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This article buy levitra online uk contains https://blog.printpapa.com/buy-levitra-canada affiliate links to products. Discover may receive a commission for purchases made through these links.Over the last few years, CBD products have continued to skyrocket in popularity. Not only are consumers more aware of the many benefits that CBD can offer, there’s buy levitra online uk a growing push for all natural products that can replace over-the-counter and even prescription medications. If you want to give CBD a try, you may be wondering where you should start looking and how to find a quality product.If you’ve ever done a quick online search for CBD, you probably noticed that there are literally pages and pages of products to choose from. With hundreds of brands that sell dozens of products, choosing doesn’t come easy!.

While having a variety of options to choose from does have its perks, it buy levitra online uk also creates a dilemma. How do consumers figure out which products are worthwhile and which ones aren't?. This is easier said than done, especially buy levitra online uk since the Internet is home to all sorts of misinformation and fake reviews.To save you some time (and probably wasted money!. ), we’ve spent months learning the ins and outs of countless CBD brands. Our goal?.

To highlight the top 5 CBD oils that are all well-rounded and worth their cost.Before we get into the important details of each CBD brand, here is the criteria we used to rank each of the CBD oils on our list.Ranking CriteriaThere buy levitra online uk are many factors to consider when ranking the CBD oils on our list. If a product didn’t meet this criteria, it didn’t make it onto our list. These are factors that all consumers should consider before buying any kind of CBD buy levitra online uk product to minimize the risk of buying a low quality product.The top factors we considered include:TasteCBD oil must be taken sublingually. Ideally you want to choose a product that tastes good and is enjoyable to take. This makes it much easier to have a great experience from the second the first drop hits your mouth.IngredientsHigh quality ingredients create a high quality product.

It's important to know where all of the ingredients originate from, as well buy levitra online uk as how they are grown. Quality-control measures, how the ingredients are sourced, and their purities and potencies are all important.ValueNo one wants to waste money on a product that isn't worthwhile. Value comes buy levitra online uk down to the cost-effectiveness of the product, such as the amount of CBD per serving, compared to the cost per bottle.Transparency &. ReputationThe more information a company provides about its products, the better. Reputable companies offer in-depth information about farming and manufacturing processes as well as certificates of analysis from a trusted third-party testing lab.Our Top 5 CBD Oils1.

Verma Farms buy levitra online uk Performance OilsVerma Farms is our top ranked CBD oil for flavor, value, and ingredient quality. This is the most potent oil we have ever tested, so make sure to start small then work your way up to a full dropper. The brand takes creating top notch products seriously, but with buy levitra online uk a unique twist. All products are inspired by the beautiful islands of Hawaii. And while they're best known for their delicious, flavored gummies, their CBD oils are also nothing short of amazing.All CBD oils from Verma Farms are made with organic hemp that is grown throughout the United States, without the use of pesticides or GMOs.

CBD per dose ranges from 16.67 mg to 33.3 mg per serving, which is a great value for the cost.So whether you’re in the mood for fruity strawberry CBD oil or want something more buy levitra online uk refreshing and uplifting like mint, Verma Farms is sure to have a product that goes beyond your wildest expectations.Type of CBD. Broad-spectrumFlavors. Mint, Lemon Lime, Pineapple, Strawberry, Watermelon, Mango, Peach and NaturalIngredients● Broad Spectrum CBD● Hemp Oil● MCT Oil● Natural Flavor● TerpenesCBD Per Dose. 16.67 mg buy levitra online uk to 33.3 mg Lab Results. Botanacor - Available on websiteCost.

$59.99 and $124.99Refund Policy buy levitra online uk. Returns accepted within 30 days of purchase2. Penguin CBDPenguin CBD is another top notch CBD brand that offers a variety of CBD options. Penguin CBD offers fruity, mint, and a cookies & buy levitra online uk. Cream flavor, all of which taste great.

This company not only offers several flavors to buy levitra online uk choose from, there are also different strengths available. So whether you're new to CBD or an experienced user, there's a dosage that meets your needs.Penguin CBD uses hemp grown on organic farms in Oregon. This means plants are grown without the use of harmful chemicals like pesticides and solvents. With broad-spectrum CBD oil, users can reap the benefits of other plant compounds without worrying about possible buy levitra online uk THC congestion.Type of CBD. Broad-spectrumFlavors.

Mint, Citrus, Strawberry, Cookies buy levitra online uk &. Cream, NaturalIngredients● Broad-spectrum CBD● Hemp oil● MCT oil● Natural flavor● TerpenesCBD Per Dose. 8.3 mg, 20 mg, 33.3 mg, 83.3 mgLab Results. Green Scientific Labs, ProVerde, Infinite Chemicals Analysis - Available on websiteCost buy levitra online uk. $45 to $105Refund Policy.

Returns accepted within 30 buy levitra online uk days of purchase3. Colorado BotanicalsObserver ranked Colorado Botanicals as the #1 CBD company to buy from in 2021, and after learning more about this forward-thinking brand, we understand why.The company sets itself apart from other CBD companies in two key ways – its proprietary purification process and its intense focus on terpenes. Most CBD brands use high heat to remove chlorophyll, fats, and waxes from their products, but this approach burns off all the terpenes and other essential compounds in CBD. Instead, Colorado Botanicals uses a pharmaceutical chemical separation process that leaves terpenes intact while simultaneously removing all traces of THC.Terpenes matter because they have a host of healing properties and, when terpenes are present with cannabinoids, buy levitra online uk receptor activity is higher, meaning more powerful CBD effects. Because Colorado Botanicals’ purification and extraction process naturally retains hemp-derived terpenes, they don’t need to add them from other plants.

When terpenes are added (versus preserved), they can dilute the final buy levitra online uk product and introduce unwanted compounds, resulting in less effective CBD.Our favorite Colorado Botanicals product is the brand’s 3,000mg bottle. Additionally, all Colorado Botanicals products are backed by a 60-day risk-free trial. Regardless of which item you pick, you’re getting amazing value, high quality, and a truly excellent product.4. BATCH CBDBATCH CBD has gained a reputation for having some of the highest quality buy levitra online uk CBD products in the industry. The BATCH team has a scientific background and makes all products in-house with a strong focus on function, not fluff.

The real reason BATCH ranks so high on this list though is because of their highly potent Gold Reserve Blend. BATCH markets this product as a heavy-hitter that’s “not meant for the rookies”, and I would take their word buy levitra online uk for it. This wildly unique product has 4000mg of CBD and is boosted with an additional 2000mg of CBG!. It is truly unlike anything else on the market, and it is no surprise that it works so well.BATCH has several other signature oils that range from 500mg all the buy levitra online uk way up to 3000mg. Every product uses their signature full-spectrum hemp extract and is mixed with the finest organic ingredients.

As a cherry on top, BATCH has won several packaging awards for their beautiful brand aesthetic.Type of CBD. Full-SpectrumFlavors. Subtle Citrus, Subtle MintIngredients● Full-Spectrum CBD Extract● Organic MCT Oil● Organic Botanical Oils (for taste)● TerpenesCBD Per Dose. 8.3 mg, 17 mg, 33.3 mg, 50 mg, 67 mg (plus CBG)Lab Results. Desert Valley Testing – available on websiteCost.

$35 to $150Refund Policy. Returns accepted within 30 days of purchase5. R+R MedicinalsR+R Medicinals is quickly becoming one of the most trusted and popular CBD brands by proving one thing - they make the CBD that works. Their unique 2500mg Tincture is an industry leader in terms of performance, potency, and value. Using supercritical CO2 extraction on their proprietary Cherry strain of USDA Certified Organic hemp, they yield an unparalleled profile of cannabinoids, terpenes, and other phytonutrients in their products that translate into guaranteed performance.

R+R boasts impressive levels of CBD, CBG, CBC, CBN, CBL, and more in their products, so you can truly feel the entourage effect. In addition to being USDA Organic Certified, they are also US Hemp Authority Certified, and they have hundreds of 5-star ratings on Google, so you can take comfort in knowing they do things with the highest standards of safety and quality in mind. Incredible value at only $0.03 per mg of CBD!. Type of CBD. Full-Spectrum (CBD, THC, CBG, CBC, CBN, CBL, CBDv) Flavors.

Fresh Mint, UnflavoredIngredients● USDA Organic Full-Spectrum CBD● Organic MCT oil from Coconut● Organic Natural FlavorCBD Per mL. 83.4mgLab Results. SC Labs - Available on website for every batchCost. $27 to $97Refund Policy. Returns accepted within 30 days of purchaseYour CBD Questions, AnsweredNow that you know about our top five CBD oils, let’s get into some of the most frequently asked questions about CBD.

The more informed you are, the more confident you’ll feel when using CBD for the first time.What is CBD?. There is a host of confusion and misinformation surrounding CBD. So here are some truths that you'll want to know so that you can make an informed decision when deciding is CBD oil or some other product is right for you.CBD, also known as cannabidiol, is a compound that is found in the cannabis sativa plant. When talking about CBD products, CBD is typically extracted from hemp plants because they contain a lower level of THC when compared to other plants.Under the 2018 Farm Bill, which legalized CBD products on a federal level, all legal CBD products must be made from hemp and must contain no more than 0.3% THC by weight. While some CBD products contain no THC, such as those made with CBD isolate and broad-spectrum CBD, others may have a trace amount.Will CBD Get Me High?.

One of the biggest misconceptions about CBD is that it will make you high. But this simply isn’t true. Even if you use a full-spectrum CBD oil that contains THC, you won’t feel any of the psychoactive effects of this cannabinoid. This is because the amount is less than 0.3%, which is very low.Unlike THC, CBD doesn’t have any psychoactive effects. It won’t alter your mental state, which means you won’t feel high, euphoric, or anxious.

Instead, CBD promotes mental relaxation, allowing you to better focus and concentration. CBD can also provide mental clarity.Is All CBD The Same?. No!. In fact, there are three different types of CBD that can be used to create tinctures and other CBD products. Here’s what you need to know about each of the types.CBD Isolate - CBD isolate is the purest form.

As the name implies, this type of CBD has been isolated from all other plant compounds, to include terpenes, flavonoids, and of course THC. CBD isolate is the safest option if you don’t want to risk exposure to any of the other compounds found in hemp plants.Broad-spectrum CBD - Broad-spectrum CBD is the middle ground between isolate and full-spectrum. This type of CBD contains all of the naturally occurring plant compounds, to include terpenes, flavonoids, and other cannabinoids. However, all traces of THC are removed completely. This means you can still experience the entourage effect without being exposed to THC.Full-spectrum CBD - Full-spectrum CBD contains all of the natural plant compounds, to include low levels of THC.

Some people prefer this type of CBD because it activates the entourage effect. This effect has shown to strengthen and heighten the overall benefits and experience. It’s ideal for those who are treating chronic conditions, like pain or anxiety.Is CBD Legal?. On the federal level, CBD is legal. However, states and local communities may have more stringent laws that require further regulation.

Some states have not legalized CBD products, so it's important to know which laws apply to you.Federal legalization also doesn't automatically mean that all CBD products are safe. Despite the passing of the 2018 Farm Bill, no government agency has been given purview over the CBD industry. The lack of oversight means that there are illegal and potential dangerous products being sold under the guise of being safe.How Does CBD Work?. When ingested, CBD works with the endocannabinoid system (ECS), which is a network of receptors that span throughout the body. The ECS sends out signals and also plays a role in many of the body's basic physiological functions, such as sleep, appetite, as well as immune system and nervous system function.The body naturally creates endocannabinoids that are used by the ECS.

