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September 24, 2020 (TORONTO) â Canada Health Infoway (Infoway) and CloudMD are pleased to announce that they have lasix 40mg injection price reached an agreement to advance e-prescribing in Canada. PrescribeITÂ® is Infowayâs national e-prescribing service that enables prescribers and pharmacists to electronically create, receive, renew and cancel prescriptions, while improving overall patient care through secure clinician messaging.Under the agreement, CloudMD will integrate its Juno electronic medical record (EMR) with PrescribeITâs solution infrastructure. CloudMD is aiming to have the technical work completed in early lasix 40mg injection price 2021. Once complete, physicians and nurse practitioners who offer virtual consultations with patients will be able to send prescriptions electronically from their EMR to the patientâs pharmacy of choice, and pharmacies will be able to request prescription renewals electronically from the patientâs prescriber.âWe are excited to partner with Infoway because we believe a national, modern e-prescribing service will engender greater patient trust and confidence in prescriptions,â said Essam Hamza, MD, Chief Executive Officer of CloudMD.

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Infoway is an independent, not-for-profit organization funded by lasix 40mg injection price the federal government. Visit www.infoway-inforoute.ca.About PrescribeITÂ®Canada Health Infoway is working with Health Canada, the provinces and territories, and industry stakeholders to develop, operate and maintain the national e-prescribing service known as PrescribeITÂ®. PrescribeITÂ® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriberâs electronic medical record lasix 40mg injection price (EMR) and the pharmacy management system (PMS) of a patientâs pharmacy of choice. PrescribeITÂ® will protect Canadiansâ personal health information from being sold or used for commercial activities.

Visit www.PrescribeIT.ca.-30-Media Inquiries Karen SchmidtDirector, Corporate/Internal CommunicationsCanada lasix 40mg injection price Health Infoway(416) 886-4967 Email UsFollow @InfowayJulia BeckerVice President, Investor RelationsCloudMDThis email address is being protected from spambots. You need JavaScript enabled to view it.Inquiries about PrescribeITÂ®August 18, 2020 (TORONTO) â Canada Health Infoway (Infoway) and Loblaw Companies Limited (Loblaw) are pleased to announce that they have reached an agreement to advance e-prescribing in Canada. Under the agreement, Shoppers Drug Mart, Loblaw retail pharmacies and QHR Technologiesâ AccuroEMRÂ®, Canadaâs largest single electronic medical record platform, will work towards lasix 40mg injection price connecting with PrescribeITÂ®, Infowayâs national e-prescribing service.As a first step in the initiative, Shoppers Drug Mart and Loblaw will begin to roll out PrescribeITÂ® in pharmacies already using software that is integrated with PrescribeITÂ®. âThis agreement will accelerate the adoption of e-prescribing in Canada, bringing significant benefits to patients, prescribers and health care systems across the country,â said Ashesh Desai, Executive Vice President Pharmacy and Healthcare Businesses at Shoppers Drug Mart.âPrescribeITÂ® has shown tremendous momentum since it launched,â said Michael Green, President and CEO of Infoway.

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PrescribeITÂ® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriberâs electronic medical record lasix 40mg injection price (EMR) and the pharmacy management system (PMS) of a patientâs pharmacy of choice. PrescribeITÂ® will protect Canadiansâ personal health information from being sold or used for commercial activities. Visit www.PrescribeIT.ca.About Loblaw Companies LimitedLoblaw is Canada's food and pharmacy leader, and the nation's lasix 40mg injection price largest retailer. Loblaw provides Canadians with grocery, pharmacy, health and beauty, apparel, general merchandise, financial services and wireless mobile products and services.

With more than 2,400 corporate, franchised and Associate-owned locations, Loblaw, its franchisees and associate-owners employ approximately 200,000 full- and part-time employees, making it one of Canada's largest private sector employers.Loblaw's purpose â Live Life WellÂ® â puts first the needs and well-being of Canadians who make one billion lasix 40mg injection price transactions annually in the company's stores. Loblaw is positioned to meet and exceed those needs in many ways. Convenient locations lasix 40mg injection price. More than 1,050 grocery stores that span the value spectrum from discount to specialty.

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For more information, visit Loblaw's website at www.loblaw.ca.-30-Media Inquiries Karen SchmidtDirector, Corporate/Internal lasix 40mg injection price CommunicationsCanada Health Infoway(416) 886-4967 Email UsFollow @InfowayCatherine ThomasSenior Director, External CommunicationLoblaw Companies Limited This email address is being protected from spambots. You need JavaScript enabled to view it.Inquiries about PrescribeITÂ®.

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Start Preamble how does lasix affect kidneys Centers for Get kamagra online Medicare &. Medicaid Services (CMS), Department of Health and Human Services (HHS). Notice. This notice announces the final Federal share (FS) disproportionate share hospital (DSH) allotments for Federal fiscal year (FY) 2018 and FY 2019, and the preliminary FS DSH allotments for FY 2020 and FY 2021.

This notice also announces the final FY 2018 and FY 2019 and the preliminary FY 2020 and FY 2021 limitations on aggregate DSH payments that States may make to institutions for mental disease and other mental health facilities. In addition, this notice includes background information describing the methodology for determining the amounts of States' FY DSH allotments. The allotments announced in this notice are effective April 15, 2022. The final allotments and limitations set forth in this notice are applicable for the fiscal years specified.

Start Further Info Stuart Goldstein, (410) 786-0694 and Richard Cuno, (410) 786-1111. End Further Info End Preamble Start Supplemental Information I. Background A. Fiscal Year DSH Allotments A State's Federal fiscal year (FY) disproportionate share hospital (DSH) allotment represents the aggregate limit on the Federal share (FS) amount of the State's DSH payments to DSH hospitals in the State for the FY.

The amount of such allotment is determined in accordance with the provisions of section 1923(f) of the Social Security Act (the Act), with some State-specific exceptions as specified in section 1923(f) of the Act. Under such provisions, in general, a State's FY DSH allotment is calculated by increasing the amount of its DSH allotment for the preceding FY by the percentage change in the Consumer Price Index for all Urban Consumers (CPI-U) for the previous FY. The Patient Protection and Affordable Care Act of 2010 (Pub. L.

111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) (collectively, the Affordable Care Act), amended Medicaid DSH provisions, adding section 1923(f)(7) of the Act. Section 1923(f)(7) of the Act would have required reductions to States' FY DSH allotments from FY 2014 through FY 2020, the calculation of which was described in the Disproportionate Share Hospital Payment Reduction final rule published in the September 18, 2013 Federal Register (78 FR 57293).

Because there are no reductions to DSH allotments for FY 2018 through FY 2023 under section 1923(f)(7) of the Act, as amended, this notice contains only the State-specific final FY 2018 and FY 2019 DSH allotments and preliminary FY 2020 and FY 2021 DSH allotments, as calculated under the statute without application of the reductions that would have been imposed beginning as early as FY 2014 under prior versions of section 1923(f)(7) of the Act. This notice also provides information on the calculation of the FY DSH allotments, the calculation of the States' institution for mental diseases (IMD) DSH limits, and the amounts of States' final FY 2018 and FY 2019 IMD DSH limits and preliminary FY 2020 and FY 2021 IMD DSH limits. B. Determination of Fiscal Year DSH Allotments Generally, in accordance with the methodology specified under section 1923(f)(3) of the Act, a State's FY DSH allotment is calculated by increasing the amount of its DSH allotment for the preceding FY by the percentage change in the CPI-U for the previous FY.

Also, in accordance with section 1923(f)(3) of Start Printed Page 14859 the Act, a State's DSH allotment for a FY is subject to the limitation that an increase to a State's DSH allotment for a FY cannot result in the DSH allotment exceeding the greater of the State's DSH allotment for the previous FY or 12 percent of the State's total medical assistance expenditures for the allotment year (this is referred to as the 12 percent limit). Furthermore, under section 1923(h) of the Act, Federal financial participation (FFP) for DSH payments to IMDs and other mental health facilities is limited to State-specific aggregate amounts. Under this provision, the aggregate limit for DSH payments to IMDs and other mental health facilities is the lesser of a State's FY 1995 total computable (State and FS) IMD and other mental health facility DSH expenditures applicable to the State's FY 1995 DSH allotment (as reported on the Form CMS-64 as of January 1, 1997), or the amount equal to the product of the State's current year total computable DSH allotment and the applicable percentage specified in section 1923(h) of the Act. C.

Determination of Fiscal Year DSH Allotments for FY 2020 and FY 2021 The Families First hypertension Response Act's (FFCRA) (Pub. L. 116-127, enacted March 18, 2020) temporary Federal medical assistance percentage (FMAP) increase of 6.2 percentage points went into effect on January 1, 2020 for eligible States, as provided in section 6008 of the FFCRA. As relevant to this notice, this FMAP increase applies to eligible Medicaid expenditures including DSH payments for FY 2020 (with the exception of the 1st quarter, from October 1, 2019 through December 31, 2019), and FY 2021, and all States currently are receiving the temporary FFCRA FMAP increase.

For States that exhaust their entire DSH allotment, the FFCRA FMAP increase would effectively reduce the amount of total computable (TC) DSH payments that such States could pay to qualifying providers. To avoid this reduction in TC DSH allotments, section 9819 of the American Rescue Plan Act of 2021 (ARP) (Pub. L. 117-2, enacted March 11, 2021) added section 1923(f)(3)(F) of the Act, adjusting FS DSH allotments during periods when and for States where the temporary 6.2 percentage point FMAP increase under section 6008 of the FFCRA is in effect.

As directed by the ARP, we are required to recalculate FS DSH allotments to an amount that will allow States to make the same amount of TC DSH payments as they would have been otherwise able to make in the absence of the FFCRA FMAP increase. In accordance with section 1923(f)(3)(B) of the Act, a State's DSH allotment for a FY is subject to the limitation that an increase to a State's DSH allotment for a FY cannot result in the DSH allotment exceeding the greater of the State's DSH allotment for the previous FY or 12 percent of the State's total medical assistance expenditures for the allotment year. Because States incur medical assistance expenditures throughout the fiscal year, the calculations for the 12 percent limit under section 1923(f)(3)(B)(ii) of the Act were performed using a prorated FMAP for FY 2020. To arrive at the stated limits, we prorated each State's FY 2020 FMAP rate because the temporary 6.2 percentage point FMAP increase under section 6008 of the FFCRA does not apply to the 1st quarter of FY 2020.

For the calculation of the 12 percent limit for FY 2021, we used the FFCRA FMAP rate (that is, the otherwise applicable FMAP rate plus the temporary 6.2 percentage point FFCRA FMAP increase), because the FFCRA FMAP rate applies to the entire FY for qualifying States, and medical assistance expenditures are made throughout the year. Section 1923(f)(3)(F)(i) of the Act requires us to recalculate the annual DSH allotment, including the DSH allotment specified under paragraph (6)(A)(vi), to ensure that the total DSH payments (including both Federal and State shares) that a State may make related to a fiscal year is equal to the total DSH payments that the State could have made for such fiscal year without such FMAP increase. To meet the statutory requirement to enable States to make the same amount of TC DSH payments as if the FFCRA FMAP increase were not in effect, we have used the full (non-prorated) FFCRA-increased FMAP rate in the calculation of the increased FY 2020 and FY 2021 FS DSH allotments. We used the full FFCRA-increased FMAP rate rather than a prorated FMAP rate for the FY 2020 calculation, despite it not being applicable to the 1st quarter of FY 2020, to ensure this provision applies to all States consistent with the statutory requirement, including a State that made all DSH payments for FY 2020 in quarters other than the first fiscal quarter of that fiscal year.

While States have distinct payment methodologies that specify when DSH payments are made to providers, States may not claim TC DSH payments in excess of the amount they would have otherwise been able to claim without the application of the temporary 6.2 percentage point FFCRA FMAP rate increase. This is regardless of whether a portion of unspent FS DSH allotment as adjusted to account for section 1923(f)(3)(F) of the Act, as added by section 9819 of the ARP, remains. For example, if the State made all DSH payments for FY 2020 during the first quarter of that FY, then no increase to the State's DSH allotment is available for that year, since the temporary 6.2 percentage point FMAP increase under section 6008 of the FFCRA was not available for that quarter and section 1923(f)(3)(F) therefore has no effect. We will monitor both the FS and TC DSH allotments to ensure that States do not exceed statutory authority to claim DSH payments.

Consistent with previous guidance by CMS during the public health emergency, States should follow existing Federal requirements regarding the applicability of a particular match rate available for a given quarter, including reporting prior period adjustments. For calculation of the FY 2020 and FY 2021 IMD limits determined under section 1923(h) of the Act, we used the ARP-adjusted DSH allotments and the associated non-prorated FFCRA-increased FMAP rates for FY 2020 and FY 2021, to reflect the maximum DSH allotment amount and IMD limit that might be available to a State, for FY 2020, depending on the State's timing of DSH payments. In general, we determine States' DSH allotments for a FY and the IMD DSH limits for the same FY using the most recent available estimates of or actual medical assistance expenditures, including DSH expenditures and the most recent available CPI-U data for the FY in accordance with the methodology prescribed in the statute. The indicated estimated or actual expenditures are obtained from States for each relevant FY from the most recent available quarterly Medicaid budget reports (Form CMS-37) or quarterly Medicaid expenditure reports (Form CMS-64), respectively, submitted by the States.

For example, as part of the initial determination of a State's FY DSH allotment (referred to as the preliminary DSH allotments) that is determined before the beginning of the FY for which the DSH allotments and IMD DSH limits are being determined, we use estimated expenditures for the FY obtained from the August submission of the CMS-37 submitted by States prior to the beginning of the FY. Such estimated expenditures are subject to update and revision during the FY before actual expenditure data become available. We also use the most recent available estimated CPI-U percentage change that Start Printed Page 14860 is available before the beginning of the FY for determining the States' preliminary FY DSH allotments. Such estimated CPI-U percentage change is subject to update and revision during the FY before the actual CPI-U percentage change becomes available.

Final FY 2018 FS State DSH Allotments Addendum 1 to this notice provides the States' final FY 2018 DSH allotments determined in accordance with section 1923(f)(3) of the Act. As described in the background section, in general, the DSH allotment for a FY is calculated by increasing the FY DSH allotment for the preceding FY by the CPI-U increase for the previous fiscal year. For purposes of calculating the States' final FY 2018 DSH allotments, the preceding final fiscal year DSH allotments (for FY 2017) were published in the February 11, 2019 Federal Register (84 FR 3169). For purposes of calculating the States' final FY 2018 DSH allotments we are using the actual Medicaid expenditures for FY 2018.

