis online in canada Association, news release, Sept.

10, 2020Latest High Blood Pressure News By Serena GordonHealthDay ReporterFRIDAY, Sept. 11, 2020People with fatter legs appear less likely to have high blood pressure, new research suggests.The cialis online in canada researchers suspect that measuring leg fat could help guide blood pressure prevention efforts. Those with cialis online in canada bigger legs may not need to worry as much about high blood pressure -- a contributor to heart attack and stroke."Distribution of fat matters.

Even though we think that fat is bad in all cases, it might be that leg fat is not as bad as we think," said the study's lead author, Aayush Visaria. He's a fourth year medical student at Rutgers New Jersey Medical School.Previous research has found that excess weight around the cialis online in canada middle can increase the risk of heart disease and diabetes. "Middle fat is really important because that's where all the organs are -- liver, pancreas, intestines -- and they're all affected by fat.

Too much fat messes up the function of those organs," Visaria said.But that doesn't mean folks who gain more cialis online in canada weight in their lower limbs don't need to maintain a healthy weight, too. "Regardless of where the fat is, a lot of fat isn't good. Having muscle cialis online in canada is better than having fat.

Our study says, if you have fat, more fat in legs is better than having it in the abdomen," Visaria said.Dr. Vivek Bhalla is director of the Hypertension Center at Stanford University cialis online in canada in California. "This study should not be interpreted to say that if a patient has higher leg fat that they will not develop high blood pressure cialis online in canada.

It is an important study to motivate further research into the factors as to why blood pressure would be lower," he explained.Bhalla said it's not yet clear how fat distribution might affect your high blood pressure risk. He said cialis online in canada it's possible that fat stored in different areas of the body may act in different ways.Visaria suggested that the difference may have something to do with triglyceride (a type of blood fat) levels. People in the study with more leg fat had decreased triglyceride levels, he noted.The new study included almost 6,000 adults participating in national health surveys between 2011 and 2016.

Their average cialis online in canada age was 37. About half were female. Nearly one-quarter of the group had high blood pressure (defined in this study as blood pressure above 130/80 cialis online in canada mm Hg).The researchers used special X-ray imaging to measure fat in the legs.

These measurements were cialis online in canada compared to overall body fat measurements. Men who had 34% fat in their legs were defined as having high leg fat. For women, the cutoff was 39%.Those cialis online in canada with higher leg fat were 61% less likely to have high blood pressure than their slim-legged counterparts.

The findings held even after the researchers adjusted for factors such as age, sex, race/ethnicity, smoking, alcohol use, cholesterol levels and levels of waist fat.The researchers noted that this study wasn't designed to prove a cause-and-effect relationship. It could only show an association between higher leg fat cialis online in canada and lower blood pressure. Visaria said more research is necessary, particularly in older people.

He said the people in this study were between 20 and 59, so these findings may not be generalizable to people over 60.Bhalla pointed out that "obesity is a major epidemic in the United States and around the world, and like many things in medicine, it's not black or white, but rather there are shades of gray."In addition, Bhalla advised, "As we learn more about different types of fat, the distribution of fat, what factors are secreted by different types of fat and how that affects risk of common conditions -- [including] high blood pressure, heart disease and diabetes -- we need to keep cialis online in canada in mind that we have to treat patients as individuals, measure their individual risk, and counsel patients appropriately." SLIDESHOW Low Blood Pressure (Hypotension). Symptoms, Signs, Causes See Slideshow He also said it's important to remember the things people can do right now to lower their blood pressure, including:The findings were scheduled for presentation Thursday at a virtual meeting of the American Heart Association. Findings presented at meetings should be viewed as preliminary until cialis online in canada they've been published in a peer-reviewed journal.Copyright © 2020 HealthDay.

All rights cialis online in canada reserved. From Heart Health Resources Featured Centers Health Solutions From Our Sponsors References SOURCES. Aayush Visaria, MPH, 4th year medical student, Rutgers New Jersey Medical cialis online in canada School, Newark, N.J..

Vivek Bhalla, MD, associate professor, medicine and nephrology, and director, Stanford Hypertension Center, AHA-Certified Comprehensive Hypertension Center, Stanford University School of Medicine, Calif.. Sept. 10, 2020, presentation, American Heart Association virtual hypertension meetingLatest HIV News By Alan MozesHealthDay ReporterTHURSDAY, Sept.

10, 2020 (HealthDay News)The daily drug regimen known as PrEP is a nearly foolproof way to prevent HIV . But a new study suggests that many high-risk Americans may be giving the medication a pass because of cost.The warning stems from a pricing analysis that tracked about 2.6 million PrEP prescriptions filled between 2014 and 2018.The researchers found that during that time frame, PrEP prices -- which were already high -- shot up an average of 5% per year."Pre-exposure prophylaxis, or PrEP, is when people at risk for HIV take a medication to prevent HIV," explained study author Dr. Nathan Furukawa.

He is a medical officer in the division of HIV/AIDS prevention at the U.S. Centers for Disease Control and Prevention.First introduced back in 2012, the regimen entails taking a single pill once a day (brand name Truvada), though the pill actually combines two antiretroviral drugs. According to the CDC, a second option -- Descovy -- is also approved for PrEP, though it is not yet clear whether it specifically protects women during vaginal intercourse.But the bottom line is that "PrEP is highly effective at preventing HIV from sex or injection drug use when taken consistently," stressed Furukawa.

"If enough people at risk of HIV take PrEP, we can stop new HIV s and end the HIV epidemic."Furukawa and his colleagues describe the widespread adoption of PrEP as "a foundational pillar" of the effort to rein in HIV among those most vulnerable, including gay and bisexual men, and drug users.But only about 18% of Americans deemed at high-risk for HIV had embraced PrEP as of 2018. And the latest findings, said Furukawa, suggest that its prohibitive cost may be to blame.The conclusion follows an examination of PrEP orders and prices compiled by the IQVIA prescription database. The database tracks more than nine in 10 medications dispensed by retail pharmacies in the United States, and between 60% and 86% of medications obtained online.The investigators found that between 2014 and 2018, the number of Americans who began taking PrEP increased significantly, rising from about 20,000 to nearly 205,000.Yet, at the same time, the cost of a month's supply of 30 tablets rose from $1,350 to $1,638, the study authors noted.But isn't PrEP covered by insurance?.

Yes and no, Furukawa said."PrEP is covered by nearly all insurance plans, most state Medicaid plans and Medicare," he noted. "However, out-of-pocket costs for patients who have not met their deductible may still be prohibitive."Out-of-pocket costs shot up by nearly 15% a year during the study period. That translates to an average out-of-pocket rise from $54 a month in 2014 to $94 a month by 2018, the findings showed."Even though insurers cover about 94% of PrEP medication costs, patients may still have difficulties paying the remaining out-of-pocket costs, since the cost of the medication is large," Furukawa explained.As for those who are underinsured or lack insurance altogether, state medication assistance programs and the manufacturer of Truvada (Gilead) may offer subsidies.

(Furukawa directed those interested to the nonprofit PrEPcost.org website.)Furukawa also acknowledged that there are other impediments to PrEP acceptance beyond cost, including lack of awareness and insufficient access to health care.Still, he suggested that lowering the cost of the medication could be an important factor in getting more people on board.That thought was seconded by Dr. Michael Horberg, associate medical director and director of HIV/AIDS and STD at the Kaiser Permanente Care Management Institute in Rockville, Md.While drug assistance programs are available, "pharmacy costs are always a big concern in preventive medicine," said Horberg.But PrEP cost is likely to fall in the coming years, he said, as a cheaper generic version of Truvada comes to market. And PrEP is also now classified as a level "A" recommended drug by the U.S.

Preventive Services Task Force. That designation should drive out-of-pocket costs down to as low as zero, Horberg added."Nonetheless, the pharmaceutical industry should aim to lower costs, and make this readily available to all U.S. Citizens who would benefit from PrEP," Horberg said.The findings were published Sept.

8 in the Annals of Internal Medicine.Copyright © 2020 HealthDay. All rights reserved. QUESTION What is HIV?.

See Answer References SOURCES. Nathan Furukawa, MD, MPH, medical officer, division of HIV/AIDS prevention, U.S. Centers for Disease Control and Prevention, Atlanta.

Michael Horberg, MD, MAS, associate medical director and director, HIV/AIDS and STD, Kaiser Permanente Care Management Institute, Rockville, Md.. Annals of Internal Medicine, Sept. 8, 2020.

