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To hug or not to hug, generic cipro prices that’s the question right now. We’re in a precarious place in the world of greetings etiquette. Depending on where you live, generic cipro prices many of us are vaccinated.

But it’s hard to know for sure before you embrace whether or not the person you’re leaning into has gotten the jab. At the same time, many of us are yearning for the warmth of a hug after a long year of social isolation. Humans, according to experts, biologically need touch and a generic cipro prices good long hug is one of the best ways to get it.

Suzanne Degges-White is a professor and researcher focused on social relationships at Northern Illinois University in Dekalb, IL. She says that our need for a hug goes all the way back to the survival of our species. When we’re born we can’t care for ourselves generic cipro prices and we need to be comfortable being held in order to survive.

We’re rewarded with a rush of feel good hormones that come from a cozy embrace.“When we hug our brains release oxytocin, the bonding hormone, as well as serotonin and endorphins,” says Degges-White.This bond and sense of community has an important evolutionary role because for humans, the security of our small groups and later communities was really important to survival. Close contact helped build generic cipro prices civilization. As a result, our brains need each other and when we miss out it has psychological repercussions.“When we can’t hug we don’t get that jolt of good hormones,” says Degges-White.The need is so deeply engrained in us that over the past year due to buy antibiotics many people have been experiencing depression and anxiety due to what Degges-White calls “touch deprivation.” At first it was most rampant in already isolated nursing homes where the cipro initially did the most damage and over time, like the cipro itself, that need for connection spread to the wider community.

We may not know what we’re getting from greeting our friends and family with a hug. We just generic cipro prices enjoy it. It isn’t until those experiences are taken away that we feel pain and sadness.

An elbow bump or air greeting does not suffice. Research published in the journal Psychological Science has shown that hugging has a “stress buffering” effect that may even protect us from chronic illness and s.“We don’t miss it until it’s gone,” says generic cipro prices Degges-White. €œUntil you get a headache you don’t how good it feels not to have one.”Some of us grew up in more formal households where hugging wasn’t common.

Others may have experienced abuse that makes generic cipro prices hugging traumatic. But in both cases when children don’t experience healthy touch, it can impact their development. Kids that didn’t grow up being held, says Degges-White, miss out on that sense of safety and protection.

They may act generic cipro prices out or isolate from those around them. In some cases, the opposite may also be true. Some children may show too much affection, craving any form of positive attention that they didn’t get at home.What About Cultures Where Hugging Isn’t Common?.

While hugging might not be generic cipro prices the norm, connection is still key. In some communities, a parent wears the baby until they’re mobile so they’re constantly being held. Cultures that don’t hug might kiss as a greeting instead.

And in other cultures where hugging and embracing are not social norms, other forms of intimacy are more prevalent generic cipro prices. When people are more restrained in terms of greetings, they may be more sexually expressive. While in the United States we may hug as a generic cipro prices greeting, we have a culture of shame around sexual expression and around the body, but other countries don’t have that, says Degges-White.“In the end, every culture figures out their way of getting connection,” she says.

Is Hugging Safe Once You’re Vaccinated?. Still, for more than a year, we’ve been missing out and many of us are in a gray area when it comes to whether or not to reach in for that much-coveted warm embrace. But according to Rajeev Fernando, director of the Division of Infectious Diseases at Stony Brook Southampton Hospital in Southampton, New York, if you’re both vaccinated then go for it because research has shown that the risk of transmission generic cipro prices is extremely low.

And if you’re vaccinated but you don’t know for sure whether the person you’re hugging has been vaccinated, it’s still most likely safe.“The cipro can in theory colonize the nose without causing clinical disease but the risk is low and the chance of a vaccinated person getting serious clinical disease and hospitalized is exceedingly low,” says Fernando.When it comes to hugging younger children who haven’t been vaccinated, there’s a little bit more risk, but it’s still minimal when parents are vaccinated. Children don’t manifest buy antibiotics in the same way as adults because the antibiotics binds to ACE2 receptors which are abundant in adults but not in young children. Even if kids aren’t yet vaccinated, if adults are, the risk of transmission is still really low.But generic cipro prices if you’re an adult that’s not vaccinated, then hugging is still off limits, especially embracing others who are also unvaccinated because the cipro can easily be transmitted.

This is particularly true in parts of the country where there’s a higher percentage of people who are not vaccinated because the cipro is still floating around their communities. ciproes, Fernando says, unlike bacteria, can’t live on surfaces for any generic cipro prices period of time. They need a cell to survive.

That’s why transmission is airborne. Wearing a mask is safer than generic cipro prices not if you haven’t been vaccinated, but there’s still a risk when you’re getting that close. Unfortunately, says Fernando, “there are no slam dunks if you’re not vaccinated.” If we want things back to a place where we can safety reach in for that long awaited embrace, everyone who can be needs to get vaccinated.Around two years ago, a former high school science teacher was walking in the woods near Atlanta, Georgia when she came across a common, yet striking mushroom.

Many folks are familiar with this fungus, with its distinctive firetruck-red cap speckled by white dots, called the fly agaric or Amanita muscaria. It’s technically poisonous, but generic cipro prices while very rarely deadly, it can cause uncomfortable nausea and seizures. It’s also psychoactive, triggering a range of hallucinations that can be stimulating or sedating, depending on the person.The teacher, who uses the pseudonym Amanita Dreamer, had been planning for this walk to be her last.

After years of struggling on prescription benzodiazepines, she made a plan generic cipro prices to end her life. But intrigued by this strange toadstool, she took it home, researched it online and then took about 15 grams in a tea after dehydrating it.“That was probably that natural substance I had been looking for my whole life,” Dreamer tells Discover. €œI woke up the next morning, my life was just completely different.

I didn't have panic and anxiety probably for the first time generic cipro prices in my life. And I never took another benzo, I had no more pain, no more withdrawals, no more nothing.”Dreamer has since started taking the fungus on a regular basis, which is not recommended by most fungi guides. Still, she claims to receive some benefit from it.

