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IntroductionThere has been considerable interest in elucidating the contribution of genetic factors to the development of common diseases and can you buy ventolin over the counter nz using this information for better prediction of disease risk. The common disease common variant hypothesis predicts that variants that are common in the population play a role in disease susceptibility.1 Genome-wide association studies (GWAS) using single nucleotide polymorphism (SNP) arrays were developed as a mechanism by which to investigate these genetic factors and it was hoped this would lead to identification of variants associated with disease risk and subsequent development of predictive can you buy ventolin over the counter nz tests. Variants identified as associated with particular traits by these studies, for the large part, are SNPs that individually have a minor effect on disease risk and hence, by themselves, cannot be reliably used in disease prediction. Looking at the aggregate impact of these SNPs in the form of a polygenic score (PGS) appeared to be one possible means of using this information to predict disease.2 It is thought this will be of benefit as can you buy ventolin over the counter nz our genetic make-up is largely stable from birth and dictates a ‘baseline risk’ on which external influences act and modulate.

Therefore, PGS are a potential mechanism to act as a risk predictor by capturing information on this genetic liability.The use of PGS as a predictive biomarker is being explored in a number of different disease areas, including cancer,3 4 psychiatric disorders,5–7 metabolic disorders (diabetes,8 obesity9) and coronary artery disease (CAD).10 The proposed applications range from aiding disease diagnosis, informing selection of therapeutic interventions, improvement of risk prediction, informing disease screening and, on a personal level, informing life planning. Therefore, genetic risk information in the form of a PGS is considered to have potential in informing both clinical and individual-level decision-making.Recent advances in statistical techniques, improved computational power and the availability can you buy ventolin over the counter nz of large data sets have led to rapid developments in this area over the past few years. This has resulted in a variety of approaches to construction of models for score calculation and the investigation of these scores for prediction of common diseases.11 Several review articles aimed at researchers with a working knowledge of this field have been produced.6 11–17 In this article, we provide an overview of the key aspects of PGS construction to assist clinicians and researchers in other areas of academia to gain an understanding of the processes involved in score construction. We also consider the implications of evolving methodologies for the development of applications of PGS in healthcare.Evolution in polygenic model can you buy ventolin over the counter nz construction methodologiesTerminology with respect to PGS has evolved over time, reflecting evolving approaches and methodology.

Other terms include PGS, polygenic risk score, polygenic load, genotype score, genetic burden, polygenic hazard score, genetic risk score (GRS), metaGRS and allelic risk score. Throughout this article we use the terms polygenic models to refer to the method used to calculate an output in the form can you buy ventolin over the counter nz of a PGS. Different polygenic models can be used to calculate a PGS and analysis of these scores can be used to examine associations with particular markers or to predict an individuals risk of diseases.12Usual practice in calculating PGS is as a weighted sum of a number of risk alleles carried by an individual, where the risk alleles and their weights are defined by SNPs and their measured effects (figure 1).11 Polygenic models have been constructed using a few, hundreds or thousands of SNPs, and more recently SNPs across the whole genome. Consequently, determining which SNPs to include and the disease-associated weighting to assign to SNPs are important aspects can you buy ventolin over the counter nz of model construction (figure 2).18 These aspects are influenced by available genotype data and effect size estimates as well as the methodology employed in turning this information into model parameters (ie, weighted SNPs).Polygenic score calculation.

This calculation aggregates the SNPs and their weights selected for a polygenic score. Common diseases are thought to be influenced by many genetic variants with small individual effect sizes, such can you buy ventolin over the counter nz that meaningful risk prediction necessitates examining the aggregated impact of these multiple variants including their weightings. PGS, polygenic score." data-icon-position data-hide-link-title="0">Figure 1 Polygenic score calculation. This calculation aggregates the SNPs and their weights selected for a polygenic score can you buy ventolin over the counter nz.

Common diseases are thought to can you buy ventolin over the counter nz be influenced by many genetic variants with small individual effect sizes, such that meaningful risk prediction necessitates examining the aggregated impact of these multiple variants including their weightings. PGS, polygenic score.Construction of a polygenic score. In the can you buy ventolin over the counter nz process of developing a polygenic score, numerous models are tested and then compared. The model that performs best (as determined by one or more measures) is then selected for validation in the external data set.

GWAS, genome-wide association studies." data-icon-position can you buy ventolin over the counter nz data-hide-link-title="0">Figure 2 Construction of a polygenic score. In the process of developing a polygenic score, numerous models are tested and then compared. The model that performs best (as determined by one or more measures) is then selected for validation in the external can you buy ventolin over the counter nz data set. GWAS, genome-wide association studies.Changes in data availability over time have had an impact on the approach taken in SNP selection and weighting.

Early studies to can you buy ventolin over the counter nz identify variants associated with common diseases took the form of candidate gene studies. The small size of candidate gene studies, the limitation of technologies available for genotyping and stringent significance thresholds meant that these studies investigated fewer variants and those that were identified with disease associations had relatively large effect sizes.19 Taken together, this meant that a relatively small number of variants were available for consideration for inclusion in a polygenic model.20 21 Furthermore, weighting parameters for these few variants were often simplistic, such as counts of the number of risk alleles carried, ignoring their individual effect sizes.16The advent of GWAS enabled assessment of SNPs across the genome, leading to the identification of a larger number of disease-associated variants and therefore more variants suitable for inclusion in a polygenic model. In addition, the increasing number of individuals in the association studies meant that the power of these studies increased, allowing for more precise estimates of effect sizes.19 Furthermore, some theorised that lowering stringent significance thresholds set for SNP–trait associations can you buy ventolin over the counter nz could also identify SNPs that might play a part in disease risk.11 16 This resulted in more options with respect to polygenic model parameters of SNPs to include and weights to assign to them. However, the inclusion of more SNPs and direct application of GWAS effect sizes as a weighting parameter does not always equate to better predictive performance.4 16 This is because GWAS do not provide perfect information with respect to the causal SNP, the effect sizes or the number of SNPs that contribute to the trait.

Therefore, different methods have been developed can you buy ventolin over the counter nz to address these issues and optimise predictive performance of the score. Current common practice is to construct models with different iterations of SNPs and weighting, with assessment of the performance of each to identify the optimum configuration of SNPs and their weights (figure 2).Methods used in SNP selection and weighting assignmentSome methods of model development will initially involve selection of SNPs followed by optimisation of weighting, whereas others may involve optimisation of weightings for all SNPs that have been genotyped using their overall GWAS effect sizes, the linkage disequilibrium (LD) and an estimate of the proportion of SNPs that are expected to contribute to the risk.22LD is the phenomenon where some SNPs are coinherited more frequently with other SNPs due to their close proximity on the genome. Segments with strong LD between SNPs are referred to as haplotype blocks can you buy ventolin over the counter nz. This phenomenon means that GWAS often identify multiple SNPs in the same haplotype block associated with disease and the true causal SNP is not known.

As models have started to assess more SNPs, careful consideration is required to take into can you buy ventolin over the counter nz account possible correlation between SNPs as a result of this phenomenon. Correlation between SNPs can lead to double counting of SNPs and association redundancy, where multiple SNPs in a region of LD are identified as being associated with can you buy ventolin over the counter nz the outcome. This can lead to reduction in the predictive performance of the model. Therefore, processes for filtering SNPs and using one SNP (tag can you buy ventolin over the counter nz SNP) to act as a marker in an area of high LD, through LD thinning, were developed.

Through these processes SNPs correlated with other SNPs in a block are removed, by either pruning or clumping. Pruning ignores p value thresholds and ‘eliminates’ SNPs by a process of iterative comparison between can you buy ventolin over the counter nz a pair of SNPs to assess if they are correlated, and subsequently could remove SNPs that are deemed to have evidence of association. Clumping (also known as informed pruning) is guided by GWAS p values and chooses the most significant SNP, therefore keeping the most significant SNP within a block.23 This is all done with the aim of pinpointing relatively small areas of the genome that contribute to risk of the trait. Different significance thresholds may be used to select SNPs from this subgroup for inclusion in models.Poor can you buy ventolin over the counter nz performance of a model can result from imperfect tagging with the underlying causal SNP.16 This is because the causal SNP that is associated with disease might not be in LD with the tag SNP that is in the model but is in LD with another SNP which is not in the model.

This particularly occurs where the LD and variant frequency differs between population groups.24 An alternate approach to filter SNPs is stepwise regression where SNPs are selected based on how much the SNPs improve the model’s performance. This is a statistical approach and can you buy ventolin over the counter nz does not consider the impact of LD or effect size.As described above, early studies used simple weighting approaches or directly applied effect sizes from GWAS as weighting parameters for SNPs. However, application of effect sizes as a weighting parameter directly from a GWAS may not be optimal, due to differences in the population that the GWAS was conducted in and the target population. Also as described above, LD and the fact that not all SNPs may contribute to the can you buy ventolin over the counter nz trait mean that these effect sizes from GWAS are imperfect estimates.

