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Clinical trials should show that a candidate treatment very significantly reduces hypertension medications in people who are how to buy cheap lasix online vaccinated, compared to a control group of people who don’t receive the treatment, through a reduction in numbers of laboratory confirmed hypertension s. It is expected that candidate treatments should also reduce the transmission of disease between individuals. Regulators may seek additional independent expert advice from independent scientific advisory committees to help inform their decision on whether to approve a treatment. These committees are made how to buy cheap lasix online up of experts in science, medicine (including infectious diseases) and public health and often include consumer representatives.

Quality. Any hypertension medications treatment that receives regulatory approval must be manufactured according to internationally agreed stringent regulatory standards of good manufacturing practices (GMP). Regulators will review data to confirm that the manufacturing process at each production site is well controlled how to buy cheap lasix online and consistent. This will include data on the identity and purity of the treatment components and its potency, as well as data on every step of manufacturing and on the controls used to ensure that each batch of treatment is consistently of a high quality.

Data on treatment stability must also be provided before a treatment can be approved. Batches may how to buy cheap lasix online also undergo evaluation by individual national regulatory authorities to ensure they meet international requirements, before they can be supplied. Monitoring safety and effectiveness after treatment approval. After a treatment is authorised, sponsors will be required to conduct robust safety and effectiveness monitoring (pharmacovigilance) and risk minimisation activities.

They will need to continuously monitor treatment safety to how to buy cheap lasix online ensure that the benefits of the treatment continue to outweigh the risks. To this end, regulators require treatment sponsors to have risk management plans describing how they will undertake to monitor and minimise risks associated with their treatments. treatment companies will also be required to continue safety surveillance from the ongoing clinical trials of their products, typically using a number of approaches. Reviewing and analysing adverse events reported by healthcare professionals and consumers and requiring industry treatment sponsors to report to regulators on adverse events received both within the regulator’s home country and how to buy cheap lasix online globally.

Many regulators will implement enhanced passive surveillance systems, and will have access to near real-time data on treatment usage in different settings. Several will also implement traceability systems for different treatment brands and batches. Working with other international regulators and researchers to share information about emerging safety issues how to buy cheap lasix online in order to take quick action to mitigate risks. And Reviewing medical literature and other sources of new safety information.It is very important that healthcare professionals not only diligently report adverse events that they see in their patients, but to also encourage people who are vaccinated to immediately report them to their healthcare professionals.

Regulators will develop lists of “Adverse Events of Special Interest” following vaccination. Some have been rarely associated with immunization and others are often reported but have not been found to have a causal how to buy cheap lasix online association. Having background rates of these events will help ensure that any increases detected can be quickly verified. If a significantly increased frequency of certain serious adverse events is detected in vaccinated groups, then this will lead rapidly to regulatory actions.

The widespread use of hypertension medications treatments, including in the elderly, will unfortunately how to buy cheap lasix online mean that there will be many purely coincidental deaths and serious illnesses, unrelated to vaccinations. The job of each regulator is to establish causality – in other words, whether the vaccination is likely to have led to the serious outcome. There will also be a special focus on monitoring safety in pregnant women, persons with severe pre-existing illness, the elderly and children and interaction with other treatments. Regulators, in collaboration with how to buy cheap lasix online public health authorities, are able to take decisive action if and when a safety issue is identified.

These actions might include issuing safety communications for patients, healthcare professionals and the community. Updating the product information or consumer information for the treatment. Preventing the release how to buy cheap lasix online of a particular batch of treatment. And, taking other regulatory actions as necessary.

Globally, the public can have confidence in the rigour of the process used to scientifically evaluate the safety, efficacy and quality of treatments before they are approved for use in the wider population. Questions and how to buy cheap lasix online Answers on hypertension medications treatments Q. How have the treatments been developed so quickly?. Does this mean that their safety and efficacy has been compromised?.

A how to buy cheap lasix online. The speed of development of hypertension medications treatments has been unprecedented for several reasons The massive financial investment by governments - in the tens of billions of dollars or more, in treatment development and the re-direction of much of the global research and commercial treatment developing and manufacturing infrastructure. This also enabled companies to take the commercial risk of manufacturing some treatment stocks ahead of regulatory approvals as governments underwrote the risks of costs of failure. New technologies adapted from the development of other how to buy cheap lasix online treatments – mRNA treatments were developed very rapidly after the sequence of the hypertension medications lasix was determined, and production was scaled up very quickly.

The adenolasix technology used in another type of treatment was first tested with SARS and MERS over the last 20 years, and so was able to be adapted quickly to hypertension medications, which has several similarities to these lasixes. Clinical trial successes - because of the high concerns about hypertension medications, it has been possible to rapidly recruit large numbers of volunteers into clinical trials and, with unfortunately high rates of in several countries, complete trials using 10,000-50,000 subjects in a short period of time. Under normal circumstances, it may take many months or even how to buy cheap lasix online a few years to determine whether a treatment is effective. Very close collaboration - between regulators, industry and clinical researchers enabled clear indications of regulatory requirements and early access to results.

Intensive and insightful research. Researchers predicted that the “spike protein” on the lasix would be a good target for how to buy cheap lasix online treatment development, and almost all treatments have used this part of the viral sequence. So far, the spike protein has produced a strong immune response in those vaccinated, and for those treatments that have reported clinical results, high efficacy of protection from hypertension medications disease.Q. Will mRNA treatments affect the DNA of vaccinated patients?.

A how to buy cheap lasix online. No. The mRNA in the treatment cannot incorporate itself into the genes of vaccinated patients and generally breaks down in the weeks after vaccination. MRNA treatments contain genetic instructions for our cells, which only read them and how to buy cheap lasix online provide copies of the SARS-CoV2 spike protein that enables the cellular and antibody immune systems to cause a response in vaccinated patients.Q.

How long will hypertension medications vaccination provide protection for immunised people?. A. The experience with other how to buy cheap lasix online treatments shows variable durations of protection. For example, the seasonal influenza requires annual vaccinations, because the lasix mutates.

Other treatments, such as those for rubella or measles provide multi-year or even life-long protection from disease. While there appears to be some mutation of the SARS-2-hypertension, results to date indicate that mutations are limited, not necessarily affecting the target of the how to buy cheap lasix online treatments. The scientific community and regulators will monitor whether the hypertension hypertension changes over time and, if so, whether treatments can continue protecting people from with new variants. However, we do not yet know how long protection from any of these treatments lasts.

We will get better insights how to buy cheap lasix online in 2021 and 2022.Q. Why are there so many treatment candidates?. A. As the global seriousness of the lasix became rapidly apparent, development of effective treatments for hypertension medications became the top priority of how to buy cheap lasix online many pharmaceutical companies and medical research institutes.

There was also unprecedented government and private sector investment on treatment development. There is now a wide range of technologies for developing new treatments - and many of the organisations developing hypertension medications treatments have particular experience in one or more of these technologies. The World Health Organisation (WHO) and governments have encouraged the development of treatments based on a wide range of technologies and this mitigated the risk that some treatments could fail regulatory approval for reasons of how to buy cheap lasix online efficacy, safety or manufacturing challenges. Developing a range of treatment technologies has been an effective way of risk mitigation.Q.

What if many people start getting a reaction from a particular hypertension medications treatment?. A how to buy cheap lasix online. Short-term reactions, such as soreness at the injection site, fatigue or headache are common following vaccination. These reactions usually pass in a day or two.

If serious adverse events emerge for a particular treatment then regulators will take how to buy cheap lasix online action, working collaboratively and on a global basis and liaise with public health authorities. The type of actions that can be taken depend on the nature of the adverse event, and could range from warnings to closely monitoring adverse events in certain groups of patients, to contraindicating the use of the treatment in particular patients (e.g. Those with certain co-morbidities) through to temporary suspension of the use of the treatment until more is known.Q. What are how to buy cheap lasix online “faster access pathways”?.

How are regulators speeding up the time it takes to authorise a hypertension medications treatment?. A. Many regulators globally have implemented faster how to buy cheap lasix online access pathways for hypertension medications treatments. Some countries have Emergency Use Authorisation pathways which assess the limited available data at the time of authorisation.

Exercising these provisions is a matter for those countries, taking into account the risks versus benefits in the context of the prevailing domestic lasix situation. Other countries have implemented how to buy cheap lasix online accelerated/priority, conditional or provisional approval schemes. Under normal circumstances, regulatory assessment begins once all information to support registration is available. For hypertension medications treatments, many regulators have agreed to accept data on a rolling basis to enable early evaluation of data as it becomes available.

Regulators will only be in a position to make a provisional registration decision for a treatment once all how to buy cheap lasix online required data has been provided and assessed and the safety, quality and effectiveness of the treatment has been satisfactorily established for its intended use. If a decision is made to grant provisional or conditional registration, it will be based on the requirement for the sponsor to submit more comprehensive, longer term clinical data, stability data and other information with agreed timelines. The implementation of various accelerated regulatory pathways in combination with international collaboration between regulators and proactive work with sponsors is expected to significantly expedite the evaluation of hypertension medications treatments without compromising on strict standards of safety, quality and efficacy.Q. Did our country approve this hypertension medications how to buy cheap lasix online treatment, or are we relying on another country’s approval?.

While there is unprecedented collaboration between regulators in different countries on hypertension medications treatments, including discussion and sharing of product assessments, most countries are carrying out independent regulatory evaluations on the submitted data for each treatment. However, regulators are communicating closely on safety, efficacy and quality data and discussing technical issues as they may arise. This approach provides the best of both worlds, independent decision making coupled with the expertise of scientists working globally together.About ICMRA ICMRA brings together the heads of 30 medicines regulatory authorities* from every region in how to buy cheap lasix online the world, with the WHO as an observer. Medicines regulators recognise their important role in facilitating the provision of access to safe and effective high-quality medicinal products that are essential to human health and well-being.

This includes ensuring that the benefits of treatments outweigh their risks. *ICMRA is an international executive-level coalition of key regulators how to buy cheap lasix online from every region in the world. It provides a global strategic focus for medicines regulators and gives strategic leadership on shared regulatory issues and challenges. Priorities include coordinated response to crisis situations.

Members of the ICMRA how to buy cheap lasix online include. Therapeutic Goods Administration (TGA), Australia. National Health Surveillance (ANVISA), Brazil. Health Products and Food Branch, Health how to buy cheap lasix online Canada (HPFB-HC), Canada.

China National Medical Products Administration (NMPA), China. European Medicines Agency (EMA) and European Commission - Directorate General for Health and Food Safety (DG - SANTE), European Union. French National Agency for Medicines and Health Products Safety (ANSM), how to buy cheap lasix online France. Paul-Ehrlich-Institute (PEI), Germany.

Health Product Regulatory Authority (HPRA), Ireland. Italian Medicines Agency (AIFA), Italy how to buy cheap lasix online. Ministry of Health, Labour and Welfare (MHLW) and Pharmaceuticals and Medical Devices Agency (PMDA), Japan. Ministry of Food and Drug Safety (MFDS), Korea.

Federal Commission how to buy cheap lasix online for the Protection against Sanitary Risks (COFEPRIS), Mexico. Medicines Evaluation Board (MEB), Netherlands. Medsafe, Clinical Leadership, Protection &. Regulation, Ministry how to buy cheap lasix online of Health, New Zealand.

National Agency for Food Drug Administration and Control (NAFDAC), Nigeria. Health Sciences Authority (HSA), Saudi Arabia Food and Drug Administration (SFDA). Singapore. Medicines Control Council (MCC), South Africa.

Medical Products Agency, Sweden. Swissmedic, Switzerland. Medicines and Healthcare Products Regulatory Agency (MHRA), United Kingdom. Food and Drug Administration (FDA), United States and the World Health Organization as an observer.

Associate members include Austrian Medicines and Medical Devices Agency (AGES), Danish Medicines Agency, Israel Office of MedicalTechnology, Health Information and Research (MTHIR), Poland Office of Registration of Medicinal Products and Biocidal Products (URPLWMiPB), Russia Roszdravnadzor and Spain Agencia Española de Medicametos y Productos Sanitarios (AEMPS).Companies are required to file submissions electronically to Health Canada in either Electronic Common Technical Document (eCTD) format or non-eCTD format, depending on the regulatory activity type. The sections below include links to documents that provide detailed information on these formats and other information related to filing submissions electronically. Due to their format, some documents are only available and labeled as "available upon request". If you have an email client installed on your computer, when you click the link to these documents, an email message should appear with some information pre-filled.

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LIS beneficiaries with incomes up to 135% FPL lasix afib are generally eligible for "full" Extra Help -- meaning they pay no Part D deductible, no charge for monthly premiums up to the benchmark amount, and fixed, relatively low co-pays (between $1.30 and $8.95 for 2020 depending on the person's income level and the tier category of url the drug. Medicaid beneficiaries in nursing homes, waiver programs, or managed long term care have $0 co-pays). Full Extra Help beneficiaries who hit the catastrophic coverage limit have $0 co-pays. See current lasix afib co-pay levels here.

Partial Extra Help. Beneficiaries between 135%-150% FPL receive "partial" Extra Help, which limits the Part D deductible to $89 (2020 figure - click here for updated chart). Sets sliding scale fees for monthly lasix afib premiums. And limits co-pays to 15%, until the beneficiary reaches the catastrophic coverage limit, at which point co-pays are limited to a $8.95 maximum (2020 or see current amount here) or 5% of the drug cost, whichever is greater.