She smokes a homemade blend of the mushrooms or sometimes eats the caps.Dreamer has started a YouTube channel with around 133,000 views dedicated to her experiences with the fungus, and opened an Etsy shop where she sells Amanita products (albeit labeled “not for human consumption.”) Amanita muscaria mushrooms are not illegal to harvest, sell, purchase or consume in the United States and most other countries, but Dreamer still prefers to stay semi-anonymous.In contrast, Amanita muscaria is almost certainly the most famous mushroom generic cipro prices in the world, found on every continent except Antarctica. The emoji for “mushroom” features the toadstool's white-freckled red caps, which have been prominent in everything from The Smurfs to Disney’s Fantasia. And yes, it's sometimes associated with images of someone magically shrinking or growing, like the shrooms in Super Mario or Alice in Wonderland.

Amanita mascara may soon become more than just a pop-culture generic cipro prices behemoth, though. It's also grabbed the attention of Psyched Wellness, a Canada-based startup seeking to capitalize on the fungi's potential wellness benefits. €œIt's kind of a rare situation, because [Amanita muscaria] has been used for centuries," says Psyched Wellness generic cipro prices CEO and director Jeff Stevens.

"But it hasn't had anyone step up and do the scientific work to get it to the point that you can put it on the shelf." Trendy Psychoactive Fungi Because fly agarics are psychoactive, many people confuse these mushrooms for psilocybin “magic” mushrooms, which are being studied by scientists for their therapeutic value in treating depression and PTSD. But the effects of these different fungi are remarkably different. For one, generic cipro prices A.

Muscaria mushrooms do not contain psilocybin. Their primary psychoactive ingredient is called muscimol and it works on GABAA receptors in the body, whereas psilocybin targets serotonin receptors. The subjective effects are quite different.There is also far less research on muscimol compared to psilocybin, which is celebrated as a primary drug generic cipro prices behind the “psychedelic renaissance” in recent years.

Psilocybin is the backbone of a handful biotech startups, including Compass Pathways, which has a market cap of $1.4 billion. Muscimol, however, has mostly been generic cipro prices ignored by scientists and recreational drug users. But that could be slowly changing, part of the broader mushroom wellness trend that is making fungus like Lion’s mane or Cordyceps popular.Psyched Wellness is in the process of making an Amanita muscaria extract into an over-the-counter wellness product for potentially treating sleep disorders, stress and even physical pain.

The company hopes to have a tincture called AME-1 on store shelves by mid-2022, followed by capsules, teas and topical ointments. They may even pursue it as a generic cipro prices prescription drug at some point.It’s long been possible to (legally) buy Amanita muscaria from online vendors. But before Psyched Wellness’s product appears next to CBD and chaga fungus, the company is doing some real science to unlock the fungi's full potential.

In May 2021, the company hired the National Research Council of Canada to study its proprietary extract for potential anti-inflammatory and neuroprotective properties. Psyched Wellness has also contracted KGK Science, a Canadian research organization, for generic cipro prices several preclinical oral toxicity study in rodents before moving onto humans. One test reported no adverse effects on treated animals after 14 days.But Stevens stresses that the doses involved won’t be enough to send someone on a trip.

€œWe're not suggesting at all that generic cipro prices this is something that you'd want to use on a macro level. We'll be framing it as microdosing tincture to help alleviate stress, similar to what effect you might have from say, melatonin, or even a glass of wine.”From Flying Reindeer to Modern MedicinePsyched Wellness is drawing on a long history of cultural use of Amanita muscaria mushrooms. For example, these mushrooms play a pivotal role in Indigenous Siberian religious practices, which may have inspired the legend of Santa Claus.

So far, Psyched Wellness is the only psychedelic startup exploring these mushrooms, which has attracted David Nutt, an English neuropsychopharmacologist at Imperial College London, who is also on the scientific advisory board of Compass Pathways.Because generic cipro prices these mushrooms aren’t illegal, unlike psilocybin, it will be a lot easier (and cheaper) to study them. Two clinical trials on muscimol have been started in the recent past, but both collapsed, allegedly due to funding issues. No data from these studies have been published.

The first was started in 2000 to see if muscimol can treat generic cipro prices epilepsy, while the other, for Parkinson’s disease, started in 2009. What makes Nutt and Psyched Wellness so sure that muscimol can help people this time around?. €œIn those days, we hadn't a clue how to use it,” says Nutt.

€œThis was a primitive pre-genome days where people hadn't a clue what they were doing [with muscimol.] I'm not pessimistic because I just think the science generic cipro prices has moved on dramatically.”Mitigating HarmsBut wait — aren’t Amanita muscaria mushrooms dangerous?. The answer is complicated. Most of the side effects generic cipro prices of fly agarics come from another compound present in the fungus called ibotenic acid.

This little molecule is the reason these mushrooms are a brilliant red, but also why they sometimes makes people vomit or become comatose.Ibotenic acid is considered by some to be neurotoxic. In fact, it has been widely used in scientific research to purposefully create lesions in the brains of rodents for studying how systems in the brain interact. But a problem with the majority of these studies is they are somewhat old and describe generic cipro prices injecting ibotenic acid directly into the brains of rodents.

That’s not really how people would consume the compound if it takes the form of tinctures, teas and capsules, so these findings may not translate. €œIbotenic acid has a really bad, distorted reputation,” Dreamer says. €œThere were never any generic cipro prices oral ingestion studies done.

And the biochemistry in the body is just radically different when you inject versus orally ingest something.”Regardless, it’s not difficult to remove the ibotenic acid from Amanita muscaria. Heat decarboxylates the ibotenic acid, turning it into muscimol, generic cipro prices which is much better tolerated. Psyched Wellness has designed a water-based extraction process that leaves only trace amounts of ibotenic acid.

The company hopes this will make it safer. €œI don't doubt that muscimol can be used both therapeutically and recreationally in a controlled dose,” says Hamilton Morris, a researcher and documentary filmmaker who has made films about the science of Amanita muscaria generic cipro prices. €œI do imagine that a lot of the problems associated with mushroom consumption could be mitigated in some kind of a standardized extract.