Finally, for purposes of calculating the States' final FY 2018 DSH allotments, the applicable historical percentage change in the CPI-U for the previous FY (FY 2017) was 2.1 percent. We note that this is lower than the estimated 2.4 percentage change in the CPI-U for FY 2017 that was available and used in the calculation of the preliminary FY 2018 DSH allotments which were published in the July 6, 2018 Federal Register (83 FR 31536). 2. Final FY 2019 FS State DSH Allotments Addendum 2 to this notice provides the States' final FY 2019 DSH allotments determined in accordance with section 1923(f)(3) of the Act.

As described in the background section, in general, the DSH allotment for a FY is calculated by increasing the FY DSH allotment for the preceding FY by the CPI-U increase for the previous fiscal year. For purposes of calculating the States' final FY 2019 DSH allotments, the preceding final fiscal year DSH allotments (for FY 2018) are being published in this notice. For purposes of calculating the States' final FY 2019 DSH allotments we are using the actual Medicaid expenditures for FY 2019. Finally, for purposes of calculating the States' final FY 2019 DSH allotments, the applicable historical percentage change in the CPI-U for the previous FY (FY 2018) was 2.4 percent.

We note that this is the same as the estimated 2.4 percentage change in the CPI-U for FY 2018 that was available and used in the calculation of the preliminary FY 2019 DSH allotments which were published in the February 11, 2019 Federal Register (84 FR 3169). 3. Calculation of the Preliminary FY 2020 FS State DSH Allotments Addendum 3 to this notice provides the preliminary FY 2020 DSH allotments determined in accordance with section 1923(f)(3) of the Act. The preliminary FY 2020 DSH allotments contained in this notice were determined based on the most recent available estimates from States of their FY 2020 total computable Medicaid expenditures and by increasing the preliminary FY 2019 DSH allotments.

The applicable historical percentage change in the CPI-U for FY 2019 was 1.9 percent (we originally published the preliminary FY 2019 DSH allotments in the February 11, 2019 Federal Register (84 FR 3169)). We then used each State's FS DSH allotment divided by its respective regular FMAP rate in order to determine the TC amount of DSH payments each State would have otherwise been able to make without application of the FFCRA-increased FMAP rate. We then multiplied each State's TC DSH payment amount by its respective FFCRA-increased FMAP rate in order to calculate the increased FY 2020 DSH allotment. We will publish States' final FY 2020 DSH allotments in a future notice based on the States' four quarterly Medicaid expenditure reports (Form CMS-64) for FY 2020 available following the end of FY 2020 utilizing the actual change in the CPI-U for FY 2019.

4. Calculation of the Preliminary FY 2021 FS State DSH Allotments Addendum 4 to this notice provides the preliminary FY 2021 DSH allotments determined in accordance with section 1923(f)(3) of the Act. The preliminary FY 2021 DSH allotments contained in this notice were determined based on the most recent available estimates from States of their FY 2021 total computable Medicaid expenditures and by increasing the preliminary FY 2020 DSH allotments calculated prior to the application of the ARP adjustment. The applicable historical percentage change in the CPI-U for FY 2020 was 1.5 percent (we are publishing the preliminary FY 2020 DSH allotments in this notice).

We then used each State's FS DSH allotment divided by its respective regular FMAP rate in order to determine the TC amount of DSH payments each State would have otherwise been able to make without application of the FFCRA-increased FMAP rate. We then multiplied each State's TC DSH payment amount by its respective FFCRA-increased FMAP rate in order to calculate the ARP-adjusted FY 2021 DSH allotment. We will publish States' final FY 2021 DSH allotments in a future notice based on the States' four quarterly Medicaid expenditure reports (Form CMS-64) for FY 2021 available following the end of FY 2021. B.

Calculation of the Final FY 2018 and FY 2019 and Preliminary FY 2020 and FY 2021 IMD DSH Limits Section 1923(h) of the Act specifies the methodology to be used to establish the limits on the amount of DSH payments that a State can make to IMDs and other mental health facilities. FFP is not available for DSH payments to IMDs or other mental health facilities that exceed the IMD DSH limits. In this notice, we are publishing the final FY 2018 and FY 2019 and the preliminary FY 2020 and FY 2021 IMD DSH limits determined in accordance with the provisions discussed above. Addendums 5 through 8 to this notice detail each State's final FY 2018 and FY 2019 and preliminary FY 2020 and FY 2021 IMD DSH limits, respectively, determined in accordance with section 1923(h) of the Act.

III. Collection of Information Requirements As it relates to the Paperwork Reduction Act of 1995 (PRA. 44 U.S.C. 3501 et seq.

), this notice does not impose any new or revised âcollection of informationâ requirements or burden. With respect to the PRA and this section of the preamble, collection of information is defined under 5 CFR 1320.3(c) of the PRA's implementing regulations. While discussed in sections I.B., I.C., II.A.3., II.A.4., and in Addendums 3 through 8 of this notice, the requirements and burden associated with form CMS-37 and form CMS-64 are unaffected by this notice. Both forms are approved by the Office of Management and Budget (OMB) under control number 0938-1265, which expires on April 30, 2024.

Since this notice will not impose any new or revised collection of information requirements/burden, we are not Start Printed Page 14861 making any changes under that control number. IV. Regulatory Impact Analysis We have examined the impact of this notice as required by Executive Order 12866 on Regulatory Planning and Review (September 1993), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L.

96-354), section 1102(b) of the Act, section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4. Enacted on March 22, 1995) (UMRA `95), Executive Order 13132 on Federalism (August 4, 1999) and the Congressional Review Act (5 U.S.C.

804(2)). Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). This notice reaches the $100 million economic threshold and thus has been designated a major rule under the Congressional Review Act by the Office of Information and Regulatory Affairs.

The final FY 2018 DSH allotments being published in this notice are $36 million less than the preliminary FY 2018 DSH allotments published in the July 6, 2018 Federal Register (83 FR 31536). This is due to the actual percentage change in the CPI-U for FY 2017 used in the calculation of the final FY 2018 allotments (2.1 percent) being less than the estimated percentage change in the CPI-U for FY 2017 used in the calculation of the preliminary FY 2018 allotments (2.4 percent). The final FY 2018 IMD DSH limits being published in this notice are $2.4 million less than the preliminary FY 2018 IMD DSH limits published in the July 6, 2018 Federal Register (83 FR 31536). Since the final FY 2018 DSH allotments were less than the preliminary FY 2018 DSH allotments, the associated FY 2018 IMD DSH limits also decreased.

The final FY 2019 DSH allotments being published in this notice are $36 million less than the preliminary FY 2019 DSH allotments published in the February 11, 2019 Federal Register (84 FR 3169). The decrease in the final FY 2019 DSH allotments is a result of being calculated by multiplying the actual increase in the CPI-U for 2018 by the final FY 2018 DSH allotments, while the preliminary FY 2019 DSH allotments were calculated by multiplying the estimated CPI-U for 2018 by the preliminary FY 2018 DSH allotments. Although the estimated and actual increase in the CPI-U remained the same at 2.4 percent, the preliminary FY 2018 DSH allotments were higher than the final FY 2018 DSH allotments and therefore the final FY 2019 DSH allotments are lower than the preliminary FY 2019 DSH allotments. The final FY 2019 IMD DSH limits being published in this notice are approximately $2 million lower than the preliminary FY 2019 IMD DSH limits published in the February 11, 2019 Federal Register (84 FR 3169).

The decreases in the IMD DSH limits are because the DSH allotment for a FY is a factor in the determination of the IMD DSH limit for the FY. Since the final FY 2019 DSH allotments were decreased as compared to the preliminary FY 2019 DSH allotments, the associated FY 2019 IMD DSH limits for some States were also decreased. This is a result of statutory provision, discussed above, that the aggregate limit for DSH payments to IMDs and other mental health facilities is the lesser of a State's FY 1995 total computable IMD and other mental health facility DSH expenditures applicable to the State's FY 1995 DSH allotment or the amount equal to the product of the State's current year total computable DSH allotment and the applicable percentage specified in section 1923(h) of the Act. As a result of the final FY 2019 DSH allotments decreasing from the preliminary FY 2019 DSH allotments, States that had applicable percentages of their current year's total computable DSH allotments lower than FY 1995 total computable IMD and other mental health facility DSH expenditures had their IMD limits decreased as a result.

The preliminary FY 2020 DSH allotments being published in this notice have been increased by approximately $1.6 billion more than the preliminary FY 2019 DSH allotments published in the February 11, 2019 Federal Register (84 FR 3169). The increase in the DSH allotments is due to the application of the statutory formula for calculating DSH allotments under which the prior fiscal year allotments are increased by the percentage increase in the CPI-U for the prior fiscal year, and to the ARP adjustment, as discussed in more detail in the next paragraph. The preliminary FY 2020 IMD DSH limits being published in this notice are approximately $246 million more than the preliminary FY 2019 IMD DSH limits published in the February 11, 2019 Federal Register (84 FR 3169). The increases in the IMD DSH limits are because the DSH allotment for a FY is a factor in the determination of the IMD DSH limit for the FY.

Since the preliminary FY 2020 DSH allotments are greater than the preliminary FY 2019 DSH allotments, the associated preliminary FY 2020 IMD DSH limits for some States also increased. The preliminary FY 2020 DSH allotments (before application of the ARP adjustment) being published in this in this notice are approximately $238 million more than the final FY 2019 DSH allotments being published in this notice. This increase is attributable to the application of the statutory formula for calculating DSH allotments under which the prior fiscal year allotments are increased by the percentage increase in the CPI-U for the prior fiscal year. The applicable historical percentage change in the CPI-U for FY 2019 was 1.9 percent.

The preliminary FY 2020 DSH allotments were further increased by approximately $1.4 billion in order to comply with the statutory provisions of the ARP requiring us to recalculate FS DSH allotments to an amount that will allow States to make the same amount of TC DSH payments as they would have been otherwise able to make in the absence of the FFCRA FMAP increase. The preliminary FY 2021 DSH allotments (before application of the ARP adjustment) being published in this notice are approximately $192 million more than the preliminary FY 2020 DSH allotments published in this notice. The increase in the DSH allotments is due to the application of the statutory formula for calculating DSH allotments under which the prior fiscal year allotments are increased by the percentage increase in the CPI-U for the prior fiscal year. The applicable historical percentage change in the CPI-U for FY 2020 was 1.5 percent.

The preliminary FY 2020 DSH allotments were increased by approximately $1.4 billion in order to comply with the statutory provisions of the ARP requiring us to recalculate FS DSH allotments to an amount that will allow States to make the same amount of TC DSH payments as they would have been otherwise able to make in the absence of the FFCRA FMAP increase. The preliminary FY 2021 DSH allotments were further increased by approximately $1.4 billion in order to comply with the statutory provisions of the ARP requiring us to recalculate FS DSH allotments to an amount that will allow States to make the same amount of TC DSH payments as they would have been otherwise able to make in the absence of the FFCRA FMAP increase. Start Printed Page 14862 The preliminary FY 2021 IMD DSH limits being published in this notice are approximately $16 million more than the preliminary FY 2020 IMD DSH limits published in this notice. The increases in the IMD DSH limits are because the DSH allotment for a FY is a factor in the determination of the IMD DSH limit for the FY.

Since the preliminary FY 2021 DSH allotments are greater than the preliminary FY 2020 DSH allotments, the associated preliminary FY 2021 IMD DSH limits for some States also increased. The RFA requires agencies to analyze options for regulatory relief of small businesses, if a rule has a significant impact on a substantial number of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of less than $8.0 million to $41.5 million in any one year.

Individuals and States are not included in the definition of a small entity. We are not preparing an analysis for the RFA because the Secretary has determined that this notice will not have significant economic impact on a substantial number of small entities. Specifically, any impact on providers is due to the effect of the various controlling statutes. Providers are not impacted as a result of the independent regulatory action in publishing this notice.

The purpose of the notice is to announce the latest DSH allotments and IMD DSH limits, as required by the statute. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Core-Based Statistical Area for Medicaid payment regulations and has fewer than 100 beds.

We are not preparing analysis for section 1102(b) of the Act because the Secretary has determined that this notice will not have a significant impact on the operations of a substantial number of small rural hospitals. The Medicaid statute specifies the methodology for determining the amounts of States' DSH allotments and IMD DSH limits. And as described previously, the application of the methodology specified in statute results in the decreases or increases in States' DSH allotments and IMD DSH limits for the applicable FYs. The statute applicable to these allotments and limits does not apply to the determination of the amounts of DSH payments made to specific DSH hospitals.

Rather, these allotments and limits represent an overall limit on the total of such DSH payments. For this reason, we do not believe that this notice will have a significant economic impact on a substantial number of small entities. Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. In 2021, that threshold is approximately $158 million.

This notice will have no consequential effect on spending by State, local, or tribal governments, in the aggregate, or on the private sector. Executive Order 13132 establishes certain requirements that an agency must meet when it issues a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. Since this notice does not impose any costs on State or local governments or otherwise have Federalism implications, the requirements of E.O. 13132 are not applicable.

A. Alternatives Considered Because the FFCRA temporary FMAP increase of 6.2 percentage points was not applicable to the 1st quarter of FY 2020, we considered utilizing prorated FMAP rates in the calculation of the ARP-adjusted FY 2020 DSH allotments. However, this could have been contrary to the statutory language at section 1923(f)(3)(F) of the Act requiring us to recalculate FS DSH allotments to an amount to allow for States to make the same amount of TC DSH payments as they would have been otherwise able to make in the absence of the FFCRA FMAP increase, depending on States' timing of their DSH payments to eligible providers. The methodologies for determining the States' fiscal year DSH allotments and IMD DSH limits, as reflected in this notice, were established in accordance with the methodologies and formula for determining States' allotments and limits as specified in statute.

This notice does not put forward any further discretionary administrative policies for determining such allotments and limits, or otherwise. B. Accounting Statement As required by OMB Circular A-4 (available at https://obamawhitehouse.archives.gov/âomb/âcirculars_âa004_âa-4/â ), in Tables 1 and 2, we have prepared an accounting statement showing the classification of the estimated expenditures associated with the provisions of this notice. Table 1 provides our best estimate of the change (decrease) in the FS of States' Medicaid DSH payments resulting from the application of the provisions of the Medicaid statute relating to the calculation of States' FY DSH allotments and the increase in the FY DSH allotments from FY 2019 to FY 2020.

Table 2 provides our best estimate of the change (decrease) in the FS of States' Medicaid DSH payments resulting from the application of the provisions of the Medicaid statute relating to the calculation of States' FY DSH allotments and the increase in the FY DSH allotments from FY 2020 to FY 2021. Table 1âAccounting Statement. Classification of Estimated Expenditures, From the FY 2019 to FY 2020[In millions]CategoryTransfersAnnualized Monetized Transfers$238.From Whom To Whom?. Federal Government to States.