2) Facilitated enrollment into a Part D plan Extra Help recipients who aren’t already enrolled in a Part D plan and don’t want to choose one on their own will be automatically enrolled into a benchmark plan by CMS. This facilitated enrollment ensures that Extra lasix afib Help recipients have Part D coverage. However, the downside to facilitated enrollment is that the plan may not be the best “fit” for the beneficiary, if it doesn’t cover all his/her drugs, assesses a higher tier level for covered drugs than other comparable plans, and/or requires the beneficiary to go through administrative hoops like prior authorization, quantity limits and/or step therapy. Fortunately, Extra Help recipients can always enroll in a new plan … see #3 below.

3) Continuous special enrollment period Extra Help recipients have a continuous special enrollment period, meaning that they can switch plans lasix afib at any time. They are not “locked into” the annual open enrollment period (October 15-December 7). NOTE. This changed in lasix afib 2019.

Starting in 2019, those with Extra Help will no longer have a continuous enrollment period. Instead, Extra Help recipients will be eligible to enroll no more than once per quarter for each of the first three quarters of the year. 4) No late enrollment penalty Non LIS beneficiaries generally face a premium penalty (higher monthly premium) if they delayed their enrollment into Part D, meaning that they didn’t enroll when they were initially eligible and didn’t have “creditable coverage.” Extra Help recipients do not lasix afib have to worry about this problem – the late enrollment penalty provision does not apply to LIS beneficiaries. 1) For “deemed” beneficiaries (Medicaid/Medicare Savings Program recipients).

Extra Help status lasts at least until the end of the current calendar year, even if the individual loses their Medicaid or Medicare Savings Program coverage during that year. Individuals who receive Medicaid or a Medicare Savings Program any month between July and lasix afib December keep their LIS status for the remainder of that calendar year and the following year. Getting Medicaid coverage for even just a short period of time (ie, meeting a spenddown for just one month) can help ensure that the individual obtains Extra Help coverage for at least 6 months, and possibly as long as 18 months. TIP.

People with a high spend-down lasix afib who want to receive Medicaid for just one month in order to get Extra Help for 6-18 months can use past medical bills to meet their spend-down for that one month. There are different rules for using past paid medical bills verses past unpaid medical bills. For information see Spend down training materials. Individuals who are losing their deemed status at the end of a calendar year because they are no longer receiving Medicaid or the Medicare Savings Program should be lasix afib notified in advance by SSA, and given an opportunity to file an Extra Help application through SSA.

2) For “non-deemed” beneficiaries (those who filed their LIS applications through SSA) Non-deemed beneficiaries retain their LIS status until/unless SSA does a redetermination and finds the individual ineligible for Extra Help. There are no reporting requirements per se in the Extra Help program, but beneficiaries must respond to SSA’s redetermination request. What to do if the Part D plan doesn't know that someone has Extra Help Sometimes lasix afib there are lengthy delays between the date that someone is approved for Medicaid or a Medicare Savings Program and when that information is formally conveyed to the Part D plan by CMS. As a practical matter, this often results in beneficiaries being charged co-pays, premiums and/or deductibles that they can't afford and shouldn't have to pay.

To protect LIS beneficiaries, CMS has a "Best Available Evidence" policy which requires plans to accept alternative forms of proof of someone's LIS status and adjust the person's cost-sharing obligation accordingly. LIS beneficiaries who are being charged improperly should be sure to contact their plan and provide proof lasix afib of their LIS status. If the plan still won't recognize their LIS status, the person or their advocate should file a complaint with the CMS regional office. The federal regulations governing the Low Income Subsidy program can be found at 42 CFR Subpart P (sections 423.771 through 423.800).

Also, CMS lasix afib provides detailed guidance on the LIS provisions in chapter 13 of its Medicare Prescription Drug Benefit Manual. This article was authored by the Empire Justice Center.Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below. Those in lasix afib QMB receive additional subsidies for Medicare costs.

See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y. Soc. Serv.

L. § 367-a(3)(a), (b), and (d). 2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A.

Summary Chart of MSP Programs 2. Income Limits &. Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?.

4. FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5. Enrolling in an MSP - Automatic Enrollment &.

Applications for People who Have Medicare What is Application Process?. 6. Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1.

NO ASSET LIMIT!. Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?.

YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A &. B deductibles &. Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?.

Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year. (No retro for January application). See GIS 07 MA 027.

Can Enroll in MSP and Medicaid at Same Time?. YES YES NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down.

2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL). 2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below.

NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented. During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA.

See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples. N.Y. Soc. Serv.

L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded. The most common income disregards, also known as deductions, include.

(a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max). (b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted).

* Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc. For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart.

As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO. 18 NYCRR 360-4.2.

See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP. EXAMPLE. Bob's Social Security is $1300/month.

He is age 67 and has Medicare. His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO.

DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP. When is One Better than Two?.

Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a). (Link is to NYC HRA form, can be adapted for other counties). 3.

The Three Medicare Savings Programs - what are they and how are they different?. 1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits.

Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive. The program’s benefits will begin the month after the month in which your client is found eligible.

** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2. Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only.

SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. 3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only.

QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage. Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid.

They cannot be in both. It is their choice. DOH MRG p. 19.

In contrast, one may receive Medicaid and either QMB or SLIMB. 4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1.

Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year. The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL.

However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason. Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients.

The effective date of the MSP application must be the same date as the Extra Help application. Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03.

Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability. An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center.

If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July. Enrollment in an MSP automatically eliminates such penalties... For life..

Even if one later ceases to be eligible for the MSP. AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3.

No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits. Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010.

The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses. Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP.

Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium. Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?.

And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification. New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods.

Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods. Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar.

A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits. See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply.

The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP. See below.

WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare. They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid.

(NYS DOH 2000-ADM-7 and GIS 05 MA 033). Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP.

Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive. Note.

The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1. Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district.

(See more in Section D. Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available).

Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &. Back), and proof of residency/address.

See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too. One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1.

Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person. Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare.

To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification. NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods.

IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test.

For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare. People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down.

If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility. EXAMPLE.

Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check.

He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district.

Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19). Obtaining MSP may increase their spenddown.

MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are. · Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium.

See Step-by-Step Guide by the Medicare Rights Center). This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment.

The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program. Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums.

In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st). 7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid.

The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check. SSA also refunds any amounts owed to the recipient. (Note. This process can take awhile!.

!. !. ) CMS “deems” the MSP recipient eligible for Part D Extra Help/ Low Income Subsidy (LIS). ​Can the MSP be retroactive like Medicaid, back to 3 months before the application?.

​The answer is different for the 3 MSP programs. QMB -No Retroactive Eligibility – Benefits begin the month after the month of the MSP application. 18 NYCRR § 360-7.8(b)(5) SLIMB - YES - Retroactive Eligibility up to 3 months before the application, if was eligible This means applicant may be reimbursed for the 3 months of Part B benefits prior to the month of application. QI-1 - YES up to 3 months but only in the same calendar year.

No retroactive eligibility to the previous year. 7. QMBs -Special Rules on Cost-Sharing. QMB is the only MSP program which pays not only the Part B premium, but also the Medicare co-insurance.

However, there are limitations. First, co-insurance will only be paid if the provide accepts Medicaid. Not all Medicare provides accept Medicaid. Second, under recent changes in New York law, Medicaid will not always pay the Medicare co-insurance, even to a Medicaid provider.

But even if the provider does not accept Medicaid, or if Medicaid does not pay the full co-insurance, the provider is banned from "balance billing" the QMB beneficiary for the co-insurance.

The Medicare Savings how to buy cheap lasix online Program includes the Qualified Medicare Beneficiary (QMB) program, how to get lasix in the us which covers beneficiaries up to 100% FPL. Specified Low-Income Medicare Beneficiary (SLIMB), for those between 100-120%. And the Qualified Individual (QI-1) program, for individuals between 120-135% FPL.

There are no resource tests in New York's Medicare Savings Program.) The New York State Department of how to buy cheap lasix online Health posts the Medicare Savings Program income guidelines on their website. Just like Medicaid, Medicare Savings Program recipients are deemed into LIS and don't need to apply through SSA. For more information see this article.

3) how to buy cheap lasix online by applying for Extra Help through the Social Security Administration. The Extra Help income limits are 150% FPL and there is an asset test. SSA lists the income and resource limits for Extra Help on their website, where you can also file an application online and get more information about the program.

You can also find out information about how to buy cheap lasix online Extra Help in many different languages. See Medicare Rights Center chart on Extra Help Income and Asset Limits - updated annually You can apply for Extra Help and MSP at the same time through SSA. SSA will forward your Extra Help application data to the New York State Department of Health, who will use that data to assess your eligibility for MSP.

Individuals who apply for LIS through SSA and how to buy cheap lasix online those who are deemed into LIS should receive written confirmation of their Extra Help status through SSA. Of course, individuals who apply for LIS through SSA and are found ineligible are also entitled to a written notice and have appeal rights. Benefits of Extra Help 1) Assistance with Part D cost-sharing The Extra Help program provides a subsidy which covers most (but not all) of beneficiary’s cost sharing obligations.

Extra Help beneficiaries do not have to worry about hitting the how to buy cheap lasix online “donut hole” – the LIS subsidy continues to cover them through the donut hole and into catastrophic coverage. Full Extra Help. LIS beneficiaries with incomes up to 135% FPL are generally eligible for "full" Extra Help -- meaning they pay no Part D deductible, no charge for monthly premiums up to the benchmark amount, and fixed, relatively low co-pays (between $1.30 and $8.95 for 2020 depending on the person's income level and the tier category of the drug.

Medicaid beneficiaries in how to buy cheap lasix online nursing homes, waiver programs, or managed long term care have $0 co-pays). Full Extra Help beneficiaries who hit the catastrophic coverage limit have $0 co-pays. See current co-pay levels here.

Partial Extra how to buy cheap lasix online Help. Beneficiaries between 135%-150% FPL receive "partial" Extra Help, which limits the Part D deductible to $89 (2020 figure - click here for updated chart). Sets sliding scale fees for monthly premiums.

And limits co-pays to 15%, until the beneficiary reaches the catastrophic coverage limit, at how to buy cheap lasix online which point co-pays are limited to a $8.95 maximum (2020 or see current amount here) or 5% of the drug cost, whichever is greater. 2) Facilitated enrollment into a Part D plan Extra Help recipients who aren’t already enrolled in a Part D plan and don’t want to choose one on their own will be automatically enrolled into a benchmark plan by CMS. This facilitated enrollment ensures that Extra Help recipients have Part D coverage.

However, the downside to facilitated enrollment is that the plan may not be the best “fit” for the beneficiary, if it how to buy cheap lasix online doesn’t cover all his/her drugs, assesses a higher tier level for covered drugs than other comparable plans, and/or requires the beneficiary to go through administrative hoops like prior authorization, quantity limits and/or step therapy. Fortunately, Extra Help recipients can always enroll in a new plan … see #3 below. 3) Continuous special enrollment period Extra Help recipients have a continuous special enrollment period, meaning that they can switch plans at any time.

They are not “locked into” the annual how to buy cheap lasix online open enrollment period (October 15-December 7). NOTE. This changed in 2019.

Starting in 2019, those with Extra Help how to buy cheap lasix online will no longer have a continuous enrollment period. Instead, Extra Help recipients will be eligible to enroll no more than once per quarter for each of the first three quarters of the year. 4) No late enrollment penalty Non LIS beneficiaries generally face a premium penalty (higher monthly premium) if they delayed their enrollment into Part D, meaning that they didn’t enroll when they were initially eligible and didn’t have “creditable coverage.” Extra Help recipients do not have to worry about this problem – the late enrollment penalty provision does not apply to LIS beneficiaries.

1) For “deemed” beneficiaries how to buy cheap lasix online (Medicaid/Medicare Savings Program recipients). Extra Help status lasts at least until the end of the current calendar year, even if the individual loses their Medicaid or Medicare Savings Program coverage during that year. Individuals who receive Medicaid or a Medicare Savings Program any month between July and December keep their LIS status for the remainder of that calendar year and the following year.

Getting Medicaid coverage for even just a short period of time (ie, meeting a spenddown for just one month) can how to buy cheap lasix online help ensure that the individual obtains Extra Help coverage for at least 6 months, and possibly as long as 18 months. TIP. People with a high spend-down who want to receive Medicaid for just one month in order to get Extra Help for 6-18 months can use past medical bills to meet their spend-down for that one month.

There are different rules for using past paid medical bills verses past unpaid how to buy cheap lasix online medical bills. For information see Spend down training materials. Individuals who are losing their deemed status at the end of a calendar year because they are no longer receiving Medicaid or the Medicare Savings Program should be notified in advance by SSA, and given an opportunity to file an Extra Help application through SSA.

2) For “non-deemed” beneficiaries (those who filed their LIS applications through SSA) Non-deemed beneficiaries retain their how to buy cheap lasix online LIS status until/unless SSA does a redetermination and finds the individual ineligible for Extra Help. There are no reporting requirements per se in the Extra Help program, but beneficiaries must respond to SSA’s redetermination request. What to do if the Part D plan doesn't know that someone has Extra Help Sometimes there are lengthy delays between the date that someone is approved for Medicaid or a Medicare Savings Program and when that information is formally conveyed to the Part D plan by CMS.

As a practical matter, this often results in beneficiaries being charged how to buy cheap lasix online co-pays, premiums and/or deductibles that they can't afford and shouldn't have to pay. To protect LIS beneficiaries, CMS has a "Best Available Evidence" policy which requires plans to accept alternative forms of proof of someone's LIS status and adjust the person's cost-sharing obligation accordingly. LIS beneficiaries who are being charged improperly should be sure to contact their plan and provide proof of their LIS status.

If the plan still won't recognize their LIS status, the person or their advocate how to buy cheap lasix online should file a complaint with the CMS regional office. The federal regulations governing the Low Income Subsidy program can be found at 42 CFR Subpart P (sections 423.771 through 423.800). Also, CMS provides detailed guidance on the LIS provisions in chapter 13 of its Medicare Prescription Drug Benefit Manual.

