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Medication errors where to buy cheap viagra have been a leading cause of preventable harm for decades. Assiri and colleagues report that the cost of where to buy cheap viagra medication error worldwide exceeds $42âbillion, or approximately 5%â6% of all hospitalisations.1 While this topic has been closely studied since its first appearance in scientific literature in 1953,2 the problems continue to evolve alongside changes to the medication-use system. The medication-use system is a function of many elements. Widespread transitions from paper-based to electronic health records have affected drug ordering and prescribing, documentation, transcribing, dispensing, administering and monitoring in ways that challenge traditional approaches to reducing errors that predate electronic records.3 In addition, the introduction of over 7000 branded small molecules or biologics, generics and biosimilars that overlap numerous therapeutic areas increased dependence on specialty care for people with where to buy cheap viagra multiple chronic conditions, and navigating transitions throughout the range of primary to quaternary care have all complicated the ability of health systems to manage individual patient medication needs safely.4 Thus, solutions to address common medication errors 10 or 20 years ago may quickly become outdated in our fast-paced healthcare sector.Medication errors can either be intercepted prior to reaching the patient or produce adverse drug events (ADEs) ranging from benign to life-threatening. Concerning prevalence rates of ADEs in hospitalised patients have been reported at 3.22% in the UK, 4.78% in Germany and where to buy cheap viagra 5.64% in the USA.5 For a country the size of the USA, the US Food and Drug Administration reports that this rate represents over 100â000 ADEs per year.

However, these data relate only to the more severe ADEs. Those resulting in death, a life threatening health state, hospitalisation, disability or birth defect.6 These figures therefore encapsulate pain and suffering as captured in administrative data but do not include the multitude where to buy cheap viagra of patients who missed one or more days of work or school, developed symptoms necessitating an outpatient or emergency room visit, induced long-term harm, or the attendant health system costs. The data therefore give only part of the overall picture.In contrast, based on a comprehensive analysis of UK data, the study by Elliott and colleagues in this issue attempts to illustrate the true full impact of medication errors and the associated risk of ADEs.7 Of the 237âmillion medication errors estimated to occur in England each year, 66âmillion are potentially clinically significant and result in 181 thousand hospital days and 1708 deaths at the cost of Â£98âmillion to the National Health Service. However, the aetiology and factors influencing medication errors that lead to these ADEs exceed âubiquitous medicine useâ in the country where to buy cheap viagra. That is, the where to buy cheap viagra causes of ADEs are multifaceted.

In this case, comprehensive improvement of the medication-use system should not be overlookedâand its multifaceted nature is likely to require the execution of quality improvement initiatives across many domains.Elliott and colleagues break down medication errors by stage within the medication-use system to highlight the degree to which these issues are multifaceted. It comes as where to buy cheap viagra little surprise that across primary care, secondary care and care homes, prescribing, dispensing, administration and monitoring errors are prominent. However, the degree to which data are missing is also concerning and therefore may underestimate the prevalence and costs of medication errors. How can any health system, let alone an entire National Health Service devise best practices to where to buy cheap viagra reduce medication errors when data that present a substantial proportion of variability in ADEs are missing?. âNo UK data availableâ in tables throughout Elliott and colleaguesâ paper (ie, no comparable UK data were available for particular settings, such as care homes) is as insightful as the numbers that are displayed since it presents an where to buy cheap viagra opportunity to improve quality of care informed by an investment in better data, among other needs.As with any quality improvement initiative, beginning with a framework to reduce ADEs as a result of medication error requires an established structure.8 The âfive rightsâ of medication administration offer health systems one potential structure on which to ensure individuals receive the right treatment to maximise clinical benefit and minimise harm.