I'd be curious to see how that pans out.”Until more research is done, the full safety profile of Amanita muscaria is still unknown and people like Dreamer could be taking risks with their health. But the cultural ubiquity generic cipro prices of this iconic mushroom attests that few can avoid the colorful, magic, strangeness of it all. And there is clearly more to learn from this fungi.

€œThe historical use of Amanita goes back many thousands of years,” says Nutt generic cipro prices. €œAnd it's quite likely to be useful in terms of stress reduction, in terms of sleep, possibly even in terms of sociability and helping people bond. It might have prosocial effects.

So it's an open book, and it's great to start writing in it.”Summer means cookouts, picnics generic cipro prices and backyard barbecues. But a generous spread of food eaten outside raises some serious health questions. Nobody wants food poisoning – or to make their guests sick.

But how do you know when you’ve kept generic cipro prices the potato salad or fruit medley out too long?. As a professor and chair of the Food Science and Human Nutrition program at Iowa State University, I’ll answer those questions by starting with the basics of food safety.Two general classes of food-related microorganisms exist. Pathogenic organisms make you sick.

Other types of organisms make food look, smell and taste bad – in other words, they make food spoil.It’s usually pretty easy generic cipro prices to tell if spoilage microorganisms have invaded your food. Molds and fuzzy growth appear on solid foods. Liquids look generic cipro prices cloudy or clumpy and often smell bad.

Eating spoiled foods is never a good idea, and you’re smart to err on the side of caution. When in doubt, throw it out.Don’t use the same cutting board for meat and vegetables. (Credit.

Getty Images/ Enrique Díaz/7cero)Cutting Boards and Kitchen ThermometersPathogenic microorganisms in foods are much more stealthy. These microorganisms are the ones that cause cramps, vomiting, diarrhea, fever and chills – symptoms that people associate with the “stomach flu.” ciproes also cause food-borne illness. Typically, detecting pathogens in foods by smell or sight isn’t possible.

So proper handling and storage, and knowing when to toss leftovers, is critical.The first rule of food safety is to keep preparation areas clean. Developing a routine helps. Always wash your hands before handling food.

Make sure you thaw meats in the refrigerator, not on the countertop. Otherwise, as the frozen meat sits at room temperature, its outer surfaces warm faster than the interior. This allows pathogens to multiply.Don’t use the same cutting board for meat, fruits and vegetables.

In my kitchen, a red cutting board is for meat. The green one for fruits and vegetables. Use different knives, plates and utensils for the raw meats, and always put cooked meats on a clean plate.Never rinse off raw meat or chicken in the sink, because that practice spreads bacteria on kitchen surfaces.

Actually, there’s no need to rinse meat and chicken before cooking. But, if you insist, sanitize the sink with an antibacterial cleaning after moving the food away. That’s “after” – be sure not to contaminate any foods with the cleaner.Any pathogens will be destroyed by fully cooking the meat to the recommended temperatures.

Invest in a good kitchen thermometer. Although recommendations can vary slightly, you basically want an internal temperature of 160 F (71 C) for beef and pork, 165 F (74 C) for pouy, and 145 F (63 C) for fish and ham. Once food is cooked, keep hot foods at 140 F (60 C) or higher.

When transporting or serving foods over a period of time, keep cold foods on ice or in a cooler, especially during the hot summer months. Don’t let leftovers stay in the refrigerator too long. (Credit.

Getty Images/Jupiterimages)Dealing With LeftoversAfter the meal is over, don’t let the leftovers linger. Move them into the refrigerator quickly.As a newlywed, I spent Thanksgiving at my in-laws’ home in northern Minnesota. After dinner, they took all the serving dishes – turkey, stuffing and mashed potatoes – and put them on the screened porch for storage.

It was probably less than 20 F (-6 C) degrees outside – but still, that’s not a great idea because weather changes quickly and temperatures will fluctuate, leading to risk of pathogen growth.My husband also believed foods should cool down on the counter before putting them in the fridge. He said it reduced stress on the refrigerator. This is not necessary and increases the risk for food pathogens.

Modern refrigerators are fully capable of cooling warm foods quickly while maintaining their internal temperatures, so don’t hesitate to put away those leftovers as soon as possible.Now, with the fridge full of leftovers, how long are they good to eat?. Most cooked foods are safe to consume within three to four days. After that, contamination risk increases.

If you have more leftovers than you can eat in that time frame, put them in the freezer. Be sure to cook leftovers to 165 F (74 C) before eating.Baked goods like breads, cakes, pies and cookies made in your kitchen will have a shorter shelf life than store-purchased items because yours are without preservatives. They will become stale, lose their texture sooner and grow mold.

Once you see that, toss the whole thing out rather than try to cut away the contaminated spots. While it’s unlikely to cause severe illness, some bread molds produce toxins that might cause problems, particularly for children or the elderly.Foods with higher moisture content spoil faster because water gives bacteria a chance to grow. So carrot cakes or zucchini bread spoil within about five days.

Refrigerate these items, and you’ll increase their shelf life. Pies should be stored in the refrigerator and eaten within three to four days. Cookies are typically low in moisture, except those containing fruit, jam or icing.

Keep these types of cookies in the refrigerator and discard if they start to grow mold.As you get ready for your summer get-togethers, keep in mind that reducing food waste is good for both the environment and your budget, so consider portion sizes and the quantity you’re making to better manage leftovers. And remember that proper handling as you prepare and then store your meals will make sure you and your family enjoy your cookouts, parties and reunions without a food-related illness.Ruth S. MacDonald is the associate dean for personnel and finance for Iowa State University’s College of Agriculture and Life Sciences.

This article is republished from The Conversation under a Creative Commons license. Read the original article.This article contains affiliate links to products. Discover may receive a commission for purchases made through these links.Taking on a weight loss program practically seems to be second nature for anyone over the age of 30.

Millions of people attempt to work out and diet their way towards a better body, but these efforts might not be enough for individuals that need a little extra boost. The constant cycle of working but failing can be overwhelming for anyone, making it impossible to keep up the hope of a healthier body. Diet and exercise may take consumers part of the way towards their journey’s end, but the use of a supplement like Leptitox might help.