This article was authored by the Empire Justice Center.Medicare Savings Programs (MSPs) pay for the monthly Medicare Part B premium for low-income Medicare beneficiaries and qualify enrollees for the "Extra Help" subsidy how to buy cheap lasix online for Part D prescription drugs. There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB) Program, the Specified Low Income Medicare Beneficiary (SLMB) Program and the Qualified Individual (QI) Program, each of which is discussed below. Those in QMB receive additional subsidies for Medicare costs.

See 2019 how to buy cheap lasix online Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH State law. N.Y. Soc.

2020 Medicare 101 Basics for New York State - 1.5 hour webinar by Eric Hausman, sponsored by NYS Office of the Aging TOPICS COVERED IN THIS ARTICLE 1. No Asset Limit 1A. Summary Chart of MSP Programs 2.

Income Limits &. Rules and Household Size 3. The Three MSP Programs - What are they and how are they Different?.

4. FOUR Special Benefits of MSP Programs. Back Door to Extra Help with Part D MSPs Automatically Waive Late Enrollment Penalties for Part B - and allow enrollment in Part B year-round outside of the short Annual Enrollment Period No Medicaid Lien on Estate to Recover Payment of Expenses Paid by MSP Food Stamps/SNAP not reduced by Decreased Medical Expenses when Enroll in MSP - at least temporarily 5.

Enrolling in an MSP - Automatic Enrollment &. Applications for People who Have Medicare What is Application Process?. 6.

Enrolling in an MSP for People age 65+ who Do Not Qualify for Free Medicare Part A - the "Part A Buy-In Program" 7. What Happens After MSP Approved - How Part B Premium is Paid 8 Special Rules for QMBs - How Medicare Cost-Sharing Works 1. NO ASSET LIMIT!.

Since April 1, 2008, none of the three MSP programs have resource limits in New York -- which means many Medicare beneficiaries who might not qualify for Medicaid because of excess resources can qualify for an MSP. 1.A. SUMMARY CHART OF MSP BENEFITS QMB SLIMB QI-1 Eligibility ASSET LIMIT NO LIMIT IN NEW YORK STATE INCOME LIMIT (2020) Single Couple Single Couple Single Couple $1,064 $1,437 $1,276 $1,724 $1,436 $1,940 Federal Poverty Level 100% FPL 100 – 120% FPL 120 – 135% FPL Benefits Pays Monthly Part B premium?.

YES, and also Part A premium if did not have enough work quarters and meets citizenship requirement. See “Part A Buy-In” YES YES Pays Part A &. B deductibles &.

Co-insurance YES - with limitations NO NO Retroactive to Filing of Application?. Yes - Benefits begin the month after the month of the MSP application. 18 NYCRR §360-7.8(b)(5) Yes – Retroactive to 3rd month before month of application, if eligible in prior months Yes – may be retroactive to 3rd month before month of applica-tion, but only within the current calendar year.

(No retro for January application). See GIS 07 MA 027. Can Enroll in MSP and Medicaid at Same Time?.

YES YES NO!. Must choose between QI-1 and Medicaid. Cannot have both, not even Medicaid with a spend-down.

2. INCOME LIMITS and RULES Each of the three MSP programs has different income eligibility requirements and provides different benefits. The income limits are tied to the Federal Poverty Level (FPL).

2019 FPL levels were released by NYS DOH in GIS 20 MA/02 - 2020 Federal Poverty Levels -- Attachment II and have been posted by Medicaid.gov and the National Council on Aging and are in the chart below. NOTE. There is usually a lag in time of several weeks, or even months, from January 1st of each year until the new FPLs are release, and then before the new MSP income limits are officially implemented.

During this lag period, local Medicaid offices should continue to use the previous year's FPLs AND count the person's Social Security benefit amount from the previous year - do NOT factor in the Social Security COLA (cost of living adjustment). Once the updated guidelines are released, districts will use the new FPLs and go ahead and factor in any COLA. See 2019 Fact Sheet on MSP in NYS by Medicare Rights Center ENGLISH SPANISH Income is determined by the same methodology as is used for determining in eligibility for SSI The rules for counting income for SSI-related (Aged 65+, Blind, or Disabled) Medicaid recipients, borrowed from the SSI program, apply to the MSP program, except for the new rules about counting household size for married couples.

L. 367-a(3)(c)(2), NYS DOH 2000-ADM-7, 89-ADM-7 p.7. Gross income is counted, although there are certain types of income that are disregarded.

The most common income disregards, also known as deductions, include. (a) The first $20 of your &. Your spouse's monthly income, earned or unearned ($20 per couple max).

(b) SSI EARNED INCOME DISREGARDS. * The first $65 of monthly wages of you and your spouse, * One-half of the remaining monthly wages (after the $65 is deducted). * Other work incentives including PASS plans, impairment related work expenses (IRWEs), blind work expenses, etc.

For information on these deductions, see The Medicaid Buy-In for Working People with Disabilities (MBI-WPD) and other guides in this article -- though written for the MBI-WPD, the work incentives apply to all Medicaid programs, including MSP, for people age 65+, disabled or blind. (c) monthly cost of any health insurance premiums but NOT the Part B premium, since Medicaid will now pay this premium (may deduct Medigap supplemental policies, vision, dental, or long term care insurance premiums, and the Part D premium but only to the extent the premium exceeds the Extra Help benchmark amount) (d) Food stamps not counted. You can get a more comprehensive listing of the SSI-related income disregards on the Medicaid income disregards chart.

As for all benefit programs based on financial need, it is usually advantageous to be considered a larger household, because the income limit is higher. The above chart shows that Households of TWO have a higher income limit than households of ONE. The MSP programs use the same rules as Medicaid does for the Disabled, Aged and Blind (DAB) which are borrowed from the SSI program for Medicaid recipients in the “SSI-related category.” Under these rules, a household can be only ONE or TWO.

18 NYCRR 360-4.2. See DAB Household Size Chart. Married persons can sometimes be ONE or TWO depending on arcane rules, which can force a Medicare beneficiary to be limited to the income limit for ONE person even though his spouse who is under 65 and not disabled has no income, and is supported by the client applying for an MSP.

EXAMPLE. Bob's Social Security is $1300/month. He is age 67 and has Medicare.

His wife, Nancy, is age 62 and is not disabled and does not work. Under the old rule, Bob was not eligible for an MSP because his income was above the Income limit for One, even though it was well under the Couple limit. In 2010, NYS DOH modified its rules so that all married individuals will be considered a household size of TWO.

DOH GIS 10 MA 10 Medicare Savings Program Household Size, June 4, 2010. This rule for household size is an exception to the rule applying SSI budgeting rules to the MSP program. Under these rules, Bob is now eligible for an MSP.

When is One Better than Two?. Of course, there may be couples where the non-applying spouse's income is too high, and disqualifies the applying spouse from an MSP. In such cases, "spousal refusal" may be used SSL 366.3(a).

(Link is to NYC HRA form, can be adapted for other counties). 3. The Three Medicare Savings Programs - what are they and how are they different?.

1. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits.

Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. QMB coverage is not retroactive.

The program’s benefits will begin the month after the month in which your client is found eligible. ** See special rules about cost-sharing for QMBs below - updated with new CMS directive issued January 2012 ** See NYC HRA QMB Recertification form ** Even if you do not have Part A automatically, because you did not have enough wages, you may be able to enroll in the Part A Buy-In Program, in which people eligible for QMB who do not otherwise have Medicare Part A may enroll, with Medicaid paying the Part A premium (Materials by the Medicare Rights Center). 2.

Specifiedl Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. SLMB is retroactive, however, providing coverage for three months prior to the month of application, as long as your client was eligible during those months.

3. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, and not receiving Medicaid, the QI-1 program will cover Medicare Part B premiums only.

QI-1 is also retroactive, providing coverage for three months prior to the month of application, as long as your client was eligible during those months. However, QI-1 retroactive coverage can only be provided within the current calendar year. (GIS 07 MA 027) So if you apply in January, you get no retroactive coverage.

Q-I-1 recipients would be eligible for Medicaid with a spend-down, but if they want the Part B premium paid, they must choose between enrolling in QI-1 or Medicaid. They cannot be in both. It is their choice.

DOH MRG p. 19. In contrast, one may receive Medicaid and either QMB or SLIMB.

4. Four Special Benefits of MSPs (in addition to NO ASSET TEST). Benefit 1.

Back Door to Medicare Part D "Extra Help" or Low Income Subsidy -- All MSP recipients are automatically enrolled in Extra Help, the subsidy that makes Part D affordable. They have no Part D deductible or doughnut hole, the premium is subsidized, and they pay very low copayments. Once they are enrolled in Extra Help by virtue of enrollment in an MSP, they retain Extra Help for the entire calendar year, even if they lose MSP eligibility during that year.

The "Full" Extra Help subsidy has the same income limit as QI-1 - 135% FPL. However, many people may be eligible for QI-1 but not Extra Help because QI-1 and the other MSPs have no asset limit. People applying to the Social Security Administration for Extra Help might be rejected for this reason.

Recent (2009-10) changes to federal law called "MIPPA" requires the Social Security Administration (SSA) to share eligibility data with NYSDOH on all persons who apply for Extra Help/ the Low Income Subsidy. Data sent to NYSDOH from SSA will enable NYSDOH to open MSP cases on many clients. The effective date of the MSP application must be the same date as the Extra Help application.

Signatures will not be required from clients. In cases where the SSA data is incomplete, NYSDOH will forward what is collected to the local district for completion of an MSP application. The State implementing procedures are in DOH 2010 ADM-03.

Also see CMS "Dear State Medicaid Director" letter dated Feb. 18, 2010 Benefit 2. MSPs Automatically Waive Late Enrollment Penalties for Part B Generally one must enroll in Part B within the strict enrollment periods after turning age 65 or after 24 months of Social Security Disability.

An exception is if you or your spouse are still working and insured under an employer sponsored group health plan, or if you have End Stage Renal Disease, and other factors, see this from Medicare Rights Center. If you fail to enroll within those short periods, you might have to pay higher Part B premiums for life as a Late Enrollment Penalty (LEP). Also, you may only enroll in Part B during the Annual Enrollment Period from January 1 - March 31st each year, with Part B not effective until the following July.

Enrollment in an MSP automatically eliminates such penalties... For life.. Even if one later ceases to be eligible for the MSP.

AND enrolling in an MSP will automatically result in becoming enrolled in Part B if you didn't already have it and only had Part A. See Medicare Rights Center flyer. Benefit 3.

No Medicaid Lien on Estate to Recover MSP Benefits Paid Generally speaking, states may place liens on the Estates of deceased Medicaid recipients to recover the cost of Medicaid services that were provided after the recipient reached the age of 55. Since 2002, states have not been allowed to recover the cost of Medicare premiums paid under MSPs. In 2010, Congress expanded protection for MSP benefits.

Beginning on January 1, 2010, states may not place liens on the Estates of Medicaid recipients who died after January 1, 2010 to recover costs for co-insurance paid under the QMB MSP program for services rendered after January 1, 2010. The federal government made this change in order to eliminate barriers to enrollment in MSPs. See NYS DOH GIS 10-MA-008 - Medicare Savings Program Changes in Estate Recovery The GIS clarifies that a client who receives both QMB and full Medicaid is exempt from estate recovery for these Medicare cost-sharing expenses.

Benefit 4. SNAP (Food Stamp) benefits not reduced despite increased income from MSP - at least temporarily Many people receive both SNAP (Food Stamp) benefits and MSP. Income for purposes of SNAP/Food Stamps is reduced by a deduction for medical expenses, which includes payment of the Part B premium.

Since approval for an MSP means that the client no longer pays for the Part B premium, his/her SNAP/Food Stamps income goes up, so their SNAP/Food Stamps go down. Here are some protections. Do these individuals have to report to their SNAP worker that their out of pocket medical costs have decreased?.

And will the household see a reduction in their SNAP benefits, since the decrease in medical expenses will increase their countable income?. The good news is that MSP households do NOT have to report the decrease in their medical expenses to the SNAP/Food Stamp office until their next SNAP/Food Stamp recertification. Even if they do report the change, or the local district finds out because the same worker is handling both the MSP and SNAP case, there should be no reduction in the household’s benefit until the next recertification.

New York’s SNAP policy per administrative directive 02 ADM-07 is to “freeze” the deduction for medical expenses between certification periods. Increases in medical expenses can be budgeted at the household’s request, but NYS never decreases a household’s medical expense deduction until the next recertification. Most elderly and disabled households have 24-month SNAP certification periods.

Eventually, though, the decrease in medical expenses will need to be reported when the household recertifies for SNAP, and the household should expect to see a decrease in their monthly SNAP benefit. It is really important to stress that the loss in SNAP benefits is NOT dollar for dollar. A $100 decrease in out of pocket medical expenses would translate roughly into a $30 drop in SNAP benefits.

See more info on SNAP/Food Stamp benefits by the Empire Justice Center, and on the State OTDA website. Some clients will be automatically enrolled in an MSP by the New York State Department of Health (NYSDOH) shortly after attaining eligibility for Medicare. Others need to apply.

The 2010 "MIPPA" law introduced some improvements to increase MSP enrollment. See 3rd bullet below. Also, some people who had Medicaid through the Affordable Care Act before they became eligible for Medicare have special procedures to have their Part B premium paid before they enroll in an MSP.

See below. WHO IS AUTOMATICALLY ENROLLED IN AN MSP. Clients receiving even $1.00 of Supplemental Security Income should be automatically enrolled into a Medicare Savings Program (most often QMB) under New York State’s Medicare Savings Program Buy-in Agreement with the federal government once they become eligible for Medicare.