Therefore, methods have been developed that adjust effect size estimates from GWAS using statistical techniques which make assumptions about factors such as the number of causal SNPs, level of LD between SNPs or knowledge of their potential function to better reflect their impact on a trait. Numerous statistical methodologies have been developed to improve weighting with a view to enhancing the discriminative power of a PGS.25 26 Examples of some methodological approaches are LDpred,22 winner’s curse correction,23 empirical Bayes can you buy ventolin over the counter nz estimation,27 shrinkage regression (Lasso),28 linear mixed models,29 with more being developed or tested. An additional improvement on the methods is to embed non-genetic information (eg, age-specific ORs).6 Determination of which methodology or hybrid of methodologies is most appropriate for various settings and conditions is continuously being explored and is evolving with new statistical approaches developing at a rapid pace.In summary, model development has evolved in an attempt to gain the most from available GWAS data and address some of the issues that arise due to working with data sets which cannot be directly translated into parameters for prediction models. The different can you buy ventolin over the counter nz approaches taken in SNP selection and weighting, and the impact on the predictive performance of a model are important to consider when assessing different models.

This is because different approaches to PGS modelling can achieve the same or a similar level of prediction. From a can you buy ventolin over the counter nz health system implementation perspective, particular approaches may be preferred following practical considerations and trade-offs between obtaining genotype data, processes for score construction and model performance. In addition, the degree to which these parameters need to be optimised will also be impacted by the input data and validation data set, and the quality control procedures that need to be applied to these data sets.12Sources of input data for score constructionKey to can you buy ventolin over the counter nz the development of a polygenic model is the availability of data sets that can provide input parameters for model construction. Genotype data used in model construction can either be available as raw GWAS data or provided as GWAS summary statistics.

Data in the raw format are individual-level data from a SNP array and may not have undergone basic quality control such as assessment of missingness, sex discrepancy checks, deviation from Hardy-Weinberg equilibrium, heterozygosity rate, relatedness or assessment for outliers.30 31 Availability of raw GWAS data allows for different polygenic models to be developed because of the richness of the data, however computational issues arise because of the size of the data can you buy ventolin over the counter nz sets. Data based on genome sequencing, as opposed to SNP arrays, could also be used in model construction. There have been limited studies of PGS developed from this form of data due to limitations in data availability, which is mainly due to cost restraints.15 32 Individual-level genomic data are also often not available to researchers due to privacy concerns.Due to these issues, the focus of polygenic model development has therefore been on using well-powered can you buy ventolin over the counter nz GWAS summary statistics.33 These are available from open access repositories and contain summary information such as the allele positions, ORs, CIs and allele frequency, without containing confidential information on individuals. These data sets have usually been through the basic quality control measures mentioned above.

There are, however, no standards for publicly available files, meaning some further processing steps may be required, in particular when various data sets can you buy ventolin over the counter nz are combined for a meta-analysis. Quality control on summary statistics is only possible if information such as missing genotype rate, minor allele frequency, Hardy-Weinberg equilibrium failures and non-Mendelian transmission rates is provided.12Processing of GWAS data may include additional quality control steps, imputation and filtering of the SNP information, which can be done at the level of genotype or summary statistics data. SNP arrays used in GWAS only have can you buy ventolin over the counter nz common SNPs represented on them as they rely on LD between SNPs to cover the entire genome. As described above, one tag SNP on the array can represent many other SNPs.

Imputation of SNPs is common in GWAS and describes the process of predicting can you buy ventolin over the counter nz genotypes that have not been directly genotyped but are statistically inferred (imputed) based on haplotype blocks from a reference sequence.33–35 Often association tests between the imputed SNPs and trait are repeated. As genotype imputation requires individual-level data, researchers have proposed summary statistics imputation as a mechanism to infer the association between untyped SNPs and a trait. The performance of imputation has been evaluated and shown that, with certain limitations, summary statistics imputation is an efficient and cost-effective methodology to identify loci associated with traits when compared with imputation done on genotypes.36An alternative source of input data for the selection of SNPs and their weightings is through literature or in existing databases, where already known trait-associated SNPs and their effect sizes are used can you buy ventolin over the counter nz as the input parameters in model development. A number of studies have taken this approach37 38 and it is possible to use multiple sources when developing various polygenic models and establishing the preferred parameters to use.Currently, there does not appear to be one methodology that works across all contexts and traits, each trait will need to be assessed to determine which method is the most suitable for the trait being evaluated.

For example, four different polygenic model construction strategies were explored for three skin cancer subtypes4 by using data on SNPs and their effect sizes from different sources, such as the latest GWAS meta-analysis results, the National Human Genome Research Institute can you buy ventolin over the counter nz (NHGRI) EBI GWAS catalogue, UK Biobank GWAS summary statistics with different thresholds and GWAS summary statistics with LDpred. In this setting for basal cell carcinoma and melanoma, the meta-analysis and catalogue-derived models were found to perform similarly but that the latter was ultimately used as it included more SNPs. For squamous cell carcinoma the can you buy ventolin over the counter nz meta-analysis-derived model performed better than the catalogue-derived model. This demonstrates how each disease subtype, model construction strategy and data set can have their own limitations and advantages.Knowledge of the sources of input data and can you buy ventolin over the counter nz its subsequent use in model development is important in understanding the limitations of available models.

Models that are developed using data sets that reflect the population in which prediction is to be carried out will perform better. For example, data collected from a symptomatic or high-risk population may not be suitable as an input data set for the development can you buy ventolin over the counter nz of a polygenic model that will be used for disease prediction in the general population. Large GWAS studies were previously focused on high-risk individuals, such as patients with breast cancer with a strong family history or known pathogenic variants in BRCA1 or BRCA2. These studies would not be suitable for the development of PGS for use in can you buy ventolin over the counter nz the general population but can inform risk assessment in high-risk individuals.

The source of the data for SNP selection and weighting also has implications for downstream uses and validation. For example, variant frequency and LD patterns can vary between populations and this can translate to poor performance of the polygenic model can you buy ventolin over the counter nz if the external validation population is different from that of the input data set.39–41 Furthermore, the power and validity of polygenic analyses are influenced by the input data sources.12 42From a model to a scorePGS can be calculated using one of the methodologies discussed above. The resulting PGS units of measurement depend on which measurement is used for the weighting.12 For example, the weightings may have been calculated based on logOR for discrete traits or linear regression coefficient (β/beta) in continuous traits from univariate regression tests carried out in the GWAS. The resulting scores are can you buy ventolin over the counter nz then usually transformed to a standard normal distribution to give scores ranging from −1 to 1, or 0 to 100 for ease of interpretation.

This enables further examination of the association between the score and a trait and the predictive ability of different scores generated by different models. Similar to other can you buy ventolin over the counter nz biomarker analyses, this involves using the PGS as a predictor of a trait with other covariates (eg, age, smoking, and so on) added, if appropriate, in a target sample. Examination of differences in the distribution of scores in cases and controls, or by examining differences in traits between different strata of PGS can enable assessment of predictive ability (figure 3). Common practice is for individual-level PGS values to be used to stratify populations into distinct groups of risk based on percentile cut-off or threshold values can you buy ventolin over the counter nz (eg, the top 1%).Example distribution of polygenic scores across a population.

Thresholds can be set to stratify risk as low (some), average (most) and high (some)." data-icon-position data-hide-link-title="0">Figure 3 Example distribution of polygenic scores across a population. Thresholds can be set to stratify risk as low (some), average (most) and high (some).Model validationPolygenic model development is reliant on further data sets for model testing and validation and the composition of these can you buy ventolin over the counter nz data sets is important in ensuring that the models are appropriate for a particular purpose. The development of a model to calculate a PGS involves refinement of can you buy ventolin over the counter nz the previously discussed input parameters, and selection of the ‘best’ of several models based on performance (figure 2). Therefore, a testing/training data set is often required to assess the model’s ability to accurately predict the trait of interest.

This is often a data set that is independent of can you buy ventolin over the counter nz the base/input/discovery data set. It may comprise a subset of the discovery data set that is only used for testing and was not included in the initial development of the model but should ideally be a separate independent data set.Genotype and phenotype data are needed in these data sets. Polygenic models are can you buy ventolin over the counter nz used to calculate PGS for individuals in the training data set and regression analysis is performed with the PGS as a predictor of a trait. Other covariates may also be included, if appropriate.

This testing phase can be considered a process for identifying models with better overall performance and/or informing refinements needed can you buy ventolin over the counter nz. Hence, this phase often involves comparison of different models that are developed using the same input data set to identify those models that have optimal performance.The primary purpose is to determine which model best discriminates between cases and controls. The area under the curve can you buy ventolin over the counter nz (AUC) or the C-statistic is the most commonly used measure in assessing discriminative ability. It has been criticised as being an insensitive measure that is not able to fully capture all aspects of predictive ability.

For instance, can you buy ventolin over the counter nz in some instances, AUC can remain unchanged between models but the individuals within are categorised into a different risk group.43 Alternative metrics that have been used to evaluate model performance include increase in risk difference, integrated discrimination improvement, R2 (estimate of variance explained by the PGS after covariate adjustment), net classification index and the relative risk (highest percentile vs lowest percentile). A clear understanding on how to interpret the performance within various settings is important in determining which model is most suitable.44As per normal practice when developing any prediction model, polygenic models with the optimal performance in a testing/training data set should be further validated in external data sets. External data sets are critical in validation of models and assessment can you buy ventolin over the counter nz of generalisability, hence must also conform to the desired situations in which a model is to be used. The goal is to find a model with suitable parameters of predictive performance in data sets outside of those in which it was developed.

Ideally, external validation requires replication in can you buy ventolin over the counter nz independent data sets. Few existing polygenic models have been validated to this extent, the focus being rather on the development of new models rather than evaluation of existing ones. One example where replication has been carried out is in the can you buy ventolin over the counter nz field of CAD, where the GPSCAD45 and metaGRSCAD10 polygenic models (both developed using UK Biobank data) were evaluated in a Finnish population cohort.46 Predictive ability was found to be lower in the Finnish population. This is likely to be due to the differences in genetic structure of this can you buy ventolin over the counter nz population and the population of the data set used for polygenic model development.