Cialis no prescription

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GREAT FALLS, wikipedia reference Mont cialis no prescription. €” For months, the jail in central Montana’s Cascade County was free of the erectile dysfunction, which seemed as distant a threat as it did in much of the nation’s rural Mountain West.Then a few people who had the cialis were arrested. By the time Paul Krogue, the jail’s medical director, realized there was a problem, nearly 50 inmates were infected in the jail, where some had been sleeping on mats cialis no prescription on an overcrowded floor. After several weeks, Mr.

Krogue got a cialis no prescription call that s were spreading to a side of the jail that had been cialis-free.He hung up the phone and put his head in his hands.“I just kind of lost it, like, ‘My God, I don’t know how much longer I can do this,’” Mr. Krogue, a nurse practitioner, recalled. €œI was just scared that I’m not going to be able to see it through, that I’m going to get sick — you just feel so exhausted and it’s just a lot.”The Mountain West, which for months avoided the worst of the cialis, has rapidly devolved into one of the most alarming hot spots in a country that recorded its eight millionth confirmed case on Thursday, a day when more than 65,000 cases were announced nationwide, the most in a single day since July.Seventeen states, including many in the Mountain West, have added more cases in the past week than any other week of the cialis. And the spread through sparsely populated areas of rural America has created problems in small towns that lack critical resources — including doctors — even in ordinary times.Wyoming, which did not have 1,000 total cases until June, recently added more than 1,000 in a single cialis no prescription week.

Reports of new s have recently reached record levels in Alaska, Colorado and Idaho. And Montana, where more than half of the state’s cases have cialis no prescription been announced since August, is averaging more than 500 cases per day.In Cascade County, more than 300 inmates and staff members have been infected in a facility meant to hold 365 people, the county’s first major outbreak in a region where the cialis is suddenly surging.The county seat, Great Falls, is seeing its worst case numbers yet. The local hospital and its 27-bed erectile dysfunction treatment unit is at capacity. The county health department is racing to hire new contact tracers.

And Mr cialis no prescription. Krogue, who also teaches nursing at Montana State University’s Great Falls campus, has seen attendance in his classes dwindle as students fall ill or quarantine.“I was just scared that I’m not going to be able to see it through, that I’m going to get sick,” said Paul Krogue, the jail’s medical director.Credit...Tailyr Irvine for The New York TimesOne place where the s have spread has been local jails, which are confined, often crowded spaces. Jails are staples of local communities and tend to cialis no prescription have people coming and going more quickly than prisons. Jails can hold everyone from people awaiting criminal trials for months to those picked up for a suspended driver’s license for a few hours.

With so many people filtering in and out, jails pose extra risks for the cialis’s spread — not only inside facilities but in potentially feeding outbreaks in the rest of the community.Nationally, jails and prisons have seen disproportionate rates of and death, with a mortality rate twice as high as in the general population and an rate more than four times as high, according to recent data.A New York Times database has tracked clusters of at least 50 erectile dysfunction cases in a dozen rural jails in Montana, Idaho, Utah cialis no prescription and New Mexico during the cialis. Among them. The Purgatory Correctional Center in Hurricane, Utah, with 166 s. The jail in Twin cialis no prescription Falls, Idaho, with 279.

And, in New Mexico, the Cibola County Correctional Center, which has reported 357 cases.In Cascade County, s at the jail make up about a quarter of all known cialis cases in the county. Health authorities say that the jail’s cialis no prescription outbreak, which began in mid-August, was not believed to be the main cause of the community’s recent surge, but that it had led to some cases. In the past two months, Mr. Krogue said, the jail released 29 people who were considered actively infected.s at the jail make up about a quarter of Cascade County’s known cialis cases.Credit...Tailyr Irvine for The New York TimesGreat Falls, home to about 58,000 residents, is in the less mountainous part of Montana, with the Missouri River flowing through and a large oil refinery on its banks.

The Cascade County cialis no prescription Detention Center sits along a highway at the edge of town. Drive five miles in any direction and you are surrounded by wide-open plains.Montana requires that masks be worn inside businesses and indoor public spaces, and many people in Great Falls wear them when walking around downtown’s Central Avenue, where shops and cafes are still recovering from shutting down in the spring. Others go without masks, citing the open space and lack of crowds.Bob Kelly, the mayor, said people had not been overly cialis no prescription worried about how the jail outbreak might affect the rest of town when it started.“I think that by the very definition of a jail, hopefully, the disease will be incarcerated, as well as the patients,” he said. €œIs there concern?.

Sure, there’s cialis no prescription concern. But is there overreaction?. No.”The mayor of Great Falls said that residents had considered the jail’s outbreak a distant concern at first.Credit...Tailyr Irvine for The New York TimesSome residents’ nonchalance about the risks of the cialis, said Mr. Krogue, the cialis no prescription jail’s medical director, can be traced to a spring and early summer when almost no one in Cascade County knew anyone who had been sickened.“We benefited from that early on,” he said.

€œBut in some ways, I think it did us a disservice, too, because it also created a certain level of complacency.”That has quickly shifted now, he said, as cases have spiked.The number of active cases known to county officials on any given day has risen sharply to about 600, according to Trisha Gardner, Cascade County’s health officer. The county has seen 1,261 cases and six deaths during the cialis, a Times database shows cialis no prescription. Some of the cases have been tied to the jail outbreak, she said, and others have been connected to bars and restaurants. Even figuring out what has led to some cases has been complex, she said, as residents have been reluctant to cooperate with contact tracers.“Our hospitals are at capacity, our public health system is at capacity,” she said.

€œIt’s not sustainable at this rate.”When the outbreak cialis no prescription at the jail began, social distancing was impossible, the authorities said. Three inmates shared cells designed for two. At night, cialis no prescription men slept on thin blue pads in every available space. On the floor in the day room, in shower stalls, in stairwells, in hallways outside of cells.Inmates did not receive masks until August, and jail officials said many have refused to wear them.In interviews with more than a dozen inmates and their family members, inmates described the jail during the outbreak as chaotic and unsanitary.

They said their pleas for help often went unanswered by nurses and guards.Newly arriving inmates were not always quarantined from one another before their test results were known because of a lack of space, inmates and jail officials said.Owen Hawley, 30, said every inmate in his living area of 38 men had tested positive for the cialis. He said he had been unable to eat for three days, had intensive body aches and suffered cialis no prescription from a headache so powerful it felt as if it was “behind my eyes.”“After the fourth day of like, not eating and stuff, I just shut off, you know?. € he said.A jail area set aside for quarantining new inmates.Credit...Tailyr Irvine for The New York TimesAt one point, Mr. Hawley said, he and other prisoners protested the way the cialis was being handled by refusing to leave cialis no prescription their living areas and by blocking new inmates from entering.

Everyone was ultimately tested, Mr. Hawley said, and each prisoner was given a disposable mask.Sierra Jasmine Wells, 25, another inmate, said women in her dormitory had grown ill, one after the next.“Everyone cialis no prescription around me was getting sick and it was tough on me,” she said. €œBy then, I had already accepted the fact that I was going to get sick.”When she became infected, she said, she was given cough syrup and Tylenol.“I kind of was just left alone to deal with it,” she said.Jesse Slaughter, the county sheriff who oversees the jail, said that the jail’s medical staff was doing everything it could, and that he had been seeking health care assistance from other counties. Officials defended their handling of the outbreak, noting that all inmates received standard medications including Tylenol twice a day and were taken to area hospitals when they needed added care.

Seven inmates, cialis no prescription as well as some staff members, were hospitalized. No one from the jail has died from the cialis, officials said.Sheriff Jesse Slaughter, who oversees the jail, said he had been seeking health care assistance from other counties.Credit...Tailyr Irvine for The New York TimesMr. Krogue said that since the start of the outbreak he had been working up to 16 cialis no prescription hours each day and sleeping in his basement, away from his wife and children. He remains healthy but says he fears bringing the cialis home.