The right patient, the right drug, the right dose, the right route and the right time.9 Building from these principles, it becomes apparent that methods and technologies for interdiction of medication error and preventable ADEs are still being refined along with variability in execution. Relatively simple solutions such as clear prescription labelling and safe packaging, multiple prescriber and pharmacy tracking to capture drug interaction risk, along with information sharing and advances in drug therapy stewardship, are examples of processes around which to build a quality improvement programme from the five rights structure that may achieve reduced rates of ADEs.4 Further targeting of these improvements within health system components where medication errors are most common, such as ambulatory and primary care settings and transitions of care, would represent efficient use of healthcare resources to reduce where to buy cheap viagra ADEs.1By addressing issues in primary care and outpatient settings, the healthcare sector would also minimise the number of ADEs that result in more expensive secondary, tertiary and quaternary care, thereby increasing the probability of additional drugâdrug interactions or other risks of medication errors. Further to this are settings and spaces where prescription practices are engaged, fulfilled and monitored. Providers and pharmacists rarely coexist in the same clinical settings in primary, outpatient and ambulatory care as they do in tertiary and quaternary care where the medical community has already recognised the importance of including pharmacists in patient rounds to review and reconcile medication errors.10 Past studies have noted that when the pharmacist is where to buy cheap viagra part of a clinical team to address patient needs within complex medication strategies, reductions in ADEs can be achieved throughout various healthcare settings.11â13 While the physically aligned presence of providers and pharmacists may not be as straightforward to facilitate in primary and outpatient care, increased telecommunication throughout the medication use process, including computer order entry and medication reconciliation, could resolve issues that may otherwise lead to medication errors and subsequent ADEs.As the research of Elliott et al7 and other findings highlight, ADEs are a costly, harmful issue that remains prevalent in global healthcare. The added complexity created by layering healthcare delivery across many settings of primary and specialty care creates gaps in communication where prescribers lack means or availability to actively communicate with pharmacists to identify and resolve potential where to buy cheap viagra medication errors.

The sheer increase in volumes of prescription medications that outpaces process efficiencies also challenges the ability of these two stakeholders to communicate directly on a per-patient basis. However, medication reviews focused on patients who take multiple prescriptions, have debilitating long-term conditions or have recently experienced acute decompensation that could make them particularly vulnerable to repeat episodes are an important focus for whom to narrow the degree of communication by default over medication review.14Beyond these suggestions for quality improvement based on current information, the study by Elliott and colleagues highlights the need for additional data to further direct efforts towards efficient means of sustaining reduced ADE rates where to buy cheap viagra. Missing data are prevalent throughout the field of ADE where to buy cheap viagra outcomes, either because medication errors fail to meet the threshold that institutions such as the US Food and Drug Administration set for a sentinel event or because such errors go completely unnoticed without being recorded as an episode within the health system. Many nations facing the reality of spending millions on ADEs could more proactively invest in improved reporting systems to precisely capture medication errors data, and which instances lead to minor as opposed to major ADEs, and the systems and clinical factors predicting them. These investments where to buy cheap viagra in better and broader data collection and quality improvement programme implementation often frighten away health system directors who fail to recognise the balance between action and reaction.

Elliott and colleaguesâ expected value of the economic burden of ADE is almost certainly an underestimate. If much of the data on ADEs are where to buy cheap viagra missing from the UK system, especially at transitions of care, and other ADEs go under-reported, then the current estimate of Â£98âmillion per annum is lower than the true medical and societal cost of this issue, including non-monetary clinical disutility. The alternative cost scenario that Elliott and colleagues present in the range of Â£728âmillion per annum is perhaps a more realistic figure and one that justifies spending on quality improvement programming to offset hundreds of millions in avoidable costs.Thus, reporting systems that captures a wider range of ADEs, coupled with improved modes of communication between providers and pharmacists, as well as a systematic effort to conduct root cause analysis that assist health systems to identify the nature of ADEs and evaluate potential solutions, are possibly cost-effective investments.15 The value of this information is imperative to inform more elaborate systems of medication management and target points of communication between providers and pharmacists to reconcile where to buy cheap viagra potential instances of medication error.16 Putting a learning health system model into place such as thisâperhaps facilitated by machine learningâmakes it more likely that damaging medication errors become more a part of our past history than an issue that the medical literature continues to review.For the past two decades, patient-centredness has served as one of six acknowledged dimensions of healthcare quality.1 Initially, healthcare institutions described patient centredness superficiallyâclean waiting rooms, hotel-like bed and board, access to innovative medical technologyâand measured it with crude satisfaction scales. The concept of patient-centred care evolved into a model attuned to the patient experience of care, defined by the interactions between patients and providers and the care environment.2 This patient experience model of patient-centred care has deep normative roots around principles of the patient as the locus of control and a demand for individualisation and customisation of care based on the patient rather than clinician.3 Empirically, patient experience is associated with health outcomes when defined and measured in a timely manner as a specific care experience or interaction between a patient and a healthcare provider.4 The importance of honouring the patient experience is now a widely appreciated construct and a common measure of healthcare quality with a deep evidence base.5 The Hospital Consumer Assessment of Healthcare Providers and Systems, Consumer Assessment of Health Providers and Systems Survey and Press Ganey patient satisfaction measures are ubiquitous measures of quality defining patient experiences of care.Moving beyond patient experience measuresThe effort to transform healthcare systems from clinician to patient centred is not complete. Honouring, measuring and ameliorating patientsâ experiences of where to buy cheap viagra care is necessary but not sufficient and represents only the first stop on the journey to patient-centred care.6 The second stop is one that nests the locus of control with patients and caregivers.