Research is ongoing to evaluate polygenic models in other populations and strategies are being developed to ensure the same performance when used more widely, possibly through reweighting and adjustment of the scores.47Moving towards clinical applicationsPGS are thought to be useful information that could improve risk estimation and provide an avenue for disease prevention and deciding treatment strategies. There are indications from a number of fields that can you buy ventolin over the counter nz genetic information in the form of PGS can act as independent biomarkers and aid stratification.11 16 48 However, the clinical benefits of stratification using a PGS and the implications for clinical practice are only just beginning to be examined. The use of PGS as part of existing risk prediction tools or as a stand-alone predictor has been suggested. This latter option may be true for diseases where knowledge or predictive ability with other risk factors is limited, such as in prostate cancer.49 In either case, polygenic models need to be individually examined to determine suitability and applicability for the specific clinical question.50 Despite some commercial companies developing PGS,51 52 currently PGS are not an established part of clinical practice.Integration into clinical practice requires evaluation of a can you buy ventolin over the counter nz PGS-based test.

An important concept to consider in this regard is the distinction between an assay and a test. This has been previously discussed with respect to genetic test evaluation.53 54 It is worth examining this concept as applied to PGS, can you buy ventolin over the counter nz as their evaluation is reliant on a clear understanding of the test to be offered. As outlined by Zimmern and Kroese,54 the method used to analyse a substance in a sample is considered the assay, whereas a test is the use of an assay within a specific context. With respect to PGS, the process of can you buy ventolin over the counter nz developing a model to derive a score can be considered the assay, while the use of this model for a particular disease, population and purpose can be considered the test.

This distinction is important when assessing if studies are reporting on assay performance as opposed to test performance. It is our view that, with respect to polygenic models, progress has been made with respect to assay development, can you buy ventolin over the counter nz but PGS-based tests are yet to be developed and evaluated. This can enable a clearer understanding of their potential clinical utility and issues that may arise for clinical implementation.11 18 55 It is clear that this is still an evolving field, and going forward different models may be required for different traits due to their underlying genetic architecture,26 different clinical contexts and needs.Clinical contexts where risk stratification is already established practice are most likely where implementation of PGS will occur first. Risk prediction models based on non-genetic factors have been developed for many conditions and are used in clinical care, for example, in cardiovascular disease over 100 such models exist.56 In such contexts, how a PGS and its ability to predict risk compared with, or improves on, these existing models is being investigated.3 can you buy ventolin over the counter nz 44 57–61 The extent to which PGS improves prediction, as well as the cost implications of including this, is likely to impact on implementation.Integration of PGS into clinical practice, for any application, requires robust and validated mechanisms to generate these scores.

Therefore, given the numerous models available, an assessment of their suitability as part of a test is required. Parameters or guidelines with respect to aspects of model performance and metrics that could assist in selecting the model to take forward as a PGS-based test are limited can you buy ventolin over the counter nz and need to be addressed. Currently, there are different mechanisms to generate PGS and have arisen in response to the challenges in aggregating large-scale genomic data for prediction. For example, a review reported 29 PGS models for breast cancer from 22 publications.62 Due to there being a number of can you buy ventolin over the counter nz different methodologies to generate a score, numerous models may exist for the same condition and each of the resulting models could perform differently.

Models may perform differently because the population, measured outcome or context of the development data sets used to generate the models is diverse, for example, a score for risk of breast cancer versus a breast cancer subtype.44 63 This diversity, alongside the lack of established best practice and standardised reporting in publications, makes comparison and can you buy ventolin over the counter nz evaluation of polygenic models for use in clinical settings challenging. It is clear that moving the field forward is reliant on transparent reporting and evaluation. Recommendations for best can you buy ventolin over the counter nz practices on the reporting of polygenic models in literature have been proposed14 64 as well as a database,65 66 which could allow for such comparisons. Statements and guidelines for risk prediction model development, such as the Genetic Risk Prediction Studies and Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD), already exist, but are not consistently used.

TRIPOD explicitly covers the development and validation of prediction models for both diagnosis and prognosis, for all medical domains.One clear issue is generalisability and drop in performance of polygenic models once they are applied in a population group different from the one in which they were developed.22 46 67–70 This is an ongoing challenge in genomics as most GWAS, from which most PGS are being developed, have been conducted in European-Caucasian populations.71 Efforts to improve representation are underway72 and there are attempts to reweight/adjust scores when applied to different population groups which are showing some potential but need can you buy ventolin over the counter nz further research.47 Others have demonstrated that models developed in more diverse population groups have improved performance when applied to external data sets in different populations.24 73 It is important to consider this issue when moving towards clinical applications as it may pose an ethical challenge if the PGS is not generalisable.A greater understanding of different complex traits and the impact of pleiotropy is only beginning to be investigated.74 There is growing appreciation of the role of pleiotropy as multiple variants have been identified to be associated with multiple traits and exert diverse effects, providing insight into overlapping mechanisms.75 76 This, together with the impact of population stratification, genetic relatedness, ascertainment and other sources of heterogeneity leading to spurious signals and reduced power in genetic association studies, all impacting on the predictive ability of PGS in different populations and for different diseases.While many publications report on model development and evaluation, often there is a lack of clarity on intended purpose,50 77 leading to uncertainties as to the clinical pathways in which implementation is envisaged. A clear description of intended use within clinical pathways is a central component in evaluating the use of an application with any form of PGS and in considering practical implications, such as mechanisms of obtaining the score, incorporation into health records, interpretation of scores, relevant cut-offs for intervention initiation, mechanisms for feedback of results and costs, among other issues. These parameters will also be impacted by the polygenic can you buy ventolin over the counter nz model that is taken forward for implementation. Meaning that there are still some important questions that need to be addressed to determine how and where PGS could work within current healthcare systems, particularly at a population level.78It is widely accepted that genotyping using arrays is a lower cost endeavour in comparison to genome sequencing, making the incorporation of PGS into routine healthcare an attractive proposition.

However, we were unable to find any studies reporting on the can you buy ventolin over the counter nz use or associated costs of such technology for population screening. Studies are beginning to examine use case scenarios and model cost-effectiveness, but this has only been in very few, specific investigations.79 80 Costs will also be influenced by the testing technology and by the downstream consequences of testing, which is likely to differ depending on specific applications that are developed and the pathways in which such tests are incorporated. This is particularly the case in screening or primary care settings, where such testing is currently not an established part of care pathways and may require additional resources, not least as a result of the volume of testing that could be expected can you buy ventolin over the counter nz. Moving forward, the clinical role of PGS needs to be developed further, including defining the clinical applications as well as supporting evidence, for example, on the effect of clinical outcomes, the feasibility for use in routine practice and cost-effectiveness.ConclusionThere is a large amount of diversity in the PGS field with respect to model development approaches, and this continues to evolve.

There is rapid can you buy ventolin over the counter nz progress which is being driven by the availability of larger data sets, primarily from GWAS and concomitant developments in statistical methodologies. As understanding and knowledge develops, the usefulness and appropriateness of polygenic models for different diseases and contexts are being explored. Nevertheless, this can you buy ventolin over the counter nz is still an emerging field, with a variable evidence base demonstrating some potential. The validity of PGS needs to be clearly demonstrated, and their applications evaluated prior to clinical implementation..

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The U.S ventolin cough syrup for toddlers. National Science Foundation (NSF), which owns the observatory, announced on November 19 that it will begin the process of planning for “controlled decommissioning” of the 305-meter telescope. Over the past several months the instrument has suffered two catastrophic failures of cables that support its 900-ton (817-metric-ton) central ventolin cough syrup for toddlers receiving platform.

€œThis decision is intended to preserve life and safety of people and prevent the loss of the entire Arecibo Observatory, including the visitor education center, in the event of an unexpected and uncontrolled collapse,” said Sean Jones, assistant director of the Directorate for Mathematical and Physical Sciences at the NSF, during a press conference. €œThis decision is not an easy one for NSF ventolin cough syrup for toddlers to make. But safety of people is our number-one priority.” Fears of Life-Threatening Danger Ralph Gaume, director of the NSF’s Division of Astronomical Sciences, says that although the telescope is being decommissioned, the agency is “not closing Arecibo Observatory.” Instead the plan is to retain as much as possible of the surrounding infrastructure in hopes that it still might fulfill various research and educational purposes.

According to the NSF’s November 19 statement the decision came after evaluating “multiple assessments by independent engineering companies that found the telescope structure is in danger of a catastrophic failure and its cables may no longer be capable of carrying the loads they were designed to support.” Any attempts at repairs, the agency noted, “could put workers in potentially life-threatening danger.” And even if repairs proved successful, engineers had “found that the structure would likely present long-term stability issues.” The NSF does not yet have a fully formed plan for the decommissioning, Gaume says. But such a ventolin cough syrup for toddlers plan should emerge in coming weeks, he adds, and it could rely on explosive demolition for some of the structure. At present, it is anyone’s guess as to how long the decommissioning would take and at what expense.