The cialis has slowed some in the jail, and officials have moved some inmates to other facilities, but other prisons and jails in the state are now seeing outbreaks.“You can start to see what some of these other places experienced much earlier on, and we just didn’t have that experience, but it’s certainly happening now,” Mr. Krogue said cialis no prescription. €œIt’s just real in a way that it wasn’t.”Lucy Tompkins reported from Great Falls, Maura Turcotte from Chicago and Libby Seline from Lincoln, Neb. Reporting was contributed by Izzy Colón from Columbia, Mo., cialis no prescription Brendon Derr from Phoenix, Rebecca Griesbach from Tuscaloosa, Ala., Danya Issawi and Timothy Williams from New York, Ann Hinga Klein from Des Moines, K.B.

Mensah from Silver Spring, Md., and Mitch Smith from Chicago.Start Preamble Federal Transit Administration (FTA), DOT. Notice of funding opportunity cialis no prescription. The erectile dysfunction Disease 2019 (erectile dysfunction treatment) public health emergency Start Printed Page 63654has had a significant impact on transit operations. During a series of FTA listening sessions held over the last three months, transit agencies asked FTA to support research to identify solutions to address the operational challenges that they are facing as a result of erectile dysfunction treatment.

In response, FTA makes available through this Notice of Funding Opportunity (NOFO) funding to support research demonstration grants to public transit agencies to develop, deploy, and demonstrate innovative solutions that improve cialis no prescription the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the erectile dysfunction treatment public health emergency. Demonstration grants under this NOFO are authorized under FTA's Public Transportation Innovation Program (49 U.S.C. 5312). Eligible projects will demonstrate innovative solutions to improve the operational efficiencies of transit systems and enhance mobility for their communities in four major areas.

(1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit services.

The total funding available for awards under this NOFO is $10,000,000. FTA may supplement this amount if additional funding becomes available. Applicants must submit completed proposals for funding opportunity FTA-2020-015-TRI through the GRANTS.GOV “APPLY” function by 11:59 p.m. Eastern Time on November 2, 2020.

Prospective applicants should register as soon as possible on the GRANTS.GOV website to ensure they can complete the application process before the submission deadline. Application instructions are available on FTA's website at http://transit.dot.gov/​howtoapply and in the “FIND” module of GRANTS.GOV. FTA will not accept mail and fax submissions. Start Further Info Please send any questions on this notice to Jamel El-Hamri email.

Jamel.El-Hamri@dot.gov phone. 2020-366-8985. A Telecommunication Device for the Deaf (TDD) is available for individuals who are deaf or hard of hearing at 1-800-877-8339. End Further Info End Preamble Start Supplemental Information Table of Contents A.

Program Description B. Federal Award Information C. Eligibility Information D. Application and Submission Information E.

Application Review Information F. Federal Award Administration Information G. Federal Awarding Agency Contact Information A. Program Description The Public Transportation erectile dysfunction treatment Research Demonstration Grant Program is funded through the Public Transportation Innovation Program (49 U.S.C.

5312), with the goal to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the erectile dysfunction treatment public health emergency. Eligible projects will propose to develop and deploy innovative solutions in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures.

(3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit. As required by 49 U.S.C. 5312(e)(4), projects funded under this NOFO must participate in an evaluation by an independent outside entity that will conduct a comprehensive evaluation of the success or failure of the projects funded under this subsection and any plan for broad-based implementation of the innovation promoted by successful projects.

B. Federal Award Information FTA makes available $10,000,000 in fiscal year (FY) 2020 funds under the Public Transportation Innovation Program (49 U.S.C. 5312) to finance the Public Transportation erectile dysfunction treatment Research Demonstration Grant Program. FTA may supplement the total funds available if additional funding becomes available at the time project selections are made.

FTA will grant pre-award authority starting on the date of the project award announcement for selected projects and should be completed within 24 months from the date of award. Funds are available only for eligible expenses incurred after the announcement of project selections. C. Eligibility Information (1) Eligible Applicants Eligible applicants include State and local governmental authorities, direct recipients of Urbanized Area (49 U.S.C.

5307) and Rural Area (49 U.S.C. 5311) formula funds, and Indian tribes. Eligible applicants are limited to FTA grantees or subrecipients who would be the primary beneficiaries of the innovative products and services that are developed—typically public transit agencies. Except for projects proposed by Indian tribes, proposals for projects in rural (non-urbanized) areas must be submitted as part of a consolidated State proposal.

States and other eligible applicants also may submit consolidated proposals for projects in urbanized areas. The submission of the Statewide application will not preclude the submission and consideration of any application from other eligible recipients in an urbanized area in a State. Proposals may contain projects to be implemented by the recipient or its subrecipients. Eligible subrecipients include public agencies, private nonprofit organizations, and private providers engaged in public transportation.

Eligible applicants may submit consolidated proposals for projects. (2) Cost Sharing or Matching The maximum Federal share of project costs is 100 percent. FTA may give additional consideration to applicants that propose a local share and may view these applicants as more competitive. The applicant must document the source(s) of the local match, if any, in the grant application.

For any applicants proposing match, eligible local match sources include the following. Cash from non-Government sources other than revenues from providing public transportation services. Revenues derived from the sale of advertising and concessions. Revenues generated from value capture financing mechanisms.

Funds from an undistributed cash surplus. Replacement or depreciation cash fund or reserve. New capital. Or in-kind contributions.

(3) Eligible Projects Eligible projects will propose innovative solutions to improve operational efficiencies of transit agencies and enhance the mobility of transit users, through projects that demonstrate innovative solutions for. Vehicle, facility, equipment and infrastructure cleaning and dis. Exposure mitigation measures such a real-time notification of rail and bus passenger loads. New multi-modal payment innovative mobility systems such as contactless payments.

And measures that strengthen public confidence in transit. Each applicant may only submit one proposal.Start Printed Page 63655 D. Application and Submission Information (1) Address and Form of Application Submission Applications must be submitted through GRANTS.GOV. Applicants can find general information for submitting applications through GRANTS.GOV at www.fta.dot.gov/​howtoapply, along with specific instructions for the forms and attachments required for submission.

Mail and fax submissions will not be accepted. (2) Content and Form of Application Submission a. Proposal Submission A complete proposal submission consists of at least two forms. 1.

The SF-424 Mandatory Form (downloadable from GRANTS.GOV) and 2. The supplemental form for the FY 2020 erectile dysfunction treatment Demonstration Program (downloadable from GRANTS.GOV), which is available on FTA's website at (placeholder for FTA erectile dysfunction treatment Demonstration Program). The application must include responses to all sections of the SF-424 mandatory form and the supplemental form unless a section is indicated as optional. FTA will use the information on the supplemental form to determine applicant and project eligibility for the program and to evaluate the proposal against the selection criteria described in part E of this notice.

FTA will accept only one supplemental form per SF-424 submission. FTA encourages applicants to consider submitting a single supplemental form that includes multiple activities to be evaluated as a consolidated proposal. Applicants may attach additional supporting information to the SF-424 submission, including but not limited to letters of support, project budgets, or excerpts from relevant planning documents. Supporting documentation must be described and referenced by file name in the appropriate response section of the supplemental form, or it may not be reviewed.

Information such as applicant name, Federal amount requested, local match amount, description of areas served, etc., may be requested in varying degrees of detail on both the SF-424 form and supplemental form. Applicants must fill in all fields unless stated otherwise on the forms. If applicants copy information into the supplemental form from another source, they should verify that the supplemental form has fully captured pasted text and that it has not truncated the text due to character limits built into the form. Applicants should use both the “Check Package for Errors” and the “Validate Form” validation buttons on both forms to check all required fields.

Applicants should also ensure that the Federal and local amounts specified are consistent. Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S. Initiative, the Department encourages applicants to consider how the project will address the challenges faced by rural areas.

B. Application Content The SF-424 Mandatory Form and the supplemental form will prompt applicants for the required information, including. I. Applicant Name ii.

Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number iii. Key contact information (contact name, address, email address, and phone number) iv. Congressional district(s) where project will take place v. Project Information (title, executive summary, and type) vi.

A detailed description of the need for the project vii. A detailed description of how the project will support the Program objectives viii. Evidence that the applicant can provide the local cost shares ix. A description of the technical, legal, and financial capacity of the applicant x.

A detailed project budget xi. Details on the local matching funds xii. A detailed project timeline xiii. Whether the project impacts an Opportunity Zone (3) Unique Entity Identifier and System for Award Management (SAM) Each applicant is required to.

(1) Be registered in SAM before submitting an application. (2) provide a valid unique entity identifier in its application. And (3) continue to maintain an active SAM registration with current information at all times during which the applicant has an active Federal award or an application or plan under consideration by FTA. These requirements do not apply if the applicant.