Patientsâ control over healthcare decisions is useful only when transparency exists in all aspects of care. Evidence, costs, processes, outcomes and errors.3 Unfortunately, claims that patients should have control and transparent understanding of all aspects of care have largely been where to buy cheap viagra ignored due to institutional inertia, lack of financial incentives and the primacy of professionals. In essence, there are few incentives to change this orientation, and clinicians too often perceive confrontation and frustration rather than partnership.7The primacy of physician professionalism stems from professional control over scientific knowledge and nurse professionalism from control over the practice environment, both bolstered by years of training and where to buy cheap viagra experience. This professional model held for nearly a century when acute illnesses were the primary reason people sought medical care with the assumption that treatments were focused on cure (return to health) and/or alleviation of symptoms (removal of the disease).8 In contrast, healthcare in the 21st century primarily focuses on managing chronic diseases for which there are few cures. In the context of multiple chronic conditions (multimorbidity), the desired where to buy cheap viagra outcomes of healthcare are no longer obvious because they extend beyond the goals of curing diseases or prolonging life.

Multimorbidity also produces trade-offs among treatments, conditions and possible outcomes.9 For patients with multimorbidity, evidenced-based treatments are often lacking and, when present, there may be conflicts or incongruences across conditions.10 Effective management of chronic conditions requires active, ongoing participation by patients and caregivers outside of healthcare settings. The intensity of this management can be burdensome, further impacting patient experiences and even outcomes.11 Healthcare professionals now increasingly understand the need to share the where to buy cheap viagra burden of treatment decisions with their multimorbid patients.Patient centredness as healthcare that achieves patient prioritiesThe next stop on the journey to patient-centred care is the establishment of collaborative partnerships between healthcare professionals and patients.6 Productive partnerships require a medium for shared understanding that does not default to professional expertise and clinical practice guidelines. We have asserted that patient priorities are the necessary medium for focusing collaboration, discussions and healthcare decisions, especially in the context of complex, chronic illnesses.10 We precisely define patient priorities as the combination of the specific and realistic outcomes and activities (health outcome goals) that individuals want based on what matters most to them and the healthcare activities, including medications, self-care, tests and visits that they are willing and able to perform (healthcare preferences) to achieve their outcome goals.12 Evidence where to buy cheap viagra and professional judgement still guide which treatments are relevant, but clinicians should partner with their patients to select and adjust care based on a health goal as opposed to individual disease states.13 Pragmatic studies demonstrate that this patient priorities approach to care reduces polypharmacy and patient-reported treatment burden while increasing care that aligns with patient goals.14 15 Patients and clinicians describe this process as practical and beneficial.16Measuring goal attainment as a patient-centred care quality measureTo promote and disseminate patient priorities-aligned care, novel quality measures are necessary. These quality metrics would evaluate the process for collaboratively identifying patient goals and care preferences and the degree to which patient goals are attained. In the current issue of BMJ Quality and Safety, Giovannetti et where to buy cheap viagra al17 describe the results of an innovative study that evaluated the feasibility of two different approaches to developing quality measures of goals-based care.