Congressional Review Act This document is subject to the Congressional Review Act provisions of the Small Business Regulatory Enforcement Fairness Act of 1996 (5 U.S.C. 801 et seq. ) and has been transmitted to the Congress and the Comptroller General for review. Start Printed Page 14863 In accordance with the provisions of Executive Order 12866, this notice was reviewed by the Office of Management and Budget.

Chiquita Brooks-LaSure, Administrator of the Centers for Medicare &. Medicaid Services, approved this document on February 1, 2022. Start Signature Dated. March 9, 2022.

Xavier Becerra, Secretary, Department of Health and Human Services. End Signature Start Printed Page 14864 Start Printed Page 14865 Start Printed Page 14866 Start Printed Page 14867 Start Printed Page 14868 Start Printed Page 14869 Start Printed Page 14870 Start Printed Page 14871 Start Printed Page 14872 Start Printed Page 14873 Start Printed Page 14874 Start Printed Page 14875 Start Printed Page 14876 Start Printed Page 14877 Start Printed Page 14878 Start Printed Page 14879 Start Printed Page 14880 Start Printed Page 14881 Start Printed Page 14882 Start Printed Page 14883 Start Printed Page 14884 Start Printed Page 14885 Start Printed Page 14886 Start Printed Page 14887 Start Printed Page 14888 End Supplemental Information.

Start Preamble Centers for Medicare & lasix 40mg injection price. Medicaid Services (CMS), Department of Health and Human Services (HHS). Notice. This notice announces the final Federal share (FS) disproportionate share hospital (DSH) allotments for Federal fiscal year (FY) 2018 and FY 2019, and the preliminary FS DSH allotments for FY 2020 and FY 2021. This notice also announces the final FY 2018 and FY 2019 and the preliminary FY 2020 and FY 2021 limitations on aggregate DSH payments that States may make to institutions for mental disease and other mental health facilities.

In addition, this notice includes background information describing the methodology for determining the amounts of States' FY DSH allotments. The allotments announced in this notice are effective April 15, 2022. The final allotments and limitations set forth in this notice are applicable for the fiscal years specified. Start Further Info Stuart Goldstein, (410) 786-0694 and Richard Cuno, (410) 786-1111. End Further Info End Preamble Start Supplemental Information I.

Background A. Fiscal Year DSH Allotments A State's Federal fiscal year (FY) disproportionate share hospital (DSH) allotment represents the aggregate limit on the Federal share (FS) amount of the State's DSH payments to DSH hospitals in the State for the FY. The amount of such allotment is determined in accordance with the provisions of section 1923(f) of the Social Security Act (the Act), with some State-specific exceptions as specified in section 1923(f) of the Act. Under such provisions, in general, a State's FY DSH allotment is calculated by increasing the amount of its DSH allotment for the preceding FY by the percentage change in the Consumer Price Index for all Urban Consumers (CPI-U) for the previous FY. The Patient Protection and Affordable Care Act of 2010 (Pub.

L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) (collectively, the Affordable Care Act), amended Medicaid DSH provisions, adding section 1923(f)(7) of the Act. Section 1923(f)(7) of the Act would have required reductions to States' FY DSH allotments from FY 2014 through FY 2020, the calculation of which was described in the Disproportionate Share Hospital Payment Reduction final rule published in the September 18, 2013 Federal Register (78 FR 57293).

Subsequent legislation, most recently the Consolidated Appropriations Act, 2021 (Pub. L. 116-260, enacted December 27, 2020), delayed the start of these reductions until FY 2024. The final rule delineating a revised methodology for the calculation of DSH allotment reductions beginning in 2020 (subsequently delayed by further statutory enactment) was published in the September 25, 2019 Federal Register (84 FR 50308). Because there are no reductions to DSH allotments for FY 2018 through FY 2023 under section 1923(f)(7) of the Act, as amended, this notice contains only the State-specific final FY 2018 and FY 2019 DSH allotments and preliminary FY 2020 and FY 2021 DSH allotments, as calculated under the statute without application of the reductions that would have been imposed beginning as early as FY 2014 under prior versions of section 1923(f)(7) of the Act.

This notice also provides information on the calculation of the FY DSH allotments, the calculation of the States' institution for mental diseases (IMD) DSH limits, and the amounts of States' final FY 2018 and FY 2019 IMD DSH limits and preliminary FY 2020 and FY 2021 IMD DSH limits. B. Determination of Fiscal Year DSH Allotments Generally, in accordance with the methodology specified under section 1923(f)(3) of the Act, a State's FY DSH allotment is calculated by increasing the amount of its DSH allotment for the preceding FY by the percentage change in the CPI-U for the previous FY. Also, in accordance with section 1923(f)(3) of Start Printed Page 14859 the Act, a State's DSH allotment for a FY is subject to the limitation that an increase to a State's DSH allotment for a FY cannot result in the DSH allotment exceeding the greater of the State's DSH allotment for the previous FY or 12 percent of the State's total medical assistance expenditures for the allotment year (this is referred to as the 12 percent limit). Furthermore, under section 1923(h) of the Act, Federal financial participation (FFP) for DSH payments to IMDs and other mental health facilities is limited to State-specific aggregate amounts.

Under this provision, the aggregate limit for DSH payments to IMDs and other mental health facilities is the lesser of a State's FY 1995 total computable (State and FS) IMD and other mental health facility DSH expenditures applicable to the State's FY 1995 DSH allotment (as reported on the Form CMS-64 as of January 1, 1997), or the amount equal to the product of the State's current year total computable DSH allotment and the applicable percentage specified in section 1923(h) of the Act. C. Determination of Fiscal Year DSH Allotments for FY 2020 and FY 2021 The Families First hypertension Response Act's (FFCRA) (Pub. L. 116-127, enacted March 18, 2020) temporary Federal medical assistance percentage (FMAP) increase of 6.2 percentage points went into effect on January 1, 2020 for eligible States, as provided in section 6008 of the FFCRA.

As relevant to this notice, this FMAP increase applies to eligible Medicaid expenditures including DSH payments for FY 2020 (with the exception of the 1st quarter, from October 1, 2019 through December 31, 2019), and FY 2021, and all States currently are receiving the temporary FFCRA FMAP increase. For States that exhaust their entire DSH allotment, the FFCRA FMAP increase would effectively reduce the amount of total computable (TC) DSH payments that such States could pay to qualifying providers. To avoid this reduction in TC DSH allotments, section 9819 of the American Rescue Plan Act of 2021 (ARP) (Pub. L. 117-2, enacted March 11, 2021) added section 1923(f)(3)(F) of the Act, adjusting FS DSH allotments during periods when and for States where the temporary 6.2 percentage point FMAP increase under section 6008 of the FFCRA is in effect.

Section 1923(f)(3)(F)(i) of the Act requires us to recalculate the annual DSH allotment, including the DSH allotment specified under paragraph (6)(A)(vi), to ensure that the total DSH payments (including both Federal and State shares) that a State may make related to a fiscal year is equal to the total DSH payments that the State could have made for such fiscal year without such FMAP increase. To meet the statutory requirement to enable States to make the same amount of TC DSH payments as if the FFCRA FMAP increase were not in effect, we have used the full (non-prorated) FFCRA-increased FMAP rate in the calculation of the increased FY 2020 and FY 2021 FS DSH allotments. We used the full FFCRA-increased FMAP rate rather than a prorated FMAP rate for the FY 2020 calculation, despite it not being applicable to the 1st quarter of FY 2020, to ensure this provision applies to all States consistent with the statutory requirement, including a State that made all DSH payments for FY 2020 in quarters other than the first fiscal quarter of that fiscal year. While States have distinct payment methodologies that specify when DSH payments are made to providers, States may not claim TC DSH payments in excess of the amount they would have otherwise been able to claim without the application of the temporary 6.2 percentage point FFCRA FMAP rate increase. This is regardless of whether a portion of unspent FS DSH allotment as adjusted to account for section 1923(f)(3)(F) of the Act, as added by section 9819 of the ARP, remains.

For example, if the State made all DSH payments for FY 2020 during the first quarter of that FY, then no increase to the State's DSH allotment is available for that year, since the temporary 6.2 percentage point FMAP increase under section 6008 of the FFCRA was not available for that quarter and section 1923(f)(3)(F) therefore has no effect. We will monitor both the FS and TC DSH allotments to ensure that States do not exceed statutory authority to claim DSH payments. Consistent with previous guidance by CMS during the public health emergency, States should follow existing Federal requirements regarding the applicability of a particular match rate available for a given quarter, including reporting prior period adjustments. For calculation of the FY 2020 and FY 2021 IMD limits determined under section 1923(h) of the Act, we used the ARP-adjusted DSH allotments and the associated non-prorated FFCRA-increased FMAP rates for FY 2020 and FY 2021, to reflect the maximum DSH allotment amount and IMD limit that might be available to a State, for FY 2020, depending on the State's timing of DSH payments. In general, we determine States' DSH allotments for a FY and the IMD DSH limits for the same FY using the most recent available estimates of or actual medical assistance expenditures, including DSH expenditures and the most recent available CPI-U data for the FY in accordance with the methodology prescribed in the statute.

The indicated estimated or actual expenditures are obtained from States for each relevant FY from the most recent available quarterly Medicaid budget reports (Form CMS-37) or quarterly Medicaid expenditure reports (Form CMS-64), respectively, submitted by the States. For example, as part of the initial determination of a State's FY DSH allotment (referred to as the preliminary DSH allotments) that is determined before the beginning of the FY for which the DSH allotments and IMD DSH limits are being determined, we use estimated expenditures for the FY obtained from the August submission of the CMS-37 submitted by States prior to the beginning of the FY. Such estimated expenditures are subject to update and revision during the FY before actual expenditure data become available. We also use the most recent available estimated CPI-U percentage change that Start Printed Page 14860 is available before the beginning of the FY for determining the States' preliminary FY DSH allotments. Such estimated CPI-U percentage change is subject to update and revision during the FY before the actual CPI-U percentage change becomes available.

In determining the final DSH allotments and IMD DSH limits for a FY we use the actual expenditures for the FY and actual CPI-U percentage change for the previous FY. II. Provisions of the Notice A. Calculation of the Final FY 2018 and FY 2019 FS State DSH Allotments and the Preliminary FY 2020 and FY 2021 FS State DSH Allotments 1. Final FY 2018 FS State DSH Allotments Addendum 1 to this notice provides the States' final FY 2018 DSH allotments determined in accordance with section 1923(f)(3) of the Act.

As described in the background section, in general, the DSH allotment for a FY is calculated by increasing the FY DSH allotment for the preceding FY by the CPI-U increase for the previous fiscal year. For purposes of calculating the States' final FY 2018 DSH allotments, the preceding final fiscal year DSH allotments (for FY 2017) were published in the February 11, 2019 Federal Register (84 FR 3169). For purposes of calculating the States' final FY 2018 DSH allotments we are using the actual Medicaid expenditures for FY 2018. Finally, for purposes of calculating the States' final FY 2018 DSH allotments, the applicable historical percentage change in the CPI-U for the previous FY (FY 2017) was 2.1 percent. We note that this is lower than the estimated 2.4 percentage change in the CPI-U for FY 2017 that was available and used in the calculation of the preliminary FY 2018 DSH allotments which were published in the July 6, 2018 Federal Register (83 FR 31536).

2. Final FY 2019 FS State DSH Allotments Addendum 2 to this notice provides the States' final FY 2019 DSH allotments determined in accordance with section 1923(f)(3) of the Act. As described in the background section, in general, the DSH allotment for a FY is calculated by increasing the FY DSH allotment for the preceding FY by the CPI-U increase for the previous fiscal year. For purposes of calculating the States' final FY 2019 DSH allotments, the preceding final fiscal year DSH allotments (for FY 2018) are being published in this notice. For purposes of calculating the States' final FY 2019 DSH allotments we are using the actual Medicaid expenditures for FY 2019.

Finally, for purposes of calculating the States' final FY 2019 DSH allotments, the applicable historical percentage change in the CPI-U for the previous FY (FY 2018) was 2.4 percent. We note that this is the same as the estimated 2.4 percentage change in the CPI-U for FY 2018 that was available and used in the calculation of the preliminary FY 2019 DSH allotments which were published in the February 11, 2019 Federal Register (84 FR 3169). 3. Calculation of the Preliminary FY 2020 FS State DSH Allotments Addendum 3 to this notice provides the preliminary FY 2020 DSH allotments determined in accordance with section 1923(f)(3) of the Act. The preliminary FY 2020 DSH allotments contained in this notice were determined based on the most recent available estimates from States of their FY 2020 total computable Medicaid expenditures and by increasing the preliminary FY 2019 DSH allotments.

Calculation of the Preliminary FY 2021 FS State DSH Allotments Addendum 4 to this notice provides the preliminary FY 2021 DSH allotments determined in accordance with section 1923(f)(3) of the Act. The preliminary FY 2021 DSH allotments contained in this notice were determined based on the most recent available estimates from States of their FY 2021 total computable Medicaid expenditures and by increasing the preliminary FY 2020 DSH allotments calculated prior to the application of the ARP adjustment. The applicable historical percentage change in the CPI-U for FY 2020 was 1.5 percent (we are publishing the preliminary FY 2020 DSH allotments in this notice). We then used each State's FS DSH allotment divided by its respective regular FMAP rate in order to determine the TC amount of DSH payments each State would have otherwise been able to make without application of the FFCRA-increased FMAP rate. We then multiplied each State's TC DSH payment amount by its respective FFCRA-increased FMAP rate in order to calculate the ARP-adjusted FY 2021 DSH allotment.

We will publish States' final FY 2021 DSH allotments in a future notice based on the States' four quarterly Medicaid expenditure reports (Form CMS-64) for FY 2021 available following the end of FY 2021. B. Calculation of the Final FY 2018 and FY 2019 and Preliminary FY 2020 and FY 2021 IMD DSH Limits Section 1923(h) of the Act specifies the methodology to be used to establish the limits on the amount of DSH payments that a State can make to IMDs and other mental health facilities. FFP is not available for DSH payments to IMDs or other mental health facilities that exceed the IMD DSH limits. In this notice, we are publishing the final FY 2018 and FY 2019 and the preliminary FY 2020 and FY 2021 IMD DSH limits determined in accordance with the provisions discussed above.

Addendums 5 through 8 to this notice detail each State's final FY 2018 and FY 2019 and preliminary FY 2020 and FY 2021 IMD DSH limits, respectively, determined in accordance with section 1923(h) of the Act. III. Collection of Information Requirements As it relates to the Paperwork Reduction Act of 1995 (PRA. 44 U.S.C. 3501 et seq.