(1) Is excepted from the requirements under 2 CFR 25.110(b) or (c). Or (2) has an exception approved by FTA under 2 CFR 25.110(d). FTA may not make an award until the applicant has complied with all applicable unique entity identifier and SAM requirements. If an applicant has not fully complied with the requirements by the time FTA is ready to make an award, FTA may determine that the applicant is not qualified to receive an award and use that determination as a basis for making a Federal award to another applicant.

All applicants must provide a unique entity identifier provided by SAM. Registration in SAM may take as little as 3-5 business days, but there can be unexpected steps or delays. For example, the applicant may need to obtain an Employer Identification Number. FTA recommends allowing ample time, up to several weeks, to complete all steps.

For additional information on obtaining a unique entity identifier, please visit www.sam.gov. (4) Submission Dates and Times Project proposals must be submitted electronically through GRANTS.GOV by 11:59 p.m. Eastern on November 2, 2020. Mail and fax submissions will not be accepted.

FTA urges applicants to submit applications at least 72 hours prior to the due date to allow time to correct any problems that may have caused either GRANTS.GOV or FTA systems to reject the submission. Proposals submitted after the deadline will only be considered under extraordinary circumstances not within the applicant's control. Deadlines will not be extended due to scheduled website maintenance. GRANTS.GOV scheduled maintenance and outage times are announced on the GRANTS.GOV website.

Within 48 hours after submitting an electronic application, the applicant should receive two email messages from GRANTS.GOV. (1) Confirmation of successful transmission to GRANTS.GOV. And (2) confirmation of successful validation by GRANTS.GOV. If the applicant does not receive confirmation of successful validation or receives a notice of failed validation or incomplete materials, the applicant must address the reason for the failed validation, as described in the email notice, and resubmit before the submission deadline.

If making a resubmission for any reason, applicants must include all original attachments regardless of which attachments were updated and check the box on the supplemental form indicating this is a resubmission. Applicants are encouraged to begin the process of registration on the GRANTS.GOV site well in advance of the submission deadline. Registration is Start Printed Page 63656a multi-step process, which may take several weeks to complete before an application can be submitted. Registered applicants may still be required to update their registration before submitting an application.

Registration in SAM is renewed annually and persons making submissions on behalf of the Authorized Organization Representative (AOR) must be authorized in GRANTS.GOV by the AOR to make submissions. (5) Funding Restrictions Funds may be used for post-award expenditures only. Funds under this NOFO cannot be used to reimburse projects for otherwise eligible expenses incurred prior to the date of project award announcements. (6) Other Submission Requirements FTA encourages applicants to identify scaled funding options in case insufficient funding is available to fund a project at the full requested amount.

If an applicant indicates that a project is scalable, the applicant must provide an appropriate minimum funding amount that will fund an eligible project that achieves the objectives of the program and meets all relevant program requirements. The applicant must provide a clear explanation of how a reduced award would affect the project budget and scope. FTA may award a lesser amount whether or not the applicant provides a scalable option. E.

Application Review Information (1) Project Evaluation Criteria Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S. Initiative, the Department will consider how the project will address the challenges faced by rural areas. In addition, the Department will review and consider applications for funding pursuant to this Notice in accordance with the President's September 2, 2020 memorandum, entitled Memorandum on Reviewing Funding to State and Local Government Recipients of Federal Funds that Are Permitting Anarchy, Violence, and Destruction in American Cities, consistent with guidance from the Office of Management and Budget and the Attorney General and with all applicable laws.

FTA will evaluate proposals submitted according to the following criteria. (a) Project Innovation and Impact. (b) Project Approach. (c) National Applicability.

(d) Commercialization and/or Knowledge Transfer. And (e) Technical, Legal and Financial Capacity. FTA encourages each applicant to demonstrate how a project supports all criteria with the most relevant information the applicant can provide, regardless of whether such information has been specifically requested or identified in this notice. A.

Project Innovation and Impact i. Effectiveness of the project in achieving and demonstrating the specific objectives of this program. Ii. Demonstration of benefits in addressing the needs of the transit agency and industry and impacts to infrastructure, equipment, transit workforce, and riders.

Iii. Degree of improvement over current and existing technologies, designs, and/or practices applicable to the transit industry. B. Project Approach i.

Quality of the project approach such as existing partnerships, collaboration strategies and level of commitment of the project partners. Ii. Proposal is realistic in its approach to fulfill the milestones/deliverables, schedule and goals. C.

National Applicability i. Degree to which the project could be replicated by other transit agencies regionally or nationally. Ii. Ability to evaluate technologies, designs and/or practices in a wide variety of conditions and locales.

Iii. Degree to which the technology, designs and/or practices can be replicated by other transportation modes. D. Commercialization and/or Knowledge Transfer i.

Demonstrates a realistic plan for moving the results of the project into the transit marketplace (patents, conferences, articles in trade magazines, webinar, site visits, etc.). Ii. How the project team plans to work with the industry on improving best practices, guidance and/or standards, if applicable. Iii.

Demonstrate a clear understanding and robust approach to data collection, access and management. E. Technical, Legal and Financial Capacity Capacity of the applicant and any partners to successfully execute the project effort. There should be no outstanding legal, technical, or financial issues with the applicant that would make this a high-risk project.

(2) Review and Selection Process An FTA technical evaluation committee will evaluate proposals based on the published project evaluation criteria. Members of the technical evaluation committee will rate the applications and may seek clarification about any statement in an application. The FTA Administrator will determine the final selection and amount of funding for each project after consideration of the findings of the technical evaluation committee. Geographic diversity, diversity of the project type, the amount of local match to be provided, and the applicant's receipt and management of other Federal transit funds may be considered in FTA's award decisions.

Prior fare payment innovation efforts may receive priority consideration. The FTA Administrator will consider the following key DOT objectives. A. Utilizing alternative funding sources and innovative financing models to attract non-Federal sources of investment.

B. Whether the project is located in or supports public transportation service in a qualified opportunity zone designated pursuant to 26.U.S.C. 1400Z-1. And c.

The extent to which the project addresses challenges specific to the provision of rural public transportation. (3) FAPIIS Review Prior to making a grant award, FTA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS) accessible through SAM. An applicant may review and comment on information about itself that a Federal awarding agency previously entered. FTA will consider any comments by the applicant, in addition to the other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 2 CFR 200.205 Federal Awarding Agency Review of Risk Posed by Applicants.

F. Federal Award Administration Information (1) Federal Award Notices FTA will announce the final project selections on the FTA website. Project recipients should contact their FTA Regional Office for additional information regarding allocations for Start Printed Page 63657projects. At the time project selections are announced, FTA will extend pre-award authority for the selected projects.

There is no blanket pre-award authority for these projects before announcement. There is no minimum or maximum grant award amount, but FTA intends to fund as many meritorious projects as possible. FTA only will consider proposals from eligible recipients for eligible activities. Due to funding limitations, projects selected for funding may receive less than the amount originally requested.

In those cases, applicants must be able to demonstrate that the proposed projects are still viable and can be completed with the amount awarded. (2) Administrative and National Policy Requirements a. Pre-Award Authority FTA will issue specific guidance to recipients regarding pre-award authority at the time of selection. FTA does not provide pre-award authority for competitive funds until projects are selected, and there are Federal requirements that must be met before costs are incurred.

For more information about FTA's policy on pre-award authority, see the FY 2020 Apportionments Notice published on June 3, 2020, at https://www.govinfo.gov/​content/​pkg/​FR-2020-06-03/​pdf/​2020-11946.pdf. b. Grant Requirements Selected applicants will submit a grant application through FTA's electronic grant management system and adhere to the customary FTA grant requirements for research project (insert Circular name). All competitive grants, regardless of award amount, will be subject to the Congressional notification and release process.

FTA emphasizes that third-party procurement applies to all funding awards, as described in FTA Circular 4220.1F, “Third Party Contracting Guidance.” However, FTA may approve applications that include a specifically identified partnering organization(s) (2 CFR 200.302(f)). When included, the application, budget, and budget narrative should provide a clear understanding of how the selection of these organizations is critical for the project and give sufficient detail about the costs involved. C. Planning FTA encourages applicants to engage the appropriate State Departments of Transportation, Regional Transportation Planning Organizations, or Metropolitan Planning Organizations in areas to be served by the project funds available under this program.