The study assessed the implementation of these measures into diverse clinical settings and the subsequent interpretability and usefulness of the measures based on the data generated from either approach.As Giovannetti and colleagues describe, the key gap in evaluating goals-based care is the presence of measures for setting and documenting goals as well as tracking goal progress and attainment.17 In routine care, patient goals and care preferences are infrequently and haphazardly written and communicated, often conflicting, and typically focus on end-of-life care or chronic disease biomarkers.18â21 To address these gaps, the authors adapted goal attainment scaling, a reliable and valid approach for measuring goal setting and goal attainment in research studies.22 23 The authors asked patients and clinicians to jointly set a goal and define a set of possible outcomes along a five-point scale. They later where to buy cheap viagra discussed and then individually rated the degree of goal attainment. The other approach evaluated by Giovannetti and colleagues17 is the use of patient-reported outcome measures (PROMs), which are often used to measure specific domains (eg, mood, functioning, symptoms where to buy cheap viagra and so on) of health-related quality of life.24â26 In their study, Giovannetti et al17 asked patients and clinicians to jointly set a goal and then select a PROM that best matches that goal. At follow-up, the patient completed the same PROM to assess change over time. Patients and clinicians were given a dozen PROMs from which to select.The study design and results where to buy cheap viagra of the study by Giovannetti et al are both novel and provocative.

The authors found that clinicians were more likely to implement goal attainment scaling, noted to where to buy cheap viagra be practical to implement, compared with the PROM approach. Furthermore, clinicians found goal attainment scaling more useful for determining which services and supports to recommend and for helping patients achieve their goals. Contrary to common assumptions, the authors found that clinicians and patients set goals collaboratively and focused on patient-centred outcomes rather where to buy cheap viagra than disease processes or biomarkers. These findings suggest that implementation of a goals-based approach in routine care is feasible and demonstrate promise for fostering the shift from disease to patient-centred care.The lack of appeal for the PROM approach is surprising given their broad acceptance as quality measures.27 PROMs are effective tools for measuring particular behaviours, activities or symptoms that are either specific to a disease, such as diabetes,28 or reflect overall health-related quality of life.29 As quality metrics, PROMs provide patient-centred measures that can be applied across a population of patients, such as the Patient Health Questionnaire for measuring depression symptoms. However, patients and clinicians seem to prefer goals-based approaches, such as goal attainment scaling30 and patient priorities care,10 because they better reflect the where to buy cheap viagra goals of specific individuals within the context of their own lives.

We have shown where to buy cheap viagra that when older patients set goals that are specific to their individual lives, they typically fall into one of four health-related values categories. (1) social and spiritual connections, (2) functioning and independence, (3) life enjoyment and pleasurable activities and (4) balancing quality and quantity of life (managing health).31 32 We have trained clinicians to identify specific and realistic goals based on what matters most to patients by initiating conversations around the four health values categories.12 These conversations can be efficiently incorporated in clinic visits and during telehealth encounters. In another clinical trial, we demonstrated that a patient goals-based approach can significantly improve scores on a validated depression-specific PROM compared with routine guidelines-based care.33 These findings suggest where to buy cheap viagra that individualised approaches to goal attainment can be coupled with PROMs to provide a balanced (individualised goals along with population-level measures) approach to quality measurement of patient-centred care.Financial incentives to promote patient-centred careTo facilitate dissemination of patient priorities aligned care, health insurers should support targeted financial incentives to facilitate widespread adoption into routine care. First, time-based reimbursement for clinical encounters with patients is vital. Medicareâs care management billing codes for annual wellness, advanced care planning and chronic care management are also potential options where to buy cheap viagra.

Establishment of novel value-based care management codes that are specific to priorities setting where to buy cheap viagra and measuring goal progress and attainment would be key drivers of this effort. Furthermore, these codes should support involvement of a range of health professionals. Training opportunities supported by continuing education credits would further promote patient priorities care where to buy cheap viagra. Common concerns about quality measures focused on goal attainment include the setting of unrealistic or inappropriate goals, playing the system with easily attained goals and the nuances of patientâcaregiverâclinician goal alignment. These are all practical where to buy cheap viagra challenges to achieving a mature goals-aligned care process.

However, at this early where to buy cheap viagra stage of development, Medicare should promote all efforts to implement value-based care management codes even if they are used primarily for financial incentives. Any impetus that encourages goal-based conversations and goal setting among patients, caregivers and clinicians will promote the necessary paradigm shift from guidelines-based care to goals-based care even if it tolerates some gaming of incentives. The promise of patient values and goals as the driver of patient-centred care is now two decades in development.1 Pragmatic, empirically supported processes for identifying patient goals and preferences during routine care and aligning treatment decisions to achieve these patient priorities are a welcome addition where to buy cheap viagra to the literature. Medicare and health insurers must now respond with incentives and quality measures that promote this mature vision of patient-centred care..