Thousands of people have already used this formula and found success when other products and programs did not work. What is Leptitox?. Leptitox is a weight loss formula, helping consumers to shed the extra fats from their body, even if they have struggled for years.

It is meant for individuals of all ages, though the user should be an adult. Women who are pregnant or breastfeeding may not want to prioritize a weight loss supplement yet, which is why they should check with their doctor ahead of time. Developed by firefighter Morgan Hurst and scientist Sonya Rhodes, this formula originally was meant to help the former's wife.

She had struggled to lose extra weight for years after giving birth to their three children. After consultation with Rhodes, Hurst finally found a solution that made it possible. The remedy is comprised of 22 ingredients that have been compressed into capsules, though the website doesn't fully discuss what each of these ingredients are.

The purpose of this supplement is to reduce the toxins that build up in the body, causing drastic decrease in energy. As this energy is replenished, users can more easily burn through the extra fat on their body. It also helps to regulate leptin, which is the hormone that signals when the individual has consumed enough food.

By taking this remedy, users can gain support and additional control of their appetites, even improving their complexion, and easing the pain on their joints. While users do not have to incorporate any diet or exercise program while they take Leptitox, the improved energy and lower appetite may be helpful to these efforts. The Pros and Cons of Leptitox Anytime someone chooses a weight loss supplement, they need to make sure they know what they're getting into.

Here are some of the pros and cons to consider before choosing Leptitox for any weight loss journey. Pros. Only uses natural ingredients to improve safety.

Causes minimal side effects, if any. Reduces hunger without artificial sensation. Allows users to continue eating favorite foods.

Improves the leptin production. Can safely stop using without withdrawal symptoms. Promotes greater energy levels.

Offers a 60-day refund policy for unsatisfied customers. Cons. May be expensive in comparison with other weight loss formulas.

Can only be purchased on the official website. May create varied results for users of different lifestyles. What Goes into Leptitox?.

The biggest appeal to the Leptitox formula is the collection of almost two dozen ingredients, working together to regulate leptin levels. Some of those ingredients include. Milk thistle Grapeseed Jujube Barberry Apium graveolens seed Brassicas Chanca Piedra Alfalfa Taraxacum leaves Meratrim Users should be aware that this is not a complete list of every ingredient in the formula.

Users can check the label to see if there are any ingredients that will interact poorly with current medication or allergies. Read on below to learn about the impact that each of the aforementioned ingredients can have on the body. Milk Thistle Milk Thistle primarily helps to detoxify the body of BPA.

This toxin is often found in items like plastic that consumers use every single day. Grapeseed Grapeseed eradicates cadmium, which is often found in many of the foods that consumers consider healthy. Nuts, vegetables, and cereal are all guilty of containing this substance.

Grapeseed is also helpful to individuals who want to burn more calories naturally. Jujube Jujube detoxifies the body of a substance called ZEA, which is primarily found in cereal products and corn products. It also promotes better energy levels, which is especially helpful for anyone who is working out while taking Leptitox.

Barberry Barberry is rich with berberine, helping to eliminate the excess fat that is stored on the body. It improves healthy cholesterol, and it stimulates the neurotransmitters in the brain to promote better focus. Apium Graveolens Seed Apium Graveolens essentially provides the user with the nutritional benefits of celery.

It eliminates DEHP stores in the body, which is a common element of all plastic sources. Brassicas Brassicas, which is a type of broccoli, floods the body with cysteine. Cysteine is an amino acid that helps users to reduce their food cravings naturally.

It is also necessary for the growth of new muscle. Chanca Piedra Chance Piedra doesn't actually reduce fat or purge the body of toxins. Instead, it works to reduce inflammation that affects the entire digestive system.

It protects the kidneys, and it can trigger a faster metabolism. Alfalfa Alfalfa also doesn't directly purge toxins or push the body to lose weight. Instead, it regulates cholesterol and manage is high blood pressure, which are two common concerns among individuals that suffer from obesity.

Taraxacum Leaves Taraxacum leaves come from dandelions. They are a rich source of vitamin K, and they help to protect the bones as they cleanse the liver. Meratrim Meratrim combines to medicinal herbs to improve metabolism.

It also protects the body from storing new fat as it sheds what it previously held. How Does Leptitox Improve Weight Loss?. The primary way that this formula improves weight loss is because it regulates leptin.

Leptin is a hormone that naturally exists in the body already, and it is released by fat cells. The purpose of this hormone is to let the body know when it is hungry, but individuals who have developed leptin resistance may not feel the urge to stop eating when they should. As the creators of this formula explain, the primary reason that this problem occurs is due to the toxins that can enter the body and collect over time.

It can also be caused by improper eating habits, causing the body to think that meals are coming infrequently. Leptitox pushes the detoxification that can accumulate, helping leptin levels to regulate again. With this regulation, the brain is able to receive the signals needed to stop the individual from consuming more food than they should.

Along with the improved reaction to leptin, the ingredients used also targets the fats that has accumulated in the body. It destroys the structure of the fat cells, helping the body to burn through stored fat for energy to lose weight quickly. Engaging in a healthy diet and regular physical activity can improve the already impressive results of any weight loss supplements, including Leptitox.

What Do Users Gain from Leptitox Use?. Consumers can find many benefits when they use Leptitox, even if they've only been trying to lose weight for a short amount of time. Many people have already found that this remedy can.

Promote incredible weight loss with minimal effort on the part of the user. Increase overall energy. Promote stronger and more consistent brain activity.

Reduce the severity of joint pain. Increased strength, texture, and overall health of hair. Improve the complexion with greater luminosity and strength.

Enhance overall health. Promote better confidence and self-worth. All of these benefits are clear signs that this remedy is good for anyone who wants to improve themselves.

Potential Side Effects of Leptitox Use The entire focus of the creators of Leptitox does not exclusively rely on the ingredients used or the benefits. The company develops each capsule within a facility that is already FDA approved, providing further validity to their products. While the FDA does not approve or disapprove of supplements (since they are neither food nor drug), using a facility that follows their regulations shows that the company prioritizes safety.