An NSF estimate from 2016, however, gauged the total cost of deconstructing the ventolin cough syrup for toddlers observatory at between $10.6 million and $18.7 million. €œOur engineers are not able to tell us when the structure would collapse on its own, and so we’re working against the clock,” Gaume says. With regard to farming out Arecibo science investigations to other observatories, he adds, “certainly some subset of the science that is being done ventolin cough syrup for toddlers on Arecibo could, potentially, transfer to other facilities and, in particular, to other NSF facilities.” But the observatory’s gargantuan dimensions and specialized hardware make it a one-of-a-kind resource.

For many applications in astronomy and planetary science, there is simply no other available facility to fill the research void Arecibo’s decommissioning will leave behind. Catastrophic Cable Failures Without question, the past few years have not been kind to Arecibo. Back in ventolin cough syrup for toddlers September 2017 the radio telescope took a beating from Hurricane Maria.

The observatory lost one of its catwalk floors, and the fall of line feed damaged dozens of the radio dish’s more than 38,000 aluminum panels. But those damaging blows pale in contrast to the havoc wrought ventolin cough syrup for toddlers by an auxiliary cable break on August 10, followed by a main cable failure on November 6. “Each of the structure’s remaining cables is now supporting more weight than before, increasing the likelihood of another cable failure, which would likely result in the collapse of the entire structure,” explained a University of Central Florida statement earlier this month.

(The university manages the facility through a contract with the NSF.) Engineers have also observed additional signs of excess wear and tear on two of the remaining cables, creating a dynamic “industrial failure” situation that ventolin cough syrup for toddlers poses severe safety risks for workers. Despite these woes, Francisco Cordova, Arecibo’s current director, had expressed cautious optimism about the observatory’s eventual recovery in an October 12 statement. €œWe continue to make progress,” he wrote, “but the process is slow as we develop a comprehensive plan for facility repairs while prioritizing the safety of our staff....

Bottom line.. ventolin cough syrup for toddlers. We are making significant progress towards restoring the operational capability of this historic facility.” An Irreplaceable Resource Built in 1963, Arecibo was the world’s largest operational single-dish radar/radio telescope until it was shuttered by the broken cables earlier this year. Scientists regularly used its outsize dimensions to pull off otherwise impossible feats of telescopic derring-do, such as constructing detailed radar maps of ventolin cough syrup for toddlers asteroids, comets and planets, studying the exotic physics of whirling pulsars, and even beaming detailed messages into intergalactic space as part of the search for extraterrestrial intelligence (SETI).

Every year roughly 200 scientists have taken advantage of Arecibo’s prowess to pursue their investigations. Jill Tarter, ventolin cough syrup for toddlers chair emeritus for SETI research at the SETI Institute in Mountain View, Calif., spoke to Scientific American prior to the NSF’s decommissioning decision. At that time, she hailed Arecibo as a one of a kind resource, noting that even today it still possesses the world’s most powerful planetary radar transmitter.

€œSome of the science can be switched to other facilities,” Tarter added, although Arecibo’s sensitivity is required by certain projects—such as NANOGrav, which seeks to directly detect and study nanohertz-frequency gravitational waves. €œI think in debating repairs versus closing it down, the cost arguments will have to include that unique capability that will be lost,” she ventolin cough syrup for toddlers said. The situation is a quandary, says Dan Werthimer, a radio astronomer and SETI researcher at the University of California, Berkeley.

€œThey don’t quite understand how this ventolin cough syrup for toddlers happened, so you don’t know how to fix the facility in a safe and guaranteed way.” Like many researchers who have utilized Arecibo, Werthimer defends the observatory as a singular source of profound discoveries that has played a critical role in piecing together the puzzle of humankind’s place in the universe. It has also served a vital science-outreach role, even outside of its Hollywood allure, by its contributions to SETI@home. That initiative, spearheaded by Werthimer, ventolin cough syrup for toddlers enlisted millions of volunteers donating computer time to analyze Arecibo data in a global science project seeking to answer that most daunting query.

€œAre we alone?. € In Arecibo’s absence, Werthimer’s SETI research will continue with ongoing collaborative work now underway at China’s newly commissioned Five-Hundred-Meter Aperture Spherical Radio Telescope (FAST), which, as its name suggests, boasts a dish even larger than Arecibo’s. €œIt’s a spectacular radio telescope, but it can’t do the things that ventolin cough syrup for toddlers Arecibo does because FAST doesn’t have a transmitter,” Werthimer says.

Meanwhile China recently announced it is opening up FAST to other collaborators, making the telescope more readily available to researchers from other nations. This “open skies” approach is the ideal way to get the best science on the telescope, Werthimer says ventolin cough syrup for toddlers. Through funding from NASA’s Near-Earth Object (NEO) Observations Program, Arecibo has also served as one of the globe’s foremost assets in studying potentially hazardous NEOs that could strike Earth.

Thanks to Arecibo’s powerful radar transmitter, researchers have fully characterized the precise orbits, sizes and ventolin cough syrup for toddlers shapes of many NEOs during the space rocks’ close encounters with our planet. In a November 19 statement reacting to the NSF decision, NASA said that its Goldstone Deep Space Communications Complex in California—which also boasts a potent planetary radar—recently returned to full operations after upgrades to its high-power transmitter. Because the space agency only uses Goldstone and Arecibo alike for studying known NEOs rather than discovering new ones, the statement noted, “NASA’s NEO search efforts are not impacted by the planned decommissioning.” “It is obviously a very difficult situation for the NSF and Arecibo,” says Anthony Beasley, director of the NSF-funded National Radio Astronomy Observatory, which does not include Arecibo in its purview.

€œIn this kind of situation, you ventolin cough syrup for toddlers can’t have a whole lot of engineers crawling all over the telescope figuring out what’s wrong,” he says. €œThey have to diagnose the problem in a safe way, and that’s a bit of a challenge.” Could the observatory have been saved?. Scientists ventolin cough syrup for toddlers and historians will likely debate the circumstances of Arecibo’s death knell for years to come.

Beasley notes one thing is indisputable, however. €œArecibo is a very unique facility,” he says, “and its capabilities are not going to be reproduced anywhere else quickly.”.

Researchers have discovered charcoal dating back almost can you buy ventolin over the counter nz 2,000 years in New Mexican ice caves—providing physical evidence that ancestral Puebloans used how can i get ventolin the ice deposits for drinking water during droughts. Scientists are working fast to sample cores from the deposits, which likely formed thousands of years ago. Rising global can you buy ventolin over the counter nz temperatures have made it warm enough that the ice is beginning to disappear from the sites at El Malpais National Monument. €œOur wish is to try and find as much climate information as possible, because this ice is going away,” said Bogdan Onac, the lead researcher on the study. To better understand the collected ice cores, Onac worked with a can you buy ventolin over the counter nz team that included University of South Florida researchers and National Park Service archaeologists.

Evidence in the ice cores suggests the caves were used more intensely during periods of drought, based primarily on data from tree rings in the southwest, according to the report, published Wednesday in Scientific Reports. The cores also provide valuable information for scientists interested in understanding weather patterns in New Mexico and the surrounding region. That includes can you buy ventolin over the counter nz the severity and cause of local droughts. Tree ring information, a common tool to study historical weather patterns, can provide a rough look at the amount of moisture in a place each year. But ice contains oxygen and can you buy ventolin over the counter nz hydrogen isotopes that can mark how precipitation in the region would have been influenced by La Niña and monsoon season, indicating shifts in regional weather patterns.

This information can be used to better prepare scientists for a region rapidly being altered by climate change. Kenny Bowekaty, a longtime archaeologist, tour guide and member of the Ashiwi people in the nearby Pueblo of Zuni, said the people in the region who were around during the study period likely would can you buy ventolin over the counter nz have used the caves for religious purposes, as well as to store animals hunted nearby. €œIce to the Ashiwi people is still a resource of life,” Bowekaty said. €œThere’s a lot of compounded uses for what would have been considered ice caves.” Bowekaty said that one group of people in particular ventured north from the present-day Zuni settlement and into more mountainous regions, where ice would have been more common. When they came back, the caves would have can you buy ventolin over the counter nz been one of the few places to find ice in the summer months.

As late as the early 1900s, Ashiwi people made pilgrimages to the caves for religious purposes, Bowekaty said. But in recent years, the sites have can you buy ventolin over the counter nz become more restricted as the ice melts. Now, archaeologists are working against the clock to preserve information from the historic deposits before it’s too late. €œWith the ice caves and the water resources, I can you buy ventolin over the counter nz think everyone is aware of global warming here,” Bowekaty said. €œIt’s the behavior of our planet, our mother, and of course, like life and like all of us, she is still growing, and so how far we have as a planet is not known.” Reprinted from Climatewire with permission from E&E News.

E&E provides daily coverage of essential energy and environmental news at www.eenews.net.After more than a half-century of supporting breakthrough scientific work—and providing a scenic backdrop for Contact, GoldenEye and other blockbuster Hollywood films—the iconic Arecibo Observatory in Puerto Rico is going dark. The U.S can you buy ventolin over the counter nz. National Science Foundation (NSF), which owns the observatory, announced on November 19 that it will begin the process of planning for “controlled decommissioning” of the 305-meter telescope. Over the past several months the instrument has suffered two catastrophic failures of cables that support its 900-ton (817-metric-ton) central can you buy ventolin over the counter nz receiving platform. €œThis decision is intended to preserve life and safety of people and prevent the loss of the entire Arecibo Observatory, including the visitor education center, in the event of an unexpected and uncontrolled collapse,” said Sean Jones, assistant director of the Directorate for Mathematical and Physical Sciences at the NSF, during a press conference.