They should receive Medicare Parts A and B. Clients who are already eligible for Medicare when they apply for Medicaid should be automatically assessed for MSP eligibility when they apply for Medicaid. (NYS DOH 2000-ADM-7 and GIS 05 MA 033).

Clients who apply to the Social Security Administration for Extra Help, but are rejected, should be contacted &. Enrolled into an MSP by the Medicaid program directly under new MIPPA procedures that require data sharing. Strategy TIP.

Since the Extra Help filing date will be assigned to the MSP application, it may help the client to apply online for Extra Help with the SSA, even knowing that this application will be rejected because of excess assets or other reason. SSA processes these requests quickly, and it will be routed to the State for MSP processing. Since MSP applications take a while, at least the filing date will be retroactive.

Note. The above strategy does not work as well for QMB, because the effective date of QMB is the month after the month of application. As a result, the retroactive effective date of Extra Help will be the month after the failed Extra Help application for those with QMB rather than SLMB/QI-1.

Applying for MSP Directly with Local Medicaid Program. Those who do not have Medicaid already must apply for an MSP through their local social services district. (See more in Section D.

Below re those who already have Medicaid through the Affordable Care Act before they became eligible for Medicare. If you are applying for MSP only (not also Medicaid), you can use the simplified MSP application form (theDOH-4328(Rev. 8/2017-- English) (2017 Spanish version not yet available).

Either application form can be mailed in -- there is no interview requirement anymore for MSP or Medicaid. See 10 ADM-04. Applicants will need to submit proof of income, a copy of their Medicare card (front &.

Back), and proof of residency/address. See the application form for other instructions. One who is only eligible for QI-1 because of higher income may ONLY apply for an MSP, not for Medicaid too.

One may not receive Medicaid and QI-1 at the same time. If someone only eligible for QI-1 wants Medicaid, s/he may enroll in and deposit excess income into a pooled Supplemental Needs Trust, to bring her countable income down to the Medicaid level, which also qualifies him or her for SLIMB or QMB instead of QI-1. Advocates in NYC can sign up for a half-day "Deputization Training" conducted by the Medicare Rights Center, at which you'll be trained and authorized to complete an MSP application and to submit it via the Medicare Rights Center, which submits it to HRA without the client having to apply in person.

Enrolling in an MSP if you already have Medicaid, but just become eligible for Medicare Those who, prior to becoming enrolled in Medicare, had Medicaid through Affordable Care Act are eligible to have their Part B premiums paid by Medicaid (or the cost reimbursed) during the time it takes for them to transition to a Medicare Savings Program. In 2018, DOH clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare ( PDF) provides, "Due to efforts to transition individuals who gain Medicare eligibility and who require LTSS, individuals may not be disenrolled from MMC upon receipt of Medicare.

To facilitate the transition and not disadvantage the recipient, the Medicaid program is approving reimbursement of Part B premiums for enrollees in MMC." The procedure for getting the Part B premium paid is different for those whose Medicaid was administered by the NYS of Health Exchange (Marketplace), as opposed to their local social services district. The procedure is also different for those who obtain Medicare because they turn 65, as opposed to obtaining Medicare based on disability. Either way, Medicaid recipients who transition onto Medicare should be automatically evaluated for MSP eligibility at their next Medicaid recertification.

NYS DOH 2000-ADM-7 Individuals can also affirmatively ask to be enrolled in MSP in between recertification periods. IF CLIENT HAD MEDICAID ON THE MARKETPLACE (NYS of Health Exchange) before obtaining Medicare. IF they obtain Medicare because they turn age 65, they will receive a letter from their local district asking them to "renew" Medicaid through their local district.

See 2014 LCM-02. Now, their Medicaid income limit will be lower than the MAGI limits ($842/ mo reduced from $1387/month) and they now will have an asset test. For this reason, some individuals may lose full Medicaid eligibility when they begin receiving Medicare.

People over age 65 who obtain Medicare do NOT keep "Marketplace Medicaid" for 12 months (continuous eligibility) See GIS 15 MA/022 - Continuous Coverage for MAGI Individuals. Since MSP has NO ASSET limit. Some individuals may be enrolled in the MSP even if they lose Medicaid, or if they now have a Medicaid spend-down.

If a Medicare/Medicaid recipient reports income that exceeds the Medicaid level, districts must evaluate the person’s eligibility for MSP. 08 OHIP/ADM-4 ​If you became eligible for Medicare based on disability and you are UNDER AGE 65, you are entitled to keep MAGI Medicaid for 12 months from the month it was last authorized, even if you now have income normally above the MAGI limit, and even though you now have Medicare. This is called Continuous Eligibility.

EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2016. He became enrolled in Medicare based on disability in August 2016, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability).

Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2016. Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund.

This will continue until the end of his 12 months of continues MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district.

Individuals who are eligible for Medicaid with a spenddown can opt whether or not to receive MSP. (Medicaid Reference Guide (MRG) p. 19).

Obtaining MSP may increase their spenddown. MIPPA - Outreach by Social Security Administration -- Under MIPPA, the SSA sends a form letter to people who may be eligible for a Medicare Savings Program or Extra Help (Low Income Subsidy - LIS) that they may apply. The letters are.

· Beneficiary has Extra Help (LIS), but not MSP · Beneficiary has no Extra Help (LIS) or MSP 6. Enrolling in MSP for People Age 65+ who do Not have Free Medicare Part A - the "Part A Buy-In Program" Seniors WITHOUT MEDICARE PART A or B -- They may be able to enroll in the Part A Buy-In program, in which people eligible for QMB who are age 65+ who do not otherwise have Medicare Part A may enroll in Part A, with Medicaid paying the Part A premium. See Step-by-Step Guide by the Medicare Rights Center).

This guide explains the various steps in "conditionally enrolling" in Part A at the SSA office, which must be done before applying for QMB at the Medicaid office, which will then pay the Part A premium. See also GIS 04 MA/013. In June, 2018, the SSA revised the POMS manual procedures for the Part A Buy-In to to address inconsistencies and confusion in SSA field offices and help smooth the path for QMB enrollment.

The procedures are in the POMS Section HI 00801.140 "Premium-Free Part A Enrollments for Qualified Medicare BenefiIaries." It includes important clarifications, such as. SSA Field Offices should explain the QMB program and conditional enrollment process if an individual lacks premium-free Part A and appears to meet QMB requirements. SSA field offices can add notes to the “Remarks” section of the application and provide a screen shot to the individual so the individual can provide proof of conditional Part A enrollment when applying for QMB through the state Medicaid program.

Beneficiaries are allowed to complete the conditional application even if they owe Medicare premiums. In Part A Buy-in states like NYS, SSA should process conditional applications on a rolling basis (without regard to enrollment periods), even if the application coincides with the General Enrollment Period. (The General Enrollment Period is from Jan 1 to March 31st every year, in which anyone eligible may enroll in Medicare Part A or Part B to be effective on July 1st).

7. What happens after the MSP approval - How is Part B premium paid For all three MSP programs, the Medicaid program is now responsible for paying the Part B premiums, even though the MSP enrollee is not necessarily a recipient of Medicaid. The local Medicaid office (DSS/HRA) transmits the MSP approval to the NYS Department of Health – that information gets shared w/ SSA and CMS SSA stops deducting the Part B premiums out of the beneficiary’s Social Security check.

SSA also refunds any amounts owed to the recipient. (Note. This process can take awhile!.

Long term effects of lasix

IntroductionThere has been long term effects of lasix considerable interest in elucidating the contribution of genetic factors to the development of common diseases and using this find this information for better prediction of disease risk. The common disease common variant hypothesis predicts that variants that are common in the population play a role in disease susceptibility.1 Genome-wide association studies (GWAS) using single nucleotide polymorphism (SNP) arrays were developed as a mechanism by which to investigate these genetic factors long term effects of lasix and it was hoped this would lead to identification of variants associated with disease risk and subsequent development of predictive tests. Variants identified as associated with particular traits by these studies, for the large part, are SNPs that individually have a minor effect on disease risk and hence, by themselves, cannot be reliably used in disease prediction.

Looking at the aggregate impact of these SNPs in the form of a polygenic score (PGS) appeared to long term effects of lasix be one possible means of using this information to predict disease.2 It is thought this will be of benefit as our genetic make-up is largely stable from birth and dictates a ‘baseline risk’ on which external influences act and modulate. Therefore, PGS are a potential mechanism to act as a risk predictor by capturing information on this genetic liability.The use of PGS as a predictive biomarker is being explored in a number of different disease areas, including cancer,3 4 psychiatric disorders,5–7 metabolic disorders (diabetes,8 obesity9) and coronary artery disease (CAD).10 The proposed applications range from aiding disease diagnosis, informing selection of therapeutic interventions, improvement of risk prediction, informing disease screening and, on a personal level, informing life planning. Therefore, genetic long term effects of lasix risk information in the form of a PGS is considered to have potential in informing both clinical and individual-level decision-making.Recent advances in statistical techniques, improved computational power and the availability of large data sets have led to rapid developments in this area over the past few years.

This has resulted in a variety of approaches to construction of models for score calculation and the investigation of these scores for prediction of common diseases.11 Several review articles aimed at researchers with a working knowledge of this field have been produced.6 11–17 In this article, we provide an overview of the key aspects of PGS construction to assist clinicians and researchers in other areas of academia to gain an understanding of the processes involved in score construction. We also consider the implications of evolving methodologies for the development of applications of PGS in healthcare.Evolution in polygenic model construction methodologiesTerminology with respect to PGS has evolved over time, long term effects of lasix reflecting evolving approaches and methodology. Other terms include PGS, polygenic risk score, polygenic load, genotype score, genetic burden, polygenic hazard score, genetic risk score (GRS), metaGRS and allelic risk score.

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

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

This calculation aggregates the SNPs and long term effects of lasix their weights selected for a polygenic score. Common diseases are thought to be influenced by many genetic variants long term effects of lasix with small individual effect sizes, such that meaningful risk prediction necessitates examining the aggregated impact of these multiple variants including their weightings. PGS, polygenic score.Construction of a polygenic score.

In the long term effects of lasix process of developing a polygenic score, numerous models are tested and then compared. The model that performs best (as determined by one or more measures) is then selected for validation in the external data set. GWAS, genome-wide association studies." data-icon-position data-hide-link-title="0">Figure 2 Construction of a polygenic long term effects of lasix score.

In the process of developing a polygenic score, numerous models are tested and then compared. The model that performs best (as long term effects of lasix determined by one or more measures) is then selected for validation in the external data set. GWAS, genome-wide association studies.Changes in data availability over time have had an impact on the approach taken in SNP selection and weighting.

Early studies to identify long term effects of lasix variants associated with common diseases took the form of candidate gene studies. The small size of candidate gene studies, the limitation of technologies available for genotyping and stringent significance thresholds meant that these studies investigated fewer variants and those that were identified with disease associations had relatively large effect sizes.19 Taken together, this meant that a relatively small number of variants were available for consideration for inclusion in a polygenic model.20 21 Furthermore, weighting parameters for these few variants were often simplistic, such as counts of the number of risk alleles carried, ignoring their individual effect sizes.16The advent of GWAS enabled assessment of SNPs across the genome, leading to the identification of a larger number of disease-associated variants and therefore more variants suitable for inclusion in a polygenic model. In addition, the increasing number of individuals in the association studies meant that the power of these studies increased, allowing for more precise estimates of effect sizes.19 Furthermore, some theorised that lowering stringent significance thresholds set for SNP–trait associations could also identify SNPs that might play a part in disease risk.11 16 This resulted in more options with respect to polygenic model parameters of SNPs to long term effects of lasix include and weights to assign to them.

However, the inclusion of more SNPs and direct application of GWAS effect sizes as a weighting parameter does not always equate to better predictive performance.4 16 This is because GWAS do not provide perfect information with respect to the causal SNP, the effect sizes or the number of SNPs that contribute to the trait. Therefore, different methods have been developed to address these issues and optimise predictive long term effects of lasix performance of the score. Current common practice is to construct models with different iterations of SNPs and weighting, with assessment of the performance of each to identify the optimum configuration of SNPs and their weights (figure 2).Methods used in SNP selection and weighting assignmentSome methods of model development will initially involve selection of SNPs followed by optimisation of weighting, whereas others may involve optimisation of weightings for all SNPs that have been genotyped using their overall GWAS effect sizes, the linkage disequilibrium (LD) and an estimate of the proportion of SNPs that are expected to contribute to the risk.22LD is the phenomenon where some SNPs are coinherited more frequently with other SNPs due to their close proximity on the genome.

Segments with strong long term effects of lasix LD between SNPs are referred to as haplotype blocks. This phenomenon means that GWAS often identify multiple SNPs in the same haplotype block associated with disease and the true causal SNP is not known. As models have started to assess more SNPs, careful consideration is required to take long term effects of lasix into account possible correlation between SNPs as a result of this phenomenon.

Correlation between SNPs can lead to double counting of SNPs and association redundancy, long term effects of lasix where multiple SNPs in a region of LD are identified as being associated with the outcome. This can lead to reduction in the predictive performance of the model. Therefore, processes for filtering SNPs and long term effects of lasix using one SNP (tag SNP) to act as a marker in an area of high LD, through LD thinning, were developed.

Through these processes SNPs correlated with other SNPs in a block are removed, by either pruning or clumping. Pruning ignores p value thresholds and ‘eliminates’ SNPs by a process of iterative comparison between a pair of SNPs to assess if they are correlated, and subsequently long term effects of lasix could remove SNPs that are deemed to have evidence of association. Clumping (also known as informed pruning) is guided by GWAS p values and chooses the most significant SNP, therefore keeping the most significant SNP within a block.23 This is all done with the aim of pinpointing relatively small areas of the genome that contribute to risk of the trait.