Considering the natural formulation, there are very few side effects ever reported regarding this formula. Even the few that customers have expressed concerns about are not severe at all. At the most, there are a few users that have said they experienced dizziness or lightheadedness, which is significantly better than the side effects reported by many medications.

Individuals that have allergies to one of the ingredients should avoid the formula entirely. The regulation of leptin can cause many different changes in the body, including. Frequent urination.

While these reactions are common with the changing hormones, the issues are less of a side effect of Leptitox and more of a hormonal reaction. There are many ingredients used to counteract these problems. Before using any remedy like Leptitox supplement, reach out to a medical professional to ensure that it is a good match.

Users that experience any adverse reaction should no longer take Leptitox. Stopping use is relatively easy because there are no addictive substances included. Who Shouldn’t Use Leptitox?.

For the most part, anyone can use the Leptitox formula if they are over age 18. Most of the reasons that the company gives for not using this product are simply a matter of safety with weight loss supplements of any kind. Women who are pregnant or breastfeeding are encouraged not to take the remedy without the approval from a doctor.

The same sentiment is extended to children since this remedy may be overwhelming for their body. Users that currently take any kind of medication may also want to consult with a doctor to determine if this remedy is safe to combine with it. How to Properly Use Leptitox Users can start taking the Leptitox formula at any time.

Users will start with two capsules each day to trigger the improvement in their leptin levels. It can be taken with or without food, leaving this preference entirely up to the user. If the user experiences weight loss rather quickly, they can reduce the serving to one capsule per day to keep up the results.

While some people experience fast weight loss, it is safe to reduce the capsule down to one every other day if necessary. Where to Buy Leptitox Right now, users are only able to purchase Leptitox on the official website. Since no other retailers have been authorized to offer it, users that find it on other websites are not likely getting a reliable source.

As an incentive for customers to purchase more of the product at one time, there are multiple packages offered. While a single bottle may only cost $59, users can reduce this cost as they stock up. Currently the packages include.

If the user finds that this formula is not the right solution for their weight loss, the company offers a 60-day money back guarantee. Users will only need to send back the amount that has not been used to get their full refund after contacting customer service. To get ahold of the customer service team, send an email to contact@leptitox.org.

Final Thoughts Leptitox provides users with a simple and proven way to eliminate their excess weight. With the added benefit of improved energy and more simulated brain activity, this supplement can improve the user's overall health with very little effort. Users can improve their sleep schedule and feel more prepared to take on the exercise that they want to integrate.

With a simple return policy that covers the first two months of use, there is no risk in trying out this remedy when so many other options have failed. Click Here to Visit the Official Leptitox Website to Buy for the Lowest Price Online.

Cipro hcl

3 February 2022 Members are invited to submit questions around buy antibiotics and Haemostasis to our Congress panel in advance Congress goers, this is cipro hcl your chance to take part in the discussion http://kcuei.com/where-can-i-get-cialis - what did we learn about buy antibiotics and haemostasis throughout the cipro?. Delegates are asked to submit questions cipro hcl to Congress@ibms.org. Then, join Professor Gary Moore, Director of Clinical Diagnostic Research, Technoclone, Dr Steve Kitchen, Clinical Scientist, The Royal Hallamshire Hospital and Dr Annette Bowyer, Clinical Scientist, The Royal Hallamshire Hospital at 11am on Wednesday 16 March 2022 for the ‘Q&A.

What we learnt from buy antibiotics’ cipro hcl. Changes in knowledge of the haemostatic system after the cipro How the cipro interferes with haemostasis What did we learn from the cipro and its effects.2 February 2022 In February's statement, David Wells talks about how the IBMS is working to broaden awareness of the value our members bring to society As the professional body for biomedical science, the IBMS has a responsibility that stretches beyond supporting the practice and careers of our members. We must also make sure that the government and public understand the value of what our members bring to society.Throughout the cipro, key decision makers did not appear to understand the value or complexities of having an accredited workforce in a diagnostics laboratory – or how our profession ensures safety, quality, well-being and peace cipro hcl of mind for patients across the UK.

However, after continually informing the press and public, we began to make headway and started meeting with policy makers.With the increased visibility that the IBMS helped to foster, things are looking better, backed up with a wave of funding. More people understand the value of what we do and how we do it but a big part of our next cipro hcl strategy is rightly focussed on taking further action to broaden this awareness.In order to change the way government and key decision makers think and respond to our role in society, it is essential that we start to build a body of peer reviewed evidence. This is why the IBMS is looking to offer funding for academic research that focuses on the value of having an accredited workforce in the biomedical science professions.

Many other areas of the healthcare services are supported by such studies and we want to make sure that our profession is better represented in this regard.The IBMS is also in the process of employing a Policy Lead. This means that we will have a dedicated expert whose sole responsibility will be to build stronger bridges and increase reach with the government and the relevant healthcare, academic and industrial leaders – constantly making sure that our profession’s concerns, information and advice are reaching the right people in the right ways.The inroads made over the last couple of years by Past-President Allan Wilson and others on our Council and Specialist Panels were hard won and we have learnt from this that the IBMS needs to establish the evidence and capability to put us on the front foot with politicians, government and policy officials going forward.While there are challenges ahead, rest assured that the IBMS is busy establishing and building upon our new strengths for the future benefit and support of our members, the profession and patient care..

3 February 2022 Members are invited to submit generic cipro prices questions around buy antibiotics and Haemostasis to our Congress panel in advance Congress goers, this is your chance to take part in the discussion - what did we learn about Where can i get cialis buy antibiotics and haemostasis throughout the cipro?. Delegates are generic cipro prices asked to submit questions to Congress@ibms.org. Then, join Professor Gary Moore, Director of Clinical Diagnostic Research, Technoclone, Dr Steve Kitchen, Clinical Scientist, The Royal Hallamshire Hospital and Dr Annette Bowyer, Clinical Scientist, The Royal Hallamshire Hospital at 11am on Wednesday 16 March 2022 for the ‘Q&A.