D. Standard Assurances The applicant assures that it will comply with all applicable Federal statutes, regulations, executive orders, FTA circulars, and other Federal administrative requirements in carrying out any project supported by the FTA grant. The applicant acknowledges that it is under a continuing obligation to comply with the terms and conditions of the grant agreement issued for its project with FTA. The applicant understands that Federal laws, regulations, policies, and administrative practices might be modified from time to time and may affect the implementation of the project.

The applicant agrees that the most recent Federal requirements will apply to the project unless FTA issues a written determination otherwise. The applicant must submit the Certifications and Assurances before receiving a grant if it does not have current certifications on file. E. Free Speech and Religious Liberty In connection with any program or activity conducted with or benefiting from funds awarded under this notice, recipients of funds must comply with all applicable requirements of Federal law, including, without limitation, the Constitution of the United States.

Statutory, regulatory, and public policy requirements, including without limitation, those protecting free speech, religious liberty, public welfare, the environment, and prohibiting discrimination. The conditions of performance, non-discrimination requirements, and other assurances made applicable to the award of funds in accordance with regulations of the Department of Transportation. And applicable Federal financial assistance and contracting principles promulgated by the Office of Management and Budget. In complying with these requirements, recipients must ensure that no concession agreements are denied or other contracting decisions made on the basis of speech or other activities protected by the First Amendment.

If the Department determines that a recipient has failed to comply with applicable Federal requirements, the Department may terminate the award of funds and disallow previously incurred costs, requiring the recipient to reimburse any expended award funds. (3) Reporting The post-award reporting requirements include submission of the Federal Financial Report (FFR) and Milestone Progress Report in TrAMS. An evaluation of the grant will occur at various points in the demonstration process and at the end of the project. In addition, FTA is responsible for producing an Annual Report to Congress that compiles evaluation of selected projects, including an evaluation of the performance measures identified by the applicants.

All applicants must develop an evaluation plan to measure the success or failure of their projects and describe any plans for broad-based implementation of successful projects. FTA may request data and reports to support the evaluation and Annual Report. A. Independent Evaluation To achieve a comprehensive understanding of the impacts and implications of each proposed erectile dysfunction treatment Research Demonstration Program, projects funded under this announcement will require the recipient to conduct a third party independent evaluation of their project.

Recipients will be required to contract with a third party independent evaluator to assist in developing an evaluation plan, and collecting, storing and managing data required to fulfill the evaluation requirement. No more than 10 percent of the Federal share of the project may be used to hire the third-party independent evaluator and the inclusion of a third-party independent evaluation should be described in the grant application. If the project duration is more than two years, an interim evaluation report would need to be submitted to FTA, otherwise the evaluation report should be included as part of the final project report. B.

erectile dysfunction treatment Research Demonstration Grant Program Evaluation Projects funded under this announcement will be required to establish a set of performance metrics set by the third-party independent evaluator and shared with FTA. G. Federal Awarding Agency Contacts Information For questions about applying, please contact Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone.

202-366-8985. A TDD is available at 1-800-877-8339 (TDDFIRS). To ensure that applicants receive accurate information about eligibility or the program, applicants are encouraged to contact FTA directly with questions, rather than through intermediaries or third parties.Start Printed Page 63658 FTA staff also may conduct briefings on the competitive grants selection and award process upon request. Start Signature K.

Jane Williams, Deputy Administrator. End Signature End Supplemental Information [FR Doc. 2020-22316 Filed 10-7-20. 8:45 am]BILLING CODE 4910-57-P.

GREAT FALLS, cialis online in canada can i buy cialis online Mont. €” For months, the jail in central Montana’s Cascade County was free of the erectile dysfunction, which seemed as distant a threat as it did in much of the nation’s rural Mountain West.Then a few people who had the cialis were arrested. By the time Paul Krogue, the jail’s medical director, realized there was a problem, nearly 50 inmates were infected in the jail, where some cialis online in canada had been sleeping on mats on an overcrowded floor. After several weeks, Mr. Krogue got a call that s were spreading to a side of the jail that had been cialis-free.He hung up the phone and put his head in his hands.“I just kind of lost it, like, ‘My God, I don’t know how much cialis online in canada longer I can do this,’” Mr.

Krogue, a nurse practitioner, recalled. €œI was just scared that I’m not going to be able to see it through, that I’m going to get sick — you just feel so exhausted and it’s just a lot.”The Mountain West, which for months avoided the worst of the cialis, has rapidly devolved into one of the most alarming hot spots in a country that recorded its eight millionth confirmed case on Thursday, a day when more than 65,000 cases were announced nationwide, the most in a single day since July.Seventeen states, including many in the Mountain West, have added more cases in the past week than any other week of the cialis. And the spread through sparsely populated areas of rural America has created problems in small towns that lack critical resources — including cialis online in canada doctors — even in ordinary times.Wyoming, which did not have 1,000 total cases until June, recently added more than 1,000 in a single week. Reports of new s have recently reached record levels in Alaska, Colorado and Idaho. And Montana, where more than half of the state’s cases have been announced since August, is averaging more cialis online in canada than 500 cases per day.In Cascade County, more than 300 inmates and staff members have been infected in a facility meant to hold 365 people, the county’s first major outbreak in a region where the cialis is suddenly surging.The county seat, Great Falls, is seeing its worst case numbers yet.

The local hospital and its 27-bed erectile dysfunction treatment unit is at capacity. The county health department is racing to hire new contact tracers. And Mr cialis online in canada. Krogue, who also teaches nursing at Montana State University’s Great Falls campus, has seen attendance in his classes dwindle as students fall ill or quarantine.“I was just scared that I’m not going to be able to see it through, that I’m going to get sick,” said Paul Krogue, the jail’s medical director.Credit...Tailyr Irvine for The New York TimesOne place where the s have spread has been local jails, which are confined, often crowded spaces. Jails are staples of local communities cialis online in canada and tend to have people coming and going more quickly than prisons.

Jails can hold everyone from people awaiting criminal trials for months to those picked up for a suspended driver’s license for a few hours. With so many people filtering in and out, jails pose extra risks for the cialis’s spread — not only inside facilities but in potentially feeding outbreaks in the rest of the community.Nationally, jails and prisons have seen disproportionate rates of and death, with a mortality rate twice as high as in the general population and an rate more than four times as high, according to recent data.A New York Times database has tracked clusters of at least 50 erectile dysfunction cases in a dozen rural jails in Montana, Idaho, cialis online in canada Utah and New Mexico during the cialis. Among them. The Purgatory Correctional Center in Hurricane, Utah, with 166 s. The jail cialis online in canada in Twin Falls, Idaho, with 279.

And, in New Mexico, the Cibola County Correctional Center, which has reported 357 cases.In Cascade County, s at the jail make up about a quarter of all known cialis cases in the county. Health authorities say that the jail’s outbreak, which began in mid-August, was not believed to be the main cause of the community’s cialis online in canada recent surge, but that it had led to some cases. In the past two months, Mr. Krogue said, the jail released 29 people who were considered actively infected.s at the jail make up about a quarter of Cascade County’s known cialis cases.Credit...Tailyr Irvine for The New York TimesGreat Falls, home to about 58,000 residents, is in the less mountainous part of Montana, with the Missouri River flowing through and a large oil refinery on its banks. The Cascade County Detention Center sits along a cialis online in canada highway at the edge of town.

Drive five miles in any direction and you are surrounded by wide-open plains.Montana requires that masks be worn inside businesses and indoor public spaces, and many people in Great Falls wear them when walking around downtown’s Central Avenue, where shops and cafes are still recovering from shutting down in the spring. Others go without masks, citing the open space and lack cialis online in canada of crowds.Bob Kelly, the mayor, said people had not been overly worried about how the jail outbreak might affect the rest of town when it started.“I think that by the very definition of a jail, hopefully, the disease will be incarcerated, as well as the patients,” he said. €œIs there concern?. Sure, there’s cialis online in canada concern. But is there overreaction?.

No.”The mayor of Great Falls said that residents had considered the jail’s outbreak a distant concern at first.Credit...Tailyr Irvine for The New York TimesSome residents’ nonchalance about the risks of the cialis, said Mr. Krogue, the jail’s medical director, can be traced to a spring and early summer when almost no one in Cascade County knew anyone who had been sickened.“We cialis online in canada benefited from that early on,” he said. €œBut in some ways, I think it did us a disservice, too, because it also created a certain level of complacency.”That has quickly shifted now, he said, as cases have spiked.The number of active cases known to county officials on any given day has risen sharply to about 600, according to Trisha Gardner, Cascade County’s health officer. The county has seen 1,261 cialis online in canada cases and six deaths during the cialis, a Times database shows. Some of the cases have been tied to the jail outbreak, she said, and others have been connected to bars and restaurants.