However, some people may have imbalanced or low levels. This is when supplemental products like CBD oil can be quite beneficial. When ingested, CBD works almost identically to the endocannabinoids that are created by the body. This helps to ensure that the body is functioning properly.CBD has also shown to play a role in promoting homeostasis. This is defined as a steady state of physical, internal, and chemical conditions.What Are the Benefits of CBD Oil?.

Even though CBD products have been on the market for years, there is still a lot to learn about the cannabinoid. This is because most studies have been conducted on animals instead of humans, so much of the evidence is anecdotal.But from what we do know, CBD oil may offer a host of therapeutic benefits. Most people take CBD oil in order to calm their mind and body, but these products can be used for all sorts of other perks.Some of the most notable benefits of CBD oil include:● Reduced inflammation● Improved management of chronic pain● Reduces stress and anxiety● Improves sleep quality● May reduce acne● Could have neuroprotective propertiesSo whether you want to use CBD oil to have a clearer, more focused mind at work or if you want to keep your chronic pain at bay, the body of evidence that supports these claims only continues to grow. The best part is that CBD is all natural, so the risk of adverse side effects is slim.Are There Any Side Effects?. Most natural products, such as CBD, have very little side effects.

But this doesn’t mean that CBD oil doesn’t pose the risk of any adverse experiences. When using CBD oil, one of the most important things to do is to avoid taking too much too soon. Most people who report negative side effects after taking CBD more than likely took too high of a dosage. Like any supplement, CBD oil needs to be gradually introduced into the body.So what are the most commonly reported side effects of CBD?. Side effects include:● Changes in appetite● Dizziness● Drowsiness● Nausea● Dry mouth● DiarrheaAs you can see, these side effects are very mild.

You can minimize the risk of experiencing any of these effects by taking a low dosage. If you experience any of these effects, stop taking CBD for a few days and restart at a lower dose.If you’re on any prescription medications or other supplements, it’s important to first check with your doctor. CBD has shown to negatively interact with certain medications, so be sure to get medical clearance before taking CBD oil.How Much CBD Oil Do I Need?. Because CBD isn’t regulated by a federal agency like the FDA, there is no set dosage. It’s also important to note that everyone reacts differently to CBD, as there are many factors that play a role in determining the kind of experience you will have.For example, some CBD oils contain a higher amount of CBD per dose than others.

It’s important to know how much CBD a dose contains so that you can use the right amount.Other factors to consider when figuring out how much CBD oil you need include:● Gender● Weight● Age● Existing endocannabinoid levels● Condition being treatedBecause there are so many variables that come into play, figuring out how much CBD oil you need in order to get the experience you want will require time and patience. It all comes down to trial and error.The best way to figure out how much CBD oil you need to take is to start with a low dosage. Most people have the best experience taking 2.85 mg to 50 mg of CBD a day. Start by taking 2-5 mg a day and make note of how you feel.If you aren’t getting the experience that you crave, up the dose, but do so slowly. You don’t want to jump from 5 mg a day to 25 mg a day overnight.

Take it slow and be patient with the process. For some people, it can take months to find their sweet spot.How Should CBD Oil Be Taken?. There are many ways that CBD oil can be taken. The best place to start is by looking at the directions provided by the manufacturer of the CBD oil that you’ve purchased. This is likely to be the best delivery method for the specific oil that you’re using.But if you want to venture outside of the box, it helps to know about the many ways that you can reap the benefits of CBD oil.As you may have guessed, the simplest and most widely recommended way to take CBD oil is sublingually.

This means putting a full dose directly under the tongue and holding it there for at least one minute. Any remaining oil is swallowed.The sublingual method is not only convenient, it maximizes bioavailability. This ensures that the cannabinoid is properly circulated throughout the bloodstream. Other ways to take CBD oil include:● Mixing it into food● Adding a few drops to your favorite drink● Vaped● Added to a topical productWhile everyone has their own preferred delivery method, what’s most important is that you take CBD oil on a regular basis. It should also be stored in a cool, dark place.

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Here’s to a healthier, happier, calmer you!. This article appeared in the January/February 2022 issue of Discover magazine. Become a subscriber for unlimited access to our archive.Malaria kills over 400,000 people a year around the world, most of them children. That toll, though grim, is a little under half what it was in 2000, thanks to campaigns to distribute mosquito nets, conduct indoor pesticide spraying and administer preventive medications. Since 2015, however, factors ranging from funding shortfalls to increased drug and insecticide resistance have caused the numbers of deaths and overall cases — more than 200 million annually — to plateau.Two breakthroughs could make a difference.

One came in October, when the World Health Organization approved the first treatment against the disease. Mosquirix, manufactured by GlaxoSmithKline, is only moderately effective. In clinical trials, it reduced cases by about 56 percent over 12 months, dropping to 36 percent over four years. Still, as Pedro Alonso, director of the WHO’s malaria program, noted, its approval is “a historic event.”Less noticed, but perhaps equally important. In April, a study posted by The Lancet revealed that a rival treatment could be far superior.

R21/Matrix-M, developed by Oxford University’s Jenner Institute, showed up to 77 percent efficacy over one year — the first malaria treatment candidate to reach the goal of 75 percent set in 2013 by the WHO.Those findings came from a clinical trial involving 450 children in the West African nation of Burkina Faso, where malaria strikes more than one-third of the population every year. Participants ranged in age from five months to 17 months. Three doses were given at four-week intervals, with a booster shot one year later. Over that period, just 38 of the 146 kids in the high-dose group developed malaria, versus 105 of the 147 in the control group.“We had to go back and look carefully to make sure what we were seeing was real,” says parasitologist Hermann Sorgho, who co-led the trial at the Clinical Research Unit of Nanoro with the site’s director, Halidou Tinto. €œIt was a fantastic result.”Bigger studies could show less impressive protection or unexpected safety issues.

But if the results hold up, R21/MM could be a powerful weapon in controlling — and eventually eliminating — one of humanity’s greatest microbial foes.Tweaking the FormulaSince the first test of a malaria treatment in the 1940s, researchers have grown accustomed to disappointment. Plasmodium falciparum, the parasite that causes the most common form of the disease, has over 5,000 genes and a daunting array of evasive tactics. Before R21, Mosquirix had been the best-performing treatment candidate ever.In some ways, the two treatments are similar. Both train the immune system to attack the same molecular target, or antigen — a protein from the parasite. Both use a similar delivery system.

Tiny spheres of hepatitis B protein (a convenient carrier) coated with the malaria antigen. But the Oxford team, which also developed the Oxford-AstraZeneca erectile dysfunction treatment, made two crucial tweaks for R21/MM. First, they found a way to increase the ratio of malaria protein to hepatitis protein on the nanosphere’s surface. €œThat gets you more antibodies,” explains Jenner Institute director Adrian Hill, “and you’re not competing so much with hepatitis B for induction of an immune response.” Second, they used a new adjuvant — an ingredient that boosts immune response — that triggers fewer side effects.Another potential advantage. Because R21/MM requires lower dosages than Mosquirix, and its adjuvant is simpler to manufacture, it can be produced more efficiently and at lower cost.

Oxford is partnering with Serum Institute of India, the world’s largest treatment manufacturer, which has pledged to churn out at least 200 million doses annually.Prior malaria treatment trials, like this 2019 pilot program in Malawi, have sought to eradicate the deadly disease. (Credit. Amos Gumulira/AFP via Getty Images)In places where malaria is endemic, the impact of an effective treatment — or two — could go beyond reduced mortality. Although patients may develop partial immunity after repeated exposures, children often suffer several severe episodes a year. €œEvery time a kid gets sent down with malaria,” Sorgho says, “the mom or dad has to stop work and care for him.

The kid is not going to school. The losses are huge.”The Oxford team launched a pivotal phase-3 trial in summer 2021, enrolling 4,800 children in Burkina Faso, Mali, Kenya and Tanzania. If all goes as hoped, results could be submitted to regulators in late 2022.This article appeared in the January/February 2022 issue of Discover magazine. Become a subscriber for unlimited access to our archive.Obesity is a modern scourge, affecting 42 percent of Americans and raising overall risk of cardiovascular disease, diabetes and cancer. It is also notoriously difficult to control.

For most people, diet and exercise offer only temporary results, even when combined with medication. Gastric bypass and similar procedures — though more effective — carry significant health risks of their own. In June, however, the U.S. Food and Drug Administration approved a treatment that could transform that outlook for millions of people. Semaglutide, a synthetic version of a gut hormone called glucagon-like peptide-1 (GLP-1), increases insulin production and adjusts the brain’s metabolic settings — helping to regulate appetite rather than suppress it.

Developed by Danish company Novo Nordisk, the drug has been used since 2017 to treat Type 2 diabetes. Subsequent clinical trials, however, showed that higher doses (alongside a reduced-calorie diet and exercise) could help eliminate fat at double or triple the rate of existing weight-loss medications.In a 68-week study of nearly 2,000 patients, those who received weekly injections of semaglutide lost an average of 15 percent of their body weight, or roughly 34 pounds. More than one-third shed 20 percent or more, comparable to bariatric surgery. Side effects, mostly gastrointestinal, were typically mild and transient.“Weight-loss drugs in the past have really not been very good,” says endocrinologist Clifford Rosen, a senior scientist at the Maine Medical Center Research Institute. Stimulants reduce appetite but can trigger insomnia or cardiac events.

Drugs that block fat absorption can lead to bowel problems. Those that alter neurotransmitters can cause fatigue and dizziness.Many experts hailed the FDA’s approval of high-dose semaglutide, marketed as Wegovy, as the dawn of a new era for obesity treatment. That reflects not only the drug’s apparent safety, but also its ability to keep weight off long term. €œWe don’t see that bounce-back effect, which is really encouraging,” Rosen says.Less encouraging is Wegovy’s cost. Over $1,200 a month.

That sounds inexpensive compared to the estimated $147 billion spent annually on obesity-related medical costs in the U.S., but it’s a daunting out-of-pocket expense for the average consumer. And, like other weight-loss medications, the drug is not currently covered by Medicare or most private insurers.“There’s nothing more devastating than having to tell a patient, ‘I’ve got nothing else for you,’” says Jennifer L. Kirby, an associate professor of endocrinology and metabolism at the University of Virginia School of Medicine, who supports legislation to change reimbursement rules. €œThis is a huge, untapped way to improve the health of our country and the world.”.

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Patients, families and carers will soon benefit from refurbishments to palliative care facilities at Deniliquin Hospital thanks to a $210,000 boost from the NSW Government.NSW Minister for Mental Health, Regional Youth and Women Bronnie Taylor said the refurbishment project at Deniliquin will help bring comfort to people at the end of life, along with their families and carers.“Ensuring that patients, their families and carers receive quality palliative care in a safe, comfortable and home-like environment is a priority for this government,” Mrs Taylor said.“The refurbishment will include a kitchenette and dining area, as well as herbal levitra direct access to the outside garden area. The furniture and fittings and overall décor will provide a more homely and comfortable space for patients, families, carers and friends.” The garden area at Deniliquin Hospital will also be redesigned and will include elements that reflect the cultural diversity of the region.Duty MLC for Murray, Wes Fang, has welcomed the announcement as an important step herbal levitra in ensuring vulnerable loved ones at the end of life are as comfortable as possible. €œThese new facilities with an emphasis on homeliness will offer more peace to patients, families and carers at their greatest time of need” Mr Fang said.The other facility in Murrumbidgee Local Health District to benefit is Hay Hospital, which will receive $40,000. The improvements at Hay Hospital will include an outdoor area with gazebo to support the existing Palliative Care space.Deniliquin and Hay Hospitals are among 34 palliative care facilities to be refurbished over herbal levitra the next two years, a total of $5.5 million investment across NSW.