Different significance thresholds may be used to select SNPs from this subgroup for inclusion in models.Poor performance of a model can result from imperfect tagging with the underlying causal SNP.16 This is long term effects of lasix because the causal SNP that is associated with disease might not be in LD with the tag SNP that is in the model but is in LD with another SNP which is not in the model. This particularly occurs where the LD and variant frequency differs between population groups.24 An alternate approach to filter SNPs is stepwise regression where SNPs are selected based on how much the SNPs improve the model’s performance. This is a statistical approach and does not consider the impact of LD or effect long term effects of lasix size.As described above, early studies used simple weighting approaches or directly applied effect sizes from GWAS as weighting parameters for SNPs.

However, application of effect sizes as a weighting parameter directly from a GWAS may not be optimal, due to differences in the population that the GWAS was conducted in and the target population. Also as described above, long term effects of lasix LD and the fact that not all SNPs may contribute to the trait mean that these effect sizes from GWAS are imperfect estimates. Therefore, methods have been developed that adjust effect size estimates from GWAS using statistical techniques which make assumptions about factors such as the number of causal SNPs, level of LD between SNPs or knowledge of their potential function to better reflect their impact on a trait.

Numerous statistical methodologies have been developed to improve weighting with a view to enhancing the discriminative power of a PGS.25 26 Examples of some methodological approaches are LDpred,22 winner’s curse correction,23 empirical Bayes estimation,27 shrinkage regression (Lasso),28 linear mixed models,29 with more being developed or tested long term effects of lasix. An additional improvement on the methods is to embed non-genetic information (eg, age-specific ORs).6 Determination of which methodology or hybrid of methodologies is most appropriate for various settings and conditions is continuously being explored and is evolving with new statistical approaches developing at a rapid pace.In summary, model development has evolved in an attempt to gain the most from available GWAS data and address some of the issues that arise due to working with data sets which cannot be directly translated into parameters for prediction models. The different approaches taken in SNP selection and weighting, and the impact on long term effects of lasix the predictive performance of a model are important to consider when assessing different models.

This is because different approaches to PGS modelling can achieve the same or a similar level of prediction. From a health system implementation perspective, particular approaches may be preferred following practical considerations and trade-offs between obtaining genotype data, processes for score construction and long term effects of lasix model performance. In addition, the degree to which these long term effects of lasix parameters need to be optimised will also be impacted by the input data and validation data set, and the quality control procedures that need to be applied to these data sets.12Sources of input data for score constructionKey to the development of a polygenic model is the availability of data sets that can provide input parameters for model construction.

Genotype data used in model construction can either be available as raw GWAS data or provided as GWAS summary statistics. Data in the raw format are individual-level data from a SNP array and may not have undergone basic quality control such as long term effects of lasix assessment of missingness, sex discrepancy checks, deviation from Hardy-Weinberg equilibrium, heterozygosity rate, relatedness or assessment for outliers.30 31 Availability of raw GWAS data allows for different polygenic models to be developed because of the richness of the data, however computational issues arise because of the size of the data sets. Data based on genome sequencing, as opposed to SNP arrays, could also be used in model construction.

There have been long term effects of lasix limited studies of PGS developed from this form of data due to limitations in data availability, which is mainly due to cost restraints.15 32 Individual-level genomic data are also often not available to researchers due to privacy concerns.Due to these issues, the focus of polygenic model development has therefore been on using well-powered GWAS summary statistics.33 These are available from open access repositories and contain summary information such as the allele positions, ORs, CIs and allele frequency, without containing confidential information on individuals. These data sets have usually been through the basic quality control measures mentioned above. There are, however, no standards for publicly available files, meaning some further processing steps may be required, in particular when various data sets are combined for a long term effects of lasix meta-analysis.

Quality control on summary statistics is only possible if information such as missing genotype rate, minor allele frequency, Hardy-Weinberg equilibrium failures and non-Mendelian transmission rates is provided.12Processing of GWAS data may include additional quality control steps, imputation and filtering of the SNP information, which can be done at the level of genotype or summary statistics data. SNP arrays used in GWAS only have common SNPs represented on them as they long term effects of lasix rely on LD between SNPs to cover the entire genome. As described above, one tag SNP on the array can represent many other SNPs.

Imputation of SNPs is common in GWAS and describes the process of long term effects of lasix predicting genotypes that have not been directly genotyped but are statistically inferred (imputed) based on haplotype blocks from a reference sequence.33–35 Often association tests between the imputed SNPs and trait are repeated. As genotype imputation requires individual-level data, researchers have proposed summary statistics imputation as a mechanism to infer the association between untyped SNPs and a trait. The performance of imputation has been evaluated and shown that, with certain limitations, summary statistics imputation is an efficient and cost-effective methodology to identify loci associated with traits when compared with imputation done on genotypes.36An alternative source of input data for the selection of SNPs and their weightings is through literature or in existing databases, where already known trait-associated SNPs and their long term effects of lasix effect sizes are used as the input parameters in model development.

A number of studies have taken this approach37 38 and it is possible to use multiple sources when developing various polygenic models and establishing the preferred parameters to use.Currently, there does not appear to be one methodology that works across all contexts and traits, each trait will need to be assessed to determine which method is the most suitable for the trait being evaluated. For example, four different polygenic model construction strategies were explored for three skin cancer subtypes4 by using data on SNPs and their effect sizes from different sources, such as the latest GWAS meta-analysis results, the National Human Genome Research Institute (NHGRI) EBI long term effects of lasix GWAS catalogue, UK Biobank GWAS summary statistics with different thresholds and GWAS summary statistics with LDpred. In this setting for basal cell carcinoma and melanoma, the meta-analysis and catalogue-derived models were found to perform similarly but that the latter was ultimately used as it included more SNPs.

For squamous cell long term effects of lasix carcinoma the meta-analysis-derived model performed better than the catalogue-derived model. This demonstrates long term effects of lasix how each disease subtype, model construction strategy and data set can have their own limitations and advantages.Knowledge of the sources of input data and its subsequent use in model development is important in understanding the limitations of available models. Models that are developed using data sets that reflect the population in which prediction is to be carried out will perform better.

For example, data collected from a symptomatic or high-risk population may not be suitable as an input data set for the development of a polygenic model that will be used for disease prediction in the general long term effects of lasix population. Large GWAS studies were previously focused on high-risk individuals, such as patients with breast cancer with a strong family history or known pathogenic variants in BRCA1 or BRCA2. These studies would not be suitable for the development of PGS for use in the general population but can inform risk assessment long term effects of lasix in high-risk individuals.

The source of the data for SNP selection and weighting also has implications for downstream uses and validation. For example, variant frequency and LD patterns can vary between populations and this can translate to poor long term effects of lasix performance of the polygenic model if the external validation population is different from that of the input data set.39–41 Furthermore, the power and validity of polygenic analyses are influenced by the input data sources.12 42From a model to a scorePGS can be calculated using one of the methodologies discussed above. The resulting PGS units of measurement depend on which measurement is used for the weighting.12 For example, the weightings may have been calculated based on logOR for discrete traits or linear regression coefficient (β/beta) in continuous traits from univariate regression tests carried out in the GWAS.

The resulting long term effects of lasix scores are then usually transformed to a standard normal distribution to give scores ranging from −1 to 1, or 0 to 100 for ease of interpretation. This enables further examination of the association between the score and a trait and the predictive ability of different scores generated by different models. Similar to other biomarker analyses, this involves using the PGS as a predictor of a trait long term effects of lasix with other covariates (eg, age, smoking, and so on) added, if appropriate, in a target sample.

Examination of differences in the distribution of scores in cases and controls, or by examining differences in traits between different strata of PGS can enable assessment of predictive ability (figure 3). Common practice is for individual-level PGS values to be used to stratify populations into distinct groups of risk based on percentile cut-off or threshold values (eg, the top long term effects of lasix 1%).Example distribution of polygenic scores across a population. Thresholds can be set to stratify risk as low (some), average (most) and high (some)." data-icon-position data-hide-link-title="0">Figure 3 Example distribution of polygenic scores across a population.

Thresholds can be set to stratify risk as low (some), average (most) and high (some).Model validationPolygenic model development is reliant on further data sets long term effects of lasix for model testing and validation and the composition of these data sets is important in ensuring that the models are appropriate for a particular purpose. The development long term effects of lasix of a model to calculate a PGS involves refinement of the previously discussed input parameters, and selection of the ‘best’ of several models based on performance (figure 2). Therefore, a testing/training data set is often required to assess the model’s ability to accurately predict the trait of interest.

This is long term effects of lasix often a data set that is independent of the base/input/discovery data set. It may comprise a subset of the discovery data set that is only used for testing and was not included in the initial development of the model but should ideally be a separate independent data set.Genotype and phenotype data are needed in these data sets. Polygenic models are used to calculate PGS for individuals in the training data set and regression analysis is performed long term effects of lasix with the PGS as a predictor of a trait.

Other covariates may also be included, if appropriate. This testing phase can be considered a process for identifying models with better overall long term effects of lasix performance and/or informing refinements needed. Hence, this phase often involves comparison of different models that are developed using the same input data set to identify those models that have optimal performance.The primary purpose is to determine which model best discriminates between cases and controls.

The area under the curve (AUC) or the C-statistic is the most commonly used measure in assessing long term effects of lasix discriminative ability. It has been criticised as being an insensitive measure that is not able to fully capture all aspects of predictive ability. For instance, in some instances, AUC can remain unchanged between models but the individuals within are categorised into a different risk group.43 Alternative long term effects of lasix metrics that have been used to evaluate model performance include increase in risk difference, integrated discrimination improvement, R2 (estimate of variance explained by the PGS after covariate adjustment), net classification index and the relative risk (highest percentile vs lowest percentile).

A clear understanding on how to interpret the performance within various settings is important in determining which model is most suitable.44As per normal practice when developing any prediction model, polygenic models with the optimal performance in a testing/training data set should be further validated in external data sets. External data sets are critical in validation of models and assessment of generalisability, hence must also conform to the desired situations in which long term effects of lasix a model is to be used. The goal is to find a model with suitable parameters of predictive performance in data sets outside of those in which it was developed.

Ideally, external long term effects of lasix validation requires replication in independent data sets. Few existing polygenic models have been validated to this extent, the focus being rather on the development of new models rather than evaluation of existing ones. One example where replication has been carried out is in the field of CAD, where the GPSCAD45 and metaGRSCAD10 polygenic models (both developed using UK Biobank data) were evaluated in a Finnish population cohort.46 Predictive ability was long term effects of lasix found to be lower in the Finnish population.

This is likely to be long term effects of lasix due to the differences in genetic structure of this population and the population of the data set used for polygenic model development. Research is ongoing to evaluate polygenic models in other populations and strategies are being developed to ensure the same performance when used more widely, possibly through reweighting and adjustment of the scores.47Moving towards clinical applicationsPGS are thought to be useful information that could improve risk estimation and provide an avenue for disease prevention and deciding treatment strategies. There are indications from a number of fields that genetic information in the form of PGS long term effects of lasix can act as independent biomarkers and aid stratification.11 16 48 However, the clinical benefits of stratification using a PGS and the implications for clinical practice are only just beginning to be examined.

The use of PGS as part of existing risk prediction tools or as a stand-alone predictor has been suggested. This latter option may be true for diseases where knowledge or predictive ability with other risk factors is limited, such as in prostate cancer.49 In either case, polygenic models need to be individually examined to determine suitability and applicability for the specific clinical question.50 Despite some commercial companies developing PGS,51 52 currently PGS are not an established long term effects of lasix part of clinical practice.Integration into clinical practice requires evaluation of a PGS-based test. An important concept to consider in this regard is the distinction between an assay and a test.

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

This distinction is important when assessing if studies are reporting on assay performance as opposed to test performance. It is our view that, with respect to polygenic models, progress has been made with respect to assay development, but PGS-based tests are yet to be developed long term effects of lasix and evaluated. This can enable a clearer understanding of their potential clinical utility and issues that may arise for clinical implementation.11 18 55 It is clear that this is still an evolving field, and going forward different models may be required for different traits due to their underlying genetic architecture,26 different clinical contexts and needs.Clinical contexts where risk stratification is already established practice are most likely where implementation of PGS will occur first.

Risk prediction models based on non-genetic factors have been developed for many conditions and are used in clinical care, for example, in cardiovascular disease over 100 such models exist.56 In such contexts, how a PGS and its ability to predict risk compared with, or improves on, these existing models is being investigated.3 44 57–61 The extent to which PGS improves prediction, as well as the cost implications of including this, is likely to impact on implementation.Integration of PGS into clinical practice, for any application, requires robust and validated long term effects of lasix mechanisms to generate these scores. Therefore, given the numerous models available, an assessment of their suitability as part of a test is required. Parameters or guidelines with respect to aspects of model long term effects of lasix performance and metrics that could assist in selecting the model to take forward as a PGS-based test are limited and need to be addressed.

Currently, there are different mechanisms to generate PGS and have arisen in response to the challenges in aggregating large-scale genomic data for prediction. For example, a review reported 29 PGS models for breast cancer from 22 publications.62 Due to there being a number of different methodologies to generate a score, numerous models may exist for the same condition and each of long term effects of lasix the resulting models could perform differently. Models may perform differently because the population, measured outcome or context of the development data sets used to generate the models is diverse, for example, a score for risk of breast cancer long term effects of lasix versus a breast cancer subtype.44 63 This diversity, alongside the lack of established best practice and standardised reporting in publications, makes comparison and evaluation of polygenic models for use in clinical settings challenging.

It is clear that moving the field forward is reliant on transparent reporting and evaluation. Recommendations for best practices on the reporting of polygenic models in literature have been proposed14 long term effects of lasix 64 as well as a database,65 66 which could allow for such comparisons. Statements and guidelines for risk prediction model development, such as the Genetic Risk Prediction Studies and Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD), already exist, but are not consistently used.