IV. Regulatory Impact Analysis We have examined the impact of this notice as required by Executive Order 12866 on Regulatory Planning and Review (September 1993), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Act, section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L.

104-4. Enacted on March 22, 1995) (UMRA `95), Executive Order 13132 on Federalism (August 4, 1999) and the Congressional Review Act (5 U.S.C. 804(2)). Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year).

This notice reaches the $100 million economic threshold and thus has been designated a major rule under the Congressional Review Act by the Office of Information and Regulatory Affairs. The final FY 2018 DSH allotments being published in this notice are $36 million less than the preliminary FY 2018 DSH allotments published in the July 6, 2018 Federal Register (83 FR 31536). This is due to the actual percentage change in the CPI-U for FY 2017 used in the calculation of the final FY 2018 allotments (2.1 percent) being less than the estimated percentage change in the CPI-U for FY 2017 used in the calculation of the preliminary FY 2018 allotments (2.4 percent). The final FY 2018 IMD DSH limits being published in this notice are $2.4 million less than the preliminary FY 2018 IMD DSH limits published in the July 6, 2018 Federal Register (83 FR 31536). Since the final FY 2018 DSH allotments were less than the preliminary FY 2018 DSH allotments, the associated FY 2018 IMD DSH limits also decreased.

Since the final FY 2019 DSH allotments were decreased as compared to the preliminary FY 2019 DSH allotments, the associated FY 2019 IMD DSH limits for some States were also decreased. This is a result of statutory provision, discussed above, that the aggregate limit for DSH payments to IMDs and other mental health facilities is the lesser of a State's FY 1995 total computable IMD and other mental health facility DSH expenditures applicable to the State's FY 1995 DSH allotment or the amount equal to the product of the State's current year total computable DSH allotment and the applicable percentage specified in section 1923(h) of the Act. As a result of the final FY 2019 DSH allotments decreasing from the preliminary FY 2019 DSH allotments, States that had applicable percentages of their current year's total computable DSH allotments lower than FY 1995 total computable IMD and other mental health facility DSH expenditures had their IMD limits decreased as a result. The preliminary FY 2020 DSH allotments being published in this notice have been increased by approximately $1.6 billion more than the preliminary FY 2019 DSH allotments published in the February 11, 2019 Federal Register (84 FR 3169). The increase in the DSH allotments is due to the application of the statutory formula for calculating DSH allotments under which the prior fiscal year allotments are increased by the percentage increase in the CPI-U for the prior fiscal year, and to the ARP adjustment, as discussed in more detail in the next paragraph.

The preliminary FY 2020 IMD DSH limits being published in this notice are approximately $246 million more than the preliminary FY 2019 IMD DSH limits published in the February 11, 2019 Federal Register (84 FR 3169). The increases in the IMD DSH limits are because the DSH allotment for a FY is a factor in the determination of the IMD DSH limit for the FY. Since the preliminary FY 2020 DSH allotments are greater than the preliminary FY 2019 DSH allotments, the associated preliminary FY 2020 IMD DSH limits for some States also increased. The preliminary FY 2020 DSH allotments (before application of the ARP adjustment) being published in this in this notice are approximately $238 million more than the final FY 2019 DSH allotments being published in this notice. This increase is attributable to the application of the statutory formula for calculating DSH allotments under which the prior fiscal year allotments are increased by the percentage increase in the CPI-U for the prior fiscal year.

The applicable historical percentage change in the CPI-U for FY 2019 was 1.9 percent. The preliminary FY 2020 DSH allotments were further increased by approximately $1.4 billion in order to comply with the statutory provisions of the ARP requiring us to recalculate FS DSH allotments to an amount that will allow States to make the same amount of TC DSH payments as they would have been otherwise able to make in the absence of the FFCRA FMAP increase. The preliminary FY 2021 DSH allotments (before application of the ARP adjustment) being published in this notice are approximately $192 million more than the preliminary FY 2020 DSH allotments published in this notice. The increase in the DSH allotments is due to the application of the statutory formula for calculating DSH allotments under which the prior fiscal year allotments are increased by the percentage increase in the CPI-U for the prior fiscal year. The applicable historical percentage change in the CPI-U for FY 2020 was 1.5 percent.

The RFA requires agencies to analyze options for regulatory relief of small businesses, if a rule has a significant impact on a substantial number of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of less than $8.0 million to $41.5 million in any one year. Individuals and States are not included in the definition of a small entity. We are not preparing an analysis for the RFA because the Secretary has determined that this notice will not have significant economic impact on a substantial number of small entities.

Specifically, any impact on providers is due to the effect of the various controlling statutes. Providers are not impacted as a result of the independent regulatory action in publishing this notice. The purpose of the notice is to announce the latest DSH allotments and IMD DSH limits, as required by the statute. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA.

For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Core-Based Statistical Area for Medicaid payment regulations and has fewer than 100 beds. We are not preparing analysis for section 1102(b) of the Act because the Secretary has determined that this notice will not have a significant impact on the operations of a substantial number of small rural hospitals. The Medicaid statute specifies the methodology for determining the amounts of States' DSH allotments and IMD DSH limits. And as described previously, the application of the methodology specified in statute results in the decreases or increases in States' DSH allotments and IMD DSH limits for the applicable FYs. The statute applicable to these allotments and limits does not apply to the determination of the amounts of DSH payments made to specific DSH hospitals.

Executive Order 13132 establishes certain requirements that an agency must meet when it issues a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. Since this notice does not impose any costs on State or local governments or otherwise have Federalism implications, the requirements of E.O. 13132 are not applicable. A. Alternatives Considered Because the FFCRA temporary FMAP increase of 6.2 percentage points was not applicable to the 1st quarter of FY 2020, we considered utilizing prorated FMAP rates in the calculation of the ARP-adjusted FY 2020 DSH allotments.

However, this could have been contrary to the statutory language at section 1923(f)(3)(F) of the Act requiring us to recalculate FS DSH allotments to an amount to allow for States to make the same amount of TC DSH payments as they would have been otherwise able to make in the absence of the FFCRA FMAP increase, depending on States' timing of their DSH payments to eligible providers. The methodologies for determining the States' fiscal year DSH allotments and IMD DSH limits, as reflected in this notice, were established in accordance with the methodologies and formula for determining States' allotments and limits as specified in statute. This notice does not put forward any further discretionary administrative policies for determining such allotments and limits, or otherwise. B. Accounting Statement As required by OMB Circular A-4 (available at https://obamawhitehouse.archives.gov/âomb/âcirculars_âa004_âa-4/â ), in Tables 1 and 2, we have prepared an accounting statement showing the classification of the estimated expenditures associated with the provisions of this notice.

Table 1 provides our best estimate of the change (decrease) in the FS of States' Medicaid DSH payments resulting from the application of the provisions of the Medicaid statute relating to the calculation of States' FY DSH allotments and the increase in the FY DSH allotments from FY 2019 to FY 2020. Table 2 provides our best estimate of the change (decrease) in the FS of States' Medicaid DSH payments resulting from the application of the provisions of the Medicaid statute relating to the calculation of States' FY DSH allotments and the increase in the FY DSH allotments from FY 2020 to FY 2021. Table 1âAccounting Statement. Classification of Estimated Expenditures, From the FY 2019 to FY 2020[In millions]CategoryTransfersAnnualized Monetized Transfers$238.From Whom To Whom?. Federal Government to States.

Table 2âAccounting Statement. Classification of Estimated Expenditures, From the FY 2020 to FY 2021[In millions]CategoryTransfersAnnualized Monetized Transfers$192.From Whom To Whom?. Federal Government to States. C. Congressional Review Act This document is subject to the Congressional Review Act provisions of the Small Business Regulatory Enforcement Fairness Act of 1996 (5 U.S.C.

801 et seq. ) and has been transmitted to the Congress and the Comptroller General for review. Start Printed Page 14863 In accordance with the provisions of Executive Order 12866, this notice was reviewed by the Office of Management and Budget. Chiquita Brooks-LaSure, Administrator of the Centers for Medicare &. Medicaid Services, approved this document on February 1, 2022.

Start Signature Dated. March 9, 2022. Xavier Becerra, Secretary, Department of Health and Human Services. End Signature Start Printed Page 14864 Start Printed Page 14865 Start Printed Page 14866 Start Printed Page 14867 Start Printed Page 14868 Start Printed Page 14869 Start Printed Page 14870 Start Printed Page 14871 Start Printed Page 14872 Start Printed Page 14873 Start Printed Page 14874 Start Printed Page 14875 Start Printed Page 14876 Start Printed Page 14877 Start Printed Page 14878 Start Printed Page 14879 Start Printed Page 14880 Start Printed Page 14881 Start Printed Page 14882 Start Printed Page 14883 Start Printed Page 14884 Start Printed Page 14885 Start Printed Page 14886 Start Printed Page 14887 Start Printed Page 14888 End Supplemental Information.

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But these gains are not across the board, and they appear to depend on social, behavioral and economic factors. A pair of new studies from Finlandâone looking at physical aging and one looking at cognitive agingâstrikingly demonstrates some of the details of generational change. The research, overseen by gerontologist Taina Rantanen of the University of JyvÃ¤skylÃ¤, compares adults born in 1910 and 1914 lasix liquid with those born roughly 30 years later.

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For example, a Dutch study of cognitive aging published in 2018 showed that elderly adults born between 1931 and 1941 outshone same-age adults born in the 1920s on a range of cognitive measuresâthough again not on short-term memory. And a 2013 Danish study revealed that birth-year-related differences can persist into very old age. 95-year-olds born in 1915 outperformed 93-year-olds born in lasix liquid 1905 on a cognitive exam.

The later-born Danish cohort did no better on measures of gait speed and grip strength, but its members were more adept at activities of daily livingâsuch as bathing and dressingâperhaps because of their improved cognitive status. There are many reasons that people are aging better, including improved medical care and a drop in smoking, but the factors that loomed largest in the Finnish study of physical function, lead author Kaisa Koivunen says, were that the later-born adults were more physically active and had bigger bodies, which suggests better nutrition. (In 1943 Finland became the world's first country to require universal free lunch at school.) For lasix liquid brain function, the key seems to be more years of education.

ÂWith more education, you are probably going to have a larger income, which means you are more likely to go to the doctor, have good nutrition and have a job that is not eviscerating your body.â In prosperous countries, these advantages have not only lengthened life but most likely ensured that more years are spent in good health. In the U.S., Ferrucci says, the benefits of prosperity are less equally distributed than in Finland or Denmark. He points out that the average life span is seven years shorter in a poor state such as Mississippi than in a wealthier lasix liquid one such as California.

ÂHere we still have lots of people who cannot take the drugs they need because they cannot pay for them,â he says, and they may lack access to healthy foods and opportunities for exercise and learning that extend our vital years. In short, 70 may be the new 60 for many of us but not for all.Edited by Dava Sobel A billion years ago âwhile here on Earth multicelled life was arising and spreadingâin a galaxy far far away two spinning black holes danced 'round one another, rippling the fabric of space and time. The ripples, called gravity waves sucked energy from the holes' orbit, soThe holes lasix liquid spiraled inward, eclipsing each other, toward a climactic collision.

The holes, at half of light speed, collided catastrophically and merged in a brief, cataclysmic storm of writhing and twisting spacetime that brought the waves to crescendo. The climaxing gravity waves surged into interstellar space.Spreading across our universe, they stretched and they squeezed all that they met (stars and planets and nebulae...) in patterns that encoded a portrait of their birth:colliding holes and spacetime storm. The gravity waves lasix liquid were hugely strong, with fifty times more total power âmore luminosityâ than all of the light from all of the stars in all of our universe, combined.

Fifty universe luminosities from two black holes colliding.But not any light. Not any x-rays. Not any gamma rays or radio lasix liquid.

No electromagnetic waves at all, None of any type. Fifty universe luminosities carried wholly and solely by gravity waves, by tendices and vortices, entwined, by structures made from warped spacetime. Fifty thousand years ago, lasix liquid when humans shared Earth with Neandertals,the waves plunged into our galaxy.

The Milky Way. Our home. On September fourteen of twenty fifteen they dove into Earth in Antarctica.Whispering up through Earth's bowels unscathed, and emerging near New Orleans, the waves lasix liquid encountered LIGO âa complex and huge, L-shaped device designed and built to perceive them.

In LIGO the gravity waves stretched and squeezed two long beams of light,which extracted the portraits the waves encoded. colliding holes and spacetime storm. A momentous Eureka Event, it washumans' first moment of contact with the Warped Side of Our Universe.This year, GPT-3, a large language model capable of understanding text, responding to questions and generating new lasix liquid writing examples, has drawn international media attention.

The model, released by OpenAI, a California-based nonprofit that builds general-purpose artificial intelligence systems, has an impressive ability to mimic human writing, but just as notable is its massive size. To build it, researchers collected 175 billion parameters (a type of computational unit) and more than 45 terabytes of text from Common Crawl, Reddit, Wikipedia and other sources, then trained it in a process that occupied hundreds of processing units for thousands of hours. GPT-3 demonstrates a broader trend in lasix liquid artificial intelligence.

Deep learning, which has in recent years become the dominant technique for creating new AIs, uses enormous amounts of data and computing power to fuel complex, accurate models. These resources are more accessible for researchers at large companies and elite universities. As a lasix liquid result, a study from Western University suggests, there has been a "de-democratization" in AI.

The number of researchers able to contribute to cutting-edge developments is shrinking. This narrows the pool of people who are able to define the research directions for this pivotal technology, which has social implications. It may even be contributing to some of the ethical challenges facing AI development, including lasix liquid privacy invasion, bias and the environmental impact of large models.

To combat these problems, researchers are trying to figure out how to do more with less. One such recent advance is called âless than oneââshot learning (LO-shot learning), developed by Ilia Sucholutsky and Matthias Schonlau from the University of Waterloo.[Office1] [RK2] The principle behind LO-shot learning is that it should be possible for an AI to learn about objects in the world without being fed an example of each one. This has been a major hurdle for contemporary AI systems, which often require thousands of examples to learn to distinguish objects lasix liquid.

An image database maintained by the National Institute for Standards and Technology, called MNIST, which contains 60,000 examples of written digits from 0 to 9, was distilled down to five images that blended features of the various numbers. After being shown only those five examples, the University of Waterloo system was able to accurately classify 92 percent of the remaining images in the database. In their latest paper, the team has extended this principle to show that, theoretically, LO-shot techniques allow AIs to potentially learn to distinguish thousands of objects given a small data set lasix liquid of even two examples.

This is a great improvement on traditional deep-learning systems, in which the demand for data grows exponentially with the need to distinguish more objects. Currently, LO-shotâs small data sets need to be carefully engineered to distill the features of the various classes of objects. But Sucholutsky is seeking to further develop this work by looking at the relationships between objects already captured in existing small lasix liquid data sets.