Every year, the NSW Government spends more than $220 million on palliative care services across the State. In addition to this funding, in 2020-21 a further $16 million of enhancement funding was spent to improve services, including a boost of $7.17 million for 35 allied health workers and 20 palliative care nurses across NSW.The latest round of funding follows the success of $4.5 million allocated for palliative care refurbishments in herbal levitra 2019-20 and 2020-21. Both funding rounds were a part of a $45 herbal levitra million enhancement for palliative care announced in the 2019-20 NSW Budget.This enhancement and a further $56 million announced in late 2020 support an additional 5,000 End of Life home support packages available across NSW from July 2021. The recruitment of 100 new palliative care nurses.

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Patients, families and carers will soon benefit from refurbishments to palliative care facilities at Deniliquin Hospital thanks to a $210,000 boost from the NSW Government.NSW Minister for Mental Health, Regional Youth and Women Bronnie Taylor said the refurbishment project at Deniliquin will help bring comfort to people at the end buy levitra online uk of life, along with their families and carers.“Ensuring that patients, their families and carers receive quality palliative care in a safe, comfortable and home-like environment is a priority for this http://akrai.org/apply/ government,” Mrs Taylor said.“The refurbishment will include a kitchenette and dining area, as well as direct access to the outside garden area. The furniture and buy levitra online uk fittings and overall décor will provide a more homely and comfortable space for patients, families, carers and friends.” The garden area at Deniliquin Hospital will also be redesigned and will include elements that reflect the cultural diversity of the region.Duty MLC for Murray, Wes Fang, has welcomed the announcement as an important step in ensuring vulnerable loved ones at the end of life are as comfortable as possible. €œThese new facilities with an emphasis on homeliness will offer more peace to patients, families and carers at their greatest time of need” Mr Fang said.The other facility in Murrumbidgee Local Health District to benefit is Hay Hospital, which will receive $40,000.

The improvements at Hay Hospital will include an outdoor area with gazebo to support the existing Palliative Care space.Deniliquin and Hay buy levitra online uk Hospitals are among 34 palliative care facilities to be refurbished over the next two years, a total of $5.5 million investment across NSW. Every year, the NSW Government spends more than $220 million on palliative care services across the State. In addition buy levitra online uk to this funding, in 2020-21 a further $16 million of enhancement funding was spent to improve services, including a boost of $7.17 million for 35 allied health workers and 20 palliative care nurses across NSW.The latest round of funding follows the success of $4.5 million allocated for palliative care refurbishments in 2019-20 and 2020-21.

Both funding buy levitra online uk rounds were a part of a $45 million enhancement for palliative care announced in the 2019-20 NSW Budget.This enhancement and a further $56 million announced in late 2020 support an additional 5,000 End of Life home support packages available across NSW from July 2021. The recruitment of 100 new palliative care nurses. More Aboriginal buy levitra online uk Health Workers.

Digital health to improve access to palliative care. Enhanced bereavement services and education to ensure a strong, competent workforce buy levitra online uk. This is in addition to the $100 million palliative care package announced in the 2017-18 Budget..

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If you notice any changes in your vision while taking this drug, notify your prescriber or health care professional as soon as possible. Stop using vardenafil right away if you have a loss of sight in one or both eyes. Contact your healthcare provider immediately. Contact your physician immediately if the erection lasts longer than 4 hours or if it becomes painful. This may be a sign of priapism and must be treated immediately to prevent permanent damage. If you experience symptoms of nausea, dizziness, chest pain or arm pain upon initiation of sexual activity after vardenafil use, you should refrain from further activity and should discuss the episode with your prescriber or health care professional as soon as possible. Do not change the dose of your medication. Please call your prescriber or health care professional to determine if your dose needs to be reevaluated. Using vardenafil does not protect you or your partner against HIV (the levitra that causes AIDS) or other sexually transmitted diseases.

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A disbelief in human evolution was associated with higher levels of prejudice, racist attitudes and support of discriminatory behavior against Blacks, immigrants and the LGBTQ community in the U.S., according to University of Massachusetts Amherst research published in the Journal of levitra nedir Personality and Social Psychology.Similarly, across the globe -- in 19 Eastern European countries, 25 Muslim countries and in Israel -- low belief in evolution was linked to higher biases within a person's group, prejudicial attitudes toward people in different Clicking Here groups and less support for conflict resolution.The findings supported the hypothesis of lead author Stylianos Syropoulos, a Ph.D. Candidate in the War and Peace Labof senior author Bernhard Leidner, associate professor of social psychology. They collaborated with co-first author Uri Lifshin at Reichman University levitra nedir in Israel and co-authors Jeff Greenberg and Dylan Horner at the University of Arizona in Tucson. The researchers theorized that belief in evolution would tend to increase people's identification with all humanity, due to the common ancestry, and would lead to less prejudicial attitudes."People who perceive themselves as more similar to animals are also people who tend to have more pro-social or positive attitudes toward outgroup members or people from stigmatized and marginalized backgrounds," Syropoulos explains. "In this investigation, we were interested in examining whether belief in evolution would also act in a similar way, because it would reinforce this levitra nedir belief that we are more similar to animals."In eight studies involving different areas of the world, the researchers analyzed data from the American General Social Survey (GSS), the Pew Research Center and three online crowdsourced samples.

In testing their hypothesis about the associations of different levels of belief in evolution, they accounted for education, political ideology, religiosity, cultural identity and scientific knowledge."We found the same results each time, which is basically that believing in evolution relates to less prejudice, regardless of the group you're in, and controlling for all of these alternative explanations," Syropoulos says. advertisement For example, religious beliefs, like political ideology, were measured separately from a belief or disbelief in evolution, the levitra nedir researchers note. "Regardless of whether one considers religion an important part of their life, belief in evolution relates to less prejudice independently from belief, or lack thereof, in God or any particular religion," Syropoulos says.Leidner adds, "This whole effect and pattern seems to be present in all major political systems. It's very much a human phenomenon, no matter where you are in the world."The researchers note that Darwin's 19th century theory of evolution has been cited to perpetrate racism, prejudice and homophobia, in part through the phrase, "survival of the fittest," used to describe the process of natural selection."There have been theoretical accounts that predict the opposite of what we found, so it levitra nedir was exciting for us to show that this actually is not the case, that the opposite is true and that belief in evolution seems to have pretty positive effects," Leidner says.The U.S.-based study involved data from 1993, 1994, 2000, 2006, 2008, 2010, 2012, 2014, 2016 and 2018 -- the years the GSS surveyed Americans about their beliefs in evolution, as well as measures of attitudes toward immigrants, Blacks, affirmative action, LGBTQ people and other social matters. advertisement The data analysis showed unfailingly "that the disbelief in human evolution is the driving factor and most consistent predictor of prejudice in comparison to other relevant constructs," the paper states.In the Israel-based study, people with a higher belief in evolution were more likely to support peace among Palestinians, Arabs and Jews.

In the study involving countries in the levitra nedir Islamic world, belief in evolution was associated with less prejudice toward Christians and Jews. And in the study based in Eastern Europe, where Orthodox Christians are the majority, a belief in evolution was linked with less prejudice toward gypsies, Jews and Muslims.Syropoulos posits that a belief in evolution may expand people's "moral circle," leading to a sense that "we have more in common than things that are different."The findings also suggest that "teaching evolution seems to have side effects that might make for a better or more harmonious society," Leidner adds.The next step, the researchers say, is to investigate how evolution is taught in the classroom and work toward developing models to study and strengthen the positive effects.What happens when we smell a rose?. How does our brain process levitra nedir the essence of its fragrance?. Is it like a painting -- a snapshot of the flickering activity of cells -- captured in a moment in time?. Or like a symphony, an evolving ensemble of different cells working together levitra nedir to capture the scent?.

New research suggests that our brain does both."These findings reveal a core principle of the nervous system, flexibility in the kinds of calculations the brain makes to represent aspects of the sensory world," said Krishnan Padmanabhan, Ph.D., an associate professor of Neuroscience and senior author of the study recently published in Cell Reports. "Our work provides scientists with new tools to quantify and interpret the levitra nedir patterns of activity of the brain."Researchers developed a model to simulate the workings of the early olfactory system -- the network the brain relies on for smelling. Employing computer simulations, they found a specific set of connections, called centrifugal fibers, which carry impulses from other parts of the central nervous system to the early sensory regions of the brain, played a critical role. These centrifugal fibers act as a switch, toggling between different strategies levitra nedir to efficiently represent smells. When the centrifugal fibers were in one state, the cells in the piriform cortex -- where the perception of an odor forms -- relied on the pattern of activity within a given instant in time.

When the centrifugal fibers were in the other state, the cells in levitra nedir the piriform cortex improved both the accuracy and the speed with which cells detected and classified the smell by relying on the patterns of brain activity across time.These processes suggest the brain has multiple responses to representing a smell. In one strategy, the brain uses a snapshot, like a painting or a photograph, at a given moment to capture the essential features of the odor. In the other strategy, the brain keeps track of the evolving levitra nedir patterns. It is attuned to which cells turn on and off and when -- like a symphony.The mathematical models the researchers developed highlight the critical feature of the nervous system -- not only diversity in terms of the components that make up the brain but also how these components work together to help the brain experience the world of smell. "These mathematical models reveal critical levitra nedir aspects of how the olfactory system in the brain might work and could help build brain-inspired artificial computing systems," Padmanabhan said.

"Computational approaches inspired by the circuits of the brain such as this have the potential to improve the safety of self-driving cars, or help computer vision algorithms more accurately identify and classify objects in an image."Additional authors include Zhen Chen of the University of Rochester. The research was funded by levitra nedir the National Institutes of Health, the National Science Foundation, the Cystinosis Research Foundation, and the Del Monte Institute for Neuroscience at the University of Rochester Pilot Program. Story Source. Materials provided by University levitra nedir of Rochester Medical Center. Original written by Kelsie Smith Hayduk.

Note. Content may be edited for style and length.According to a study by researchers from the Socio-Economic Panel (SOEP) at the German Institute for Economic Research (DIW Berlin) and the University of Münster, millionaires are more risk-tolerant, emotionally stable, open, extroverted, and conscientious than the general population. The study is published in the journal Humanities and Social Sciences Communications.The data used for the analysis of personality traits come from the SOEP, a representative random sample of the German population. In 2019, a subsample of more than 2,000 high-wealth individuals was added to the SOEP. The SOEP now surveys more than 1,100 millionaires whose net worth averages around 4 million euros.

"This means that the very wealthy are now overrepresented in the SOEP, making it possible to analyze this very small population in a meaningful way," explains SOEP researcher Carsten Schröder, who initiated the top-wealth subsample.The results show that the typical millionaire personality profile is especially pronounced among self-made millionaires, who see themselves as having made their money on their own rather than through inheritance. The profile is less pronounced among millionaires who attribute their wealth primarily to inheritance.Within the sample of millionaires, those whose personality traits correspond most closely to the typical profile have the highest wealth. In the rest of the population, a weaker form of this personality profile can be found in individuals who have worked their way up through their own efforts. Although they are not millionaires yet, they see themselves as having earned their money on their own and, therefore, as self-made. Johannes König, research associate at SOEP and lead author of the study, explains, "Taken together, the results suggest that personality is a relevant factor in wealth accumulation."Coauthor Mitja Back, Professor of Psychological Diagnostics and Personality Psychology at the University of Münster, adds.