Even figuring out what has led to some cases has been complex, she said, as residents have been reluctant to cooperate with contact tracers.“Our hospitals are at capacity, our public health system is at capacity,” she said. €œIt’s not sustainable at this rate.”When the outbreak at the cialis online in canada jail began, social distancing was impossible, the authorities said. Three inmates shared cells designed for two. At night, cialis online in canada men slept on thin blue pads in every available space. On the floor in the day room, in shower stalls, in stairwells, in hallways outside of cells.Inmates did not receive masks until August, and jail officials said many have refused to wear them.In interviews with more than a dozen inmates and their family members, inmates described the jail during the outbreak as chaotic and unsanitary.

They said their pleas for help often went unanswered by nurses and guards.Newly arriving inmates were not always quarantined from one another before their test results were known because of a lack of space, inmates and jail officials said.Owen Hawley, 30, said every inmate in his living area of 38 men had tested positive for the cialis. He said he had been unable to eat for three days, had intensive body aches and suffered from a headache so powerful it felt as if it was “behind my eyes.”“After the fourth day of like, not eating and cialis online in canada stuff, I just shut off, you know?. € he said.A jail area set aside for quarantining new inmates.Credit...Tailyr Irvine for The New York TimesAt one point, Mr. Hawley said, he and other cialis online in canada prisoners protested the way the cialis was being handled by refusing to leave their living areas and by blocking new inmates from entering. Everyone was ultimately tested, Mr.

Hawley said, and each prisoner was given a disposable mask.Sierra Jasmine Wells, 25, another inmate, said cialis online in canada women in her dormitory had grown ill, one after the next.“Everyone around me was getting sick and it was tough on me,” she said. €œBy then, I had already accepted the fact that I was going to get sick.”When she became infected, she said, she was given cough syrup and Tylenol.“I kind of was just left alone to deal with it,” she said.Jesse Slaughter, the county sheriff who oversees the jail, said that the jail’s medical staff was doing everything it could, and that he had been seeking health care assistance from other counties. Officials defended their handling of the outbreak, noting that all inmates received standard medications including Tylenol twice a day and were taken to area hospitals when they needed added care. Seven inmates, as well cialis online in canada as some staff members, were hospitalized. No one from the jail has died from the cialis, officials said.Sheriff Jesse Slaughter, who oversees the jail, said he had been seeking health care assistance from other counties.Credit...Tailyr Irvine for The New York TimesMr.

Krogue said that since the start of the outbreak he had been working up to 16 hours each day and sleeping in his basement, away from his wife and cialis online in canada children. He remains healthy but says he fears bringing the cialis home. The cialis has slowed some in the jail, and officials have moved some inmates to other facilities, but other prisons and jails in the state are now seeing outbreaks.“You can start to see what some of these other places experienced much earlier on, and we just didn’t have that experience, but it’s certainly happening now,” Mr. Krogue said cialis online in canada. €œIt’s just real in a way that it wasn’t.”Lucy Tompkins reported from Great Falls, Maura Turcotte from Chicago and Libby Seline from Lincoln, Neb.

Reporting was contributed cialis online in canada by Izzy Colón from Columbia, Mo., Brendon Derr from Phoenix, Rebecca Griesbach from Tuscaloosa, Ala., Danya Issawi and Timothy Williams from New York, Ann Hinga Klein from Des Moines, K.B. Mensah from Silver Spring, Md., and Mitch Smith from Chicago.Start Preamble Federal Transit Administration (FTA), DOT. Notice of cialis online in canada funding opportunity. The erectile dysfunction Disease 2019 (erectile dysfunction treatment) public health emergency Start Printed Page 63654has had a significant impact on transit operations. During a series of FTA listening sessions held over the last three months, transit agencies asked FTA to support research to identify solutions to address the operational challenges that they are facing as a result of erectile dysfunction treatment.

In response, FTA makes available through this Notice of Funding Opportunity (NOFO) funding to support research demonstration grants to public transit agencies to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the erectile dysfunction treatment public health emergency cialis online in canada. Demonstration grants under this NOFO are authorized under FTA's Public Transportation Innovation Program (49 U.S.C. 5312). Eligible projects will demonstrate innovative solutions to improve the operational efficiencies of transit systems and enhance mobility for their communities in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and dis.

(2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit services. The total funding available for awards under this NOFO is $10,000,000. FTA may supplement this amount if additional funding becomes available.

Applicants must submit completed proposals for funding opportunity FTA-2020-015-TRI through the GRANTS.GOV “APPLY” function by 11:59 p.m. Eastern Time on November 2, 2020. Prospective applicants should register as soon as possible on the GRANTS.GOV website to ensure they can complete the application process before the submission deadline. Application instructions are available on FTA's website at http://transit.dot.gov/​howtoapply and in the “FIND” module of GRANTS.GOV. FTA will not accept mail and fax submissions.

Start Further Info Please send any questions on this notice to Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone. 2020-366-8985. A Telecommunication Device for the Deaf (TDD) is available for individuals who are deaf or hard of hearing at 1-800-877-8339. End Further Info End Preamble Start Supplemental Information Table of Contents A.

Program Description B. Federal Award Information C. Eligibility Information D. Application and Submission Information E. Application Review Information F.

Federal Award Administration Information G. Federal Awarding Agency Contact Information A. Program Description The Public Transportation erectile dysfunction treatment Research Demonstration Grant Program is funded through the Public Transportation Innovation Program (49 U.S.C. 5312), with the goal to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the erectile dysfunction treatment public health emergency. Eligible projects will propose to develop and deploy innovative solutions in four major areas.

(1) Vehicle, facility, equipment and infrastructure cleaning and dis. (2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit. As required by 49 U.S.C.

5312(e)(4), projects funded under this NOFO must participate in an evaluation by an independent outside entity that will conduct a comprehensive evaluation of the success or failure of the projects funded under this subsection and any plan for broad-based implementation of the innovation promoted by successful projects. B. Federal Award Information FTA makes available $10,000,000 in fiscal year (FY) 2020 funds under the Public Transportation Innovation Program (49 U.S.C. 5312) to finance the Public Transportation erectile dysfunction treatment Research Demonstration Grant Program. FTA may supplement the total funds available if additional funding becomes available at the time project selections are made.

FTA will grant pre-award authority starting on the date of the project award announcement for selected projects and should be completed within 24 months from the date of award. Funds are available only for eligible expenses incurred after the announcement of project selections. C. Eligibility Information (1) Eligible Applicants Eligible applicants include State and local governmental authorities, direct recipients of Urbanized Area (49 U.S.C. 5307) and Rural Area (49 U.S.C.

5311) formula funds, and Indian tribes. Eligible applicants are limited to FTA grantees or subrecipients who would be the primary beneficiaries of the innovative products and services that are developed—typically public transit agencies. Except for projects proposed by Indian tribes, proposals for projects in rural (non-urbanized) areas must be submitted as part of a consolidated State proposal. States and other eligible applicants also may submit consolidated proposals for projects in urbanized areas. The submission of the Statewide application will not preclude the submission and consideration of any application from other eligible recipients in an urbanized area in a State.

Proposals may contain projects to be implemented by the recipient or its subrecipients. Eligible subrecipients include public agencies, private nonprofit organizations, and private providers engaged in public transportation. Eligible applicants may submit consolidated proposals for projects. (2) Cost Sharing or Matching The maximum Federal share of project costs is 100 percent. FTA may give additional consideration to applicants that propose a local share and may view these applicants as more competitive.

The applicant must document the source(s) of the local match, if any, in the grant application. For any applicants proposing match, eligible local match sources include the following. Cash from non-Government sources other than revenues from providing public transportation services. Revenues derived from the sale of advertising and concessions. Revenues generated from value capture financing mechanisms.

Funds from an undistributed cash surplus. Replacement or depreciation cash fund or reserve. New capital. Or in-kind contributions. (3) Eligible Projects Eligible projects will propose innovative solutions to improve operational efficiencies of transit agencies and enhance the mobility of transit users, through projects that demonstrate innovative solutions for.