Allowing AIs to learn with considerably less data is important for several reasons. First, it better encapsulates the actual process of learning by forcing the system to generalize to classes it has not seen. By building in abstractions that capture the relationships between objects, this lasix liquid technique also reduces the potential for bias.

Currently, deep-learning systems fall prey to bias arising from irrelevant features in the data they use to train. A well-known example of this problem is that AI classifies dogs as wolves when shown images of dogs in a snowy environmentâbecause most images of wolves feature them near snow. Being able to zero in on relevant aspects lasix liquid of the image would help prevent these mistakes.

Reducing data needs thus makes these systems less liable to this sort of bias. Next, the less extensive the data one needs to use, the less incentive exists to surveil people to build better algorithms. For example, soft distillation techniques have already impacted medical AI research, which trains its models using sensitive health information lasix liquid.

In one recent paper, researchers used soft distillation in diagnostic x-ray imagery based on a small, privacy-preserving data set. Finally, allowing AIs to learn with less plentiful lasix liquid data helps to democratize the field of artificial intelligence. With smaller AIs, academia can remain relevant and avoid the risk of professors being poached by industry.

Not only does LO-shot learning make the barriers to entry lower by reducing training costs and lowering data requirements, but it also provides more flexibility for users to create novel data sets and experiment with new approaches. By reducing the time spent on data and architecture engineering, researchers looking to leverage AI can spend more time focusing on the practical problems they are aiming to solve.1971 Antievolution Evolves âIn recent months the teaching of evolution has come under attack in a number of lasix liquid states. The revival of fundamentalism in biology takes a somewhat new form.

The emphasis is on opposition to current theories of the origin of life and the diversity of species not by theologians but by scientists. The movement is led by the Creation Research Society, whose members have appeared before state boards of education and textbook committees in California, lasix liquid Texas, Arkansas and Tennessee. The society's credo says that it is âcommitted to full belief in the Biblical record of creation and early historyâ and that its goal is âthe realignment of science based on theistic creation concepts.ââ Joy of Pulsars âThe origin of the energy input to the Crab Nebula had been a puzzle that had long defied attempts at solution.

Among the various possibilities considered, John Archibald Wheeler at Princeton in 1966 and Franco Pacini at Cornell in 1967 had independently put forward the apparently far-fetched idea that a rotating neutron star might be the energy source. Now, after the fact, it is possible to use the observations of the Crab Nebula and its pulsar (NP0531) to invert the problem and show that if the pulsar is a rotating star, lasix liquid it must have the mass and radius of a neutron star. In other words, even without the theory developed over the past 40 years, it is possible to assert that stars of approximately one solar mass and radii on the order of 10 kilometers must exist since the pulsar in the Crab Nebula is such a star.

ÂJeremiah P. Ostrikerâ 1921 Truck Transport âThis is the era of lasix liquid the motor truck. Yesterday it was the railroad.

Before that it was the stage coach. And still further lasix liquid back it was the canal. The motor truck, and by that we mean modern highway transportation, has come into its own.

It has defined its field of service and established itself therein. In the field of short-haul transportation, the motor truck is the last word lasix liquid in efficiency. The use of the motor truck, both in the handling of passengers and freight, is entirely an economic proposition for the benefit, according to the leading motor truck authorities, of the country at large.

If that is so, there is no justification for limiting by legislation the use of the highway by that vehicle.â Connecting Coast to Coast âThe Longest Land Line in the United States was recently opened to the public by the Western Union Telegraph Company, giving direct communication between New York and Seattle. Four messages simultaneously each way can be sent over the single copper strand.â 1871 Thomas Henry lasix liquid Huxley âAlthough Dr. Huxley is profoundly learned in natural history, he has also found time for general literary culture, and is fond of poetry, fiction, and fine writing.

It is this wide culture that gives him such power in his controversial writings. He seems lasix liquid to like nothing better than a regular set-to with some members of the old-school scientists, and he has sometimes been accused of exhibiting a pugnacious and acrimonious spirit. On one occasion Samuel Wilberforce, Bishop of Oxford, blandly asked him in the presence of a large audience.

ÂIs the learned gentleman really willing to have it go forth to the world that he believes himself to be descended from a monkey?. Â Professor Huxley rose and replied in his quiet manner, âWhether I should be descended from a respectable monkey, or from a bishop of the English church, who can put his brains to no lasix liquid better use than to ridicule science and misrepresent its cultivators, I would certainly choose the monkey!. Ââ Camels in Nevada âOn a ranch on the Carson river is to be seen a herd of twenty-six camels, all but two of which were born and raised in this State.

The camel may now be said to be acclimated to Nevada. The ranch lasix liquid upon which they are kept is sandy and sterile in the extreme, yet the animals feast and grow fat on such prickly shrubs and bitter weeds as no other animal would touch. When left to themselves, their great delight, after filling themselves with the coarse herbage of the desert, is to lie and roll in the hot sand.

They are used in packing salt to the mills on the river, from the marshes lying in the deserts, some sixty miles to the eastward. Some of the animals easily pack 1,100 pounds.âEver since the deadly parasite responsible for malaria was discovered in the late 19th century, science and global health experts have been lasix liquid waging a vigorous Sisyphean battle against the disease it causes. Humans have brought an arsenal of toolsânets, rapid tests, medicationâto bear against the mosquito-borne parasite, which cannily mutates to become resistant to drug treatments.

Weâre holding our own. Global malaria deaths declined to 409,000 in 2019, lasix liquid compared to 585,000 in 2010, and a number of countries have eliminated it altogether or are on the verge of doing so. However, more than 90 percent of the deaths occur in Africa, and there is a threat that could set progress back again.

Researchers in Rwanda identified a strain of the malaria parasite P. Falciparum with mutations on a gene known as K13 that enable resistance to artemisinin, the foundation of artemisinin-based combination therapies (ACTs), the most lasix liquid commonly used malaria treatments. While ACTs still work, a weakened treatment regimen could lead to more deaths on the continent, an increased spread of resistance itself, and loss of confidence in malaria treatment.

We must act now to increase surveillance and monitoring for signs of new K13 mutations, even as we battle the hypertension medications lasix. In addition lasix liquid to basic tactics like increasing peopleâs access to insecticide-treated mosquito nets, hereâs what can help make a difference. Ensure that providers and patients use drugs effectively.

When providers donât prescribe treatments correctly or their patients donât take the complete course as prescribed, it contributes to the emergence of drug-resistant malaria parasites. Governments and global lasix liquid health programs need to reinforce effective, safe prescribing and appropriate use of ACTs. For example, largely through USAID-funded initiatives, Management Sciences for Health supports malaria case management in Benin, Madagascar, Malawi, and Nigeria.

The program trains, mentors and evaluates health care providers on the use of national malaria treatment guidelines. Take action today lasix liquid to maximize the longevity of ACTs. The battle to delay artemisinin drug resistance must be fought on two fronts.

The first is to support the use of quality-assured medicines at the correct dosage and to continually monitor their therapeutic efficacy against any emerging signs of resistance. The second is to support national malaria programs to adopt and deploy more lasix liquid than one artemisinin-based treatment, such as second-line or even multiple first-line therapies along with the addition of single low-dose primaquine to help block the transmission of resistant parasites, in line with WHO guidance. Strategies such as adding a third drug to an ACTâforming a triple ACT, or TACTâare also being investigated.

Finally, we need to acknowledge that the sun may be setting on today's drugs. It may be a long sunset, but we need to be ready for lasix liquid tomorrow. Develop the next generation of treatments.

Medicines for Malaria Venture (MMV), a not-for-profit research and development organization, and its research and pharma partners have developed the largest portfolio of antimalarials in history. The most advanced new antimalarial medicine targeting parasites showing resistance to current drugs is lasix liquid in development with Swiss health care company Novartis. It's currently in clinical trials and is aimed at treating children as young as six months, as malaria kills more children under five than any other age group.

National malaria control programs must be ready to incorporate this potential new medicine in their budgets and treatment guidelines when it becomes available. Expand lab lasix liquid testing capacity. Improved surveillance to track the spread of resistant plasmodia is critical to maintaining progress, including using molecular and genomic techniques.

However, many sub-Saharan African countries do not yet have the equipment, personnel, funding or infrastructure to efficiently handle sequencing for malaria. Here, too, investors and collaborators must lasix liquid strengthen and build additional capacity. The National Institutes of Health and the Wellcome Trust have established the Human Heredity and Health in Africa (H3Africa) initiative to build capacity on the continent, as is the U.S.

Presidentâs Malaria Initiativeâsupported Antimalarial Resistance Monitoring in Africa Network, which also supports collaborative efforts across the continent. The Africa CDC and the African Academy of lasix liquid Sciences have provided funding. Yet much more is needed for sufficient lab capacity.

Develop a cross-border action plan with neighboring countries. Now that resistant parasites have been documented in Rwanda, they may be carried by travelers across borders lasix liquid or may already be in other African countries. National malaria control programs and WHOâs regional and country offices need to reinforce intercountry collaboration, sharing information as well as educating health care providers and communities about the implications of the mutation.

Pharmaceutical regulatory agencies should continue to monitor and enforce quality standards to prevent and tackle substandard and falsified medicines, which greatly contribute to drug resistance. The West African Health Organization. Southern African Development Community.

And East, Central and Southern African Health Community should work together to align efforts. Southeast Asia has already seen this mutation as of 2013 and is holding it at bay with careful use of drugs that work where they are most needed. We can outsmart this.

We must bring our collective human ingenuity and determination to ensure that the continent bearing the worldâs greatest burden of malaria stays one step ahead of the emerging threat of this dangerous mutant parasite..

We often hear that 60 is the new 50 and 70 lasix 40mg injection price the new 60. It is a bromide borne out by old photos. Just check out images of your grandparents or great-grandparents (depending on your age) and notice their stooped and soft bodies, lasix 40mg injection price their lined faces and how they seem anchored in their chairs when they were barely pushing 60. What a contrast with vigorous, gym-going sexagenarians of today!.

Recent studies comparing populations born in different decades have looked beyond these surface impressions to nail down actual physical and mental differences in the ways we are aging. This research has identified particular lasix 40mg injection price areas of improvement. But these gains are not across the board, and they appear to depend on social, behavioral and economic factors. A pair of new studies from Finlandâone looking at physical aging and one looking at cognitive agingâstrikingly demonstrates some of the details of generational change.

The research, overseen by gerontologist Taina Rantanen of lasix 40mg injection price the University of JyvÃ¤skylÃ¤, compares adults born in 1910 and 1914 with those born roughly 30 years later. The two age groups were assessed in 1989 and 1990 and in 2017 and 2018, respectively. The beauty of this work is that both birth cohorts were examined in person at age 75 and again at 80 with the same substantial battery of six physical tests and five measures of cognition. Most cohort studies look at a lasix 40mg injection price narrower range of measures, and many of them rely on self-assessments.

The later-born group could walk faster, had a stronger hand grip and could exert more force with their lower leg. Such metrics are reliable predictors of disability and mortality. On cognitive tests, the later cohort had better verbal lasix 40mg injection price fluency (naming more words beginning with a K in three minutes), clocked faster reaction time on a complex finger-movement task, and scored higher on a test matching numbers to symbols. But not everything changed across the generations.

Measures of lung function were surprisingly static, and there was no improvement in the short-term-memory task of recalling a string of digitsâpossibly because rote memorization has been de-emphasized in school and in daily life in recent decades, the researchers suspect. Many of lasix 40mg injection price these findings fit with other cohort studies. For example, a Dutch study of cognitive aging published in 2018 showed that elderly adults born between 1931 and 1941 outshone same-age adults born in the 1920s on a range of cognitive measuresâthough again not on short-term memory. And a 2013 Danish study revealed that birth-year-related differences can persist into very old age.

95-year-olds born in 1915 outperformed 93-year-olds born in lasix 40mg injection price 1905 on a cognitive exam. The later-born Danish cohort did no better on measures of gait speed and grip strength, but its members were more adept at activities of daily livingâsuch as bathing and dressingâperhaps because of their improved cognitive status. There are many reasons that people are aging better, including improved medical care and a drop in smoking, but the factors that loomed largest in the Finnish study of physical function, lead author Kaisa Koivunen says, were that the later-born adults were more physically active and had bigger bodies, which suggests better nutrition. (In 1943 Finland became the world's first country to require universal free lunch at school.) For brain function, the key seems to be more years of lasix 40mg injection price education.

In both the Finnish and the Dutch studies, cognitive differences between the cohorts largely disappeared when researchers controlled for this factor. Education is a powerful influence on aging and health, says Luigi Ferrucci, scientific director of the U.S. National Institute on lasix 40mg injection price Aging. ÂWith more education, you are probably going to have a larger income, which means you are more likely to go to the doctor, have good nutrition and have a job that is not eviscerating your body.â In prosperous countries, these advantages have not only lengthened life but most likely ensured that more years are spent in good health.

In the U.S., Ferrucci says, the benefits of prosperity are less equally distributed than in Finland or Denmark. He points out that the average life span is seven years shorter in a poor state such as Mississippi than in a wealthier one lasix 40mg injection price such as California. ÂHere we still have lots of people who cannot take the drugs they need because they cannot pay for them,â he says, and they may lack access to healthy foods and opportunities for exercise and learning that extend our vital years. In short, 70 may be the new 60 for many of us but not for all.Edited by Dava Sobel A billion years ago âwhile here on Earth multicelled life was arising and spreadingâin a galaxy far far away two spinning black holes danced 'round one another, rippling the fabric of space and time.

The ripples, called gravity waves sucked energy from the holes' orbit, soThe holes spiraled inward, eclipsing each other, toward lasix 40mg injection price a climactic collision. The holes, at half of light speed, collided catastrophically and merged in a brief, cataclysmic storm of writhing and twisting spacetime that brought the waves to crescendo. The climaxing gravity waves surged into interstellar space.Spreading across our universe, they stretched and they squeezed all that they met (stars and planets and nebulae...) in patterns that encoded a portrait of their birth:colliding holes and spacetime storm. The gravity waves were hugely strong, with fifty times more total power âmore luminosityâ than all of the light from all lasix 40mg injection price of the stars in all of our universe, combined.

Fifty universe luminosities from two black holes colliding.But not any light. Not any x-rays. Not any gamma rays or radio lasix 40mg injection price. No electromagnetic waves at all, None of any type.

Fifty universe luminosities carried wholly and solely by gravity waves, by tendices and vortices, entwined, by structures made from warped spacetime. Fifty thousand years ago, when humans shared Earth with Neandertals,the lasix 40mg injection price waves plunged into our galaxy. The Milky Way. Our home.