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

Meaning that there are still some important questions that need to be addressed to determine how and where PGS could work within current healthcare systems, particularly at a population level.78It is widely accepted that genotyping using arrays is a lower cost endeavour in comparison to genome sequencing, making the incorporation of PGS into routine healthcare an attractive proposition. However, we were unable to find any studies reporting on the use or associated costs long term effects of lasix of such technology for population screening. Studies are beginning to examine use case scenarios and model cost-effectiveness, but this has only been in very few, specific investigations.79 80 Costs will also be influenced by the testing technology and by the downstream consequences of testing, which is likely to differ depending on specific applications that are developed and the pathways in which such tests are incorporated.

This is particularly the case in screening or primary care settings, where such testing is currently not an established part of care pathways and may require additional resources, not least as long term effects of lasix a result of the volume of testing that could be expected. Moving forward, the clinical role of PGS needs to be developed further, including defining the clinical applications as well as supporting evidence, for example, on the effect of clinical outcomes, the feasibility for use in routine practice and cost-effectiveness.ConclusionThere is a large amount of diversity in the PGS field with respect to model development approaches, and this continues to evolve. There is rapid progress long term effects of lasix which is being driven by the availability of larger data sets, primarily from GWAS and concomitant developments in statistical methodologies.

As understanding and knowledge develops, the usefulness and appropriateness of polygenic models for different diseases and contexts are being explored. Nevertheless, this is still an emerging field, with a long term effects of lasix variable evidence base demonstrating some potential. The validity of PGS needs to be clearly demonstrated, and their applications evaluated prior to clinical implementation..

IntroductionThere has been considerable interest in elucidating how to buy cheap lasix online the contribution of genetic factors to the development of common diseases and using this information for better http://rebelsessions.com/portfolio-view/rebel-sessions-2011-rebel-session2-big-wave-surfing-event-in-cape-town-south-africa-9/ prediction of disease risk. The common disease common variant hypothesis predicts that variants that are common in the population play a role in disease susceptibility.1 Genome-wide association how to buy cheap lasix online studies (GWAS) using single nucleotide polymorphism (SNP) arrays were developed as a mechanism by which to investigate these genetic factors and it was hoped this would lead to identification of variants associated with disease risk and subsequent development of predictive tests. Variants identified as associated with particular traits by these studies, for the large part, are SNPs that individually have a minor effect on disease risk and hence, by themselves, cannot be reliably used in disease prediction.

Looking at the aggregate impact of these SNPs in the form of a polygenic score (PGS) appeared to be one possible means of using this information to predict disease.2 It is thought this how to buy cheap lasix online will be of benefit as our genetic make-up is largely stable from birth and dictates a ‘baseline risk’ on which external influences act and modulate. Therefore, PGS are a potential mechanism to act as a risk predictor by capturing information on this genetic liability.The use of PGS as a predictive biomarker is being explored in a number of different disease areas, including cancer,3 4 psychiatric disorders,5–7 metabolic disorders (diabetes,8 obesity9) and coronary artery disease (CAD).10 The proposed applications range from aiding disease diagnosis, informing selection of therapeutic interventions, improvement of risk prediction, informing disease screening and, on a personal level, informing life planning. Therefore, genetic risk information in the form of a PGS is considered how to buy cheap lasix online to have potential in informing both clinical and individual-level decision-making.Recent advances in statistical techniques, improved computational power and the availability of large data sets have led to rapid developments in this area over the past few years.

This has resulted in a variety of approaches to construction of models for score calculation and the investigation of these scores for prediction of common diseases.11 Several review articles aimed at researchers with a working knowledge of this field have been produced.6 11–17 In this article, we provide an overview of the key aspects of PGS construction to assist clinicians and researchers in other areas of academia to gain an understanding of the processes involved in score construction. We also consider the implications of evolving methodologies for the development of applications of PGS in healthcare.Evolution in polygenic model construction methodologiesTerminology with respect to PGS has evolved over time, reflecting how to buy cheap lasix online evolving approaches and methodology. Other terms include PGS, polygenic risk score, polygenic load, genotype score, genetic burden, polygenic hazard score, genetic risk score (GRS), metaGRS and allelic risk score.

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

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

This calculation aggregates the SNPs and their how to buy cheap lasix online weights selected for a polygenic score. Common diseases are thought to be influenced by many genetic variants with small individual effect sizes, such that meaningful risk prediction necessitates examining the aggregated impact of these multiple variants including their how to buy cheap lasix online weightings. PGS, polygenic score.Construction of a polygenic score.

In the how to buy cheap lasix online process of developing a polygenic score, numerous models are tested and then compared. The model that performs best (as determined by one or more measures) is then selected for validation in the external data set. GWAS, genome-wide association how to buy cheap lasix online studies." data-icon-position data-hide-link-title="0">Figure 2 Construction of a polygenic score.

In the process of developing a polygenic score, numerous models are tested and then compared. The model that performs best (as determined how to buy cheap lasix online by one or more measures) is then selected for validation in the external data set. GWAS, genome-wide association studies.Changes in data availability over time have had an impact on the approach taken in SNP selection and weighting.

Early studies to identify variants associated with common diseases how to buy cheap lasix online took the form of candidate gene studies. The small size of candidate gene studies, the limitation of technologies available for genotyping and stringent significance thresholds meant that these studies investigated fewer variants and those that were identified with disease associations had relatively large effect sizes.19 Taken together, this meant that a relatively small number of variants were available for consideration for inclusion in a polygenic model.20 21 Furthermore, weighting parameters for these few variants were often simplistic, such as counts of the number of risk alleles carried, ignoring their individual effect sizes.16The advent of GWAS enabled assessment of SNPs across the genome, leading to the identification of a larger number of disease-associated variants and therefore more variants suitable for inclusion in a polygenic model. In addition, the increasing number of individuals in the association studies meant that the power of these studies increased, allowing for more precise estimates of effect sizes.19 Furthermore, some theorised how to buy cheap lasix online that lowering stringent significance thresholds set for SNP–trait associations could also identify SNPs that might play a part in disease risk.11 16 This resulted in more options with respect to polygenic model parameters of SNPs to include and weights to assign to them.

However, the inclusion of more SNPs and direct application of GWAS effect sizes as a weighting parameter does not always equate to better predictive performance.4 16 This is because GWAS do not provide perfect information with respect to the causal SNP, the effect sizes or the number of SNPs that contribute to the trait. Therefore, different methods have been developed to address these issues and optimise predictive performance of the score how to buy cheap lasix online. Current common practice is to construct models with different iterations of SNPs and weighting, with assessment of the performance of each to identify the optimum configuration of SNPs and their weights (figure 2).Methods used in SNP selection and weighting assignmentSome methods of model development will initially involve selection of SNPs followed by optimisation of weighting, whereas others may involve optimisation of weightings for all SNPs that have been genotyped using their overall GWAS effect sizes, the linkage disequilibrium (LD) and an estimate of the proportion of SNPs that are expected to contribute to the risk.22LD is the phenomenon where some SNPs are coinherited more frequently with other SNPs due to their close proximity on the genome.

Segments with strong LD between SNPs are how to buy cheap lasix online referred to as haplotype blocks. This phenomenon means that GWAS often identify multiple SNPs in the same haplotype block associated with disease and the true causal SNP is not known. As models have started to assess more SNPs, careful consideration is required how to buy cheap lasix online to take into account possible correlation between SNPs as a result of this phenomenon.

Correlation between SNPs can lead how to buy cheap lasix online to double counting of SNPs and association redundancy, where multiple SNPs in a region of LD are identified as being associated with the outcome. This can lead to reduction in the predictive performance of the model. Therefore, processes for filtering SNPs and using one SNP (tag SNP) to act as a marker in an area of high LD, how to buy cheap lasix online through LD thinning, were developed.

Through these processes SNPs correlated with other SNPs in a block are removed, by either pruning or clumping. Pruning ignores p how to buy cheap lasix online value thresholds and ‘eliminates’ SNPs by a process of iterative comparison between a pair of SNPs to assess if they are correlated, and subsequently could remove SNPs that are deemed to have evidence of association. Clumping (also known as informed pruning) is guided by GWAS p values and chooses the most significant SNP, therefore keeping the most significant SNP within a block.23 This is all done with the aim of pinpointing relatively small areas of the genome that contribute to risk of the trait.

Different significance thresholds may be how to buy cheap lasix online used to select SNPs from this subgroup for inclusion in models.Poor performance of a model can result from imperfect tagging with the underlying causal SNP.16 This is because the causal SNP that is associated with disease might not be in LD with the tag SNP that is in the model but is in LD with another SNP which is not in the model. This particularly occurs where the LD and variant frequency differs between population groups.24 An alternate approach to filter SNPs is stepwise regression where SNPs are selected based on how much the SNPs improve the model’s performance. This is a statistical approach and does how to buy cheap lasix online not consider the impact of LD or effect size.As described above, early studies used simple weighting approaches or directly applied effect sizes from GWAS as weighting parameters for SNPs.

However, application of effect sizes as a weighting parameter directly from a GWAS may not be optimal, due to differences in the population that the GWAS was conducted in and the target population. Also as described above, LD how to buy cheap lasix online and the fact that not all SNPs may contribute to the trait mean that these effect sizes from GWAS are imperfect estimates. Therefore, methods have been developed that adjust effect size estimates from GWAS using statistical techniques which make assumptions about factors such as the number of causal SNPs, level of LD between SNPs or knowledge of their potential function to better reflect their impact on a trait.

Numerous statistical methodologies have been developed to improve weighting with a view to enhancing the discriminative power of a PGS.25 26 Examples of some methodological approaches are LDpred,22 winner’s curse correction,23 empirical Bayes estimation,27 shrinkage regression (Lasso),28 linear mixed models,29 with how to buy cheap lasix online more being developed or tested. An additional improvement on the methods is to embed non-genetic information (eg, age-specific ORs).6 Determination of which methodology or hybrid of methodologies is most appropriate for various settings and conditions is continuously being explored and is evolving with new statistical approaches developing at a rapid pace.In summary, model development has evolved in an attempt to gain the most from available GWAS data and address some of the issues that arise due to working with data sets which cannot be directly translated into parameters for prediction models. The different approaches taken in SNP selection and weighting, and the impact on how to buy cheap lasix online the predictive performance of a model are important to consider when assessing different models.

This is because different approaches to PGS modelling can achieve the same or a similar level of prediction. From a health system implementation perspective, particular approaches may be preferred following practical considerations and trade-offs between obtaining how to buy cheap lasix online genotype data, processes for score construction and model performance. In addition, the degree how to buy cheap lasix online to which these parameters need to be optimised will also be impacted by the input data and validation data set, and the quality control procedures that need to be applied to these data sets.12Sources of input data for score constructionKey to the development of a polygenic model is the availability of data sets that can provide input parameters for model construction.

Genotype data used in model construction can either be available as raw GWAS data or provided as GWAS summary statistics. Data in how to buy cheap lasix online the raw format are individual-level data from a SNP array and may not have undergone basic quality control such as assessment of missingness, sex discrepancy checks, deviation from Hardy-Weinberg equilibrium, heterozygosity rate, relatedness or assessment for outliers.30 31 Availability of raw GWAS data allows for different polygenic models to be developed because of the richness of the data, however computational issues arise because of the size of the data sets. Data based on genome sequencing, as opposed to SNP arrays, could also be used in model construction.

There have been limited studies of PGS developed from this form of data due to limitations in data availability, which is mainly due to cost restraints.15 32 Individual-level genomic data are also often not available to researchers due to privacy concerns.Due to these issues, the focus of polygenic model development has therefore been on using well-powered GWAS summary statistics.33 These are available from open access repositories and contain summary information such as the allele how to buy cheap lasix online positions, ORs, CIs and allele frequency, without containing confidential information on individuals. These data sets have usually been through the basic quality control measures mentioned above. There are, however, no standards for publicly available files, meaning some further processing steps may be required, in particular when various data sets are combined for how to buy cheap lasix online a meta-analysis.

Quality control on summary statistics is only possible if information such as missing genotype rate, minor allele frequency, Hardy-Weinberg equilibrium failures and non-Mendelian transmission rates is provided.12Processing of GWAS data may include additional quality control steps, imputation and filtering of the SNP information, which can be done at the level of genotype or summary statistics data. SNP arrays used in GWAS only how to buy cheap lasix online have common SNPs represented on them as they rely on LD between SNPs to cover the entire genome. As described above, one tag SNP on the array can represent many other SNPs.

Imputation of SNPs is common in GWAS and describes the process of predicting how to buy cheap lasix online genotypes that have not been directly genotyped but are statistically inferred (imputed) based on haplotype blocks from a reference sequence.33–35 Often association tests between the imputed SNPs and trait are repeated. As genotype imputation requires individual-level data, researchers have proposed summary statistics imputation as a mechanism to infer the association between untyped SNPs and a trait. The performance of imputation has been evaluated and shown that, how to buy cheap lasix online with certain limitations, summary statistics imputation is an efficient and cost-effective methodology to identify loci associated with traits when compared with imputation done on genotypes.36An alternative source of input data for the selection of SNPs and their weightings is through literature or in existing databases, where already known trait-associated SNPs and their effect sizes are used as the input parameters in model development.