What we generic cipro prices learnt from buy antibiotics’. Changes in knowledge of the haemostatic system after the cipro How the cipro interferes with haemostasis What did we learn from the cipro and its effects.2 February 2022 In February's statement, David Wells talks about how the IBMS is working to broaden awareness of the value our members bring to society As the professional body for biomedical science, the IBMS has a responsibility that stretches beyond supporting the practice and careers of our members. We must also make sure that the government and public understand the value of what our members bring to society.Throughout the cipro, generic cipro prices key decision makers did not appear to understand the value or complexities of having an accredited workforce in a diagnostics laboratory – or how our profession ensures safety, quality, well-being and peace of mind for patients across the UK.

However, after continually informing the press and public, we began to make headway and started meeting with policy makers.With the increased visibility that the IBMS helped to foster, things are looking better, backed up with a wave of funding. More people understand the value of what we do and how we do it but a big part of our next strategy is rightly focussed generic cipro prices on taking further action to broaden this awareness.In order to change the way government and key decision makers think and respond to our role in society, it is essential that we start to build a body of peer reviewed evidence. This is why the IBMS is looking to offer funding for academic research that focuses on the value of having an accredited workforce in the biomedical science professions.

Many other areas of the healthcare services are supported by such studies and we want to make sure that our profession is better represented in this regard.The IBMS is also in the process of employing generic cipro prices a Policy Lead. This means that we will have a dedicated expert whose sole responsibility will be to build stronger bridges and increase reach with the government and the relevant healthcare, academic and industrial leaders – constantly making sure that our profession’s concerns, information and advice are reaching the right people in the right ways.The inroads made over the last couple of years by Past-President Allan Wilson and others on our Council and Specialist Panels were hard won and we have learnt from this that the IBMS needs to establish the evidence and capability to put us on the front foot with politicians, government and policy officials going forward.While there are challenges ahead, rest assured that the IBMS is busy establishing and building upon our new strengths for the future benefit and support of our members, the profession and patient care..

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KANSAS CITY, MO – After long http://www.ec-hay-reichstett.ac-strasbourg.fr/?page_id=2521 days spent toiling in fields under a hot Missouri sun, immigrant workers returned to what was once a county jail where their employer housed aeroporto cipro nord them in unsanitary living conditions and added to their misery by failing to pay them the wages they earned under their contract. Under terms of a settlement agreement signed by the U.S. Department of Labor and Marin aeroporto cipro nord J.

Corp of Avon Park, Florida, on Feb. 23, 2022, Marin aeroporto cipro nord J. Has agreed to pay $165,805 in back wages to 85 workers and a penalty of $75,000 for failing to provide meals, pay the required wage rate and charging workers to obtain employment in violation of the Immigrant and Naturalization Act and requirements of the H-2A visa program.

€œInvestigators found Marin J. Corp provided these workers with living quarters that were woefully inadequate and violated basic human decency, and violated aeroporto cipro nord specific guidelines of the H-2A program, including charging workers to obtain employment,” said Wage and Hour Regional Administrator Michael Lazzeri in Chicago. €œWhile it’s taken several years to settle this matter, the Department of Labor will pursue violators like Marin J.

Corp doggedly to uphold the law and ensure the safety of vulnerable workers, and recover the rightful wages of workers cheated by their employers.” In July 2018, the aeroporto cipro nord U.S. Department of Labor filed a complaint and a motion for a temporary restraining order and preliminary injunction with the U.S. District Court for the Eastern District of Missouri to aeroporto cipro nord enjoin Marin J.

Corp. From violating its obligations concerning its employment and housing of H-2A temporary agriculture workers under the H-2A visa program. The company complied with housing requirements following the court’s issuance of the temporary restraining aeroporto cipro nord order.

For more information about the FLSA and other laws enforced by the Wage and Hour Division, contact the division’s toll-free helpline at 866-4US-WAGE (487-9243). Calls can be answered in more than aeroporto cipro nord 200 languages, regardless of immigration status. Learn more about the Wage and Hour Division, including a search tool to use if you think you may be owed back wages collected by the division.ORLANDO, FL – Employers cannot avoid paying overtime by simply putting employees on a salary, a costly lesson learned by a Florida equipment rental company after a U.S.

Department of Labor investigation.The department’s Wage and aeroporto cipro nord Hour Division investigators determined that DeLand’s CJ Don’s Rental Group LLC and Ormond Beach’s Logsyd Group LLC – both operating as Southern Equipment Rental – paid flat salaries to certain employees, regardless of the number of hours they worked. By doing so, the employer violated overtime requirements of the Fair Labor Standards Act that require most employees to receive additional half-time when they work more than 40 hours in a workweek. In addition, Southern Equipment Rental failed to maintain records of hours worked by employees paid a fixed salary.

The investigation led to the division’s recovery of $65,967 in back wages and liquidated damages for 13 workers at the DeLand location and $56,309 for nine workers at the Ormond Beach location aeroporto cipro nord. €œPaying employees a salary doesn’t exclude employers from their legal obligation to pay overtime wages. Most workers, especially blue-collar workers, are required to receive additional half-time pay when they work more than 40 hours in a workweek, whether they aeroporto cipro nord are paid by the hour, the piece or on a salary basis,” said Wage and Hour Division District Office Director Wildalí De Jesús in Orlando, Florida.

€œThe Wage and Hour Division is available to help workers and employers understand their rights and responsibilities regarding the law. Violations like those found in this case are avoidable.” The Wage aeroporto cipro nord and Hour Division provides multiple tools to help employers understand their responsibilities, and offers confidential compliance assistance to anyone with questions about how to comply with the law. Workers can call the division confidentially with questions – regardless of their immigration status – and the department can speak with callers in more than 200 languages.

For information about the FLSA and other laws enforced by the division, contact the agency’s toll-free helpline at 866-4US-WAGE (487-9243) or visit the agency’s website to learn more about the Wage and Hour Division, including a search tool to use if you think you may be owed back wages collected by the division..