Vehicle, facility, equipment and infrastructure cleaning and dis. Exposure mitigation measures such a real-time notification of rail and bus passenger loads. New multi-modal payment innovative mobility systems such as contactless payments. And measures that strengthen public confidence in transit. Each applicant may only submit one proposal.Start Printed Page 63655 D.

Application and Submission Information (1) Address and Form of Application Submission Applications must be submitted through GRANTS.GOV. Applicants can find general information for submitting applications through GRANTS.GOV at www.fta.dot.gov/​howtoapply, along with specific instructions for the forms and attachments required for submission. Mail and fax submissions will not be accepted. (2) Content and Form of Application Submission a. Proposal Submission A complete proposal submission consists of at least two forms.

1. The SF-424 Mandatory Form (downloadable from GRANTS.GOV) and 2. The supplemental form for the FY 2020 erectile dysfunction treatment Demonstration Program (downloadable from GRANTS.GOV), which is available on FTA's website at (placeholder for FTA erectile dysfunction treatment Demonstration Program). The application must include responses to all sections of the SF-424 mandatory form and the supplemental form unless a section is indicated as optional. FTA will use the information on the supplemental form to determine applicant and project eligibility for the program and to evaluate the proposal against the selection criteria described in part E of this notice.

FTA will accept only one supplemental form per SF-424 submission. FTA encourages applicants to consider submitting a single supplemental form that includes multiple activities to be evaluated as a consolidated proposal. Applicants may attach additional supporting information to the SF-424 submission, including but not limited to letters of support, project budgets, or excerpts from relevant planning documents. Supporting documentation must be described and referenced by file name in the appropriate response section of the supplemental form, or it may not be reviewed. Information such as applicant name, Federal amount requested, local match amount, description of areas served, etc., may be requested in varying degrees of detail on both the SF-424 form and supplemental form.

Applicants must fill in all fields unless stated otherwise on the forms. If applicants copy information into the supplemental form from another source, they should verify that the supplemental form has fully captured pasted text and that it has not truncated the text due to character limits built into the form. Applicants should use both the “Check Package for Errors” and the “Validate Form” validation buttons on both forms to check all required fields. Applicants should also ensure that the Federal and local amounts specified are consistent. Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage.

Consistent with the R.O.U.T.E.S. Initiative, the Department encourages applicants to consider how the project will address the challenges faced by rural areas. B. Application Content The SF-424 Mandatory Form and the supplemental form will prompt applicants for the required information, including. I.

Applicant Name ii. Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number iii. Key contact information (contact name, address, email address, and phone number) iv. Congressional district(s) where project will take place v. Project Information (title, executive summary, and type) vi.

A detailed description of the need for the project vii. A detailed description of how the project will support the Program objectives viii. Evidence that the applicant can provide the local cost shares ix. A description of the technical, legal, and financial capacity of the applicant x. A detailed project budget xi.

Details on the local matching funds xii. A detailed project timeline xiii. Whether the project impacts an Opportunity Zone (3) Unique Entity Identifier and System for Award Management (SAM) Each applicant is required to. (1) Be registered in SAM before submitting an application. (2) provide a valid unique entity identifier in its application.

And (3) continue to maintain an active SAM registration with current information at all times during which the applicant has an active Federal award or an application or plan under consideration by FTA. These requirements do not apply if the applicant. (1) Is excepted from the requirements under 2 CFR 25.110(b) or (c). Or (2) has an exception approved by FTA under 2 CFR 25.110(d). FTA may not make an award until the applicant has complied with all applicable unique entity identifier and SAM requirements.

If an applicant has not fully complied with the requirements by the time FTA is ready to make an award, FTA may determine that the applicant is not qualified to receive an award and use that determination as a basis for making a Federal award to another applicant. All applicants must provide a unique entity identifier provided by SAM. Registration in SAM may take as little as 3-5 business days, but there can be unexpected steps or delays. For example, the applicant may need to obtain an Employer Identification Number. FTA recommends allowing ample time, up to several weeks, to complete all steps.

For additional information on obtaining a unique entity identifier, please visit www.sam.gov. (4) Submission Dates and Times Project proposals must be submitted electronically through GRANTS.GOV by 11:59 p.m. Eastern on November 2, 2020. Mail and fax submissions will not be accepted. FTA urges applicants to submit applications at least 72 hours prior to the due date to allow time to correct any problems that may have caused either GRANTS.GOV or FTA systems to reject the submission.

Proposals submitted after the deadline will only be considered under extraordinary circumstances not within the applicant's control. Deadlines will not be extended due to scheduled website maintenance. GRANTS.GOV scheduled maintenance and outage times are announced on the GRANTS.GOV website. Within 48 hours after submitting an electronic application, the applicant should receive two email messages from GRANTS.GOV. (1) Confirmation of successful transmission to GRANTS.GOV.

And (2) confirmation of successful validation by GRANTS.GOV. If the applicant does not receive confirmation of successful validation or receives a notice of failed validation or incomplete materials, the applicant must address the reason for the failed validation, as described in the email notice, and resubmit before the submission deadline. If making a resubmission for any reason, applicants must include all original attachments regardless of which attachments were updated and check the box on the supplemental form indicating this is a resubmission. Applicants are encouraged to begin the process of registration on the GRANTS.GOV site well in advance of the submission deadline. Registration is Start Printed Page 63656a multi-step process, which may take several weeks to complete before an application can be submitted.

Registered applicants may still be required to update their registration before submitting an application. Registration in SAM is renewed annually and persons making submissions on behalf of the Authorized Organization Representative (AOR) must be authorized in GRANTS.GOV by the AOR to make submissions. (5) Funding Restrictions Funds may be used for post-award expenditures only. Funds under this NOFO cannot be used to reimburse projects for otherwise eligible expenses incurred prior to the date of project award announcements. (6) Other Submission Requirements FTA encourages applicants to identify scaled funding options in case insufficient funding is available to fund a project at the full requested amount.

If an applicant indicates that a project is scalable, the applicant must provide an appropriate minimum funding amount that will fund an eligible project that achieves the objectives of the program and meets all relevant program requirements. The applicant must provide a clear explanation of how a reduced award would affect the project budget and scope. FTA may award a lesser amount whether or not the applicant provides a scalable option. E. Application Review Information (1) Project Evaluation Criteria Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage.

Consistent with the R.O.U.T.E.S. Initiative, the Department will consider how the project will address the challenges faced by rural areas. In addition, the Department will review and consider applications for funding pursuant to this Notice in accordance with the President's September 2, 2020 memorandum, entitled Memorandum on Reviewing Funding to State and Local Government Recipients of Federal Funds that Are Permitting Anarchy, Violence, and Destruction in American Cities, consistent with guidance from the Office of Management and Budget and the Attorney General and with all applicable laws. FTA will evaluate proposals submitted according to the following criteria. (a) Project Innovation and Impact.

(b) Project Approach. (c) National Applicability. (d) Commercialization and/or Knowledge Transfer. And (e) Technical, Legal and Financial Capacity. FTA encourages each applicant to demonstrate how a project supports all criteria with the most relevant information the applicant can provide, regardless of whether such information has been specifically requested or identified in this notice.

A. Project Innovation and Impact i. Effectiveness of the project in achieving and demonstrating the specific objectives of this program. Ii. Demonstration of benefits in addressing the needs of the transit agency and industry and impacts to infrastructure, equipment, transit workforce, and riders.

Iii. Degree of improvement over current and existing technologies, designs, and/or practices applicable to the transit industry. B. Project Approach i. Quality of the project approach such as existing partnerships, collaboration strategies and level of commitment of the project partners.

Ii. Proposal is realistic in its approach to fulfill the milestones/deliverables, schedule and goals. C. National Applicability i. Degree to which the project could be replicated by other transit agencies regionally or nationally.

Ii. Ability to evaluate technologies, designs and/or practices in a wide variety of conditions and locales. Iii. Degree to which the technology, designs and/or practices can be replicated by other transportation modes. D.

Commercialization and/or Knowledge Transfer i. Demonstrates a realistic plan for moving the results of the project into the transit marketplace (patents, conferences, articles in trade magazines, webinar, site visits, etc.). Ii. How the project team plans to work with the industry on improving best practices, guidance and/or standards, if applicable. Iii.