€œThis decision is not an easy one can you buy ventolin over the counter nz for NSF to make. But safety of people is our number-one priority.” Fears of Life-Threatening Danger Ralph Gaume, director of the NSF’s Division of Astronomical Sciences, says that although the telescope is being decommissioned, the agency is “not closing Arecibo Observatory.” Instead the plan is to retain as much as possible of the surrounding infrastructure in hopes that it still might fulfill various research and educational purposes. According to the NSF’s November 19 statement the decision came after evaluating “multiple assessments by independent engineering companies that found the telescope structure is in danger of a catastrophic failure and its cables may no longer be capable of carrying the loads they were designed to support.” Any attempts at repairs, the agency noted, “could put workers in potentially life-threatening danger.” And even if repairs proved successful, engineers had “found that the structure would likely present long-term stability issues.” The NSF does not yet have a fully formed plan for the decommissioning, Gaume says. But such a plan should emerge in coming weeks, he adds, can you buy ventolin over the counter nz and it could rely on explosive demolition for some of the structure. At present, it is anyone’s guess as to how long the decommissioning would take and at what expense.

An NSF estimate from 2016, however, gauged the total cost of deconstructing the observatory at between $10.6 million and $18.7 million can you buy ventolin over the counter nz. €œOur engineers are not able to tell us when the structure would collapse on its own, and so we’re working against the clock,” Gaume says. With regard to farming out Arecibo science investigations to other observatories, he adds, can you buy ventolin over the counter nz “certainly some subset of the science that is being done on Arecibo could, potentially, transfer to other facilities and, in particular, to other NSF facilities.” But the observatory’s gargantuan dimensions and specialized hardware make it a one-of-a-kind resource. For many applications in astronomy and planetary science, there is simply no other available facility to fill the research void Arecibo’s decommissioning will leave behind. Catastrophic Cable Failures Without question, the past few years have not been kind to Arecibo.

Back in September 2017 the radio telescope took a beating from Hurricane can you buy ventolin over the counter nz Maria. The observatory lost one of its catwalk floors, and the fall of line feed damaged dozens of the radio dish’s more than 38,000 aluminum panels. But those damaging blows pale in contrast to the havoc wrought by an auxiliary cable break on August 10, can you buy ventolin over the counter nz followed by a main cable failure on November 6. “Each of the structure’s remaining cables is now supporting more weight than before, increasing the likelihood of another cable failure, which would likely result in the collapse of the entire structure,” explained a University of Central Florida statement earlier this month. (The university manages the facility through a contract with the NSF.) Engineers have also observed additional signs of excess wear and tear on two of the remaining cables, creating a dynamic can you buy ventolin over the counter nz “industrial failure” situation that poses severe safety risks for workers.

Despite these woes, Francisco Cordova, Arecibo’s current director, had expressed cautious optimism about the observatory’s eventual recovery in an October 12 statement. €œWe continue to make progress,” he wrote, “but the process is slow as we develop a comprehensive plan for facility repairs while prioritizing the safety of our staff.... Bottom line.. can you buy ventolin over the counter nz. We are making significant progress towards restoring the operational capability of this historic facility.” An Irreplaceable Resource Built in 1963, Arecibo was the world’s largest operational single-dish radar/radio telescope until it was shuttered by the broken cables earlier this year. Scientists regularly used its outsize dimensions to pull off otherwise impossible feats of telescopic derring-do, such as constructing detailed can you buy ventolin over the counter nz radar maps of asteroids, comets and planets, studying the exotic physics of whirling pulsars, and even beaming detailed messages into intergalactic space as part of the search for extraterrestrial intelligence (SETI).

Every year roughly 200 scientists have taken advantage of Arecibo’s prowess to pursue their investigations. Jill Tarter, chair emeritus for SETI research at the SETI can you buy ventolin over the counter nz Institute in Mountain View, Calif., spoke to Scientific American prior to the NSF’s decommissioning decision. At that time, she hailed Arecibo as a one of a kind resource, noting that even today it still possesses the world’s most powerful planetary radar transmitter. €œSome of the science can be switched to other facilities,” Tarter added, although Arecibo’s sensitivity is required by certain projects—such as NANOGrav, which seeks to directly detect and study nanohertz-frequency gravitational waves. €œI think in debating repairs versus closing it down, the cost arguments will have to include can you buy ventolin over the counter nz that unique capability that will be lost,” she said.

The situation is a quandary, says Dan Werthimer, a radio astronomer and SETI researcher at the University of California, Berkeley. €œThey don’t quite understand how this happened, so you don’t know how to fix the facility in a safe and guaranteed way.” Like many researchers who have utilized Arecibo, Werthimer defends the observatory as a singular source of profound discoveries that has played a critical role in piecing together the puzzle of humankind’s can you buy ventolin over the counter nz place in the universe. It has also served a vital science-outreach role, even outside of its Hollywood allure, by its contributions to SETI@home. That initiative, spearheaded by Werthimer, enlisted millions of volunteers donating computer time to analyze Arecibo data in can you buy ventolin over the counter nz a global science project seeking to answer that most daunting query. €œAre we alone?.

€ In Arecibo’s absence, Werthimer’s SETI research will continue with ongoing collaborative work now underway at China’s newly commissioned Five-Hundred-Meter Aperture Spherical Radio Telescope (FAST), which, as its name suggests, boasts a dish even larger than Arecibo’s. €œIt’s a spectacular radio telescope, but it can’t do the things that can you buy ventolin over the counter nz Arecibo does because FAST doesn’t have a transmitter,” Werthimer says. Meanwhile China recently announced it is opening up FAST to other collaborators, making the telescope more readily available to researchers from other nations. This “open skies” can you buy ventolin over the counter nz approach is the ideal way to get the best science on the telescope, Werthimer says. Through funding from NASA’s Near-Earth Object (NEO) Observations Program, Arecibo has also served as one of the globe’s foremost assets in studying potentially hazardous NEOs that could strike Earth.

Thanks to Arecibo’s powerful radar transmitter, researchers have fully characterized the precise orbits, sizes and shapes of can you buy ventolin over the counter nz many NEOs during the space rocks’ close encounters with our planet. In a November 19 statement reacting to the NSF decision, NASA said that its Goldstone Deep Space Communications Complex in California—which also boasts a potent planetary radar—recently returned to full operations after upgrades to its high-power transmitter. Because the space agency only uses Goldstone and Arecibo alike for studying known NEOs rather than discovering new ones, the statement noted, “NASA’s NEO search efforts are not impacted by the planned decommissioning.” “It is obviously a very difficult situation for the NSF and Arecibo,” says Anthony Beasley, director of the NSF-funded National Radio Astronomy Observatory, which does not include Arecibo in its purview. €œIn this kind of situation, you can’t have a whole lot of engineers crawling can you buy ventolin over the counter nz all over the telescope figuring out what’s wrong,” he says. €œThey have to diagnose the problem in a safe way, and that’s a bit of a challenge.” Could the observatory have been saved?.

Scientists and historians will likely debate the circumstances of Arecibo’s death knell can you buy ventolin over the counter nz for years to come. Beasley notes one thing is indisputable, however. €œArecibo is a very unique facility,” he says, “and its capabilities are not going to be reproduced anywhere else quickly.”.

What is Ventolin?

ALBUTEROL (also known as salbutamol) is a bronchodilator. It helps open up the airways in your lungs to make it easier to breathe. Ventolin is used to treat and to prevent bronchospasm.

Ventolin vs proair

Latest Alzheimer's ventolin vs proair News By Dennis can i get ventolin over the counter Thompson HealthDay ReporterFRIDAY, July 30, 2021 (HealthDay News) asthma treatment can kill you. It can rob you of your breath, cause strange blood clots, and prompt side effects that last for months after you're over the initial . It's also possible ventolin vs proair that asthma treatment might impact the human brain in ways that could promote the onset of Alzheimer's disease, a new study reports. Severely ill asthma treatment patients display biological evidence of brain injury and inflammation as well as early markers of Alzheimer's, according to data gathered by an international consortium reviewing the asthma' effects on brain health.

This includes an uptick in tau, a sticky protein that forms tangles in the brains of later-stage Alzheimer's patients, said study author Dr. Thomas Wisniewski ventolin vs proair. He is a professor of neurology, pathology and psychiatry at New York University Grossman School of Medicine. asthma treatment "accelerates Alzheimer's biomarkers, and if you have preexisting Alzheimer's or related dementias, you're much more likely to have neurological complications and more severe disease," Wisniewski said.

"The fact that asthma treatment can increase Alzheimer's biomarkers suggests that long-term it could ventolin vs proair be a predisposing factor to accelerating the pathology." The findings were presented Thursday at the Alzheimer's Association's annual meeting, which is being held in Denver and online. Such research is considered preliminary until published in a peer-reviewed journal. In this study, researchers evaluated 310 patients admitted to NYU Langone Health in New York City with asthma treatment. Of those, about half developed neurological ventolin vs proair symptoms, most commonly confusion due to toxic-metabolic encephalopathy (TME), a condition in which an disrupts brain function by causing chemical abnormalities.

asthma treatment patients who developed TME were more likely than those without to have elevated levels of biological markers in their blood related to brain injury and Alzheimer's, the investigators found. These markers also appeared to be linked with blood indicators of inflammation, suggesting that asthma treatment could cause the brain to swell and potentially damage neurons, the researchers added. Although more research is required, the evidence suggests that asthma treatment might do enough harm to the brain that it could predispose an ventolin vs proair otherwise healthy person to later develop dementia or Alzheimer's, Wisniewski said. It also could be that people already at risk for Alzheimer's would be pushed further down that dark path after a case of asthma treatment, he added.