On September fourteen of twenty fifteen they lasix 40mg injection price dove into Earth in Antarctica.Whispering up through Earth's bowels unscathed, and emerging near New Orleans, the waves encountered LIGO âa complex and huge, L-shaped device designed and built to perceive them. In LIGO the gravity waves stretched and squeezed two long beams of light,which extracted the portraits the waves encoded. colliding holes and spacetime storm. A momentous Eureka Event, it washumans' first moment of contact with the Warped Side of Our Universe.This year, GPT-3, a large language model capable of understanding text, responding to questions and generating new writing examples, has drawn international lasix 40mg injection price media attention.

These resources are more accessible for researchers at large companies and elite universities. As a result, a study from Western University suggests, there has been lasix 40mg injection price a "de-democratization" in AI. The number of researchers able to contribute to cutting-edge developments is shrinking. This narrows the pool of people who are able to define the research directions for this pivotal technology, which has social implications.

It may even be contributing to some lasix 40mg injection price of the ethical challenges facing AI development, including privacy invasion, bias and the environmental impact of large models. To combat these problems, researchers are trying to figure out how to do more with less. One such recent advance is called âless than oneââshot learning (LO-shot learning), developed by Ilia Sucholutsky and Matthias Schonlau from the University of Waterloo.[Office1] [RK2] The principle behind LO-shot learning is that it should be possible for an AI to learn about objects in the world without being fed an example of each one. This has been a major hurdle for contemporary AI systems, which often require thousands of examples lasix 40mg injection price to learn to distinguish objects.

Humans, on the other hand, are often able to abstract away from existing examples in order to recognize new never-before-seen items. For example, when shown different shapes, a child is able to easily distinguish between the examples and to recognize the relationships between what they were shown and new shapes. The team lasix 40mg injection price first introduced this sort of learning through a process called soft distillation. An image database maintained by the National Institute for Standards and Technology, called MNIST, which contains 60,000 examples of written digits from 0 to 9, was distilled down to five images that blended features of the various numbers.

After being shown only those five examples, the University of Waterloo system was able to accurately classify 92 percent of the remaining images in the database. In their latest paper, the team has extended this principle to show that, theoretically, LO-shot techniques allow AIs to potentially lasix 40mg injection price learn to distinguish thousands of objects given a small data set of even two examples. This is a great improvement on traditional deep-learning systems, in which the demand for data grows exponentially with the need to distinguish more objects. Currently, LO-shotâs small data sets need to be carefully engineered to distill the features of the various classes of objects.

But Sucholutsky is seeking to further develop this work by looking at the relationships between objects already captured in existing small data lasix 40mg injection price sets. Allowing AIs to learn with considerably less data is important for several reasons. First, it better encapsulates the actual process of learning by forcing the system to generalize to classes it has not seen. By building in abstractions that capture the relationships between objects, this technique also reduces the potential lasix 40mg injection price for bias.

Currently, deep-learning systems fall prey to bias arising from irrelevant features in the data they use to train. A well-known example of this problem is that AI classifies dogs as wolves when shown images of dogs in a snowy environmentâbecause most images of wolves feature them near snow. Being able lasix 40mg injection price to zero in on relevant aspects of the image would help prevent these mistakes. Reducing data needs thus makes these systems less liable to this sort of bias.

Next, the less extensive the data one needs to use, the less incentive exists to surveil people to build better algorithms. For example, lasix 40mg injection price soft distillation techniques have already impacted medical AI research, which trains its models using sensitive health information. In one recent paper, researchers used soft distillation in diagnostic x-ray imagery based on a small, privacy-preserving data set. Finally, allowing AIs lasix 40mg injection price to learn with less plentiful data helps to democratize the field of artificial intelligence.

With smaller AIs, academia can remain relevant and avoid the risk of professors being poached by industry. Not only does LO-shot learning make the barriers to entry lower by reducing training costs and lowering data requirements, but it also provides more flexibility for users to create novel data sets and experiment with new approaches. By reducing the time spent on data and architecture engineering, researchers looking to leverage AI can spend more time focusing on the practical problems they are aiming to solve.1971 Antievolution Evolves âIn recent months the teaching lasix 40mg injection price of evolution has come under attack in a number of states. The revival of fundamentalism in biology takes a somewhat new form.

The emphasis is on opposition to current theories of the origin of life and the diversity of species not by theologians but by scientists. The movement is led by the Creation Research Society, whose members have appeared before state boards of lasix 40mg injection price education and textbook committees in California, Texas, Arkansas and Tennessee. The society's credo says that it is âcommitted to full belief in the Biblical record of creation and early historyâ and that its goal is âthe realignment of science based on theistic creation concepts.ââ Joy of Pulsars âThe origin of the energy input to the Crab Nebula had been a puzzle that had long defied attempts at solution. Among the various possibilities considered, John Archibald Wheeler at Princeton in 1966 and Franco Pacini at Cornell in 1967 had independently put forward the apparently far-fetched idea that a rotating neutron star might be the energy source.

Now, after the fact, it is lasix 40mg injection price possible to use the observations of the Crab Nebula and its pulsar (NP0531) to invert the problem and show that if the pulsar is a rotating star, it must have the mass and radius of a neutron star. In other words, even without the theory developed over the past 40 years, it is possible to assert that stars of approximately one solar mass and radii on the order of 10 kilometers must exist since the pulsar in the Crab Nebula is such a star. ÂJeremiah P. Ostrikerâ 1921 lasix 40mg injection price Truck Transport âThis is the era of the motor truck.

Yesterday it was the railroad. Before that it was the stage coach. And still further back it was lasix 40mg injection price the canal. The motor truck, and by that we mean modern highway transportation, has come into its own.

It has defined its field of service and established itself therein. In the field of short-haul transportation, the motor truck is the lasix 40mg injection price last word in efficiency. The use of the motor truck, both in the handling of passengers and freight, is entirely an economic proposition for the benefit, according to the leading motor truck authorities, of the country at large. If that is so, there is no justification for limiting by legislation the use of the highway by that vehicle.â Connecting Coast to Coast âThe Longest Land Line in the United States was recently opened to the public by the Western Union Telegraph Company, giving direct communication between New York and Seattle.

Four messages simultaneously each way can be sent over the single copper strand.â 1871 Thomas Henry Huxley âAlthough lasix 40mg injection price Dr. Huxley is profoundly learned in natural history, he has also found time for general literary culture, and is fond of poetry, fiction, and fine writing. It is this wide culture that gives him such power in his controversial writings. He seems to lasix 40mg injection price like nothing better than a regular set-to with some members of the old-school scientists, and he has sometimes been accused of exhibiting a pugnacious and acrimonious spirit.

On one occasion Samuel Wilberforce, Bishop of Oxford, blandly asked him in the presence of a large audience. ÂIs the learned gentleman really willing to have it go forth to the world that he believes himself to be descended from a monkey?. Â Professor Huxley rose and replied in his quiet manner, âWhether I should be descended from a respectable monkey, or from a lasix 40mg injection price bishop of the English church, who can put his brains to no better use than to ridicule science and misrepresent its cultivators, I would certainly choose the monkey!. Ââ Camels in Nevada âOn a ranch on the Carson river is to be seen a herd of twenty-six camels, all but two of which were born and raised in this State.

The camel may now be said to be acclimated to Nevada. The ranch upon which they are kept is sandy and sterile in the extreme, yet the animals feast and grow fat on such prickly shrubs and bitter weeds lasix 40mg injection price as no other animal would touch. When left to themselves, their great delight, after filling themselves with the coarse herbage of the desert, is to lie and roll in the hot sand. They are used in packing salt to the mills on the river, from the marshes lying in the deserts, some sixty miles to the eastward.

Some of the animals easily pack 1,100 pounds.âEver since the deadly parasite responsible for malaria was discovered in the late 19th century, science and global health experts have been waging a vigorous lasix 40mg injection price Sisyphean battle against the disease it causes. Humans have brought an arsenal of toolsânets, rapid tests, medicationâto bear against the mosquito-borne parasite, which cannily mutates to become resistant to drug treatments. Weâre holding our own. Global malaria deaths declined to 409,000 in 2019, compared to 585,000 in 2010, and a number of countries have eliminated it altogether or lasix 40mg injection price are on the verge of doing so.

However, more than 90 percent of the deaths occur in Africa, and there is a threat that could set progress back again. Researchers in Rwanda identified a strain of the malaria parasite P. Falciparum with mutations on a gene known as K13 that enable resistance to artemisinin, the foundation of artemisinin-based combination lasix 40mg injection price therapies (ACTs), the most commonly used malaria treatments. While ACTs still work, a weakened treatment regimen could lead to more deaths on the continent, an increased spread of resistance itself, and loss of confidence in malaria treatment.

We must act now to increase surveillance and monitoring for signs of new K13 mutations, even as we battle the hypertension medications lasix. In addition to basic tactics like increasing peopleâs access to insecticide-treated mosquito nets, hereâs what lasix 40mg injection price can help make a difference. Ensure that providers and patients use drugs effectively. When providers donât prescribe treatments correctly or their patients donât take the complete course as prescribed, it contributes to the emergence of drug-resistant malaria parasites.

Governments and global health programs need to lasix 40mg injection price reinforce effective, safe prescribing and appropriate use of ACTs. For example, largely through USAID-funded initiatives, Management Sciences for Health supports malaria case management in Benin, Madagascar, Malawi, and Nigeria. The program trains, mentors and evaluates health care providers on the use of national malaria treatment guidelines. Take action today lasix 40mg injection price to maximize the longevity of ACTs.

The battle to delay artemisinin drug resistance must be fought on two fronts. The first is to support the use of quality-assured medicines at the correct dosage and to continually monitor their therapeutic efficacy against any emerging signs of resistance. The second is to support national lasix 40mg injection price malaria programs to adopt and deploy more than one artemisinin-based treatment, such as second-line or even multiple first-line therapies along with the addition of single low-dose primaquine to help block the transmission of resistant parasites, in line with WHO guidance. Strategies such as adding a third drug to an ACTâforming a triple ACT, or TACTâare also being investigated.

Finally, we need to acknowledge that the sun may be setting on today's drugs. It may be a lasix 40mg injection price long sunset, but we need to be ready for tomorrow. Develop the next generation of treatments. Medicines for Malaria Venture (MMV), a not-for-profit research and development organization, and its research and pharma partners have developed the largest portfolio of antimalarials in history.

The most advanced new antimalarial medicine targeting parasites showing resistance lasix 40mg injection price to current drugs is in development with Swiss health care company Novartis. It's currently in clinical trials and is aimed at treating children as young as six months, as malaria kills more children under five than any other age group. National malaria control programs must be ready to incorporate this potential new medicine in their budgets and treatment guidelines when it becomes available. Expand lab lasix 40mg injection price testing capacity.

Improved surveillance to track the spread of resistant plasmodia is critical to maintaining progress, including using molecular and genomic techniques. However, many sub-Saharan African countries do not yet have the equipment, personnel, funding or infrastructure to efficiently handle sequencing for malaria. Here, too, investors and collaborators must strengthen and build additional capacity lasix 40mg injection price. The National Institutes of Health and the Wellcome Trust have established the Human Heredity and Health in Africa (H3Africa) initiative to build capacity on the continent, as is the U.S.

Presidentâs Malaria Initiativeâsupported Antimalarial Resistance Monitoring in Africa Network, which also supports collaborative efforts across the continent. The Africa lasix 40mg injection price CDC and the African Academy of Sciences have provided funding. Yet much more is needed for sufficient lab capacity. Develop a cross-border action plan with neighboring countries.

Now that resistant parasites have been documented in lasix 40mg injection price Rwanda, they may be carried by travelers across borders or may already be in other African countries. National malaria control programs and WHOâs regional and country offices need to reinforce intercountry collaboration, sharing information as well as educating health care providers and communities about the implications of the mutation. Pharmaceutical regulatory agencies should continue to monitor and enforce quality standards to prevent and tackle substandard and falsified medicines, which greatly contribute to drug resistance. The West African Health lasix 40mg injection price Organization.

Southern African Development Community. And East, Central and Southern African Health Community should work together to align efforts. Southeast Asia has already seen this mutation as of 2013 and is holding it at bay with careful use of drugs that work where they are most needed. We can outsmart this.

Cheap generic lasix

ÂOK, so we know you're not going to get pregnant.âSexuality educator Jane Fleishman, PhD, typically opens with this line you could look here when she goes into senior communities to talk cheap generic lasix about safe sex. Itâs her way cheap generic lasix of trying to break the tension and clear the air. Sex talk can be awkward at any age, whether youâre 15 or 50-plus.Then she brings out the puppets. But these arenât the kind you see at a childrenâs puppet show cheap generic lasix. Theyâre made in the form of male and female sex organs â a vulva and a penis.

That usually breaks the ice and cheap generic lasix gets a laugh.âBut then I say, âThis is real stuff. You don't want to get an from somebody else,â â says Fleishman, who got her degree in human sexuality studies while in her 60s.Thereâs a real need for this type of education among people who are older, she says. To start cheap generic lasix with, sexual intimacy does not end when a person receives their AARP card. About three-quarters of adults 65 to 80 agree that sex is an cheap generic lasix important part of a romantic relationship, regardless of age, according to a 2018 survey from the University of Michigan. And more than half of those in romantic relationships reported being sexually active.

Men in this group were about four times more likely than women to be cheap generic lasix âextremely interestedâ or âvery interestedâ in sex.Another recent study found that 43% of women ages 50 to 80 were sexually active in the past year. And 62% were satisfied with their sexual activity. Only about 28% said menopause-related symptoms interfered with their ability to be sexually active.Fleishman wants to make sure that cheap generic lasix those adults â many of whom may be widowed or divorced and dating someone new â are approaching sex safely, so she starts with the basics. ÂI talk about mouth to anus, mouth to vulva, mouth to penis, penis to vulva, penis to anus,â she says. ÂI really try to be as cheap generic lasix blunt as I possibly can be.âJust as importantly, she discusses the need for consent and communication in a sexual relationship.

ÂThe business of cheap generic lasix consent is taught to teenagers and to college students now,â she says. ÂBut nobody's teaching older adults about it.âFinding the GapsOlder adults are far less likely to get sexually transmitted s (STIs), compared to other adult age groups. Still, rates are going up cheap generic lasix at an alarming rate, experts say. Between 2009 and 2019, in people 55 and older, STIs â including hepatitis C, syphilis, chlamydia, and gonorrhea â increased by four to five times, according to the CDC.Part of the problem is a lack of knowledge. When researchers tested STI awareness in adults 65 and older with a questionnaire, they cheap generic lasix found plenty of gaps.