"This is the first study to describe the personality of millionaires using robust data. Since the rich wield particular influence over societal decision-making processes, and since personality has a determining influence on the way people think and behave, the investigation of millionaires' personality traits is of great social relevance." Story Source. Materials provided by University of Münster. Note. Content may be edited for style and length..

A disbelief in human evolution was associated with higher levels of prejudice, racist attitudes and support of discriminatory behavior against Blacks, immigrants and the LGBTQ community in the U.S., according to University of Massachusetts Amherst research published in http://markgrigsby.biz/low-cost-seroquel/ the Journal of Personality and Social Psychology.Similarly, across the globe -- in 19 Eastern European countries, 25 Muslim countries and in Israel -- low belief in buy levitra online uk evolution was linked to higher biases within a person's group, prejudicial attitudes toward people in different groups and less support for conflict resolution.The findings supported the hypothesis of lead author Stylianos Syropoulos, a Ph.D. Candidate in the War and Peace Labof senior author Bernhard Leidner, associate professor of social psychology. They collaborated with co-first author Uri Lifshin at Reichman University in Israel and co-authors Jeff Greenberg and Dylan Horner at the University of Arizona in buy levitra online uk Tucson. The researchers theorized that belief in evolution would tend to increase people's identification with all humanity, due to the common ancestry, and would lead to less prejudicial attitudes."People who perceive themselves as more similar to animals are also people who tend to have more pro-social or positive attitudes toward outgroup members or people from stigmatized and marginalized backgrounds," Syropoulos explains. "In this buy levitra online uk investigation, we were interested in examining whether belief in evolution would also act in a similar way, because it would reinforce this belief that we are more similar to animals."In eight studies involving different areas of the world, the researchers analyzed data from the American General Social Survey (GSS), the Pew Research Center and three online crowdsourced samples.

In testing their hypothesis about the associations of different levels of belief in evolution, they accounted for education, political ideology, religiosity, cultural identity and scientific knowledge."We found the same results each time, which is basically that believing in evolution relates to less prejudice, regardless of the group you're in, and controlling for all of these alternative explanations," Syropoulos says. advertisement For example, religious beliefs, like political ideology, were measured separately from a buy levitra online uk belief or disbelief in evolution, the researchers note. "Regardless of whether one considers religion an important part of their life, belief in evolution relates to less prejudice independently from belief, or lack thereof, in God or any particular religion," Syropoulos says.Leidner adds, "This whole effect and pattern seems to be present in all major political systems. It's very much a human phenomenon, no matter where you are in the world."The researchers note that Darwin's 19th century theory of evolution has been cited to perpetrate racism, prejudice and homophobia, in part through the phrase, "survival of the fittest," used to describe the process of natural selection."There have been theoretical accounts that predict the opposite of what we found, so it was exciting for us to show that this actually is not the case, that the opposite is true and that belief in evolution seems to have pretty positive effects," Leidner says.The U.S.-based study involved data from 1993, 1994, 2000, 2006, 2008, 2010, 2012, 2014, 2016 and 2018 -- the years the GSS surveyed Americans about their buy levitra online uk beliefs in evolution, as well as measures of attitudes toward immigrants, Blacks, affirmative action, LGBTQ people and other social matters. advertisement The data analysis showed unfailingly "that the disbelief in human evolution is the driving factor and most consistent predictor of prejudice in comparison to other relevant constructs," the paper states.In the Israel-based study, people with a higher belief in evolution were more likely to support peace among Palestinians, Arabs and Jews.

In the study involving buy levitra online uk countries in the Islamic world, belief in evolution was associated with less prejudice toward Christians and Jews. And in the study based in Eastern Europe, where Orthodox Christians are the majority, a belief in evolution was linked with less prejudice toward gypsies, Jews and Muslims.Syropoulos posits that a belief in evolution may expand people's "moral circle," leading to a sense that "we have more in common than things that are different."The findings also suggest that "teaching evolution seems to have side effects that might make for a better or more harmonious society," Leidner adds.The next step, the researchers say, is to investigate how evolution is taught in the classroom and work toward developing models to study and strengthen the positive effects.What happens when we smell a rose?. How does our brain buy levitra online uk process the essence of its fragrance?. Is it like a painting -- a snapshot of the flickering activity of cells -- captured in a moment in time?. Or like a symphony, an evolving ensemble of different cells buy levitra online uk working together to capture the scent?.

New research suggests that our brain does both."These findings reveal a core principle of the nervous system, flexibility in the kinds of calculations the brain makes to represent aspects of the sensory world," said Krishnan Padmanabhan, Ph.D., an associate professor of Neuroscience and senior author of the study recently published in Cell Reports. "Our work provides scientists with new tools to quantify and interpret the buy levitra online uk patterns of activity of the brain."Researchers developed a model to simulate the workings of the early olfactory system -- the network the brain relies on for smelling. Employing computer simulations, they found a specific set of connections, called centrifugal fibers, which carry impulses from other parts of the central nervous system to the early sensory regions of the brain, played a critical role. These centrifugal fibers act as a switch, toggling between different strategies to efficiently represent smells buy levitra online uk. When the centrifugal fibers were in one state, the cells in the piriform cortex -- where the perception of an odor forms -- relied on the pattern of activity within a given instant in time.

When the centrifugal fibers were in the other state, the cells in the piriform cortex improved both the accuracy and the speed with which cells detected and classified the smell by relying on the patterns of brain activity buy levitra online uk across time.These processes suggest the brain has multiple responses to representing a smell. In one strategy, the brain uses a snapshot, like a painting or a photograph, at a given moment to capture the essential features of the odor. In the buy levitra online uk other strategy, the brain keeps track of the evolving patterns. It is attuned to which cells turn on and off and when -- like a symphony.The mathematical models the researchers developed highlight the critical feature of the nervous system -- not only diversity in terms of the components that make up the brain but also how these components work together to help the brain experience the world of smell. "These mathematical models reveal critical aspects of how the buy levitra online uk olfactory system in the brain might work and could help build brain-inspired artificial computing systems," Padmanabhan said.

"Computational approaches inspired by the circuits of the brain such as this have the potential to improve the safety of self-driving cars, or help computer vision algorithms more accurately identify and classify objects in an image."Additional authors include Zhen Chen of the University of Rochester. The research was funded by the National Institutes of Health, the National Science Foundation, the Cystinosis Research Foundation, and the Del Monte Institute for Neuroscience at the University of buy levitra online uk Rochester Pilot Program. Story Source. Materials provided by University of Rochester Medical buy levitra online uk Center. Original written by Kelsie Smith Hayduk.

Note. Content may be edited for style and length.According to a study by researchers from the Socio-Economic Panel (SOEP) at the German Institute for Economic Research (DIW Berlin) and the University of Münster, millionaires are more risk-tolerant, emotionally stable, open, extroverted, and conscientious than the general population. The study is published in the journal Humanities and Social Sciences Communications.The data used for the analysis of personality traits come from the SOEP, a representative random sample of the German population. In 2019, a subsample of more than 2,000 high-wealth individuals was added to the SOEP. The SOEP now surveys more than 1,100 millionaires whose net worth averages around 4 million euros.

"This means that the very wealthy are now overrepresented in the SOEP, making it possible to analyze this very small population in a meaningful way," explains SOEP researcher Carsten Schröder, who initiated the top-wealth subsample.The results show that the typical millionaire personality profile is especially pronounced among self-made millionaires, who see themselves as having made their money on their own rather than through inheritance. The profile is less pronounced among millionaires who attribute their wealth primarily to inheritance.Within the sample of millionaires, those whose personality traits correspond most closely to the typical profile have the highest wealth. In the rest of the population, a weaker form of this personality profile can be found in individuals who have worked their way up through their own efforts. Although they are not millionaires yet, they see themselves as having earned their money on their own and, therefore, as self-made. Johannes König, research associate at SOEP and lead author of the study, explains, "Taken together, the results suggest that personality is a relevant factor in wealth accumulation."Coauthor Mitja Back, Professor of Psychological Diagnostics and Personality Psychology at the University of Münster, adds.

"This is the first study to describe the personality of millionaires using robust data. Since the rich wield particular influence over societal decision-making processes, and since personality has a determining influence on the way people think and behave, the investigation of millionaires' personality traits is of great social relevance." Story Source. Materials provided by University of Münster. Note. Content may be edited for style and length..

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€œProtecting Workers. Guidance on Mitigating and Preventing the Spread of erectile dysfunction treatment in the Workplace” provides updated guidance and recommendations, and outlines existing safety and health standards. OSHA is providing the recommendations to assist employers in providing buy levitra online uk a safe and healthful workplace.

€œMore than 400,000 Americans have died from erectile dysfunction treatment and millions of people are out of work as a result of this crisis. Employers and workers can help our nation fight and overcome this deadly levitra by committing themselves to making their workplaces as safe as possible,” buy levitra online uk said Senior Counselor to the Secretary of Labor M. Patricia Smith.

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Implement protections from retaliation for workers who buy levitra online uk raise erectile dysfunction-related concerns. €œOSHA is updating its guidance to reduce the risk of transmission of the erectile dysfunction and improve worker protections so businesses can operate safely and employees can stay safe and working,” said Principal Deputy Assistant Secretary for Occupational Safety and Health Jim Frederick. The guidance details key measures for limiting erectile dysfunction’s spread, including ensuring infected or potentially buy levitra online uk infected people are not in the workplace, implementing and following physical distancing protocols and using surgical masks or cloth face coverings.

It also provides guidance on use of personal protective equipment, improving ventilation, good hygiene and routine cleaning. OSHA will update today’s guidance as developments in science, best practices and standards warrant. This guidance is not a buy levitra online uk standard or regulation, and it creates no new legal obligations.

It contains recommendations as well as descriptions of existing mandatory safety and health standards. The recommendations are advisory in nature, informational in content and are intended to assist employers in recognizing and abating hazards likely to cause death or serious physical harm as part of their obligation to provide a safe and healthful workplace buy levitra online uk. Under the Occupational Safety and Health Act of 1970, employers are responsible for providing safe and healthful workplaces for their employees.

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The Department’s Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large buy levitra online uk print. For alternative format requests, please contact the Department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay).January 13, 2021Contact. Office of CommunicationsPhone buy levitra online uk.

202-693-1999U.S. Department of Labor Announces Annual Adjustments toOSHA Civil Penalties WASHINGTON, DC – The U.S. Department of Labor has announced buy levitra online uk adjustments to Occupational Safety and Health Administration (OSHA) civil penalty amounts based on cost-of-living adjustments for 2021.

In 2015, Congress passed the Federal Civil Penalties Inflation Adjustment Act Improvements Act to advance the effectiveness of civil monetary penalties and to maintain their deterrent effect. Under the Act, agencies are required to publish “catch-up” rules that adjust the level of civil monetary penalties, and buy levitra online uk make subsequent annual adjustments for inflation no later than January 15 of each year. OSHA's maximum penalties for serious and other-than-serious violations will increase from $13,494 per violation to $13,653 per violation.