"Particularly for anyone who's predisposed to any of these neurodegenerative conditions, anyone who's older, this looks like a very significant risk of getting asthma treatment that can push you over the brink," Wisniewski said. The finding results from a collaboration between the Alzheimer's Association and representatives from nearly 40 countries to evaluate the long-term consequences of asthma treatment on the brain and nervous system ventolin vs proair. Heather Snyder, vice president of scientific and medical relations for the Alzheimer's Association, said, "One of the hallmark symptoms by which we define asthma treatment is a loss of taste or smell. That's an indicator that something is going on in the brain, because those are functions our brain controls." There's also concern about "brain fog" among asthma treatment sufferers and survivors, she added.

"We are seeing that individuals are experiencing changes in their memory, their thinking, ventolin vs proair their reasoning, their behavior," Snyder said. "What we don't know is, does that persist, is it able to be reversed, and what that means in terms of long-term impact or risk of Alzheimer's or other cognitive changes," Snyder continued. "Those are some of the questions we need to be asking." There's a simple fix for folks who want to protect their brain health against asthma treatment, Snyder added. "If you're not yet ventolin vs proair vaccinated, get vaccinated.

Protect yourself," she said. More information Johns Hopkins has more on asthma treatment's effects on the brain. SOURCES. Thomas Wisniewski, MD, professor, neurology, pathology and psychiatry, New York University Grossman School of Medicine, New York City.

Heather Snyder, PhD, vice president, scientific and medical relations, Alzheimer's Association Copyright © 2021 HealthDay. All rights reserved.Latest Senior Health News FRIDAY, July 30, 2021 (HealthDay News) The Biden administration has reversed a Trump policy that limited the size of fines that U.S. Nursing homes could be slapped with for violating safety standards. The Trump policy was adopted in 2017 and prevented the U.S.

Centers for Medicare and Medicaid Services (CMS) from hitting a nursing home with a fine for each day it didn't comply with federal standards. That reduced many penalties to a single fine, lowering total amounts from hundreds of thousands of dollars to a maximum of $22,000, The New York Times reported. Many nursing homes cited for violations such as poor controls, not protecting residents from avoidable accidents, neglect, mistreatment and bedsores, are repeat offenders, according to Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy. Larger fines are a deterrent and are more likely to indicate strong enforcement of the rules, Edelman told the Times.

In early July, the Biden administration changed guidance on the CMS website, saying it had "determined that the agency should retain the discretion at this time to impose a per-day penalty where appropriate to address specific circumstances of prior noncompliance." The new policy means that regulators can impose either per-day or per-instance penalties, the Times reported. Deaths in nursing homes account for nearly a third of the overall asthma treatment death toll in the United States. While there's been a sharp drop in asthma treatment deaths in nursing homes since treatments became available, inadequate staffing, shortages of protective equipment and poor control are still problems, according to advocates and some officials, the Times reported. Federal data show that while 81% of nursing home residents are vaccinated, only 58% of workers are immunized, which increases the risk of outbreaks even among fully vaccinated residents.

Fines levied on a per-day basis "only take precious resources away from an already underfunded industry, especially during an unprecedented time when nursing homes need every support to protect their residents," the main industry trade group, the American Health Care Association and National Center for Assisted Living, said in a statement, the Times reported. More information Visit the Agency for Healthcare Research and Quality for more on nursing home safety. SOURCE. The New York Times Robert Preidt Copyright © 2021 HealthDay.

All rights reserved. SLIDESHOW Exercise Tips for Seniors See SlideshowLatest Neurology News FRIDAY, July 30, 2021 (HealthDay News) Extremely premature babies have a much higher risk of cerebral palsy and other neurological conditions than full-term infants, a large Israeli study affirms. Cerebral palsy -- the name for a group of lifelong conditions that affect movement and coordination -- is the most common cause of severe childhood physical disability and motor impairment. It can also affect sensation, perception, thinking, communication and behavior.

"Extremely premature exposure to the environment outside of the uterus may alter musculoskeletal and nervous system development, and shift the trajectory of motor development for otherwise healthy children," study co-author Dr. Eyal Sheiner said in a news release from Ben-Gurion University of the Negev in Beer-Sheva, Israel. He is vice dean for academic promotion at the university and is also director of obstetrics and gynecology at Soroka University Medical Center in Beer-Sheva. For this study, Sheiner and his colleagues examined the outcomes of more than 220,500 deliveries over 23 years.

They found that babies born before 25 weeks' gestation had four times the risk of developing long-term neurological issues and significantly higher rates of cerebral palsy. Each additional week in the womb up to 37 weeks was linked to a decrease in the risk of long-term neurological problems, the researchers said. The findings were recently published in the Journal of Clinical Medicine. "Neurological disorders that stem from premature births are devastating," said Doug Seserman, chief executive officer of Americans for Ben-Gurion University, which supported the research.

More information The March of Dimes has more on cerebral palsy. SOURCE Related Site. Ben-Gurion University of the Negev, news release, July 29, 2021 Robert Preidt Copyright © 2021 HealthDay. All rights reserved.

SLIDESHOW Brain Food Pictures. What to Eat to Boost Focus See SlideshowLatest Diabetes News FRIDAY, July 30, 2021 (HealthDay News) As many Americans know, today's health insurance plans often come with high deductibles. Those out-of-pocket costs could cause harm. New research shows that 20% of people who have diabetes and high-deductible health plans regularly skip their medications.

Not keeping up with your diabetes medications comes with the potential risk of an emergency room visit or a hospitalization. Compared to people without high-deductible health plans, people with high deductibles are also 28% more likely to not take their medicines on time due to cost, the new study found. "Taking prescribed medications is essential for maintaining good health for patients with diabetes," stressed study author Dr. Vikas Gampa, a primary care doctor at Massachusetts General Hospital and instructor in medicine at Harvard Medical School.

"Our results show that high-deductible health plans, particularly in this period of escalating prices for diabetes medication, are discouraging patients from getting the medications they need and thus they are placing patients with diabetes at risk." High-deductible health plans require patients to pay for all care until they reach the plan's deductible. Insurance begins to cover medical costs after the patient pays the deductible, typically $1,300 for an individual or $2,600 for a family. These plans now comprise half of all commercial health insurance plans. The researchers examined U.S.

Federal survey data on more than 7,000 adult patients with diabetes who were enrolled in a commercial health insurance plan. They looked for how often patients reported not taking their prescription medication because they could not afford it, comparing both the traditional and the high-deductible patients. Roughly 25% of high-deductible plan enrollees who take insulin for diabetes could not afford their medication, compared to 19% of those with traditional plans, the study found. That's a 31% higher rate.

Researchers also found that diabetic patients who could not take their medications as prescribed were more likely to have one or more emergency department visits and potentially more hospitalizations per year than patients who did not skip medicines. "Putting up financial barriers to care in order to save plans money -- as high-deductible plans do -- not only takes a medical toll on patients, it is also short-sighted because doing so actually increases other health care costs such as covering emergency department visits," Gampa said in a Harvard news release. The findings were published online July 29 in the Journal of General Internal Medicine. "Patients with diabetes should recognize that a high-deductible plan will put them at risk for missing or delaying their medications, and doctors need to recognize that their patients with these plans may not be able to adhere to treatment plans," said study senior author Dr.

Danny McCormick, an associate professor of medicine at Harvard Medical School and a primary care physician at the Cambridge Health Alliance. "Ultimately, policymakers need to enact reforms that discourage health plans from implementing financial barriers that block access to needed care, such as high-deductible plans," McCormick said in the release. "Our results suggest that policymakers must enact reforms that control rapidly escalating prices for diabetic medications." More information The American Diabetes Association has more on diabetes. SOURCE.

Harvard Medical School, news release, July 29, 2021 Cara Murez Copyright © 2021 HealthDay. All rights reserved. SLIDESHOW Type 2 Diabetes. Signs, Symptoms, Treatments See SlideshowLatest Mental Health News FRIDAY, July 30, 2021 Opioid overdose-related visits to U.S.

Emergency departments rose by nearly one-third during the asthma treatment ventolin last year. That's the key finding in a new analysis of data from 25 emergency departments in Alabama, Colorado, Connecticut, North Carolina, Massachusetts and Rhode Island. "asthma treatment, and the disruptions in every part of our social and work lives, made this situation even harder by increasing the risk of opioid misuse and relapse because people were separated from their social support and normal routines," said senior study author Molly Jeffery, a researcher at the Mayo Clinic in Rochester, Minn. The study revealed that opioid overdose-related emergency department visits rose 28.5% last year, compared to 2018 and 2019.

The raw numbers in the study were 3,486 in 2020. 3,285 in 2019. And 3,020 in 2018. The researchers tied opioid overdoses to one in every 313 ER visits last year, compared with one in 400 in the previous two years.

While ER visits related to opioid overdoses rose 10.5% last year, overall ER visits dropped 14%, according to findings published in the Annals of Emergency Medicine, and presented recently at the AcademyHealth annual research meeting. Preliminary data recently released by the U.S. Centers for Disease Control and Prevention show more than 93,000 opioid overdose deaths in 2020 — up 29.4% from 2019 and the most ever recorded in a 12-month period in the United States. "While institutions across the U.S.