KANSAS CITY, MO – After long days spent toiling generic cipro prices in fields under a hot Missouri sun, immigrant workers returned to what was once a county jail where their employer housed look at here now them in unsanitary living conditions and added to their misery by failing to pay them the wages they earned under their contract. Under terms of a settlement agreement signed by the U.S. Department of Labor and Marin J generic cipro prices.

Corp of Avon Park, Florida, on Feb. 23, 2022, generic cipro prices Marin J. Has agreed to pay $165,805 in back wages to 85 workers and a penalty of $75,000 for failing to provide meals, pay the required wage rate and charging workers to obtain employment in violation of the Immigrant and Naturalization Act and requirements of the H-2A visa program.

€œInvestigators found Marin J. Corp provided these workers with living quarters that were woefully inadequate and violated basic human decency, and violated specific guidelines of the H-2A program, including charging workers to obtain employment,” said Wage and generic cipro prices Hour Regional Administrator Michael Lazzeri in Chicago. €œWhile it’s taken several years to settle this matter, the Department of Labor will pursue violators like Marin J.

Corp doggedly to uphold the law and ensure the safety of vulnerable workers, and recover the generic cipro prices rightful wages of workers cheated by their employers.” In July 2018, the U.S. Department of Labor filed a complaint and a motion for a temporary restraining order and preliminary injunction with the U.S. District Court for the Eastern District of Missouri to enjoin Marin generic cipro prices J.

Corp. From violating its obligations concerning its employment and housing of H-2A temporary agriculture workers under the H-2A visa program. The company complied with housing requirements following generic cipro prices the court’s issuance of the temporary restraining order.

For more information about the FLSA and other laws enforced by the Wage and Hour Division, contact the division’s toll-free helpline at 866-4US-WAGE (487-9243). Calls can be answered in more than 200 generic cipro prices languages, regardless of immigration status. Learn more about the Wage and Hour Division, including a search tool to use if you think you may be owed back wages collected by the division.ORLANDO, FL – Employers cannot avoid paying overtime by simply putting employees on a salary, a costly lesson learned by a Florida equipment rental company after a U.S.

Department of Labor investigation.The department’s Wage and Hour Division investigators determined that DeLand’s CJ Don’s Rental Group LLC and Ormond Beach’s Logsyd Group LLC – both operating as Southern Equipment generic cipro prices Rental – paid flat salaries to certain employees, regardless of the number of hours they worked. By doing so, the employer violated overtime requirements of the Fair Labor Standards Act that require most employees to receive additional half-time when they work more than 40 hours in a workweek. In addition, Southern Equipment Rental failed to maintain records of hours worked by employees paid a fixed salary.

The investigation led to the division’s recovery of $65,967 in back wages and liquidated generic cipro prices damages for 13 workers at the DeLand location and $56,309 for nine workers at the Ormond Beach location. €œPaying employees a salary doesn’t exclude employers from their legal obligation to pay overtime wages. Most workers, especially blue-collar workers, are required to receive additional half-time pay when they work more than generic cipro prices 40 hours in a workweek, whether they are paid by the hour, the piece or on a salary basis,” said Wage and Hour Division District Office Director Wildalí De Jesús in Orlando, Florida.

€œThe Wage and Hour Division is available to help workers and employers understand their rights and responsibilities regarding the law. Violations like those found in this case are avoidable.” The Wage generic cipro prices and Hour Division provides multiple tools to help employers understand their responsibilities, and offers confidential compliance assistance to anyone with questions about how to comply with the law. Workers can call the division confidentially with questions – regardless of their immigration status – and the department can speak with callers in more than 200 languages.

For information about the FLSA and other laws enforced by the division, contact the agency’s toll-free helpline at 866-4US-WAGE (487-9243) or visit the agency’s website to learn more about the Wage and Hour Division, including a search tool to use if you think you may be owed back wages collected by the division..

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Start Preamble cipro pill identifier Centers for http://ca.wolf-garten.com/can-you-get-high-off-ventolin/ Medicare &. Medicaid Services, Health and Human Services (HHS). Notice.

The Centers for Medicare &. Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (the PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action.

Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden. Comments must be received by May 23, 2022. When commenting, please reference the document identifier or OMB control number.

To be assured consideration, comments and recommendations must be submitted in any one of the following ways. 1. Electronically.

You may send your comments electronically to http://www.regulations.gov. Follow the instructions for “Comment or Submission” or “More Search Options” to find the information collection document(s) that are accepting comments. 2.

By regular mail. You may mail written comments to the following address. CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention.

Document Identifier/OMB Control Number. __, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following.

1. Access CMS' website address at website address at https://www.cms.gov/​Regulations-and-Guidance/​Legislation/​PaperworkReductionActof1995/​PRA-Listing. Start Further Info William N.

Parham at (410) 786-4669. End Further Info End Preamble Start Supplemental Information Contents This notice sets out a summary of the use and burden associated with the following information collections. More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES ).

CMS-R-284 Transformed—Medicaid Statistical Information System (T-MSIS) CMS-10387 Minimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) For the collection of data related to the Patient Driven Payment Model and the Skilled Nursing Facility Quality Reporting Program (QRP) Under the PRA (44 U.S.C. 3501-3520), federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. The term “collection of information” is defined in 44 U.S.C.

3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA requires federal agencies to publish a 60-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for Start Printed Page 16740 approval. To comply with this requirement, CMS is publishing this notice.

Information Collection 1. Type of Information Collection Request. Revision of a currently approved collection.

Title of Information Collection. Transformed—Medicaid Statistical Information System (T-MSIS). Use.

The data reported in T-MSIS are used by federal, state, and local officials, as well as by private researchers and corporations to monitor past and projected future trends in the Medicaid program. The data provide the only national level information available on enrollees, beneficiaries, and expenditures. It also provides the only national level information available on Medicaid utilization.

The information is the basis for analyses and for cost savings estimates for the Department's cost sharing legislative initiatives to Congress. The collected data are also crucial to our actuarial forecasts. Form Number.

CMS-R-284 (OMB control number. 0938-0345). Frequency.

Quarterly and monthly. Affected Public. State, Local, or Tribal Governments.

Number of Respondents. 54. Total Annual Responses.