The maximum penalty for willful or repeated violations will increase from $134,937 per violation to $136,532 per violation. Visit the OSHA Penalties page buy levitra online uk for more information. The Department of Labor Federal Civil Penalties Inflation Adjustment Act Annual Adjustments for 2021 final rule is effective January 15, 2021, and the increased penalty levels apply to any penalties assessed after January 15, 2021.

Under the Occupational Safety and Health buy levitra online uk Act of 1970, employers are responsible for providing safe and healthful workplaces for their employees. OSHA's role is to help ensure these conditions for America's working men and women by setting and enforcing standards, and providing training, education and assistance. For more information, visit www.osha.gov.

The mission buy levitra online uk of the Department of Labor is to foster, promote, and develop the welfare of the wage earners, job seekers, and retirees of the United States. Improve working conditions. Advance opportunities buy levitra online uk for profitable employment.

And assure work-related benefits and rights. # # # U.S. Department of Labor news materials are accessible buy levitra online uk at http://www.dol.gov.

The Department's Reasonable Accommodation Resource Center converts departmental information and documents into alternative formats, which include Braille and large print. For alternative format requests, please contact the Department at (202) 693-7828 (voice) or (800) 877-8339 (federal relay)..

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Start Preamble https://alistkandb.co.uk/lasix-cost Agency for Healthcare Research and Quality (AHRQ), HHS generic levitra best price. Request for supplemental evidence generic levitra best price and data submissions. The Agency for Healthcare Research and Quality (AHRQ) is seeking scientific information submissions from the public.

Scientific information is being solicited to generic levitra best price inform our review on Postpartum Care for Women Up to One Year After Pregnancy, which is currently being conducted by the AHRQ's Evidence-based Practice Centers (EPC) Program. Access to published and unpublished pertinent scientific information will improve the quality of this review. Submission Deadline on or generic levitra best price before April 11, 2022.

Email submissions generic levitra best price. Epc@ahrq.hhs.gov. Print submissions generic levitra best price.

Mailing Address. Center for Evidence and generic levitra best price Practice Improvement, Agency for Healthcare Research and Quality, Attn. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857.

Shipping Address (FedEx, UPS, etc.) generic levitra best price. Center for Evidence and Practice Improvement, Agency for Healthcare generic levitra best price Research and Quality, ATTN. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E77D, Rockville, MD 20857.

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End Preamble Start Supplemental Information The Agency for Healthcare Research and Quality has commissioned the Evidence-based Practice Centers (EPC) Program to complete a review of the evidence for Postpartum Care for Women Up to One Year After Pregnancy. AHRQ is conducting this technical brief pursuant to Section 902 of the Public Health Service Act, 42 U.S.C. 299a.

The EPC Program is dedicated to identifying as many studies as possible that are relevant to the questions for each of its reviews. In order to do so, we are supplementing the usual manual and electronic database searches of the literature by requesting information from the public ( e.g., details of studies conducted). We are looking for studies that report on Postpartum Care for Women Up to One Year After Pregnancy, including those that describe adverse events.

The entire research protocol is available online at. Https://effectivehealthcare.ahrq.gov/​products/​postpartum-care-one-year/​protocol. This is to notify the public that the EPC Program would find the following information on Postpartum Care for Women Up to One Year After Pregnancy helpful.

A list of completed studies that your organization has sponsored for this indication. In the list, please indicate whether results are available on ClinicalTrials.gov along with the ClinicalTrials.gov trial number. For completed studies that do not have results on ClinicalTrials.gov, a summary, including the following elements.

Study number, study period, design, methodology, indication and diagnosis, proper use instructions, inclusion and exclusion criteria, primary and secondary outcomes, baseline characteristics, number of patients screened/eligible/enrolled/lost to follow-up/withdrawn/analyzed, effectiveness/efficacy, and safety results. A list of ongoing studies that your organization has sponsored for this indication. In the list, please provide the ClinicalTrials.gov trial number or, if the trial is not registered, the protocol for the study including a study number, the study period, design, methodology, indication and diagnosis, proper use instructions, inclusion and exclusion criteria, and primary and secondary outcomes.

Description of whether the above studies constitute ALL Phase II and above clinical trials sponsored by your organization for this indication and an index outlining the relevant information in each submitted file. Your contribution is very beneficial to the Program. Materials submitted must be publicly available or able to be made public.

Materials that are considered confidential. Marketing materials. Study types not included in the review.

Or information on indications not included in the review cannot be used by the EPC Program. This is a voluntary request for information, and all costs for complying Start Printed Page 14012 with this request must be borne by the submitter. The draft of this review will be posted on AHRQ's EPC Program website and available for public comment for a period of 4 weeks.

If you would like to be notified when the draft is posted, please sign up for the email list at. Https://www.effectivehealthcare.ahrq.gov/​email-updates. The systematic review will answer the following questions.

This information is provided as background. AHRQ is not requesting that the public provide answers to these questions. Key Questions (KQ) KQ 1.

What healthcare delivery strategies affect postpartum healthcare utilization and improve maternal outcomes within 1 year postpartum?. a. Do the healthcare delivery strategies affect postpartum healthcare utilization and improve maternal outcomes within 3 months postpartum?.

Does this relationship differ by timing of outcomes, specifically within 6 days postpartum, between 1 to 6 weeks postpartum, and between 6 weeks and 3 months postpartum?. b. Do the healthcare delivery strategies affect postpartum healthcare utilization and improve maternal outcomes between 3 months and 1 year postpartum?.

KQ 2. Does extension of health insurance coverage or improvements in access to healthcare affect postpartum healthcare utilization and improve maternal outcomes within 1 year postpartum?. PICOTSD (Populations, Interventions, Comparators, Outcomes, Timing, Settings, and Design) Key Question 1 (Strategies for Healthcare Delivery) Populations Individuals (of any age) who are in the postpartum period (defined as within 1 year after giving birth).

○ For this review, “giving birth” is defined as a live birth, intrauterine fetal death (IUFD)/stillbirth, or induced abortion that occurred at 20 or more weeks of gestation ( i.e., the duration of gestation that is commonly considered to denote the viability of the fetus). Eligible populations ○ Healthy individuals (general population) ○ Individuals at increased risk of postpartum complications due to pregnancy-related conditions ( e.g., hypertensive disorders of pregnancy, gestational diabetes) ○ Individuals at increased risk of postpartum complications due to incident or newly diagnosed conditions postpartum ( e.g., postpartum hypertension, postpartum depression, new-onset diabetes) • Exclude. ○ Individuals with specific health conditions not typically managed by providers of pregnancy and postpartum care, (e.g., multiple sclerosis, HIV, cancer, substance use disorders other than tobacco).

○ Individuals with diagnosed chronic conditions—pre-existing (non-gestational) diabetes, cardiac disease/risk factors (e.g., cardiomyopathy, pre-existing [non-gestational] hypertension), mood disorders (e.g., major depression, anxiety), stress urinary incontinence, and dyspareunia. Content of Interventions Provided (note that these are not the interventions being compared in the review). Categories of interventions include components of the ACOG Postpartum Care Plan: 18 Counseling, support, and education regarding ○ Infant care and feeding ○ Reproductive life planning and contraception ○ Adverse pregnancy outcomes associated with cardiometabolic disease ○ Risks and behaviors associated with poor postpartum health Screening or prevention of.

○ Pregnancy complications ○ Common chronic health conditions ( e.g., hypertension, diabetes) ○ Mental health conditions ( e.g., depression, anxiety) ○ Common gynecologic problems ( e.g., sexually transmitted s, cervical cancer) ○ Common postpartum problems ( e.g., stress urinary incontinence, dyspareunia) • Exclude. ○ Treatments for acute or emergency postpartum conditions (e.g., for mastitis, urinary tract s, other s) ○ Treatments or other interventions for conditions unrelated to pregnancy (e.g., HIV, schizophrenia) ○ Treatments or other interventions for acute conditions during pregnancy or occurring around the time of giving birth (e.g., for postpartum hemorrhage, preeclampsia with severe features) ○ Treatments or other interventions directed at the infant (e.g., well-child visits, otitis media, colic) ○ Referral-only interventions (e.g., lactation consultants for specific lactation problems) Delivery Strategies • Where healthcare is delivered— e.g., hospital, clinic, home visit, community health center, birth center, virtual care/telehealth, Women Infants and Children (WIC) program office/site • How healthcare is delivered— e.g., dedicated postpartum care visit, as part of well-child visit, group visit • When healthcare is delivered— e.g., timing before giving birth, after giving birth, or at postpartum visits Who provides healthcare/support ○ Predominantly health system-based care — e.g., OB/GYN, midwife, pediatrician, family physician, internist, physician assistant, nurse practitioner, nurse, lactation consultant (when integrated as part of the care), clinical psychologist or other mental health professional ○ Predominantly community-based care — e.g., doula support, community health worker, lay support, social worker/support, peer support, case manager • Healthcare coordination and management of care— e.g., patient navigators, creation and implementation of post-birth care plans, strategies for continuity of care/care transitions, strategies to facilitate access to appointments/scheduling, postpartum specialty care clinics, multidisciplinary care models ( e.g., maternal and child health centers, maternity care homes), evidence-based care protocols, incentives for care completion • Information and communication technology— e.g., bidirectional telemedicine, virtual televisits, phone visits, bidirectional texting, real-time chat-bots, smartphone or computer applications designed to enhance provision of postpartum healthcare ○ Exclude. Social media or support groups (without provider involvement), web or device applications aimed at general health maintenance • Interventions targeted at healthcare providers or systems— e.g., interventions to improve guideline-adherent care, clinical decision support tools, interventions to help reduce healthcare inequities ( e.g., promoting respectful care) • Exclude.

○ Referral-only interventions (e.g., lactation consultants for specific lactation problems) Start Printed Page 14013 ○ Treatments for specific ailments or conditions (e.g., pelvic floor physical therapy, urinary incontinence treatment, contraception, pain treatment, cognitive behavioral therapy) ○ Insurance extension (which is covered in KQ 2) Comparator Delivery Strategies Standard delivery strategy Alternative delivery strategy Outcomes (* and bold font denotes important outcomes that will be used when developing Strength of Evidence tables) • Intermediate and healthcare utilization outcomes ○ Attendance at postpartum visits * ○ Unplanned care utilization ( e.g., unplanned readmissions, emergency room visits) * ○ Adherence to condition-specific screening/testing ( e.g., blood pressure monitoring, glucose tolerance testing) or treatment * ○ Transition to primary care provider for long-term care * • Clinical outcomes (as appropriate, outcomes include incidence, prevalence/continuation, severity, and resolution) ○ Maternal mortality * ○ Symptoms or diagnosis of mental health conditions ( e.g., anxiety, depression, substance use) * ○ Patient-reported outcomes Quality of life (using validated measures) * Perceived stress * Pain Sleep quality Fatigue Sexual well-being and satisfaction Awareness of risk factors for long-term ill health ○ Physical health/medical outcomes Postpartum onset of preeclampsia or hypertension s ( e.g., mastitis, wound s) Severe maternal morbidity ○ Cardiovascular disorders ( e.g., cardiomyopathy) ○ Cerebrovascular disorders ( e.g., stroke) ○ Bleeding ○ Venous thromboembolism ○ Other ○ Interpregnancy interval ○ Unintended pregnancies ○ Contraceptive initiation and continuation ○ Breastfeeding intention, initiation, duration, and exclusivity ○ Reduction in health inequities ( e.g., by race, ethnicity, geography, disability status) • Harms ○ Health inequities * ○ Perceived discrimination * ○ Over-utilization of healthcare ○ Patient burden regarding postpartum care Potential Effect Modifiers • Patient-level factors ○ Age ○ Race/ethnicity ○ Gender identity ○ Sexual identity ○ Physical disability status ○ Socioeconomic status ○ Immigration status ○ Barriers to transportation to healthcare facility ○ Paid family leave policies ( e.g., presence versus absence, different durations of leave) ○ Access to internet (for virtual care/telehealth questions) ○ Substance use/substance use disorder ○ Type of insurance coverage (insured versus uninsured, private versus public [ e.g., Medicaid], insurance coverage of postpartum care, Medicaid insurance coverage extension or expansion) ○ Presence versus absence of disorders of pregnancy ( e.g., hypertensive, cardiovascular, gestational diabetes mellitus) or peripartum complications that increase risk of postpartum complications ○ Preterm versus term delivery ○ Live birth versus stillbirth/spontaneous abortion/induced abortion ○ Number of infants (singleton versus twins/triplets, etc.) ○ Presence versus absence of a supportive partner ○ Infant health ( e.g., neonatal intensive care unit [NICU] admission, congenital anomalies) • Setting factors ○ Country (U.S. Versus other high-income countries) ○ Geographic location (urban versus suburban versus rural) ○ Different levels of neighborhood vulnerability ( e.g., social vulnerability index) ○ Volume of facility/hospital (high versus low) ○ Type of facility/hospital (private versus public) ○ Racial/ethnic concordance between provider and patient ○ Language concordance between provider and patient Timing • Delivery strategy and comparator delivery strategy. Antenatal or postpartum (or both) ○ If the service is delivered antenatally, the strategy must be aimed at postpartum health (not just that the outcome was measured during the postpartum period).