Are keenly aware that opioid misuse is a major health concern, this shows that there is more work to be done, and it provides an opportunity for institutions and policymakers to expand evidence-based treatments and resources," Jeffrey said in a clinic news release. More than 70% of drug overdose deaths in 2019 involved opioids, according to the CDC, but trends were leveling off before the asthma ventolin. However, data reveal a significant reversal in that trend since the start of the ventolin. Actual opioid overdose rates may be higher than the study suggests, because the number of people who overdose but don't go to the emergency department is likely on the rise, the researchers noted.

In response to the surge, Jeffrey said opioid addiction treatments such as buprenorphine and methadone, and the opioid overdose reversal drug naloxone need to be more accessible. She also noted that telehealth access for psychiatric care increased during the ventolin and has remained high. "We think this may be an important way to increase the accessibility of care for many people with opioid misuse disorder or addiction," Jeffery said. More information The U.S.

National Institute on Drug Abuse has more about the opioid crisis. SOURCE. Mayo Clinic, news release, July 28, 2021 Robert Preidt Copyright © 2021 HealthDay. All rights reserved.

QUESTION What are opioids used to treat?. See Answer.

Latest Alzheimer's can you buy ventolin over the counter nz News By Dennis Thompson HealthDay ReporterFRIDAY, July 30, 2021 (HealthDay News) asthma treatment can kill you. It can rob you of your breath, cause strange blood clots, and prompt side effects that last for months after you're over the initial . It's also possible that asthma treatment might impact the can you buy ventolin over the counter nz human brain in ways that could promote the onset of Alzheimer's disease, a new study reports.

Severely ill asthma treatment patients display biological evidence of brain injury and inflammation as well as early markers of Alzheimer's, according to data gathered by an international consortium reviewing the asthma' effects on brain health. This includes an uptick in tau, a sticky protein that forms tangles in the brains of later-stage Alzheimer's patients, said study author Dr. Thomas Wisniewski can you buy ventolin over the counter nz.

He is a professor of neurology, pathology and psychiatry at New York University Grossman School of Medicine. asthma treatment "accelerates Alzheimer's biomarkers, and if you have preexisting Alzheimer's or related dementias, you're much more likely to have neurological complications and more severe disease," Wisniewski said. "The fact that asthma treatment can you buy ventolin over the counter nz can increase Alzheimer's biomarkers suggests that long-term it could be a predisposing factor to accelerating the pathology." The findings were presented Thursday at the Alzheimer's Association's annual meeting, which is being held in Denver and online.

Such research is considered preliminary until published in a peer-reviewed journal. In this study, researchers evaluated 310 patients admitted to NYU Langone Health in New York City with asthma treatment. Of those, about half developed neurological symptoms, most can you buy ventolin over the counter nz commonly confusion due to toxic-metabolic encephalopathy (TME), a condition in which an disrupts brain function by causing chemical abnormalities.

asthma treatment patients who developed TME were more likely than those without to have elevated levels of biological markers in their blood related to brain injury and Alzheimer's, the investigators found. These markers also appeared to be linked with blood indicators of inflammation, suggesting that asthma treatment could cause the brain to swell and potentially damage neurons, the researchers added. Although more research is required, the evidence suggests that asthma treatment might do enough harm to the brain that it can you buy ventolin over the counter nz could predispose an otherwise healthy person to later develop dementia or Alzheimer's, Wisniewski said.

It also could be that people already at risk for Alzheimer's would be pushed further down that dark path after a case of asthma treatment, he added. "Particularly for anyone who's predisposed to any of these neurodegenerative conditions, anyone who's older, this looks like a very significant risk of getting asthma treatment that can push you over the brink," Wisniewski said. The finding results from a collaboration between the Alzheimer's Association and representatives can you buy ventolin over the counter nz from nearly 40 countries to evaluate the long-term consequences of asthma treatment on the brain and nervous system.

Heather Snyder, vice president of scientific and medical relations for the Alzheimer's Association, said, "One of the hallmark symptoms by which we define asthma treatment is a loss of taste or smell. That's an indicator that something is going on in the brain, because those are functions our brain controls." There's also concern about "brain fog" among asthma treatment sufferers and survivors, she added. "We are can you buy ventolin over the counter nz seeing that individuals are experiencing changes in their memory, their thinking, their reasoning, their behavior," Snyder said.

"What we don't know is, does that persist, is it able to be reversed, and what that means in terms of long-term impact or risk of Alzheimer's or other cognitive changes," Snyder continued. "Those are some of the questions we need to be asking." There's a simple fix for folks who want to protect their brain health against asthma treatment, Snyder added. "If you're not yet vaccinated, get can you buy ventolin over the counter nz vaccinated.

Protect yourself," she said. More information Johns Hopkins has more on asthma treatment's effects on the brain. SOURCES.

Thomas Wisniewski, MD, professor, neurology, pathology and psychiatry, New York University Grossman School of Medicine, New York City. Heather Snyder, PhD, vice president, scientific and medical relations, Alzheimer's Association Copyright © 2021 HealthDay. All rights reserved.Latest Senior Health News FRIDAY, July 30, 2021 (HealthDay News) The Biden administration has reversed a Trump policy that limited the size of fines that U.S.

Nursing homes could be slapped with for violating safety standards. The Trump policy was adopted in 2017 and prevented the U.S. Centers for Medicare and Medicaid Services (CMS) from hitting a nursing home with a fine for each day it didn't comply with federal standards.

That reduced many penalties to a single fine, lowering total amounts from hundreds of thousands of dollars to a maximum of $22,000, The New York Times reported. Many nursing homes cited for violations such as poor controls, not protecting residents from avoidable accidents, neglect, mistreatment and bedsores, are repeat offenders, according to Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy. Larger fines are a deterrent and are more likely to indicate strong enforcement of the rules, Edelman told the Times.

In early July, the Biden administration changed guidance on the CMS website, saying it had "determined that the agency should retain the discretion at this time to impose a per-day penalty where appropriate to address specific circumstances of prior noncompliance." The new policy means that regulators can impose either per-day or per-instance penalties, the Times reported. Deaths in nursing homes account for nearly a third of the overall asthma treatment death toll in the United States. While there's been a sharp drop in asthma treatment deaths in nursing homes since treatments became available, inadequate staffing, shortages of protective equipment and poor control are still problems, according to advocates and some officials, the Times reported.

Federal data show that while 81% of nursing home residents are vaccinated, only 58% of workers are immunized, which increases the risk of outbreaks even among fully vaccinated residents. Fines levied on a per-day basis "only take precious resources away from an already underfunded industry, especially during an unprecedented time when nursing homes need every support to protect their residents," the main industry trade group, the American Health Care Association and National Center for Assisted Living, said in a statement, the Times reported. More information Visit the Agency for Healthcare Research and Quality for more on nursing home safety.

SOURCE. The New York Times Robert Preidt Copyright © 2021 HealthDay. All rights reserved.

SLIDESHOW Exercise Tips for Seniors See SlideshowLatest Neurology News FRIDAY, July 30, 2021 (HealthDay News) Extremely premature babies have a much higher risk of cerebral palsy and other neurological conditions than full-term infants, a large Israeli study affirms. Cerebral palsy -- the name for a group of lifelong conditions that affect movement and coordination -- is the most common cause of severe childhood physical disability and motor impairment. It can also affect sensation, perception, thinking, communication and behavior.

"Extremely premature exposure to the environment outside of the uterus may alter musculoskeletal and nervous system development, and shift the trajectory of motor development for otherwise healthy children," study co-author Dr. Eyal Sheiner said in a news release from Ben-Gurion University of the Negev in Beer-Sheva, Israel. He is vice dean for academic promotion at the university and is also director of obstetrics and gynecology at Soroka University Medical Center in Beer-Sheva.

For this study, Sheiner and his colleagues examined the outcomes of more than 220,500 deliveries over 23 years. They found that babies born before 25 weeks' gestation had four times the risk of developing long-term neurological issues and significantly higher rates of cerebral palsy. Each additional week in the womb up to 37 weeks was linked to a decrease in the risk of long-term neurological problems, the researchers said.

The findings were recently published in the Journal of Clinical Medicine. "Neurological disorders that stem from premature births are devastating," said Doug Seserman, chief executive officer of Americans for Ben-Gurion University, which supported the research. More information The March of Dimes has more on cerebral palsy.

SOURCE. Ben-Gurion University of the Negev, news release, July 29, 2021 Robert Preidt Copyright © 2021 HealthDay. All rights reserved.

SLIDESHOW Brain Food Pictures. What to Eat to Boost Focus See SlideshowLatest Diabetes News FRIDAY, July 30, 2021 (HealthDay News) As many Americans know, today's health insurance plans often come with high deductibles. Those out-of-pocket costs could cause harm.

New research shows that 20% of people who have diabetes and high-deductible health plans regularly skip their medications. Not keeping up with your diabetes medications comes with the potential risk of an emergency room visit or a hospitalization. Compared to people without high-deductible health plans, people with high deductibles are also 28% more likely to not take their medicines on time due to cost, the new study found.

"Taking prescribed medications is essential for maintaining good health for patients with diabetes," stressed study author Dr. Vikas Gampa, a primary care doctor at Massachusetts General Hospital and instructor in medicine at Harvard Medical School. "Our results show that high-deductible health plans, particularly in this period of escalating prices for diabetes medication, are discouraging patients from getting the medications they need and thus they are placing patients with diabetes at risk." High-deductible health plans require patients to pay for all care until they reach the plan's deductible.