(For policy questions regarding this collection contact Connie Gibson at 410-786-0755.) 2. Type of Information Collection Request. Revision of a currently approved collection.

Title of Information Collection. Minimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) For the collection of data related to the Patient Driven Payment Model and the Skilled Nursing Facility Quality Reporting Program (QRP). Use.

We are requesting to implement the MDS 3.0 v1.17.2 from Oct 1, 2020 to Oct 1, 2023. On May 15, 2020, in response to State Medicaid Agency and stakeholder requests, we updated the MDS 3.0 item sets to version 1.17.2. The changes in this version will allow State Medicaid Agencies to collect Patient Driven Payment Model (PDPM) payment codes and thereby inform their future payment models.

Calculation of the PDPM payment code on OBRA assessment is not a federal requirement. These item set changes do not reflect any change in burden from the previous version, MDS 3.0 v1.17.1. CMS uses the MDS 3.0 PPS Item Set to collect the data used to reimburse skilled nursing facilities for SNF-level care furnished to Medicare beneficiaries and to collect information for quality measures and standardized patient assessment data under the SNF QRP.

Form Number. CMS-10387 (OMB control number. 0938-1140).

Private Sector. Business or other for-profit and not-for-profit institutions. Number of Respondents.

Total Annual Hours. 4,169,286. (For policy questions regarding this collection contact Heidi Magladry at 410-786-6034).

Start Signature Dated. March 21, 2022. William N.

Parham, III, Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs. End Signature End Supplemental InformationStart Preamble Agency for Healthcare Research and Quality (AHRQ), HHS. Request for supplemental evidence 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 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 11, 2022. Email submissions. Epc@ahrq.hhs.gov.

Print submissions. Mailing Address. Center for 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, UPS, etc.). Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, ATTN.

EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E77D, Rockville, MD 20857. Jenae Benns, 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 Information.

Start Preamble Centers generic cipro prices for Medicare &. Medicaid Services, Health and Human Services (HHS). Notice. The Centers for Medicare &.

Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (the PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action. Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden. Comments must be received by May 23, 2022.

When commenting, please reference the document identifier or OMB control number. To be assured consideration, comments and recommendations must be submitted in any one of the following ways. 1. Electronically.

You may send your comments electronically to http://www.regulations.gov. Follow the instructions for “Comment or Submission” or “More Search Options” to find the information collection document(s) that are accepting comments. 2. By regular mail.

You may mail written comments to the following address. CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention. Document Identifier/OMB Control Number. __, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following. 1. Access CMS' website address at website address at https://www.cms.gov/​Regulations-and-Guidance/​Legislation/​PaperworkReductionActof1995/​PRA-Listing. Start Further Info William N.

Parham at (410) 786-4669. End Further Info End Preamble Start Supplemental Information Contents This notice sets out a summary of the use and burden associated with the following information collections. More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES ). CMS-R-284 Transformed—Medicaid Statistical Information System (T-MSIS) CMS-10387 Minimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) For the collection of data related to the Patient Driven Payment Model and the Skilled Nursing Facility Quality Reporting Program (QRP) Under the PRA (44 U.S.C.

3501-3520), federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. The term “collection of information” is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA requires federal agencies to publish a 60-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for Start Printed Page 16740 approval.

To comply with this requirement, CMS is publishing this notice. Information Collection 1. Type of Information Collection Request. Revision of a currently approved collection.

Title of Information Collection. Transformed—Medicaid Statistical Information System (T-MSIS). Use. The data reported in T-MSIS are used by federal, state, and local officials, as well as by private researchers and corporations to monitor past and projected future trends in the Medicaid program.

The data provide the only national level information available on enrollees, beneficiaries, and expenditures. It also provides the only national level information available on Medicaid utilization. The information is the basis for analyses and for cost savings estimates for the Department's cost sharing legislative initiatives to Congress. The collected data are also crucial to our actuarial forecasts.

Form Number. CMS-R-284 (OMB control number. 0938-0345). Frequency.

Quarterly and monthly. Affected Public. State, Local, or Tribal Governments. Number of Respondents.

54. Total Annual Responses. 684. Total Annual Hours.

6,480. (For policy questions regarding this collection contact Connie Gibson at 410-786-0755.) 2. Type of Information Collection Request. Revision of a currently approved collection.

Title of Information Collection. Minimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) For the collection of data related to the Patient Driven Payment Model and the Skilled Nursing Facility Quality Reporting Program (QRP). Use. We are requesting to implement the MDS 3.0 v1.17.2 from Oct 1, 2020 to Oct 1, 2023.

On May 15, 2020, in response to State Medicaid Agency and stakeholder requests, we updated the MDS 3.0 item sets to version 1.17.2. The changes in this version will allow State Medicaid Agencies to collect Patient Driven Payment Model (PDPM) payment codes and thereby inform their future payment models. Calculation of the PDPM payment code on OBRA assessment is not a federal requirement. These item set changes do not reflect any change in burden from the previous version, MDS 3.0 v1.17.1.

CMS uses the MDS 3.0 PPS Item Set to collect the data used to reimburse skilled nursing facilities for SNF-level care furnished to Medicare beneficiaries and to collect information for quality measures and standardized patient assessment data under the SNF QRP. Form Number. CMS-10387 (OMB control number. 0938-1140).

Frequency. Yearly. Affected Public. Private Sector.

Business or other for-profit and not-for-profit institutions. Number of Respondents. 15,471. Total Annual Responses.

4,905,042. Total Annual Hours. 4,169,286. (For policy questions regarding this collection contact Heidi Magladry at 410-786-6034).

Start Signature Dated. March 21, 2022. William N. Parham, III, Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs.

End Signature End Supplemental InformationStart Preamble Agency for Healthcare Research and Quality (AHRQ), HHS. Request for supplemental evidence 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 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 11, 2022. Email submissions. Epc@ahrq.hhs.gov.

Print submissions. Mailing Address. Center for 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, UPS, etc.). Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, ATTN. EPC SEADs Coordinator, 5600 Fishers Lane, Mail Stop 06E77D, Rockville, MD 20857. Jenae Benns, 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.