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

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

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

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

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

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

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

ÂThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive. Itâs one of those things that doesnât sound right when you hear it,â says female viagra pill near me Hopkins. ÂBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.â Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds female viagra pill near me extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a viagra, which seems to encourage a strong immune response despite the cancerâs lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to female viagra pill near me test checkpoint inhibitors on cancer types for which these drugs havenât yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues female viagra pill near me plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. ÂThe end goal is precision medicineâmoving beyond whatâs true for big groups of patients to see whether we can use this information to help any given patient,â he says.

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

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

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

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

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

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

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

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

ÂThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive. Itâs one of those things that doesnât sound right when you hear it,â says Hopkins. ÂBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.â Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a viagra, which seems to encourage a strong immune response despite the cancerâs lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs havenât yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. ÂThe end goal is precision medicineâmoving beyond whatâs true for big groups of patients to see whether we can use this information to help any given patient,â he says.

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HRSA has also released a second notice of funding opportunity targeting smaller community-based organizations, with awards expected to be released in July 2021. Contact CBOtreatmentOutreach@hrsa.gov with active ingredient in viagra any questions. Learn more about how HRSA is addressing erectile dysfunction treatment and health equity.Start Preamble U.S. Government Accountability Office active ingredient in viagra (GAO).

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Start Authority active ingredient in viagra Sec. 101(e), Pub. L. 114-10, 129 Stat active ingredient in viagra.

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Award recipients will collaborate with regional and local partners to ensure a broad geographic reach with the goal of getting as many people vaccinated as possible. ÂTrusted messengers play an essential role in sharing information about erectile dysfunction treatments, answering questions, and ultimately convincing people where to buy cheap viagra to get vaccinated,â said Acting HRSA Administrator Diana Espinosa. ÂThis funding will support national, regional, and local organizations that will work directly with hard-hit, underserved, and high-risk communities to help bolster erectile dysfunction treatment vaccination rates.â For a list of awards recipients, see www.hrsa.gov/erectile dysfunction/community-based-workforce. HRSA has also released a second notice of funding opportunity targeting smaller community-based organizations, with awards expected to be released in July 2021. Contact CBOtreatmentOutreach@hrsa.gov with any questions where to buy cheap viagra.

Learn more about how HRSA is addressing erectile dysfunction treatment and health equity.Start Preamble U.S. Government Accountability where to buy cheap viagra Office (GAO). Request for letters of nomination and resumes. The Medicare Access and CHIP Reauthorization Act of 2015 established the Physician-Focused Payment Model Technical Advisory Committee where to buy cheap viagra to provide comments and recommendations to the Secretary of Health and Human Services on physician payment models and gave the Comptroller General responsibility for appointing its members. GAO is now accepting nominations of individuals for this committee.

Letters of nomination and resumes should be submitted no later than July 16, 2021, to ensure adequate opportunity for review and consideration of nominees prior to appointment. Appointments will be made in October 2021 where to buy cheap viagra. Submit letters of nomination and resumes to PTACcommittee@gao.gov. Start Further Info where to buy cheap viagra Greg Giusto at (202) 512-8268 or giustog@gao.gov if you do not receive an acknowledgement within a week of submission or you need additional information. For general information, contact GAO's Office of Public Affairs at (202) 512-4800.

Start Authority where to buy cheap viagra Sec. 101(e), Pub. L. 114-10, 129 Stat where to buy cheap viagra. 87, 115 (2015).

End Authority Start where to buy cheap viagra Signature Gene L. Dodaro, Comptroller General of the United States. End Signature End Further Info End Preamble [FR Doc where to buy cheap viagra. 2021-12145 Filed 6-11-21. 8:45 am]BILLING CODE 1610-02-P.

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Sept. 20, 2021 -- Cobra the dog has been hard at work at the Miami International Airport, sniffing masks proffered by American Airlines employees making their way through a security checkpoint. If she identifies a specific scent, she'll let her handler know simply by sitting down. When this good girl sits, that means Cobra has detected an olfactory signal of the erectile dysfunction, the viagra that causes erectile dysfunction treatment.