ÂOn average, older adults only correctly answered about 12 of the 27 items, which means they did not know facts about STI risk, presentation, transmission, or treatment,â says Matthew Lee Smith, PhD, who led the research at Texas A&Mâs School of Public Health.Health care professionals can provide helpful education and guidance, but only to people who are open and honest about their sex lives. Thatâs happening more now than it cheap generic lasix has in the past, says Nicole Williams, MD, of the Gynecology Institute of Chicago. But often, the conversation cheap generic lasix happens too late with her older patients. Theyâre just not as willing to talk about sex. ÂThey're not worried about pregnancy cheap generic lasix.

They're just having unprotected sex and then coming to me and asking for testing,â she says. ÂI find that problematic because they're getting exposed to HPV, trichomoniasis, bacterial vaginosis, and other sexually related s.âCornelius Jamison, MD, makes it a point to bring up sex cheap generic lasix with his patients in his family medicine practice in Michigan. He does his best to make the conversation comfortable and easy, but even still, older patients often have trouble speaking openly about it, says Jamison, an assistant professor in the Department of Family Medicine at the University of Michigan.âIt will be like the last thing at the end of the visit, where they'll say, âOh, and by the way, Doc, I was wondering, is it possible to get Viagra, Cialis?. I've seen that they work, and I'm having some issues.ââJamison cheap generic lasix says he wishes more doctors would ask about sex during standard physical exams, no matter what the age of the person. ÂThe desire to have sex never really goes away,â he says.

ÂSometimes providers aren't thinking about that.âLetâs Talk About cheap generic lasix (Safe) SexGynecologist Barb DePree, MD, has noticed a big spike in dating among women 50 and up. Dating apps that zero in on certain age groups could be one cheap generic lasix reason for that, says DePree, director of women's health at Holland Hospital in Holland, MI. And the numbers bear that out. Nearly 20% of adults ages 50 to cheap generic lasix 64 report using dating apps or sites, according to Pew Research. While thatâs not as high as the next age group down (38% for ages 30-49) itâs still a lot of online activity.Whatever the reason, this spike in dating could do much to explain the rising number of STI cases in this older set.

In addition, DePree says, cheap generic lasix many older adults donât seem as accepting of condoms as younger people.But protection is still important at every age when thereâs a possibility of an STI. Where the penis is involved, that typically means a condom. For women, in particular, the vulva and vaginal tissues thin with age and could be more susceptible to cheap generic lasix s such as human papillomalasix (HPV), herpes simplex lasix (HSV), hepatitis B, and hepatitis C, says DePree. As women age, vaginal dryness is cheap generic lasix common, and DePree says most will benefit from a lubricant. But where condoms are involved, DePree has a tip.

While silicone lubricant cheap generic lasix is a popular choice for postmenopausal women, it doesnât pair well with condoms.âMost condoms will be somewhat degraded with a silicone lube,â she says. Use a water-based lubricant instead.But condoms wonât always help. Oral-to-genital transmission is also possible for STIs such as herpes and HPV, as well as in other types of cheap generic lasix sex. Ask your doctor about ways to protect against STIs when a condom isnât possible.Keeping It FunFun starts with being comfortable with your partner. And getting comfortable often starts with a conversation.âTalk about previous STIs, talk about sexual partners, talk about whether or not you want to use condoms, whether or not you feel comfortable doing certain positions,â cheap generic lasix says Jamison from the University of Michigan.âIf someone's had a hip replacement, then maybe this is not the position to do.â And, importantly, get tested for STIs, says Williams.

ÂI offer that to every one of my patients, no matter how old cheap generic lasix they are.âSafe sex education, at all stages of life, tends to include only the cautions. Fleishman, the sex educator, says itâs important to talk about the joys and pleasures as well.Many adults in their 50s, 60s, 70s, and beyond discover a chance for renewal, excitement, and liberation in their sex lives. After all, says Fleishman, âThereâs no expiration date on pleasure.âMay 27, 2022 -- Amy Chambers cheap generic lasix is planning a visit soon with the principal of her son's elementary school in Joplin, MO. The grade level of the 19 children killed in the Tuesday school shooting in Uvalde, TX, was not unnoticed by her. Her son, the youngest of her three, is also a fourth grader.Chambers, a church secretary in Joplin, thinks the security to get into her son's school is good, but she has questions about how the school's individual classrooms would handle an intruder.When one of her older children was at a college meeting about security, cheap generic lasix she remembers hearing the speaker talk about having the entire class throw things at an intruder to deflect attention, and perhaps then attack.

"I want to visit with our school about that," she says, and find out, "Do they have individual class protocols" to deal with the what-ifs.Likewise, Dana Pustetta, a television camera operator in Long Beach, CA, and the father of a 5-year-old daughter, plans to get info about the security situation at her school. "I will talk to my kid's school and see what training they will employ," he says.He hopes they call it "emergency preparedness" rather than an "active shooter drill." The latter, he says, "I think feeds the fear." He would prefer if school officials explain it like "if this happens" and tell the kids what to do, rather than give the impression they cheap generic lasix should expect the incident. "I would rather not assume the worst."In the wake of the Uvalde tragedy, in which two teachers also died, school safety is understandably on the minds of parents with kids in school. Kim Vann is the chief operations officer of Safe and Sound Schools, a national nonprofit safety and advocacy center founded by parents of children killed in the Sandy Hook Elementary School cheap generic lasix shooting in 2012. She says theyâve been hearing from parents and others since cheap generic lasix the Tuesday tragedy."We can't keep up," she says of inquiries.

"The calls we have been getting are [also] from schools and state associations looking to share resources with parents and schools." Besides asking schools for specifics about safety protocols, some parents are reaching out to lawmakers, and others asking for gun legislation changes.But Pustetta isn't planning to reach out to lawmakers to ask for gun reform."I think a letter to a senator will fall on deaf ears, until a senator's kid or grandkid is directly involved, unfortunately," he says.But other parents â some high-profile â are urging people to reach out to their lawmakers.Steve Kerr, coach of the NBAâs Golden State Warriors, and a parent whose father was murdered in 1984 while a professor at the American University of Beirut, devoted a pregame news conference on Tuesday to a plea to take action on gun legislation."Enough is enough," a very emotional Kerr said as he cut short the conference before the Western Conference playoffs and talked not at all about basketball.Petitions on the internet platform Change.org asking for gun legislation, specifically mentioning Uvalde, increased after Tuesday. Status of School SecuritySchool security overall has been improving in recent years, according to Michele Gay, executive cheap generic lasix director and founder of Safe and Sound Schools. She lost her daughter, Josephine Grace, in the Sandy Hook shooting. In a statement, cheap generic lasix she says the organization does an annual State of School Safety survey. Its next report will be released in early July."Over the past 10 years, we have seen steady improvement nationwide in basic safety and security measures," she says.

Her organization has a Framework for Comprehensive School Safety, which emphasizes a team approach, as well as including many areas of school safety such as mental health, emergency management, health and wellness, and security.But she acknowledges that "Safety programming, measures, and policies vary greatly from district to district, state cheap generic lasix to state, and across urban, rural, and suburban settings."How Parents Can Research, Get InvolvedParents should definitely understand their children's school security and emergency planning, says Robin Gurwitch, PhD, a psychologist and professor at Duke University in Durham, NC.She suggests a two-step process for parents. Find out what the cheap generic lasix plan is. Find out how you can take an active role. Parents should also think about any special skills they have that would be cheap generic lasix useful as school officials are developing or updating safety and security plans. For instance, parents may be first responders who can share their insight.

"They can bring their knowledge to the planning,â she says.And, of course, these same conversations have occurred after each in the seemingly endless string of school shootings in the United States.Some families have tried to make meaning out cheap generic lasix of tragedy by running for a school board seat, she says, so they will have a hand in policy about safety and security.Knowing what the plan is at your children's school may help reduce parental anxiety, she says.Offering your help through the school PTA would be one avenue, Gurwitch says.Ken Trump is president of National School Safety and Security Services, a school safety consulting firm in Cleveland, OH. On his website, he lists 10 practical things parents can do to assess school security and emergency preparedness. The list includes things you can ask your child, depending on age, about safety â like where they feel cheap generic lasix safe and what can be done to improve safety. It also says parents should know about cheap generic lasix access to the school and how visitors are allowed to enter. Safe and Sound Schools posts its Framework for Comprehensive School Safety.

Its categories reflect cheap generic lasix the complexity of school safety.The PTA also offers guidance on what parents should expect in terms of school safety and suggests important questions to ask.But security at schools isnât always enough. Uvaldeâs school system received a nearly $70,000 grant from the state, increased the number of officers in its police force, and doubled spending on security over the past 4 years, according to The New York Times.A 2019 study published in the journal Violence and Gender found that increased security in schools has not been an effective deterrent.âThis comprehensive review of the literature from 2000 to 2018 regarding school firearm violence prevention failed to find any programs or practices with evidence indicating that they reduced such firearm violence,â the authors wrote. ÂThe adoption cheap generic lasix of ineffective measures to reduce school firearm violence may lull parents, school personnel, and students into thinking they no longer have to be concerned about their safety at school.â Modeling a Thoughtful ConversationDespite the anxiety around school safety, Gurwitch advises parents to enter conversations with school officials with an eye and a mindset of modeling thoughtful discussion for their children. "We don't have a uniform idea of what to do to make this unlikely to happen again," she says. "People have different opinions."She recalls the often brutal disagreements among cheap generic lasix parents and between parents and educators during hypertension medications masking debates, and she urges parents to keep the conversations calm.

"We have to be mindful we still have to be role models for our children.".

ÂOK, so we know you're not going to get pregnant.âSexuality educator Jane buy generic lasix Fleishman, PhD, typically opens with lasix 40mg injection price this line when she goes into senior communities to talk about safe sex. Itâs her way of trying to break lasix 40mg injection price the tension and clear the air. Sex talk can be awkward at any age, whether youâre 15 or 50-plus.Then she brings out the puppets.

But these arenât lasix 40mg injection price the kind you see at a childrenâs puppet show. Theyâre made in the form of male and female sex organs â a vulva and a penis. That usually breaks the ice and gets a laugh.âBut then I say, lasix 40mg injection price âThis is real stuff.

You don't want to get an from somebody else,â â says Fleishman, who got her degree in human sexuality studies while in her 60s.Thereâs a real need for this type of education among people who are older, she says. To start with, sexual intimacy does not end when a person receives their AARP card lasix 40mg injection price. About three-quarters of adults 65 to 80 agree that sex is an important part of a lasix 40mg injection price romantic relationship, regardless of age, according to a 2018 survey from the University of Michigan.

And more than half of those in romantic relationships reported being sexually active. Men in this group were about four times more likely than women to be âextremely interestedâ or âvery interestedâ in sex.Another recent study found that 43% of women ages 50 to 80 were sexually active in the lasix 40mg injection price past year. And 62% were satisfied with their sexual activity.

Only about 28% said menopause-related symptoms interfered with lasix 40mg injection price their ability to be sexually active.Fleishman wants to make sure that those adults â many of whom may be widowed or divorced and dating someone new â are approaching sex safely, so she starts with the basics. ÂI talk about mouth to anus, mouth to vulva, mouth to penis, penis to vulva, penis to anus,â she says. ÂI really try to be as blunt as I possibly can be.âJust as importantly, she discusses lasix 40mg injection price the need for consent and communication in a sexual relationship.

ÂThe business of consent is lasix 40mg injection price taught to teenagers and to college students now,â she says. ÂBut nobody's teaching older adults about it.âFinding the GapsOlder adults are far less likely to get sexually transmitted s (STIs), compared to other adult age groups. Still, rates are going up at an alarming rate, experts lasix 40mg injection price say.

Between 2009 and 2019, in people 55 and older, STIs â including hepatitis C, syphilis, chlamydia, and gonorrhea â increased by four to five times, according to the CDC.Part of the problem is a lack of knowledge. When researchers tested STI awareness lasix 40mg injection price in adults 65 and older with a questionnaire, they found plenty of gaps. ÂOn average, older adults only correctly answered about 12 of the 27 items, which means they did not know facts about STI risk, presentation, transmission, or treatment,â says Matthew Lee Smith, PhD, who led the research at Texas A&Mâs School of Public Health.Health care professionals can provide helpful education and guidance, but only to people who are open and honest about their sex lives.

Thatâs happening more now than lasix 40mg injection price it has in the past, says Nicole Williams, MD, of the Gynecology Institute of Chicago. But often, the conversation happens too late with her lasix 40mg injection price older patients. Theyâre just not as willing to talk about sex.

ÂThey're not lasix 40mg injection price worried about pregnancy. They're just having unprotected sex and then coming to me and asking for testing,â she says. ÂI find that problematic because they're getting exposed to HPV, trichomoniasis, bacterial vaginosis, and other sexually related s.âCornelius Jamison, MD, lasix 40mg injection price makes it a point to bring up sex with his patients in his family medicine practice in Michigan.

He does his best to make the conversation comfortable and easy, but even still, older patients often have trouble speaking openly about it, says Jamison, an assistant professor in the Department of Family Medicine at the University of Michigan.âIt will be like the last thing at the end of the visit, where they'll say, âOh, and by the way, Doc, I was wondering, is it possible to get Viagra, Cialis?. I've seen that they work, and I'm having some issues.ââJamison says he wishes more doctors lasix 40mg injection price would ask about sex during standard physical exams, no matter what the age of the person. ÂThe desire to have sex never really goes away,â he says.

ÂSometimes providers aren't thinking about that.âLetâs Talk About (Safe) SexGynecologist Barb DePree, MD, has noticed a lasix 40mg injection price big spike in dating among women 50 and up. Dating apps that zero in on certain age groups could be one reason for that, says DePree, director of women's health at Holland Hospital in Holland, lasix 40mg injection price MI. And the numbers bear that out.

Nearly 20% of adults ages 50 to 64 report lasix 40mg injection price using dating apps or sites, according to Pew Research. While thatâs not as high as the next age group down (38% for ages 30-49) itâs still a lot of online activity.Whatever the reason, this spike in dating could do much to explain the rising number of STI cases in this older set. In addition, DePree says, many older adults donât seem as accepting lasix 40mg injection price of condoms as younger people.But protection is still important at every age when thereâs a possibility of an STI.

Where the penis is involved, that typically means a condom. For women, in particular, the vulva and vaginal tissues thin with age and could be more susceptible to s lasix 40mg injection price such as human papillomalasix (HPV), herpes simplex lasix (HSV), hepatitis B, and hepatitis C, says DePree. As women age, vaginal dryness is common, and lasix pill price DePree says most will benefit from a lubricant lasix 40mg injection price.

But where condoms are involved, DePree has a tip. While silicone lubricant is a popular choice for postmenopausal lasix 40mg injection price women, it doesnât pair well with condoms.âMost condoms will be somewhat degraded with a silicone lube,â she says. Use a water-based lubricant instead.But condoms wonât always help.