Demonstrate a clear understanding and robust approach to data collection, access and management. E. Technical, Legal and Financial Capacity Capacity of the applicant and any partners to successfully execute the project effort. There should be no outstanding legal, technical, or financial issues with the applicant that would make this a high-risk project. (2) Review and Selection Process An FTA technical evaluation committee will evaluate proposals based on the published project evaluation criteria.

Members of the technical evaluation committee will rate the applications and may seek clarification about any statement in an application. The FTA Administrator will determine the final selection and amount of funding for each project after consideration of the findings of the technical evaluation committee. Geographic diversity, diversity of the project type, the amount of local match to be provided, and the applicant's receipt and management of other Federal transit funds may be considered in FTA's award decisions. Prior fare payment innovation efforts may receive priority consideration. The FTA Administrator will consider the following key DOT objectives.

A. Utilizing alternative funding sources and innovative financing models to attract non-Federal sources of investment. B. Whether the project is located in or supports public transportation service in a qualified opportunity zone designated pursuant to 26.U.S.C. 1400Z-1.

And c. The extent to which the project addresses challenges specific to the provision of rural public transportation. (3) FAPIIS Review Prior to making a grant award, FTA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS) accessible through SAM. An applicant may review and comment on information about itself that a Federal awarding agency previously entered. FTA will consider any comments by the applicant, in addition to the other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 2 CFR 200.205 Federal Awarding Agency Review of Risk Posed by Applicants.

F. Federal Award Administration Information (1) Federal Award Notices FTA will announce the final project selections on the FTA website. Project recipients should contact their FTA Regional Office for additional information regarding allocations for Start Printed Page 63657projects. At the time project selections are announced, FTA will extend pre-award authority for the selected projects. There is no blanket pre-award authority for these projects before announcement.

There is no minimum or maximum grant award amount, but FTA intends to fund as many meritorious projects as possible. FTA only will consider proposals from eligible recipients for eligible activities. Due to funding limitations, projects selected for funding may receive less than the amount originally requested. In those cases, applicants must be able to demonstrate that the proposed projects are still viable and can be completed with the amount awarded. (2) Administrative and National Policy Requirements a.

Pre-Award Authority FTA will issue specific guidance to recipients regarding pre-award authority at the time of selection. FTA does not provide pre-award authority for competitive funds until projects are selected, and there are Federal requirements that must be met before costs are incurred. For more information about FTA's policy on pre-award authority, see the FY 2020 Apportionments Notice published on June 3, 2020, at https://www.govinfo.gov/​content/​pkg/​FR-2020-06-03/​pdf/​2020-11946.pdf. b. Grant Requirements Selected applicants will submit a grant application through FTA's electronic grant management system and adhere to the customary FTA grant requirements for research project (insert Circular name).

All competitive grants, regardless of award amount, will be subject to the Congressional notification and release process. FTA emphasizes that third-party procurement applies to all funding awards, as described in FTA Circular 4220.1F, “Third Party Contracting Guidance.” However, FTA may approve applications that include a specifically identified partnering organization(s) (2 CFR 200.302(f)). When included, the application, budget, and budget narrative should provide a clear understanding of how the selection of these organizations is critical for the project and give sufficient detail about the costs involved. C. Planning FTA encourages applicants to engage the appropriate State Departments of Transportation, Regional Transportation Planning Organizations, or Metropolitan Planning Organizations in areas to be served by the project funds available under this program.

D. Standard Assurances The applicant assures that it will comply with all applicable Federal statutes, regulations, executive orders, FTA circulars, and other Federal administrative requirements in carrying out any project supported by the FTA grant. The applicant acknowledges that it is under a continuing obligation to comply with the terms and conditions of the grant agreement issued for its project with FTA. The applicant understands that Federal laws, regulations, policies, and administrative practices might be modified from time to time and may affect the implementation of the project. The applicant agrees that the most recent Federal requirements will apply to the project unless FTA issues a written determination otherwise.

The applicant must submit the Certifications and Assurances before receiving a grant if it does not have current certifications on file. E. Free Speech and Religious Liberty In connection with any program or activity conducted with or benefiting from funds awarded under this notice, recipients of funds must comply with all applicable requirements of Federal law, including, without limitation, the Constitution of the United States. Statutory, regulatory, and public policy requirements, including without limitation, those protecting free speech, religious liberty, public welfare, the environment, and prohibiting discrimination. The conditions of performance, non-discrimination requirements, and other assurances made applicable to the award of funds in accordance with regulations of the Department of Transportation.

And applicable Federal financial assistance and contracting principles promulgated by the Office of Management and Budget. In complying with these requirements, recipients must ensure that no concession agreements are denied or other contracting decisions made on the basis of speech or other activities protected by the First Amendment. If the Department determines that a recipient has failed to comply with applicable Federal requirements, the Department may terminate the award of funds and disallow previously incurred costs, requiring the recipient to reimburse any expended award funds. (3) Reporting The post-award reporting requirements include submission of the Federal Financial Report (FFR) and Milestone Progress Report in TrAMS. An evaluation of the grant will occur at various points in the demonstration process and at the end of the project.

In addition, FTA is responsible for producing an Annual Report to Congress that compiles evaluation of selected projects, including an evaluation of the performance measures identified by the applicants. All applicants must develop an evaluation plan to measure the success or failure of their projects and describe any plans for broad-based implementation of successful projects. FTA may request data and reports to support the evaluation and Annual Report. A. Independent Evaluation To achieve a comprehensive understanding of the impacts and implications of each proposed erectile dysfunction treatment Research Demonstration Program, projects funded under this announcement will require the recipient to conduct a third party independent evaluation of their project.

Recipients will be required to contract with a third party independent evaluator to assist in developing an evaluation plan, and collecting, storing and managing data required to fulfill the evaluation requirement. No more than 10 percent of the Federal share of the project may be used to hire the third-party independent evaluator and the inclusion of a third-party independent evaluation should be described in the grant application. If the project duration is more than two years, an interim evaluation report would need to be submitted to FTA, otherwise the evaluation report should be included as part of the final project report. B. erectile dysfunction treatment Research Demonstration Grant Program Evaluation Projects funded under this announcement will be required to establish a set of performance metrics set by the third-party independent evaluator and shared with FTA.

G. Federal Awarding Agency Contacts Information For questions about applying, please contact Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone. 202-366-8985. A TDD is available at 1-800-877-8339 (TDDFIRS).

To ensure that applicants receive accurate information about eligibility or the program, applicants are encouraged to contact FTA directly with questions, rather than through intermediaries or third parties.Start Printed Page 63658 FTA staff also may conduct briefings on the competitive grants selection and award process upon request. Start Signature K. Jane Williams, Deputy Administrator. End Signature End Supplemental Information [FR Doc. 2020-22316 Filed 10-7-20.

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Credit. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia in this population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries.

During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls.

Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the two conditions remains unclear,” she says. However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other authors on this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit. The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors.

- Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows. The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells. As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an .

These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer.

€œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive. It’s one of those things that doesn’t sound right when you hear it,” says Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a cialis, which seems to encourage a strong immune response despite the cancer’s lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. €œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says.

Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

Credit http://howyouruletheworld.com/atlanta-play-to-your-strengths/ cialis online in canada. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the cialis online in canada most common form of permanent alopecia in this population.

The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to cialis online in canada develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over.

The prevalence of those with fibroids was compared cialis online in canada in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids.

The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, cialis online in canada sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the two conditions remains unclear,” she says cialis online in canada.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not cialis online in canada only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other authors cialis online in canada on this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit.

The New cialis online in canada England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors. - Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s DNA, is a good predictor of whether that cancer type will respond to a class of cancer cialis online in canada immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows.

The finding, published in the Dec. 21 New England Journal of Medicine, could be cialis online in canada used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

As a result, the drugs cause the immune system to fight cancer in the same way that it would fight discount cialis an . These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such cialis online in canada as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma.

The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others cialis online in canada to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the cialis online in canada mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data cialis online in canada on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation.

The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by cialis online in canada the mutational burden of that cancer. €œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

It’s one of those cialis online in canada things that doesn’t sound right when you hear it,” says Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, cialis online in canada a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors.

However, he explains, this cancer type is often caused by a cialis, which seems to encourage a strong immune response despite the cancer’s lower mutational burden. In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been cialis online in canada tried.

Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational cialis online in canada burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. €œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says.

Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..