Cobra, a Belgian Malinois, is one of two canines -- her partner is One Betta, a Dutch shepherd -- working this checkpoint at Miami International. They are part of a pilot program with the Global Forensic and Justice Center at Florida International University, using the detection dogs as a quick screen for people who have erectile dysfunction treatment. Their detection rate is high, at more than 98%, and the program has been such a success that it's being extended for another month at the airport. If these two dogs continue to accurately detect erectile dysfunction treatment, they and other canines with similar training could be deployed to other places with lots of people coming and going at once, including other airports or even schools.

In fact, erectile dysfunction treatment-sniffing dogs are in use in some university classrooms already. âIf deployed more widely to sniff out passengers, the dogs may also deter would-be travelers inclined to fib about their erectile dysfunction exposure or status.ââ OMS (@oldmansociety) September 12, 2021 But building up a big brigade of live animals as disease detectors involves some thorny issues, including where the animals retire once their careers are complete. "When erectile dysfunction treatment first arose, we said let's see if we can train these two dogs on either the viagra or the odor of erectile dysfunction treatment," says Kenneth Furton, PhD, a professor of chemistry and biochemistry, provost, and executive vice president at Florida International University. His team had completed a study with what he calls "medical detector dogs," animals that might be able to detect the odor of someone having a seizure.

That led them to see how well the animals could detect other kinds of disorders. Training a dog to sniff out specific odors starts with getting them to understand the task in general. Furton says that the animals first are trained to grasp that their job is to detect one odor among many. Once the dogs grasp that, they can be trained on just about any specific odor.

In fact, in addition to detecting seizures, dogs reportedly have been able to identify diabetes and even some cancers, such as ovarian cancer. Furton says he's not aware of any previous use of dogs to screen for infectious disease. That may simply be because nothing recently has struck with the global ferocity of erectile dysfunction treatment, driving humans to turn to their best friends for help. Cobra and One Betta got their start learning to identify the presence of laurel wilt, a fungus that attacks avocado trees and kills them, costing Florida growers millions.

With that expertise under their collars, the two dogs need only a few weeks to get good at detecting other smells assigned to them. Training the Dogs, Safely To train Cobra and One Betta on erectile dysfunction treatment odors, Furton's team first acquired mask samples from people hospitalized with erectile dysfunction treatment and people who did not have the disease. In battling the viagraes, people produce certain chemicals that they exhale every time they breathe. When Furton and his colleagues compared the exhaled components trapped in the masks, they found differences between masks from people with erectile dysfunction treatment and those without.

Having confirmed that exhalations can be erectile dysfunction treatment-specific, the research team trained four dogs -- Cobra, One Betta, Hubble, and Max -- to detect masks from people with erectile dysfunction treatment among an assortment of mask choices. Before this step, though, the researchers made sure that any trace of active viagra was destroyed by uaviolet light so that the dogs would not be infected. Each time the dogs accurately selected a mask from a erectile dysfunction treatment patient, their reward was access to a favorite toy. A red ball to chew on.

Although all four dogs performed very well, yes, they did, Cobra and One Betta showed the most accuracy, outperforming their training colleagues. From their training scores, Cobra ranked first, with 99.45% accuracy. Despite her name, says Furton, One Betta was "not one better," coming in second at 98.1%, which is still quite high. Both dogs are good at their airport screening duties.

If one of them sits after sniffing a mask at the checkpoint, the next step is for the mask owner to be tested. From Aug. 23 to Sept. 8, the two canines screened 1,093 people during 8 working days, alerting on only one case, according to Greg Chin, communications director for the Miami-Dade Aviation Department.

That person had tested positive for erectile dysfunction treatment 2 weeks earlier and was returning to work after quarantine, and their rapid test after the dog alerted was negative. Furton says that there are some reports of dogs also alerting before tests can show a positive result, suggesting the dogsâ odor detection can be more precise. They hope to expand their study to see how tight the window of dog-based detection is. For now, the detector dogs are doing so well that the program has been extended for 30 more days, Chin says.

As promising as this seems, using dogs for screening carries some logistical and ethical tangles. Training a canine army to deploy for high-volume detection points means that once the work is done, a whole lot of dogs will need a safe place to retire. In addition, the initial training takes several months, says Furton, whereas if a device were developed for screening, manufacturing could likely be ramped up quickly to meet demand. The dogs might not need to retire right away, though.