• Outcome measurement. For KQ 1a. Within 3 months after giving birth.

For KQ 1b. 3 months to 1 year after giving birth (except interpregnancy interval, unintended pregnancies, and chronic diseases [ e.g., diabetes, hypertension], which can be later) Settings • High-income countries (as classified by the World Bank—see https://datahelpdesk.worldbank.org/​knowledgebase/​articles/​906519-world-bank-country-and-lending-groups ) Outpatient care • Exclude. Institutionalized settings (e.g., prisons) Design Randomized controlled trials (N ≥10 participants per group) Nonrandomized comparative studies, longitudinal (prospective or retrospective) (N ≥30 participants per group) Case-control studies (N ≥30 participants per group) • Exclude.

Single-group (noncomparative) studies, comparative cross-sectional studies (without a discernable time-period between implementation of strategy for intervention and measurement of outcomes), qualitative studies Key Question 2 (Extension of Healthcare or Insurance Coverage) Populations Individuals (of any age) who are in the postpartum period (defined as within 1 year after giving birth). ○ For this review, “giving birth” is defined as a live birth, intrauterine fetal death (IUFD)/stillbirth, or induced abortion that occurred at 20 or more weeks of gestation ( i.e., the duration of gestation that is commonly considered to denote the viability of the fetus). Eligible populations ○ Healthy individuals (general population) ○ Individuals at increased risk of postpartum complications due to pregnancy-related conditions ( e.g., hypertensive disorders of pregnancy, gestational diabetes) ○ Individuals at increased risk of postpartum complications due to incident or newly diagnosed conditions postpartum ( e.g., postpartum hypertension, Start Printed Page 14014 postpartum depression, new-onset diabetes) • Exclude.

○ Individuals with specific health conditions not typically managed by providers of pregnancy and postpartum care, (e.g., multiple sclerosis, HIV, cancer, substance use disorders other than tobacco). ○ Individuals with diagnosed chronic conditions—pre-existing (non-gestational) diabetes, cardiac disease/risk factors (e.g., cardiomyopathy, pre-existing [non-gestational] hypertension), mood disorders (e.g., major depression, anxiety), stress urinary incontinence, and dyspareunia. Interventions More comprehensive insurance coverage Extended duration of insurance coverage More continuous insurance coverage • Better/more continuous access to care as the result of a targeted program at the state, system, or provider level ( e.g., Medicaid expansion) Comparators Less comprehensive level of or no insurance coverage Less continuous insurance coverage Worse, less continuous, or no access to healthcare Outcomes (* and bold font denotes important outcomes that will be used when developing Strength of Evidence tables) • Intermediate and healthcare utilization outcomes ○ Attendance at postpartum visits * ○ Unplanned care utilization ( e.g., readmissions, emergency room visits) * ○ Adherence to condition-specific screening/testing ( e.g., blood pressure monitoring, glucose tolerance testing) or treatment * ○ Transition to primary care provider for long-term care * • Clinical outcomes (as appropriate, outcomes include incidence, prevalence/continuation, severity, and resolution) ○ Maternal mortality * ○ Symptoms or diagnosis of mental health conditions ( e.g., anxiety, depression, substance use) * ○ Patient-reported outcomes Quality of life (using validated measures) * Perceived stress * Pain Sleep quality Fatigue Sexual well-being and satisfaction Awareness of risk factors for long-term ill health ○ Physical health/medical outcomes Postpartum onset of preeclampsia or hypertension s ( e.g., mastitis, wound s) Severe maternal morbidity ○ Cardiovascular disorders ( e.g., cardiomyopathy) ○ Cerebrovascular disorders ( e.g., stroke) ○ Bleeding ○ Venous thromboembolism ○ Other ○ Interpregnancy interval ○ Unintended pregnancies ○ Contraceptive initiation and continuation ○ Breastfeeding intention, initiation, duration, and exclusivity ○ Reduction in health inequities ( e.g., by race, ethnicity, geography, disability status) • Harms ○ Health inequities * ○ Perceived discrimination * ○ Over-utilization of healthcare ○ Patient burden regarding postpartum care Potential Effect Modifiers • Patient-level factors ○ Age ○ Race/ethnicity ○ Gender identity ○ Sexual identity ○ Physical disability status ○ Socioeconomic status ○ Immigration status ○ Barriers to transportation to healthcare facility ○ Paid family leave policies ( e.g., presence versus absence, different durations of leave) ○ Substance use/substance use disorder ○ Type of insurance coverage (insured versus uninsured, private versus public [ e.g., Medicaid], insurance coverage of postpartum care, Medicaid insurance coverage extension or expansion) ○ Presence versus absence of disorders of pregnancy ( e.g., hypertensive, cardiovascular, gestational diabetes mellitus) or peripartum complications that increase risk of postpartum complications ○ Preterm versus term delivery ○ Live birth versus stillbirth/spontaneous abortion/induced abortion ○ Number of infants (singleton versus twins/triplets, etc.) ○ Presence versus absence of a supportive partner ○ Infant health ( e.g., neonatal intensive care unit [NICU] admission, congenital anomalies) • Setting factors ○ Geographic location (urban versus suburban versus rural) ○ Different levels of neighborhood vulnerability ( e.g., social vulnerability index) ○ Volume of facility/hospital (high versus low) ○ Type of facility/hospital (private versus public) ○ Racial/ethnic concordance between provider and patient ○ Language concordance between provider and patient Timing • Interventions and Comparators.

Within 1 year after giving birth • Outcome measurement. Up to 1 year after giving birth (except interpregnancy interval, unintended pregnancies, and chronic diseases [ e.g., diabetes, hypertension], which can be later) Settings U.S. Only Outpatient care • Exclude.

Institutionalized settings (e.g., prisons) Design Randomized controlled trials (N ≥10 participants per group) Nonrandomized comparative studies, longitudinal (prospective or retrospective) or cross-sectional (N ≥30 participants per group) Case-control studies (N ≥30 participants per group) • Exclude. Single-group (noncomparative) studies, comparative cross-sectional studies (without a discernable time-period between intervention and measurement of outcomes), qualitative studies Start Signature Dated. March 7, 2022.

Marquita Cullom, Associate Director. End Signature End Supplemental InformationStart Preamble Start Printed Page 13300 Health Resources and Services Administration (HRSA), Department of Health and Human Services. Notice.

In compliance with the requirement for opportunity for public comment on proposed data collection projects of the Paperwork Reduction Act of 1995, HRSA announces plans to submit an Information Collection Request (ICR), described below, to the Office of Management and Budget (OMB). Prior to submitting the ICR to OMB, HRSA seeks comments from the public regarding the burden estimate, below, or any other aspect of the ICR. Comments on this ICR should be received no later than May 9, 2022.

Submit your comments to paperwork@hrsa.gov or by mail to the HRSA Information Collection Clearance Officer, Room 14N136B, 5600 Fishers Lane, Rockville, MD 20857. Start Further Info To request more information on the proposed project or to obtain a copy of the data collection plans and draft instruments, email paperwork@hrsa.gov or call Samantha Miller, the HRSA Information Collection Clearance Officer at (301) 443-9094. End Further Info End Preamble Start Supplemental Information When submitting comments or requesting information, please include the information collection request title for reference.

Information Collection Request Title. Medicare Rural Hospital Flexibility Program Performance OMB No. 0915-0363—Revision.

Abstract. This information collection request is for continued approval of the Medicare Rural Hospital Flexibility Program Performance Measures. HRSA is proposing to continue this data collection with minor changes to the organization of the data.

The current performance measures are collected electronically in the Performance Improvement and Measurement System which awardees access securely through the HRSA Electronic Handbooks. The Medicare Rural Hospital Flexibility Program (Flex Program) is authorized by Section 1820 of the Social Security Act (42 U.S.C. 1395i-4), as amended.

The purpose of the Flex Program is to enable state designated entities to support critical access hospitals in quality improvement, quality reporting, performance improvement, and benchmarking. To assist facilities seeking designation as critical access hospitals. And to create a program to establish or expand the provision of rural emergency medical services (EMS).

Need and Proposed Use of the Information. For this program, performance measures were developed to provide data useful to the Flex program and to enable HRSA to provide aggregate program data required by Congress under the Government Performance and Results Modernization Act of 2010. These measures cover principal topic areas of interest to the Federal Office of Rural Health Policy, including.

(a) Quality reporting, (b) quality improvement interventions, (c) financial and operational improvement initiatives, (d) population health management, (e) rural EMS integration and (f) innovative care models. In addition to informing the Office's progress toward meeting the goals set in the Government Performance and Results Modernization Act of 2010, the information is important in identifying and understanding programmatic improvement across program areas, as well as guiding future iterations of the Flex Program and prioritizing areas of need and support. This submission includes the addition of minor revisions in the organization of the measures to align with the changes to the organization of the program areas within the Flex Program.

The revisions include changes to align with current language and a broadening of scope for some activities. The measures will remain unchanged. For example.

Previously, population health improvement activities were combined with rural EMS integration, and these measures will be separated into two distinct program areas. The burden remains unchanged with these changes. Likely Respondents.

Respondents are the Flex Program coordinators for the states participating in the Flex Program. There are currently 45 states participating in the Flex Program. Burden Statement.

Burden in this context means the time expended by persons to generate, maintain, retain, disclose or provide the information requested. This includes the time needed to review instructions. To develop, acquire, install, and utilize technology and systems for the purpose of collecting, validating and verifying information, processing and maintaining information, and disclosing and providing information.

To train personnel and to be able to respond to a collection of information. To search data sources. To complete and review the collection of information.