A number of studies have taken this approach37 38 and it is possible to use multiple sources when developing various polygenic models and establishing the preferred parameters to use.Currently, there does not appear to be one methodology that works across all contexts and traits, each trait will need to be assessed to determine which method is the most suitable for the trait being evaluated. For example, four different polygenic model construction strategies were explored for three skin cancer subtypes4 by using data on SNPs and their effect sizes from different sources, such as the latest GWAS meta-analysis results, the National Human Genome how to buy cheap lasix online Research Institute (NHGRI) EBI GWAS catalogue, UK Biobank GWAS summary statistics with different thresholds and GWAS summary statistics with LDpred. In this setting for basal cell carcinoma and melanoma, the meta-analysis and catalogue-derived models were found to perform similarly but that the latter was ultimately used as it included more SNPs.

For squamous cell carcinoma the meta-analysis-derived http://scaeyc.net/www-ececompsat-org/ model how to buy cheap lasix online performed better than the catalogue-derived model. This demonstrates how each disease subtype, model construction strategy and data set can have their own limitations and advantages.Knowledge of the sources of input data and its subsequent use in model development is important in understanding the limitations how to buy cheap lasix online of available models. Models that are developed using data sets that reflect the population in which prediction is to be carried out will perform better.

For example, data collected from a symptomatic or high-risk population may not be suitable as an input data set for the development of a polygenic model that will be how to buy cheap lasix online used for disease prediction in the general population. Large GWAS studies were previously focused on high-risk individuals, such as patients with breast cancer with a strong family history or known pathogenic variants in BRCA1 or BRCA2. These studies would not be suitable for the development of PGS for use in the general population how to buy cheap lasix online but can inform risk assessment in high-risk individuals.

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

The resulting scores are then usually transformed to a standard normal distribution to give scores ranging from −1 to 1, or 0 to how to buy cheap lasix online 100 for ease of interpretation. This enables further examination of the association between the score and a trait and the predictive ability of different scores generated by different models. Similar to other biomarker analyses, this involves using the PGS as a predictor of a trait with other covariates (eg, age, smoking, and so on) added, if appropriate, in a target how to buy cheap lasix online sample.

Examination of differences in the distribution of scores in cases and controls, or by examining differences in traits between different strata of PGS can enable assessment of predictive ability (figure 3). Common practice is for individual-level PGS values to be used to stratify populations into distinct groups of risk based on how to buy cheap lasix online percentile cut-off or threshold values (eg, the top 1%).Example distribution of polygenic scores across a population. Thresholds can be set to stratify risk as low (some), average (most) and high (some)." data-icon-position data-hide-link-title="0">Figure 3 Example distribution of polygenic scores across a population.

Thresholds can be set to stratify risk as low (some), average (most) and high (some).Model validationPolygenic model development is reliant on further data sets for model testing and validation and the composition of these data sets is important in ensuring that the models are appropriate for a particular purpose how to buy cheap lasix online. The development of a how to buy cheap lasix online model to calculate a PGS involves refinement of the previously discussed input parameters, and selection of the ‘best’ of several models based on performance (figure 2). Therefore, a testing/training data set is often required to assess the model’s ability to accurately predict the trait of interest.

This is how to buy cheap lasix online often a data set that is independent of the base/input/discovery data set. It may comprise a subset of the discovery data set that is only used for testing and was not included in the initial development of the model but should ideally be a separate independent data set.Genotype and phenotype data are needed in these data sets. Polygenic models are used to calculate how to buy cheap lasix online PGS for individuals in the training data set and regression analysis is performed with the PGS as a predictor of a trait.

Other covariates may also be included, if appropriate. This testing how to buy cheap lasix online phase can be considered a process for identifying models with better overall performance and/or informing refinements needed. Hence, this phase often involves comparison of different models that are developed using the same input data set to identify those models that have optimal performance.The primary purpose is to determine which model best discriminates between cases and controls.

The area under the curve (AUC) or the C-statistic is the most commonly used measure in assessing discriminative how to buy cheap lasix online ability. It has been criticised as being an insensitive measure that is not able to fully capture all aspects of predictive ability. For instance, in some instances, AUC can remain unchanged between models but the individuals within are categorised into a different risk group.43 Alternative metrics that have been used to evaluate model performance include increase in risk difference, integrated discrimination improvement, R2 how to buy cheap lasix online (estimate of variance explained by the PGS after covariate adjustment), net classification index and the relative risk (highest percentile vs lowest percentile).

A clear understanding on how to interpret the performance within various settings is important in determining which model is most suitable.44As per normal practice when developing any prediction model, polygenic models with the optimal performance in a testing/training data set should be further validated in external data sets. External data sets are critical in validation of models and assessment of generalisability, hence how to buy cheap lasix online must also conform to the desired situations in which a model is to be used. The goal is to find a model with suitable parameters of predictive performance in data sets outside of those in which it was developed.

Ideally, external validation requires replication in independent how to buy cheap lasix online data sets. Few existing polygenic models have been validated to this extent, the focus being rather on the development of new models rather than evaluation of existing ones. One example where replication has been carried out is in the field of CAD, where the GPSCAD45 and how to buy cheap lasix online metaGRSCAD10 polygenic models (both developed using UK Biobank data) were evaluated in a Finnish population cohort.46 Predictive ability was found to be lower in the Finnish population.

This is likely to how to buy cheap lasix online be due to the differences in genetic structure of this population and the population of the data set used for polygenic model development. Research is ongoing to evaluate polygenic models in other populations and strategies are being developed to ensure the same performance when used more widely, possibly through reweighting and adjustment of the scores.47Moving towards clinical applicationsPGS are thought to be useful information that could improve risk estimation and provide an avenue for disease prevention and deciding treatment strategies. There are indications from a number of fields that genetic information in the form of PGS can act as independent biomarkers and aid stratification.11 16 48 However, the how to buy cheap lasix online clinical benefits of stratification using a PGS and the implications for clinical practice are only just beginning to be examined.

The use of PGS as part of existing risk prediction tools or as a stand-alone predictor has been suggested. This latter option may be true for diseases where knowledge or predictive ability with other risk factors is limited, such as in prostate cancer.49 In either case, polygenic models need to be individually examined to determine suitability and applicability for the specific clinical question.50 Despite some how to buy cheap lasix online commercial companies developing PGS,51 52 currently PGS are not an established part of clinical practice.Integration into clinical practice requires evaluation of a PGS-based test. An important concept to consider in this regard is the distinction between an assay and a test.

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

This distinction is important when assessing if studies are reporting on assay performance as opposed to test performance. It is our view that, with respect to polygenic models, progress has been made with respect to assay development, but PGS-based tests are how to buy cheap lasix online yet to be developed and evaluated. This can enable a clearer understanding of their potential clinical utility and issues that may arise for clinical implementation.11 18 55 It is clear that this is still an evolving field, and going forward different models may be required for different traits due to their underlying genetic architecture,26 different clinical contexts and needs.Clinical contexts where risk stratification is already established practice are most likely where implementation of PGS will occur first.

Risk prediction models based on non-genetic factors have been developed for many conditions and are used in clinical care, how to buy cheap lasix online for example, in cardiovascular disease over 100 such models exist.56 In such contexts, how a PGS and its ability to predict risk compared with, or improves on, these existing models is being investigated.3 44 57–61 The extent to which PGS improves prediction, as well as the cost implications of including this, is likely to impact on implementation.Integration of PGS into clinical practice, for any application, requires robust and validated mechanisms to generate these scores. Therefore, given the numerous models available, an assessment of their suitability as part of a test is required. Parameters or guidelines with respect to aspects of model performance and metrics that could assist in selecting the model to take forward as a how to buy cheap lasix online PGS-based test are limited and need to be addressed.

Currently, there are different mechanisms to generate PGS and have arisen in response to the challenges in aggregating large-scale genomic data for prediction. For example, a review reported 29 PGS models for breast cancer from 22 publications.62 Due to there being a number of different methodologies to generate a score, numerous models may exist how to buy cheap lasix online for the same condition and each of the resulting models could perform differently. Models may perform differently because the population, measured outcome or context of the development data sets used to generate the models is diverse, for example, a score for risk how to buy cheap lasix online of breast cancer versus a breast cancer subtype.44 63 This diversity, alongside the lack of established best practice and standardised reporting in publications, makes comparison and evaluation of polygenic models for use in clinical settings challenging.

It is clear that moving the field forward is reliant on transparent reporting and evaluation. Recommendations for how to buy cheap lasix online best practices on the reporting of polygenic models in literature have been proposed14 64 as well as a database,65 66 which could allow for such comparisons. Statements and guidelines for risk prediction model development, such as the Genetic Risk Prediction Studies and Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD), already exist, but are not consistently used.

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

Meaning that there are still some important questions that need to be addressed to determine how and where PGS could work within current healthcare systems, particularly at a population level.78It is widely accepted that genotyping using arrays is a lower cost endeavour in comparison to genome sequencing, making the incorporation of PGS into routine healthcare an attractive proposition. However, we were unable to find any studies reporting on how to buy cheap lasix online the use or associated costs of such technology for population screening. Studies are beginning to examine use case scenarios and model cost-effectiveness, but this has only been in very few, specific investigations.79 80 Costs will also be influenced by the testing technology and by the downstream consequences of testing, which is likely to differ depending on specific applications that are developed and the pathways in which such tests are incorporated.

This is particularly the case in screening or primary care settings, where such testing is currently not an established part of care pathways and may require additional resources, not least as how to buy cheap lasix online a result of the volume of testing that could be expected. Moving forward, the clinical role of PGS needs to be developed further, including defining the clinical applications as well as supporting evidence, for example, on the effect of clinical outcomes, the feasibility for use in routine practice and cost-effectiveness.ConclusionThere is a large amount of diversity in the PGS field with respect to model development approaches, and this continues to evolve. There is rapid progress which is being driven by the availability of larger data sets, primarily from GWAS and concomitant developments how to buy cheap lasix online in statistical methodologies.

As understanding and knowledge develops, the usefulness and appropriateness of polygenic models for different diseases and contexts are being explored. Nevertheless, this how to buy cheap lasix online is still an emerging field, with a variable evidence base demonstrating some potential. The validity of PGS needs to be clearly demonstrated, and their applications evaluated prior to clinical implementation..

Lasix syrup

Latest Healthy Kids News By lasix syrup Alan Mozes HealthDay ReporterFRIDAY, Nov. 13, 2020 lasix syrup (HealthDay)Since last April, hospital emergency rooms across the United States have seen a sustained surge in visits related to the mental health of school-aged kids, a new report reveals.The findings suggest the hypertension medications lasix is taking a toll on children because of disruptions to their everyday life, anxiety about illness and social isolation. That conclusion comes from a U.S. Centers for Disease Control and Prevention review of data on lasix syrup hospitals in 47 states. Those hospitals account for nearly three-quarters of emergency department visits nationwide.The study tracked emergency visits involving children under age 18 who sought care lasix syrup for a mental health issue between Jan.

1 and Oct. 17, 2020."Our study looked at a composite group of mental health concerns that included conditions that are likely to increase during and after a public health emergency, such as stress, anxiety, acute post-traumatic stress disorder and panic," said lead author Rebecca Leeb, a health scientist at the CDC in Atlanta who is part of its hypertension medications Response Team."We found that from March through October, the proportion of mental health-related emergency department visits increased 24% for children aged 5 to 11, and 31% among teenagers aged 12 to 17 years, compared lasix syrup to 2019," Leeb said.Pediatric mental health visits actually dropped off dramatically from mid-March to mid-April, when stay-at-home orders were in effect in much of the country. Since then, however, such visits have steadily increased, according to the report.But lasix syrup Leeb said interpreting the numbers is not straightforward.On the one hand, she said even the large jumps seen in the report likely underestimate the total number of pediatric mental health emergencies. "Many mental health care encounters occur outside of emergency departments," Leeb explained.But additional research indicates emergency department visits as a whole dropped significantly between January and October. And that, Leeb said, might mean that "the relative proportion of emergency department visits for children's mental health-related concerns may be inflated."Regardless, Leeb said the findings show that many kids' mental health was sufficiently concerning to prompt ER visits lasix syrup at a time when the public was being discouraged from using emergency departments for anything but the most critical care.As such, the findings "highlight the importance of continuing to monitor children's mental health during the lasix to ensure access to mental health services during public health crises," Leeb said.The study did not set out to identify specific reasons for emergency visits and Leeb said figuring that out requires more study.But past research shows that the lost sense of safety and disruption to daily living that often accompanies disasters is a common trigger for stress.

And that stress, in turn, can lead to isolation and trigger mental health emergencies, Leeb said.This is not surprising, according to psychologist Lynn Bufka, senior director for practice, research and policy at the American Psychological Association."These are stressful times for many and stress can exacerbate mental health concerns," Bufka noted. "Previous research indicates that a portion of children do have adverse outcomes from traumatic events, and this lasix is no different."Bufka pointed to the wholesale uprooting of kids' routines and structure, both in lasix syrup terms of school and socializing."Children's play is one way children explore and understand their world, so not being able to play with friends gives them fewer outlets for fun, but also just fewer general opportunities to cope and explore," she explained.Kids may also pick up on parents' stress, which can magnify their own fears."All of this has an impact on children and how they understand their world and interpret the events around them," Bufka said. Some kids lasix syrup adapt more easily. Others will struggle. For youngsters with existing mental health problems, the current stresses will add to them.But parents and other adults can do a lot to support kids and help those who are struggling.On that lasix syrup front, Leeb advised parents to foster a supportive environment and learn about behavior that signals kids are under mounting stress.

The CDC has a number of helpful resources, she said, lasix syrup including an online primer on talking with your child about the hypertension.Leeb and her colleagues published their findings in the Nov. 13 issue of the CDC's Morbidity and Mortality Weekly Report.More informationGet tips on talking with your child about hypertension at the U.S. Centers for lasix syrup Disease Control and Prevention. SOURCES. Rebecca Leeb, PhD, health scientist, U.S.