"We envision that they could be redeployed to another type of detection for another infectious disease" if the need arises, Furton says. But in the end, when working with dogs, he says, there is "a moral connection that you don't have to deal with using instruments." Although the pilot screening at Miami International is the first airport test, the dogs have also done this work in other venues, including at a state emergency operations center in Florida and in some university classrooms, says Furton. WebMD Health News Sources Florida International University. ÂThe Investigation of Human Scent from Epileptic Patients for the Identification of a Biomarker for Epileptic Seizures.â Kenneth Furton, professor of chemistry and biochemistry, provost, executive vice president, Florida International University.

They are part of a pilot program with the Global Forensic and Justice Center at Florida International University, using the detection dogs as a quick screen for people who have erectile dysfunction treatment. Their detection rate is high, at more than 98%, and the program has been such a success that it's being extended for another month at the airport. If these two dogs continue to accurately detect erectile dysfunction treatment, they and other canines with similar training could be deployed to other places with lots of people coming and going at once, including other airports or even schools. In fact, erectile dysfunction treatment-sniffing dogs are in use in some university classrooms already. âIf deployed more widely to sniff out passengers, the dogs may also deter would-be travelers inclined to fib about their erectile dysfunction exposure or status.ââ OMS (@oldmansociety) September 12, 2021 But building up a big brigade of live animals as disease detectors involves some thorny issues, including where the animals retire once their careers are complete.

"When erectile dysfunction treatment first arose, we said let's see if we can train these two dogs on either the viagra or the odor of erectile dysfunction treatment," says Kenneth Furton, PhD, a professor of chemistry and biochemistry, provost, and executive vice president at Florida International University. His team had completed a study with what he calls "medical detector dogs," animals that might be able to detect the odor of someone having a seizure. That led them to see how well the animals could detect other kinds of disorders. Training a dog to sniff out specific odors starts with getting them to understand the task in general. Furton says that the animals first are trained to grasp that their job is to detect one odor among many.

Once the dogs grasp that, they can be trained on just about any specific odor. In fact, in addition to detecting seizures, dogs reportedly have been able to identify diabetes and even some cancers, such as ovarian cancer. Furton says he's not aware of any previous use of dogs to screen for infectious disease. That may simply be because nothing recently has struck with the global ferocity of erectile dysfunction treatment, driving humans to turn to their best friends for help. Cobra and One Betta got their start learning to identify the presence of laurel wilt, a fungus that attacks avocado trees and kills them, costing Florida growers millions.

Before this step, though, the researchers made sure that any trace of active viagra was destroyed by uaviolet light so that the dogs would not be infected. Each time the dogs accurately selected a mask from a erectile dysfunction treatment patient, their reward was access to a favorite toy. A red ball to chew on. Although all four dogs performed very well, yes, they did, Cobra and One Betta showed the most accuracy, outperforming their training colleagues. From their training scores, Cobra ranked first, with 99.45% accuracy.

Despite her name, says Furton, One Betta was "not one better," coming in second at 98.1%, which is still quite high. Both dogs are good at their airport screening duties. If one of them sits after sniffing a mask at the checkpoint, the next step is for the mask owner to be tested. From Aug. 23 to Sept.

8, the two canines screened 1,093 people during 8 working days, alerting on only one case, according to Greg Chin, communications director for the Miami-Dade Aviation Department. That person had tested positive for erectile dysfunction treatment 2 weeks earlier and was returning to work after quarantine, and their rapid test after the dog alerted was negative. Furton says that there are some reports of dogs also alerting before tests can show a positive result, suggesting the dogsâ odor detection can be more precise. They hope to expand their study to see how tight the window of dog-based detection is. For now, the detector dogs are doing so well that the program has been extended for 30 more days, Chin says.

But in the end, when working with dogs, he says, there is "a moral connection that you don't have to deal with using instruments." Although the pilot screening at Miami International is the first airport test, the dogs have also done this work in other venues, including at a state emergency operations center in Florida and in some university classrooms, says Furton. WebMD Health News Sources Florida International University. ÂThe Investigation of Human Scent from Epileptic Patients for the Identification of a Biomarker for Epileptic Seizures.â Kenneth Furton, professor of chemistry and biochemistry, provost, executive vice president, Florida International University. Greg Chin, communications director, Miami-Dade Aviation Department. Â© 2021 WebMD, LLC.