And to transmit or otherwise disclose the information. The total annual burden hours estimated for this ICR are summarized in the table below. Total Estimated Annualized Burden HoursForm nameNumber of respondentsNumber of responses per respondentTotal responsesAverage burden per response (in hours)Total burden hoursPerformance Improvement Measurement System (within the Electronic Handbooks system45145703,150Total4545703,150 Start Printed Page 13301 HRSA specifically requests comments on (1) the necessity and utility of the proposed information collection for the proper performance of the agency's functions, (2) the accuracy of the estimated burden, (3) ways to enhance the quality, utility, and clarity of the information to be collected, and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

Start Signature Maria G. Button, Director, Executive Secretariat. End Signature End Supplemental Information.

Start Preamble Agency for buy levitra online uk Healthcare Research and Quality https://alistkandb.co.uk/lasix-cost (AHRQ), HHS. Request for supplemental evidence and data submissions buy levitra online uk. The Agency for Healthcare Research and Quality (AHRQ) is seeking scientific information submissions from the public. Scientific information is buy levitra online uk being solicited to inform our review on Postpartum Care for Women Up to One Year After Pregnancy, which is currently being conducted by the AHRQ's Evidence-based Practice Centers (EPC) Program. Access to published and unpublished pertinent scientific information will improve the quality of this review.

Submission Deadline on or before April buy levitra online uk 11, 2022. Email buy levitra online uk submissions. Epc@ahrq.hhs.gov. Print submissions buy levitra online uk. Mailing Address.

Center for buy levitra online uk Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Attn. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857. Shipping Address (FedEx, buy levitra online uk UPS, etc.). Center for Evidence and Practice Improvement, Agency for Healthcare buy levitra online uk Research and Quality, ATTN. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E77D, Rockville, MD 20857.

Jenae Benns, buy levitra online uk Telephone. 301-427-1496 or Email. Epc@ahrq.hhs.gov. End Preamble Start Supplemental Information The Agency for Healthcare Research and Quality has commissioned the Evidence-based Practice Centers (EPC) Program to complete a review of the evidence for Postpartum Care for Women Up to One Year After Pregnancy. AHRQ is conducting this technical brief pursuant to Section 902 of the Public Health Service Act, 42 U.S.C.

299a. The EPC Program is dedicated to identifying as many studies as possible that are relevant to the questions for each of its reviews. In order to do so, we are supplementing the usual manual and electronic database searches of the literature by requesting information from the public ( e.g., details of studies conducted). We are looking for studies that report on Postpartum Care for Women Up to One Year After Pregnancy, including those that describe adverse events. The entire research protocol is available online at.

Https://effectivehealthcare.ahrq.gov/​products/​postpartum-care-one-year/​protocol. This is to notify the public that the EPC Program would find the following information on Postpartum Care for Women Up to One Year After Pregnancy helpful. A list of completed studies that your organization has sponsored for this indication. In the list, please indicate whether results are available on ClinicalTrials.gov along with the ClinicalTrials.gov trial number. For completed studies that do not have results on ClinicalTrials.gov, a summary, including the following elements.

Study number, study period, design, methodology, indication and diagnosis, proper use instructions, inclusion and exclusion criteria, primary and secondary outcomes, baseline characteristics, number of patients screened/eligible/enrolled/lost to follow-up/withdrawn/analyzed, effectiveness/efficacy, and safety results. A list of ongoing studies that your organization has sponsored for this indication. In the list, please provide the ClinicalTrials.gov trial number or, if the trial is not registered, the protocol for the study including a study number, the study period, design, methodology, indication and diagnosis, proper use instructions, inclusion and exclusion criteria, and primary and secondary outcomes. Description of whether the above studies constitute ALL Phase II and above clinical trials sponsored by your organization for this indication and an index outlining the relevant information in each submitted file. Your contribution is very beneficial to the Program.

Materials submitted must be publicly available or able to be made public. Materials that are considered confidential. Marketing materials. Study types not included in the review. Or information on indications not included in the review cannot be used by the EPC Program.

This is a voluntary request for information, and all costs for complying Start Printed Page 14012 with this request must be borne by the submitter. The draft of this review will be posted on AHRQ's EPC Program website and available for public comment for a period of 4 weeks. If you would like to be notified when the draft is posted, please sign up for the email list at. Https://www.effectivehealthcare.ahrq.gov/​email-updates. The systematic review will answer the following questions.

This information is provided as background. AHRQ is not requesting that the public provide answers to these questions. Key Questions (KQ) KQ 1. What healthcare delivery strategies affect postpartum healthcare utilization and improve maternal outcomes within 1 year postpartum?. a.

Do the healthcare delivery strategies affect postpartum healthcare utilization and improve maternal outcomes within 3 months postpartum?. Does this relationship differ by timing of outcomes, specifically within 6 days postpartum, between 1 to 6 weeks postpartum, and between 6 weeks and 3 months postpartum?. b. Do the healthcare delivery strategies affect postpartum healthcare utilization and improve maternal outcomes between 3 months and 1 year postpartum?. KQ 2.

Does extension of health insurance coverage or improvements in access to healthcare affect postpartum healthcare utilization and improve maternal outcomes within 1 year postpartum?. PICOTSD (Populations, Interventions, Comparators, Outcomes, Timing, Settings, and Design) Key Question 1 (Strategies for Healthcare Delivery) Populations Individuals (of any age) who are in the postpartum period (defined as within 1 year after giving birth). ○ For this review, “giving birth” is defined as a live birth, intrauterine fetal death (IUFD)/stillbirth, or induced abortion that occurred at 20 or more weeks of gestation ( i.e., the duration of gestation that is commonly considered to denote the viability of the fetus). Eligible populations ○ Healthy individuals (general population) ○ Individuals at increased risk of postpartum complications due to pregnancy-related conditions ( e.g., hypertensive disorders of pregnancy, gestational diabetes) ○ Individuals at increased risk of postpartum complications due to incident or newly diagnosed conditions postpartum ( e.g., postpartum hypertension, postpartum depression, new-onset diabetes) • Exclude. ○ Individuals with specific health conditions not typically managed by providers of pregnancy and postpartum care, (e.g., multiple sclerosis, HIV, cancer, substance use disorders other than tobacco).

○ Individuals with diagnosed chronic conditions—pre-existing (non-gestational) diabetes, cardiac disease/risk factors (e.g., cardiomyopathy, pre-existing [non-gestational] hypertension), mood disorders (e.g., major depression, anxiety), stress urinary incontinence, and dyspareunia. Content of Interventions Provided (note that these are not the interventions being compared in the review). Categories of interventions include components of the ACOG Postpartum Care Plan: 18 Counseling, support, and education regarding ○ Infant care and feeding ○ Reproductive life planning and contraception ○ Adverse pregnancy outcomes associated with cardiometabolic disease ○ Risks and behaviors associated with poor postpartum health Screening or prevention of. ○ Pregnancy complications ○ Common chronic health conditions ( e.g., hypertension, diabetes) ○ Mental health conditions ( e.g., depression, anxiety) ○ Common gynecologic problems ( e.g., sexually transmitted s, cervical cancer) ○ Common postpartum problems ( e.g., stress urinary incontinence, dyspareunia) • Exclude. ○ Treatments for acute or emergency postpartum conditions (e.g., for mastitis, urinary tract s, other s) ○ Treatments or other interventions for conditions unrelated to pregnancy (e.g., HIV, schizophrenia) ○ Treatments or other interventions for acute conditions during pregnancy or occurring around the time of giving birth (e.g., for postpartum hemorrhage, preeclampsia with severe features) ○ Treatments or other interventions directed at the infant (e.g., well-child visits, otitis media, colic) ○ Referral-only interventions (e.g., lactation consultants for specific lactation problems) Delivery Strategies • Where healthcare is delivered— e.g., hospital, clinic, home visit, community health center, birth center, virtual care/telehealth, Women Infants and Children (WIC) program office/site • How healthcare is delivered— e.g., dedicated postpartum care visit, as part of well-child visit, group visit • When healthcare is delivered— e.g., timing before giving birth, after giving birth, or at postpartum visits Who provides healthcare/support ○ Predominantly health system-based care — e.g., OB/GYN, midwife, pediatrician, family physician, internist, physician assistant, nurse practitioner, nurse, lactation consultant (when integrated as part of the care), clinical psychologist or other mental health professional ○ Predominantly community-based care — e.g., doula support, community health worker, lay support, social worker/support, peer support, case manager • Healthcare coordination and management of care— e.g., patient navigators, creation and implementation of post-birth care plans, strategies for continuity of care/care transitions, strategies to facilitate access to appointments/scheduling, postpartum specialty care clinics, multidisciplinary care models ( e.g., maternal and child health centers, maternity care homes), evidence-based care protocols, incentives for care completion • Information and communication technology— e.g., bidirectional telemedicine, virtual televisits, phone visits, bidirectional texting, real-time chat-bots, smartphone or computer applications designed to enhance provision of postpartum healthcare ○ Exclude.

Social media or support groups (without provider involvement), web or device applications aimed at general health maintenance • Interventions targeted at healthcare providers or systems— e.g., interventions to improve guideline-adherent care, clinical decision support tools, interventions to help reduce healthcare inequities ( e.g., promoting respectful care) • Exclude. ○ Referral-only interventions (e.g., lactation consultants for specific lactation problems) Start Printed Page 14013 ○ Treatments for specific ailments or conditions (e.g., pelvic floor physical therapy, urinary incontinence treatment, contraception, pain treatment, cognitive behavioral therapy) ○ Insurance extension (which is covered in KQ 2) Comparator Delivery Strategies Standard delivery strategy Alternative delivery strategy Outcomes (* and bold font denotes important outcomes that will be used when developing Strength of Evidence tables) • Intermediate and healthcare utilization outcomes ○ Attendance at postpartum visits * ○ Unplanned care utilization ( e.g., unplanned readmissions, emergency room visits) * ○ Adherence to condition-specific screening/testing ( e.g., blood pressure monitoring, glucose tolerance testing) or treatment * ○ Transition to primary care provider for long-term care * • Clinical outcomes (as appropriate, outcomes include incidence, prevalence/continuation, severity, and resolution) ○ Maternal mortality * ○ Symptoms or diagnosis of mental health conditions ( e.g., anxiety, depression, substance use) * ○ Patient-reported outcomes Quality of life (using validated measures) * Perceived stress * Pain Sleep quality Fatigue Sexual well-being and satisfaction Awareness of risk factors for long-term ill health ○ Physical health/medical outcomes Postpartum onset of preeclampsia or hypertension s ( e.g., mastitis, wound s) Severe maternal morbidity ○ Cardiovascular disorders ( e.g., cardiomyopathy) ○ Cerebrovascular disorders ( e.g., stroke) ○ Bleeding ○ Venous thromboembolism ○ Other ○ Interpregnancy interval ○ Unintended pregnancies ○ Contraceptive initiation and continuation ○ Breastfeeding intention, initiation, duration, and exclusivity ○ Reduction in health inequities ( e.g., by race, ethnicity, geography, disability status) • Harms ○ Health inequities * ○ Perceived discrimination * ○ Over-utilization of healthcare ○ Patient burden regarding postpartum care Potential Effect Modifiers • Patient-level factors ○ Age ○ Race/ethnicity ○ Gender identity ○ Sexual identity ○ Physical disability status ○ Socioeconomic status ○ Immigration status ○ Barriers to transportation to healthcare facility ○ Paid family leave policies ( e.g., presence versus absence, different durations of leave) ○ Access to internet (for virtual care/telehealth questions) ○ Substance use/substance use disorder ○ Type of insurance coverage (insured versus uninsured, private versus public [ e.g., Medicaid], insurance coverage of postpartum care, Medicaid insurance coverage extension or expansion) ○ Presence versus absence of disorders of pregnancy ( e.g., hypertensive, cardiovascular, gestational diabetes mellitus) or peripartum complications that increase risk of postpartum complications ○ Preterm versus term delivery ○ Live birth versus stillbirth/spontaneous abortion/induced abortion ○ Number of infants (singleton versus twins/triplets, etc.) ○ Presence versus absence of a supportive partner ○ Infant health ( e.g., neonatal intensive care unit [NICU] admission, congenital anomalies) • Setting factors ○ Country (U.S. Versus other high-income countries) ○ Geographic location (urban versus suburban versus rural) ○ Different levels of neighborhood vulnerability ( e.g., social vulnerability index) ○ Volume of facility/hospital (high versus low) ○ Type of facility/hospital (private versus public) ○ Racial/ethnic concordance between provider and patient ○ Language concordance between provider and patient Timing • Delivery strategy and comparator delivery strategy. Antenatal or postpartum (or both) ○ If the service is delivered antenatally, the strategy must be aimed at postpartum health (not just that the outcome was measured during the postpartum period). • Outcome measurement.