Oral-to-genital transmission is also possible for STIs such as herpes and lasix 40mg injection price HPV, as well as in other types of sex. Ask your doctor about ways to protect against STIs when a condom isnât possible.Keeping It FunFun starts with being comfortable with your partner. And getting comfortable often starts with a conversation.âTalk about previous STIs, talk about sexual partners, talk about whether or not you want to use condoms, whether or not you feel comfortable doing certain positions,â says Jamison from the University of Michigan.âIf someone's had a hip replacement, then maybe this is not the position to do.â And, lasix 40mg injection price importantly, get tested for STIs, says Williams.

ÂI offer that to every one of my patients, no matter how old they lasix 40mg injection price are.âSafe sex education, at all stages of life, tends to include only the cautions. Fleishman, the sex educator, says itâs important to talk about the joys and pleasures as well.Many adults in their 50s, 60s, 70s, and beyond discover a chance for renewal, excitement, and liberation in their sex lives. After all, says Fleishman, âThereâs no lasix 40mg injection price expiration date on pleasure.âMay 27, 2022 -- Amy Chambers is planning a visit soon with the principal of her son's elementary school in Joplin, MO.

The grade level of the 19 children killed in the Tuesday school shooting in Uvalde, TX, was not unnoticed by her. Her son, the youngest of lasix 40mg injection price her three, is also a fourth grader.Chambers, a church secretary in Joplin, thinks the security to get into her son's school is good, but she has questions about how the school's individual classrooms would handle an intruder.When one of her older children was at a college meeting about security, she remembers hearing the speaker talk about having the entire class throw things at an intruder to deflect attention, and perhaps then attack. "I want to visit with our school about that," she says, and find out, "Do they have individual class protocols" to deal with the what-ifs.Likewise, Dana Pustetta, a television camera operator in Long Beach, CA, and the father of a 5-year-old daughter, plans to get info about the security situation at her school.

"I will talk to my lasix 40mg injection price kid's school and see what training they will employ," he says.He hopes they call it "emergency preparedness" rather than an "active shooter drill." The latter, he says, "I think feeds the fear." He would prefer if school officials explain it like "if this happens" and tell the kids what to do, rather than give the impression they should expect the incident. "I would rather not assume the worst."In the wake of the Uvalde tragedy, in which two teachers also died, school safety is understandably on the minds of parents with kids in school. Kim Vann is the chief operations officer lasix 40mg injection price of Safe and Sound Schools, a national nonprofit safety and advocacy center founded by parents of children killed in the Sandy Hook Elementary School shooting in 2012.

She says theyâve been hearing from parents and others since the Tuesday tragedy."We can't lasix 40mg injection price keep up," she says of inquiries. "The calls we have been getting are [also] from schools and state associations looking to share resources with parents and schools." Besides asking schools for specifics about safety protocols, some parents are reaching out to lawmakers, and others asking for gun legislation changes.But Pustetta isn't planning to reach out to lawmakers to ask for gun reform."I think a letter to a senator will fall on deaf ears, until a senator's kid or grandkid is directly involved, unfortunately," he says.But other parents â some high-profile â are urging people to reach out to their lawmakers.Steve Kerr, coach of the NBAâs Golden State Warriors, and a parent whose father was murdered in 1984 while a professor at the American University of Beirut, devoted a pregame news conference on Tuesday to a plea to take action on gun legislation."Enough is enough," a very emotional Kerr said as he cut short the conference before the Western Conference playoffs and talked not at all about basketball.Petitions on the internet platform Change.org asking for gun legislation, specifically mentioning Uvalde, increased after Tuesday. Status of School SecuritySchool security overall has been improving lasix 40mg injection price in recent years, according to Michele Gay, executive director and founder of Safe and Sound Schools.

She lost her daughter, Josephine Grace, in the Sandy Hook shooting. In a lasix 40mg injection price statement, she says the organization does an annual State of School Safety survey. Its next report will be released in early July."Over the past 10 years, we have seen steady improvement nationwide in basic safety and security measures," she says.

Her organization lasix 40mg injection price has a Framework for Comprehensive School Safety, which emphasizes a team approach, as well as including many areas of school safety such as mental health, emergency management, health and wellness, and security.But she acknowledges that "Safety programming, measures, and policies vary greatly from district to district, state to state, and across urban, rural, and suburban settings."How Parents Can Research, Get InvolvedParents should definitely understand their children's school security and emergency planning, says Robin Gurwitch, PhD, a psychologist and professor at Duke University in Durham, NC.She suggests a two-step process for parents. Find out what lasix 40mg injection price the plan is. Find out how you can take an active role.

Parents should also think about any special skills they lasix 40mg injection price have that would be useful as school officials are developing or updating safety and security plans. For instance, parents may be first responders who can share their insight. "They can bring their knowledge to the planning,â she says.And, of course, these same conversations have occurred after each in the seemingly endless string lasix 40mg injection price of school shootings in the United States.Some families have tried to make meaning out of tragedy by running for a school board seat, she says, so they will have a hand in policy about safety and security.Knowing what the plan is at your children's school may help reduce parental anxiety, she says.Offering your help through the school PTA would be one avenue, Gurwitch says.Ken Trump is president of National School Safety and Security Services, a school safety consulting firm in Cleveland, OH.

On his website, he lists 10 practical things parents can do to assess school security and emergency preparedness. The list includes things you can ask lasix 40mg injection price your child, depending on age, about safety â like where they feel safe and what can be done to improve safety. It also says parents should know about access to the school and how visitors are allowed lasix 40mg injection price to enter.

Safe and Sound Schools posts its Framework for Comprehensive School Safety. Its categories reflect the complexity of school safety.The PTA also offers guidance on what parents should expect in terms of school safety and suggests important questions to ask.But security at schools isnât always enough lasix 40mg injection price. Uvaldeâs school system received a nearly $70,000 grant from the state, increased the number of officers in its police force, and doubled spending on security over the past 4 years, according to The New York Times.A 2019 study published in the journal Violence and Gender found that increased security in schools has not been an effective deterrent.âThis comprehensive review of the literature from 2000 to 2018 regarding school firearm violence prevention failed to find any programs or practices with evidence indicating that they reduced such firearm violence,â the authors wrote.

ÂThe adoption of ineffective measures to reduce school firearm violence may lull parents, school personnel, and students into thinking they no longer have to be concerned about their safety at school.â Modeling a Thoughtful ConversationDespite the anxiety around school safety, Gurwitch advises parents to enter conversations with school officials with an eye lasix 40mg injection price and a mindset of modeling thoughtful discussion for their children. "We don't have a uniform idea of what to do to make this unlikely to happen again," she says. "People have different opinions."She recalls the often brutal disagreements among parents and between parents and educators during hypertension medications masking debates, and she urges parents to keep lasix 40mg injection price the conversations calm.

"We have to be mindful we still have to be role models for our children.".

Lasix side effects in elderly

ATLANTA â Georgia lawmakers will consider a bill that could force the stateâs Medicaid managed-care insurers to repay millions of dollars if Best place to purchase cialis online their spending on lasix side effects in elderly medical care doesnât reach a certain threshold. The bipartisan bill, introduced Jan. 26 by the powerful Georgia House Speaker David lasix side effects in elderly Ralston, a Republican, is focused on improving the stateâs mental health care system. Tucked inside the legislation is a provision that would require the Medicaid managed-care companies to refund payments to the state if they donât spend enough on medical care and quality improvements for patients. Georgia Health News and KHN reported in September that Georgia was one of only a few states that doesnât mandate a minimum level of medical spending for its Medicaid insurers.

Each year, Georgia pays three insurance companies â CareSource, Peach State Health Plan, and Amerigroup â lasix side effects in elderly a total of more than $4 billion to run the federal-state health insurance program for low-income residents and people with disabilities. For 2019 and 2020, the companiesâ combined profits averaged $189 million per year, according to insurer filings reported by the National Association of Insurance Commissioners. ÂInstead of ensuring adequate health care networks for Georgiaâs children, Georgians with disabilities, and Georgians in nursing facilities, hundreds of millions of dollars go instead to the Georgia [insurersâ] bottom lines,â said Roland Behm, a board member for the Georgia chapter of the American Foundation for Suicide Prevention. Behm, who advised lawmakers on the bill, said the KHN and Georgia Health News article helped bring the issue to the attention of legislators crafting lasix side effects in elderly the bill. Georgia is among more than 40 states that have turned to managed-care companies to run their Medicaid programs â and ostensibly control costs.

According to an August report from the U.S. Department of Health and Human Servicesâ Office of Inspector General, 36 of those states and lasix side effects in elderly the District of Columbia set a benchmark âmedical loss ratioâ for the minimum spending by insurers on medical care. Besides Georgia, the report said, the five states not requiring a managed-care spending threshold were Kansas, Rhode Island, Tennessee, Texas, and Wisconsin. Republican state Rep. Todd Jones, a co-sponsor of the new bill, told KHN that Georgia lawmakers should establish lasix side effects in elderly a strong benchmark for insurers to meet.

ÂWe should look at what other states are doing,â he said. Most states with a spending requirement set that ratio at a minimum of 85% of premium dollars that insurers are paid. So when a Medicaid insurer spends less than that on medical care and quality improvements, it must return money lasix side effects in elderly to the government. The Georgia bill also calls for setting the threshold at 85%. If the bill is approved, the Medicaid insurers would face the medical spending requirement in 2023.

If the benchmark had been in place in recent lasix side effects in elderly years, it could have forced a recoupment from the Peach State company, which has the largest Georgia Medicaid enrollment of the three insurers. State documents show it failed to reach the 85% mark from 2018 to 2020, KHN previously reported. Andy Schneider, a research professor at Georgetown Universityâs Center for Children and Families, called the 85% mark âa win for taxpayers, for Medicaid providers, and for Medicaid beneficiaries.â He also said it would be more than fair to the Medicaid insurers, which could keep 15% of what the state pays them for administrative costs and profit. Because Ralston is the lead lasix side effects in elderly sponsor of the bill in the House, itâs expected to pass that chamber. But the insurance industry likely will work to remove the medical spending provision.

An industry official, Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group, declined to comment on the legislation. Fiona Roberts, a spokesperson for the state Department of Community Health, which oversees the Medicaid program, said the agency needs time to review the measure before lasix side effects in elderly commenting on it. The main provisions of the bill require insurers to provide coverage for mental health care or substance use treatment at the same level as other physical health needs. The legislation would provide education loan support for people training in the fields of mental health and substance use disorders and seek to expand behavioral health services for children. It would also facilitate âassisted outpatient treatmentâ lasix side effects in elderly â when a judge could order a person with a serious mental illness to follow a court-ordered treatment plan in the community.

Andy Miller. amiller@kff.org, @gahealthnews Related Topics Contact Us Submit a Story Tip.

ATLANTA â Georgia lawmakers will consider a bill that could force the stateâs lasix 40mg injection price Medicaid managed-care insurers to repay http://bricksource.se/best-place-to-purchase-cialis-online/ millions of dollars if their spending on medical care doesnât reach a certain threshold. The bipartisan bill, introduced Jan. 26 by lasix 40mg injection price the powerful Georgia House Speaker David Ralston, a Republican, is focused on improving the stateâs mental health care system. Tucked inside the legislation is a provision that would require the Medicaid managed-care companies to refund payments to the state if they donât spend enough on medical care and quality improvements for patients. Georgia Health News and KHN reported in September that Georgia was one of only a few states that doesnât mandate a minimum level of medical spending for its Medicaid insurers.

Each year, Georgia pays lasix 40mg injection price three insurance companies â CareSource, Peach State Health Plan, and Amerigroup â a total of more than $4 billion to run the federal-state health insurance program for low-income residents and people with disabilities. For 2019 and 2020, the companiesâ combined profits averaged $189 million per year, according to insurer filings reported by the National Association of Insurance Commissioners. ÂInstead of ensuring adequate health care networks for Georgiaâs children, Georgians with disabilities, and Georgians in nursing facilities, hundreds of millions of dollars go instead to the Georgia [insurersâ] bottom lines,â said Roland Behm, a board member for the Georgia chapter of the American Foundation for Suicide Prevention. Behm, who lasix 40mg injection price advised lawmakers on the bill, said the KHN and Georgia Health News article helped bring the issue to the attention of legislators crafting the bill. Georgia is among more than 40 states that have turned to managed-care companies to run their Medicaid programs â and ostensibly control costs.

According to an August report from the U.S. Department of Health and Human Servicesâ Office of Inspector General, 36 of those states and the District of Columbia lasix 40mg injection price set a benchmark âmedical loss ratioâ for the minimum spending by insurers on medical care. Besides Georgia, the report said, the five states not requiring a managed-care spending threshold were Kansas, Rhode Island, Tennessee, Texas, and Wisconsin. Republican state Rep. Todd Jones, a co-sponsor of the new bill, told KHN that Georgia lawmakers should establish a strong benchmark lasix 40mg injection price for insurers to meet.

ÂWe should look at what other states are doing,â he said. Most states with a spending requirement set that ratio at a minimum of 85% of premium dollars that insurers are paid. So when a Medicaid insurer spends less than that on lasix 40mg injection price medical care and quality improvements, it must return money to the government. The Georgia bill also calls for setting the threshold at 85%. If the bill is approved, the Medicaid insurers would face the medical spending requirement in 2023.

If the benchmark had been in place in recent years, it could have forced a recoupment from lasix 40mg injection price the Peach State company, which has the largest Georgia Medicaid enrollment of the three insurers. State documents show it failed to reach the 85% mark from 2018 to 2020, KHN previously reported. Andy Schneider, a research professor at Georgetown Universityâs Center for Children and Families, called the 85% mark âa win for taxpayers, for Medicaid providers, and for Medicaid beneficiaries.â He also said it would be more than fair to the Medicaid insurers, which could keep 15% of what the state pays them for administrative costs and profit. Because Ralston is the lead sponsor of the bill in the House, itâs expected lasix 40mg injection price to pass that chamber. But the insurance industry likely will work to remove the medical spending provision.

An industry official, Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group, declined to comment on the legislation. Fiona Roberts, a spokesperson for the state Department of Community Health, which oversees the Medicaid program, said the agency needs time to review the measure before commenting on lasix 40mg injection price it. The main provisions of the bill require insurers to provide coverage for mental health care or substance use treatment at the same level as other physical health needs. The legislation would provide education loan support for people training in the fields of mental health and substance use disorders and seek to expand behavioral health services for children. It would also facilitate âassisted outpatient treatmentâ â when a judge could order a person with a serious mental illness to lasix 40mg injection price follow a court-ordered treatment plan in the community.

Andy Miller. amiller@kff.org, @gahealthnews Related Topics Contact Us Submit a Story Tip.