Insurance begins to cover medical costs after the patient pays the deductible, typically $1,300 for an individual or $2,600 for a family. These plans now comprise half of all commercial health insurance plans. The researchers examined U.S.

Federal survey data on more than 7,000 adult patients with diabetes who were enrolled in a commercial health insurance plan. They looked for how often patients reported not taking their prescription medication because they could not afford it, comparing both the traditional and the high-deductible patients. Roughly 25% of high-deductible plan enrollees who take insulin for diabetes could not afford their medication, compared to 19% of those with traditional plans, the study found.

That's a 31% higher rate. Researchers also found that diabetic patients who could not take their medications as prescribed were more likely to have one or more emergency department visits and potentially more hospitalizations per year than patients who did not skip medicines. "Putting up financial barriers to care in order to save plans money -- as high-deductible plans do -- not only takes a medical toll on patients, it is also short-sighted because doing so actually increases other health care costs such as covering emergency department visits," Gampa said in a Harvard news release.

The findings were published online July 29 in the Journal of General Internal Medicine. "Patients with diabetes should recognize that a high-deductible plan will put them at risk for missing or delaying their medications, and doctors need to recognize that their patients with these plans may not be able to adhere to treatment plans," said study senior author Dr. Danny McCormick, an associate professor of medicine at Harvard Medical School and a primary care physician at the Cambridge Health Alliance.

"Ultimately, policymakers need to enact reforms that discourage health plans from implementing financial barriers that block access to needed care, such as high-deductible plans," McCormick said in the release. "Our results suggest that policymakers must enact reforms that control rapidly escalating prices for diabetic medications." More information The American Diabetes Association has more on diabetes. SOURCE.

Harvard Medical School, news release, July 29, 2021 Cara Murez Copyright © 2021 HealthDay. All rights reserved. SLIDESHOW Type 2 Diabetes.

Signs, Symptoms, Treatments See SlideshowLatest Mental Health News FRIDAY, July 30, 2021 Opioid overdose-related visits to U.S. Emergency departments rose by nearly one-third during the asthma treatment ventolin last year. That's the key finding in a new analysis of data from 25 emergency departments in Alabama, Colorado, Connecticut, North Carolina, Massachusetts and Rhode Island.

"asthma treatment, and the disruptions in every part of our social and work lives, made this situation even harder by increasing the risk of opioid misuse and relapse because people were separated from their social support and normal routines," said senior study author Molly Jeffery, a researcher at the Mayo Clinic in Rochester, Minn. The study revealed that opioid overdose-related emergency department visits rose 28.5% last year, compared to 2018 and 2019. The raw numbers in the study were 3,486 in 2020.

3,285 in 2019. And 3,020 in 2018. The researchers tied opioid overdoses to one in every 313 ER visits last year, compared with one in 400 in the previous two years.

While ER visits related to opioid overdoses rose 10.5% last year, overall ER visits dropped 14%, according to findings published in the Annals of Emergency Medicine, and presented recently at the AcademyHealth annual research meeting. Preliminary data recently released by the U.S. Centers for Disease Control and Prevention show more than 93,000 opioid overdose deaths in 2020 — up 29.4% from 2019 and the most ever recorded in a 12-month period in the United States.

"While institutions across the U.S. Are keenly aware that opioid misuse is a major health concern, this shows that there is more work to be done, and it provides an opportunity for institutions and policymakers to expand evidence-based treatments and resources," Jeffrey said in a clinic news release. More than 70% of drug overdose deaths in 2019 involved opioids, according to the CDC, but trends were leveling off before the asthma ventolin.

However, data reveal a significant reversal in that trend since the start of the ventolin. Actual opioid overdose rates may be higher than the study suggests, because the number of people who overdose but don't go to the emergency department is likely on the rise, the researchers noted. In response to the surge, Jeffrey said opioid addiction treatments such as buprenorphine and methadone, and the opioid overdose reversal drug naloxone need to be more accessible.

She also noted that telehealth access for psychiatric care increased during the ventolin and has remained high. "We think this may be an important way to increase the accessibility of care for many people with opioid misuse disorder or addiction," Jeffery said. More information The U.S.

National Institute on Drug Abuse has more about the opioid crisis. SOURCE. Mayo Clinic, news release, July 28, 2021 Robert Preidt Copyright © 2021 HealthDay.

All rights reserved. QUESTION What are opioids used to treat?. See Answer.

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About This TrackerThis tracker provides the number of confirmed what does ventolin treat cases and deaths from novel asthma by country, the trend in confirmed case and death counts by country, and a global map showing which countries have confirmed cases and deaths. The data are drawn from the Johns Hopkins University (JHU) asthma Resource Center’s asthma treatment Map and the World Health Organization’s (WHO) asthma Disease (asthma treatment-2019) situation reports.This tracker will be what does ventolin treat updated regularly, as new data are released.Related Content. About asthma treatment asthmaIn late 2019, a new asthma emerged in central China to cause disease in humans. Cases of this disease, known as asthma treatment, what does ventolin treat have since been reported across around the globe. On January 30, 2020, the World Health Organization (WHO) declared the ventolin represents a public health emergency of international concern, and on January 31, 2020, the U.S.

Department of Health and Human Services declared it to be a health emergency for what does ventolin treat the United States.As India and other countries continue to grapple with major asthma treatment outbreaks even as cases decline in this country, there is increasing attention to the global role that could be played by the U.S. Government. This is particularly the what does ventolin treat case now that the U.S. Will soon have enough asthma treatment doses to fully vaccinate everyone in the country, and has also purchased additional doses of treatments not yet authorized in the U.S. A new issue what does ventolin treat brief identifies the actions already taken by the U.S.

Government, reviews the main policy options on the table, and discusses key considerations in evaluating what does ventolin treat those options.The main U.S. Policy options for expanding global access that have been proposed fall into four general areas. Scaling up donations of surplus asthma treatments, providing additional funding for global treatment efforts such as COVAX, helping to expand treatment manufacturing, and relaxing or waiving intellectual property restrictions on asthma treatment technologies.Some of the steps already taken by what does ventolin treat the U.S. Include providing $4 billion in funding for COVAX, announcing plans to donate U.S. Doses of the AstraZeneca treatment to India, and announcing it would prioritize what does ventolin treat production and export of materials and supplies for treatment manufacturing to India.

The brief examines these and other proposed policy actions. With growing attention what does ventolin treat to global disparities in treatment access, calls for U.S. Action across these areas are likely to increase over time..

About This TrackerThis tracker provides the number of confirmed cases and deaths from novel asthma by country, the trend in confirmed case and death counts by country, and can you buy ventolin over the counter nz a global map showing which countries have confirmed cases and deaths. The data are drawn from the can you buy ventolin over the counter nz Johns Hopkins University (JHU) asthma Resource Center’s asthma treatment Map and the World Health Organization’s (WHO) asthma Disease (asthma treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About asthma treatment asthmaIn late 2019, a new asthma emerged in central China to cause disease in humans. Cases of this disease, known can you buy ventolin over the counter nz as asthma treatment, have since been reported across around the globe. On January 30, 2020, the World Health Organization (WHO) declared the ventolin represents a public health emergency of international concern, and on January 31, 2020, the U.S.

Department of Health and Human Services declared it to be a health emergency for the United States.As India and other countries continue to grapple with major asthma treatment outbreaks even as cases decline in this country, there is increasing attention to the global role that could be played by the U.S can you buy ventolin over the counter nz. Government. This is particularly can you buy ventolin over the counter nz the case now that the U.S. Will soon have enough asthma treatment doses to fully vaccinate everyone in the country, and has also purchased additional doses of treatments not yet authorized in the U.S. A new issue brief identifies the actions already can you buy ventolin over the counter nz taken by the U.S.

Government, reviews the main policy options can you buy ventolin over the counter nz on the table, and discusses key considerations in evaluating those options.The main U.S. Policy options for expanding global access that have been proposed fall into four general areas. Scaling up donations of surplus asthma treatments, providing additional can you buy ventolin over the counter nz funding for global treatment efforts such as COVAX, helping to expand treatment manufacturing, and relaxing or waiving intellectual property restrictions on asthma treatment technologies.Some of the steps already taken by the U.S. Include providing $4 billion in funding for COVAX, announcing plans to donate U.S. Doses of the AstraZeneca treatment to India, and announcing it would prioritize production and export of materials and supplies for treatment manufacturing to India.

The brief examines these and other proposed policy actions. With growing attention to global disparities in treatment access, calls for U.S. Action across these areas are likely to increase over time..

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Dear Reader, Thank my ventolin is not working you ventolin cost for following the Me&MyDoctor blog. I'm writing to let you know we are moving the public health stories authored by Texas physicians, residents, and medical students, and patients to the Texas Medical Association's social media channels. Be sure to follow us on all our social media accounts (Facebook, Twitter, Instagram) as well as Texas Medicine Today to access these stories http://yohoho.co.uk/hudson-hawk-phil-stokes-yorkshire-tv-interview/ and more. We look forward to seeing you there.Best, Olivia Suarez Me&My Doctor Editor.

Dear Reader, Thank you for following the Me&MyDoctor can you buy ventolin over the counter nz blog. I'm writing to let you know we are moving the public health stories authored by Texas physicians, residents, and medical students, and patients to the Texas Medical Association's social media channels. Be sure to follow us on all our social media accounts (Facebook, Twitter, Instagram) as well as Texas Medicine Today to access these stories and more. We look forward to seeing you there.Best, Olivia Suarez Me&My Doctor Editor.