For KQ 1a. Within 3 months after giving birth. For KQ 1b. 3 months to 1 year after giving birth (except interpregnancy interval, unintended pregnancies, and chronic diseases [ e.g., diabetes, hypertension], which can be later) Settings • High-income countries (as classified by the World Bank—see https://datahelpdesk.worldbank.org/​knowledgebase/​articles/​906519-world-bank-country-and-lending-groups ) Outpatient care • Exclude. Institutionalized settings (e.g., prisons) Design Randomized controlled trials (N ≥10 participants per group) Nonrandomized comparative studies, longitudinal (prospective or retrospective) (N ≥30 participants per group) Case-control studies (N ≥30 participants per group) • Exclude.

Single-group (noncomparative) studies, comparative cross-sectional studies (without a discernable time-period between implementation of strategy for intervention and measurement of outcomes), qualitative studies Key Question 2 (Extension of Healthcare or Insurance Coverage) Populations Individuals (of any age) who are in the postpartum period (defined as within 1 year after giving birth). ○ For this review, “giving birth” is defined as a live birth, intrauterine fetal death (IUFD)/stillbirth, or induced abortion that occurred at 20 or more weeks of gestation ( i.e., the duration of gestation that is commonly considered to denote the viability of the fetus). Eligible populations ○ Healthy individuals (general population) ○ Individuals at increased risk of postpartum complications due to pregnancy-related conditions ( e.g., hypertensive disorders of pregnancy, gestational diabetes) ○ Individuals at increased risk of postpartum complications due to incident or newly diagnosed conditions postpartum ( e.g., postpartum hypertension, Start Printed Page 14014 postpartum depression, new-onset diabetes) • Exclude. ○ Individuals with specific health conditions not typically managed by providers of pregnancy and postpartum care, (e.g., multiple sclerosis, HIV, cancer, substance use disorders other than tobacco). ○ Individuals with diagnosed chronic conditions—pre-existing (non-gestational) diabetes, cardiac disease/risk factors (e.g., cardiomyopathy, pre-existing [non-gestational] hypertension), mood disorders (e.g., major depression, anxiety), stress urinary incontinence, and dyspareunia.

Interventions More comprehensive insurance coverage Extended duration of insurance coverage More continuous insurance coverage • Better/more continuous access to care as the result of a targeted program at the state, system, or provider level ( e.g., Medicaid expansion) Comparators Less comprehensive level of or no insurance coverage Less continuous insurance coverage Worse, less continuous, or no access to healthcare Outcomes (* and bold font denotes important outcomes that will be used when developing Strength of Evidence tables) • Intermediate and healthcare utilization outcomes ○ Attendance at postpartum visits * ○ Unplanned care utilization ( e.g., readmissions, emergency room visits) * ○ Adherence to condition-specific screening/testing ( e.g., blood pressure monitoring, glucose tolerance testing) or treatment * ○ Transition to primary care provider for long-term care * • Clinical outcomes (as appropriate, outcomes include incidence, prevalence/continuation, severity, and resolution) ○ Maternal mortality * ○ Symptoms or diagnosis of mental health conditions ( e.g., anxiety, depression, substance use) * ○ Patient-reported outcomes Quality of life (using validated measures) * Perceived stress * Pain Sleep quality Fatigue Sexual well-being and satisfaction Awareness of risk factors for long-term ill health ○ Physical health/medical outcomes Postpartum onset of preeclampsia or hypertension s ( e.g., mastitis, wound s) Severe maternal morbidity ○ Cardiovascular disorders ( e.g., cardiomyopathy) ○ Cerebrovascular disorders ( e.g., stroke) ○ Bleeding ○ Venous thromboembolism ○ Other ○ Interpregnancy interval ○ Unintended pregnancies ○ Contraceptive initiation and continuation ○ Breastfeeding intention, initiation, duration, and exclusivity ○ Reduction in health inequities ( e.g., by race, ethnicity, geography, disability status) • Harms ○ Health inequities * ○ Perceived discrimination * ○ Over-utilization of healthcare ○ Patient burden regarding postpartum care Potential Effect Modifiers • Patient-level factors ○ Age ○ Race/ethnicity ○ Gender identity ○ Sexual identity ○ Physical disability status ○ Socioeconomic status ○ Immigration status ○ Barriers to transportation to healthcare facility ○ Paid family leave policies ( e.g., presence versus absence, different durations of leave) ○ Substance use/substance use disorder ○ Type of insurance coverage (insured versus uninsured, private versus public [ e.g., Medicaid], insurance coverage of postpartum care, Medicaid insurance coverage extension or expansion) ○ Presence versus absence of disorders of pregnancy ( e.g., hypertensive, cardiovascular, gestational diabetes mellitus) or peripartum complications that increase risk of postpartum complications ○ Preterm versus term delivery ○ Live birth versus stillbirth/spontaneous abortion/induced abortion ○ Number of infants (singleton versus twins/triplets, etc.) ○ Presence versus absence of a supportive partner ○ Infant health ( e.g., neonatal intensive care unit [NICU] admission, congenital anomalies) • Setting factors ○ Geographic location (urban versus suburban versus rural) ○ Different levels of neighborhood vulnerability ( e.g., social vulnerability index) ○ Volume of facility/hospital (high versus low) ○ Type of facility/hospital (private versus public) ○ Racial/ethnic concordance between provider and patient ○ Language concordance between provider and patient Timing • Interventions and Comparators. Within 1 year after giving birth • Outcome measurement. Up to 1 year after giving birth (except interpregnancy interval, unintended pregnancies, and chronic diseases [ e.g., diabetes, hypertension], which can be later) Settings U.S. Only Outpatient care • Exclude. Institutionalized settings (e.g., prisons) Design Randomized controlled trials (N ≥10 participants per group) Nonrandomized comparative studies, longitudinal (prospective or retrospective) or cross-sectional (N ≥30 participants per group) Case-control studies (N ≥30 participants per group) • Exclude.

Single-group (noncomparative) studies, comparative cross-sectional studies (without a discernable time-period between intervention and measurement of outcomes), qualitative studies Start Signature Dated. March 7, 2022. Marquita Cullom, Associate Director. End Signature End Supplemental InformationStart Preamble Start Printed Page 13300 Health Resources and Services Administration (HRSA), Department of Health and Human Services. Notice.

In compliance with the requirement for opportunity for public comment on proposed data collection projects of the Paperwork Reduction Act of 1995, HRSA announces plans to submit an Information Collection Request (ICR), described below, to the Office of Management and Budget (OMB). Prior to submitting the ICR to OMB, HRSA seeks comments from the public regarding the burden estimate, below, or any other aspect of the ICR. Comments on this ICR should be received no later than May 9, 2022. Submit your comments to paperwork@hrsa.gov or by mail to the HRSA Information Collection Clearance Officer, Room 14N136B, 5600 Fishers Lane, Rockville, MD 20857. Start Further Info To request more information on the proposed project or to obtain a copy of the data collection plans and draft instruments, email paperwork@hrsa.gov or call Samantha Miller, the HRSA Information Collection Clearance Officer at (301) 443-9094.

End Further Info End Preamble Start Supplemental Information When submitting comments or requesting information, please include the information collection request title for reference. Information Collection Request Title. Medicare Rural Hospital Flexibility Program Performance OMB No. 0915-0363—Revision. Abstract.

This information collection request is for continued approval of the Medicare Rural Hospital Flexibility Program Performance Measures. HRSA is proposing to continue this data collection with minor changes to the organization of the data. The current performance measures are collected electronically in the Performance Improvement and Measurement System which awardees access securely through the HRSA Electronic Handbooks. The Medicare Rural Hospital Flexibility Program (Flex Program) is authorized by Section 1820 of the Social Security Act (42 U.S.C. 1395i-4), as amended.

The purpose of the Flex Program is to enable state designated entities to support critical access hospitals in quality improvement, quality reporting, performance improvement, and benchmarking. To assist facilities seeking designation as critical access hospitals. And to create a program to establish or expand the provision of rural emergency medical services (EMS). Need and Proposed Use of the Information. For this program, performance measures were developed to provide data useful to the Flex program and to enable HRSA to provide aggregate program data required by Congress under the Government Performance and Results Modernization Act of 2010.

These measures cover principal topic areas of interest to the Federal Office of Rural Health Policy, including. (a) Quality reporting, (b) quality improvement interventions, (c) financial and operational improvement initiatives, (d) population health management, (e) rural EMS integration and (f) innovative care models. In addition to informing the Office's progress toward meeting the goals set in the Government Performance and Results Modernization Act of 2010, the information is important in identifying and understanding programmatic improvement across program areas, as well as guiding future iterations of the Flex Program and prioritizing areas of need and support. This submission includes the addition of minor revisions in the organization of the measures to align with the changes to the organization of the program areas within the Flex Program. The revisions include changes to align with current language and a broadening of scope for some activities.

The measures will remain unchanged. For example. Previously, population health improvement activities were combined with rural EMS integration, and these measures will be separated into two distinct program areas. The burden remains unchanged with these changes. Likely Respondents.

Respondents are the Flex Program coordinators for the states participating in the Flex Program. There are currently 45 states participating in the Flex Program. Burden Statement. Burden in this context means the time expended by persons to generate, maintain, retain, disclose or provide the information requested. This includes the time needed to review instructions.

To develop, acquire, install, and utilize technology and systems for the purpose of collecting, validating and verifying information, processing and maintaining information, and disclosing and providing information. To train personnel and to be able to respond to a collection of information. To search data sources. To complete and review the collection of information. And to transmit or otherwise disclose the information.

The total annual burden hours estimated for this ICR are summarized in the table below. Total Estimated Annualized Burden HoursForm nameNumber of respondentsNumber of responses per respondentTotal responsesAverage burden per response (in hours)Total burden hoursPerformance Improvement Measurement System (within the Electronic Handbooks system45145703,150Total4545703,150 Start Printed Page 13301 HRSA specifically requests comments on (1) the necessity and utility of the proposed information collection for the proper performance of the agency's functions, (2) the accuracy of the estimated burden, (3) ways to enhance the quality, utility, and clarity of the information to be collected, and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden. Start Signature Maria G. Button, Director, Executive Secretariat. End Signature End Supplemental Information.