Centers for Disease Control and Prevention, Atlanta. Lynn Bufka, senior director for practice, research and policy, American Psychological Association, Washington, D.C.. Morbidity and Mortality Weekly Report, Nov. 13, 2020Copyright © 2020 HealthDay. All rights reserved.

QUESTION Laughter feels good because… See AnswerLatest hypertension News MONDAY, Nov. 16, 2020 (HealthDay News) -- BioNTech and Pfizer's experimental hypertension treatment could cut transmission of the lasix in half, leading to a "dramatic" curb of its spread, according to a company executive."I'm very confident that transmission between people will be reduced by such a highly effective treatment -- maybe not 90% but maybe 50%," said Ugur Sahin, chief executive of Germany's BioNTech, the Associated Press reported.Last week, the companies claimed the treatment was 90% effective in protecting people from the new hypertension."If everything continues to go well, we will start to deliver the treatment end of this year, beginning next year," Sahin said. "Our goal is to deliver more than 300 million of treatment doses until April next year, which could allow us to already start to make an impact."Researchers are gathering more information on safety and manufacturing quality of the treatment, the AP reported.Copyright © 2020 HealthDay. All rights reserved. SLIDESHOW Whooping Cough (Pertussis) Symptoms, treatment Facts See SlideshowLatest Infectious Disease News By Dennis Thompson HealthDay ReporterMONDAY, Nov.

16, 2020 (HealthDay News)A deadly South American lasix that causes Ebola-like bleeding can spread human-to-human, public health officials have learned from its second-ever outbreak.Public health investigators have reconstructed the path by which the Chapare lasix spread from person to person during a 2019 outbreak in Bolivia, leaping from the initial patient to several health care workers.But while the rodent-borne Chapare lasix is highly lethal -- killing three of the five confirmed patients in the latest outbreak -- the pathogen poses very little risk to people in North America, experts said."This lasix is not one we think is going to really be a major threat to the United States," said Dr. Dan Bausch, president-elect of the American Society of Tropical Medicine and Hygiene. "The lasix is important to understand for people who might be traveling in this area of Bolivia, important to understand for people living in that area of the world, and to our greater understanding of these types of lasixes, but not something your average person in the U.S. Needs to be worried about."The lasix first emerged in 2004, in the Chapare province of Bolivia, about 370 miles east of the country's capital city, La Paz. There was a small cluster of illnesses in that first outbreak, but only a single confirmed case, researchers said in background notes.The Chapare lasix belongs to a different viral family from Ebola, but both can cause hemorrhagic fever in the infected.In the case of Chapare lasix, symptoms can include fever, headache, abdominal pain, rash, and bleeding of the gums, researchers noted.

Hemorrhagic fevers ultimately can cause life-threatening organ failure and bleeding.There is no treatment for Chapare lasix, outside of IV fluids and supportive care.The second outbreak started with a 65-year-old rice farmer who likely caught Chapare lasix through contact with rat urine or droppings, said lead researcher Dr. Caitlin Cossaboom, an epidemiologist with the U.S. Centers for Disease Control and Prevention's Division of High Consequence Pathogens and Pathology.Cossaboom reported on the new outbreak Monday at the American Society of Tropical Medicine and Hygiene's annual meeting. Such research is considered preliminary until published in a peer-reviewed journal.A 25-year-old doctor caring for the farmer at a hospital in the village of Caranavi was next infected, the investigation revealed."The night before he died, she suctioned saliva from his mouth, and then she fell ill nine days later," Cossaboom explained.A 48-year-old paramedic working in an ambulance that transported the doctor to a La Paz hospital then became the next person in the chain of ."When she was in the ambulance, she needed CPR," Cossaboom said of the doctor. "The ambulance worker that performed CPR on her 16 days later developed symptoms."When the doctor arrived in La Paz, a gastroenterologist performed an endoscopy on her as part of her treatment -- a procedure in which a small camera is snaked into the mouth to examine a person's upper GI tract.The gastroenterologist developed symptoms 14 days later, Cossaboom said."In all of those cases, we have definitive evidence of exposure to bodily fluids," Cossaboom said.The initial patient, the village doctor and the gastroenterologist all died from Chapare lasix.

The ambulance medic and a fifth patient -- a farm worker also from Caranavi -- survived their .Bolivian health officials investigating the outbreak trapped rats in Caranavi, and genetic testing showed that the rats carry the Chapare lasix, Cossaboom said.The species are the pygmy rice rat and the small-eared pygmy rice rat, and they are found across Bolivia and several neighboring countries, researchers said.South American countries adjacent to Bolivia should be on the lookout for potential Chapare lasix outbreaks where these mouse species are common, Cossaboom said.Scientists suspect Chapare lasix might have been circulating in Bolivia for years now, but infected patients may have been wrongly diagnosed with dengue, a mosquito-borne viral that is common in the region."This really raises the importance of improving surveillance for Chapare lasix and other arenalasixes in South America, because they look like other very common diseases like dengue," Cossaboom said. "In these cases, the initial patients were assumed to have dengue, because their clinical signs looked just like dengue. The difference is that dengue can't be transmitted human-to-human." QUESTION Bowel regularity means a bowel movement every day. See Answer Arenalasixes are very vulnerable to heat and disinfectants like alcohol, Bausch said."It might be in the rice before you cook it, and if you're the preparer of rice that's contaminated with rodent urine you can get infected, but if you're the consumer of the hot rice once it's cooked, that's really not the risk," Bausch said.Other known arenalasixes include dangerous pathogens such as Lassa lasix, which causes thousands of deaths annually in West Africa, and Machupo lasix, which has caused deadly outbreaks in Bolivia, researchers said.Outside of someone contracting Chapare lasix in South America and then traveling home, there's not much risk of an outbreak in the United States anytime soon, Bausch and Cossaboom said.That's because the pygmy rice rats that harbor Chapare lasix are not typically located as far north as the United States, they said.More InformationThe U.S. National Institutes of Health has more about hemorrhagic fevers.SOURCES.

Caitlin Cossaboom, DVM, PhD, MPH, epidemiologist, U.S. Centers for Disease Control and Prevention's Division of High Consequence Pathogens and Pathology. Dan Bausch, MD, scientific program chair and president-elect, American Society of Tropical Medicine and Hygiene. Virtual annual meeting, American Society of Tropical Medicine and Hygiene, Nov. 16, 2020Copyright © 2020 HealthDay.

All rights reserved. From Infectious Disease Resources Featured Centers Health Solutions From Our SponsorsLatest Heart News By Steven Reinberg and Ernie Mundell HealthDay ReportersMONDAY, Nov. 16, 2020Does high-strength fish oil help the heart or doesn't it?. Prior research into a prescription medicine derived from fish called Vascepa, announced earlier this year, suggested it might be of real value for heart patients.But the results from a trial of another such drug called Epanova, released Sunday, are disappointing. Researchers found no benefit from taking the medicine for a wide range of heart health outcomes, compared to taking a placebo pill containing only corn oil."Many people continue to take fish oil supplements to prevent heart disease.

However, the fish oil medication we tested in the [new] trial was not effective for that purpose," co-researcher Dr. A. Michael Lincoff said in a news release from the American Heart Association.He's vice chairman for research in the department of cardiovascular medicine at the Cleveland Clinic's Heart, Vascular and Thoracic Institute.The research was presented Sunday at the AHA's virtual annual meeting. It was also published simultaneously in the Journal of the American Medical Association.The new study was funded by AstraZeneca, which makes Epanova. AstraZeneca announced Friday that it was halting the phase III trial, based on disappointing results.The conflicting results from trials of the two different prescription-strength medicines, Vascepa and Epanova, throws confusion on whether or not heart patients really benefit from the nutrient."The question of whether omega-3 fatty acids improve health is important to patients, physicians, and the health care system," noted Dr.

Gregory Curfman, who penned an editorial on the trial. "Even in the hypertension medications era, cardiovascular disease is the leading cause of death in the U.S.""Given the current uncertain state of knowledge, neither patients nor physicians can be confident that omega-3 fatty acids have any health benefits ," he said.That probably won't stop Americans from buying the supplements. "In 2019, the global market for omega-3 fatty acids reached $4.1 billion and is expected to double by 2025," Curfman noted.The new study focused on Epanova, which contains a combination of two omega-3 carboxylic acids — eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA].More than 13,000 patients, treated at centers around the world, were given either Epanova or a placebo pill containing corn oil. All patients had conditions putting them at at "high cardiovascular risk." For example, they were being treated with cholesterol-lowering statins and had either blockages of the coronary arteries, or arteries in the brain or legs, or were at risk for heart disease because of conditions such as diabetes or lifestyle risk factors like smoking.Enrollment into the trial began in 2014. The trial was terminated in January of 2020, Lincoff's group said.Over that period of time, over 1,600 patients experienced some kind of cardiac event.

But the use of Epanova did not decrease deaths from heart disease, heart attack, stroke, the need for stents or bypass surgery, or being hospitalized for angina. IMAGES Heart Illustration Browse through our medical image collection to see illustrations of human anatomy and physiology See Images There was even one downside to the treatment. Researchers say that use of the prescription-strength fish oil appeared tied to a rise in the risk for the common abnormal heart rhythm called atrial fibrillation.But if Epanova appears to confer no benefit, why did heart patients given another omega-3 prescription drug, Vascepa, seemingly get a health boost?. According to Curfman, the answer may lie in trial design.Vascepa contains a form of purified EPA known as icosapent ethyl. The clinical trial which appeared to validate Vascepa's effectiveness lasted 5 years.

Researchers found that use of the drug was tied to a 25% reduction in a variety of cardiac events when compared to placebo — in this case, mineral oil."Why did these 2 high-quality clinical trials, both using the same high dose of omega-3 fatty acids, come to opposite conclusions?. ," Curfman asked.The choice of placebo -- mineral oil or corn oil -- might help explain the discrepancy, he said. Perhaps Vascepa "did not reduce the risk of cardiovascular events, but instead, the comparator, mineral oil, increased the risk of cardiovascular events," Curfman theorized. That might create the illusion that Vascepa helped patients, he reasoned.There is some evidence that mineral oil can boost levels of LDL 'bad" cholesterol, Curfman noted.But right now, the theory that the choice of placebo influenced the Vascepa trial results has not been tested, he stressed."Only a new clinical trial of icosapent ethyl versus corn oil would settle the question definitively, but this is unlikely to be undertaken" by private industry, Curfman said.Therefore, he added, "the FDA should require a post-marketing clinical trial of high-dose icosapent ethyl versus corn oil in patients at risk for cardiovascular events."More informationThere's more about the benefits of fish oil supplements at the American Heart Association.SOURCE. American Heart Association annual meeting, news release, Nov.

15, 2020. Journal of the American Medical Association, Nov. 15, 2020Copyright © 2020 HealthDay. All rights reserved. From Healthy Heart Resources Featured Centers Health Solutions From Our SponsorsLatest Prevention &.

Wellness News MONDAY, Nov. 16, 2020 (HealthDay News)Despite skyrocketing hypertension rates, many Americans plan to attend large holiday gatherings, a nationwide survey finds.Nearly two in five respondents said they will likely gather with more than 10 people, according to the Ohio State University Wexner Medical Center poll.And while many plan to take precautions -- such as social distancing and asking those with hypertension medications symptoms not to attend holiday gatherings -- one-third of respondents said they won't ask guests to wear masks.The United States is seeing record numbers of hypertension s, and colder weather is leading to more get-togethers indoors, where the lasix can more easily spread."We're going to look back at what happened during this holiday season and ask ourselves, 'Were we part of the solution or were we part of the problem?. '" said Dr. Iahn Gonsenhauser, chief quality and patient safety officer at the Wexner Medical Center."When you're gathered together around the table, engaged in conversation, sitting less than six feet apart with your masks down, even in a small group, that's when the spread of this lasix can really happen," he warned in a university news release.The safest way to mark the holidays is to cancel in-person plans with family and friends, and connect virtually instead, Gonsenhauser advised.If you do decide to host a gathering, it's crucial to create a safety plan and outline it to all your guests, he added.Measures could include having everyone wear masks at all times. Separating seating arrangements by household.

And assigning one or two people to serve the food. The same precautions should be used even if your holiday event is held outdoors, Gonsenhauser said.If you plan to travel or host out-of-town guests, monitor hypertension medications rates and restrictions in both locations."If you have someone in your household who's high risk and you're in a low-incidence area, you're going to want to think twice about having a celebration where people are coming from an area where there's a lot of lasix in the community," Gonsenhauser said.More informationFor more on hypertension medications, go to the U.S. Centers for Disease Control and Prevention.SOURCE. Ohio State University, news release, Nov. 12, 2020Robert PreidtCopyright © 2020 HealthDay.

All rights reserved. QUESTION Bowel regularity means a bowel movement every day. See Answer.

Latest Healthy Kids http://ilovepte.com/sweet-16s/ News By Alan Mozes HealthDay ReporterFRIDAY, Nov how to buy cheap lasix online. 13, 2020 (HealthDay)Since last April, hospital emergency rooms across the United States have seen a sustained surge in how to buy cheap lasix online visits related to the mental health of school-aged kids, a new report reveals.The findings suggest the hypertension medications lasix is taking a toll on children because of disruptions to their everyday life, anxiety about illness and social isolation. That conclusion comes from a U.S. Centers for Disease Control and Prevention review how to buy cheap lasix online of data on hospitals in 47 states.

Those hospitals account for nearly three-quarters of emergency department visits nationwide.The study tracked emergency how to buy cheap lasix online visits involving children under age 18 who sought care for a mental health issue between Jan. 1 and Oct. 17, 2020."Our study looked at a composite group of mental health concerns how to buy cheap lasix online that included conditions that are likely to increase during and after a public health emergency, such as stress, anxiety, acute post-traumatic stress disorder and panic," said lead author Rebecca Leeb, a health scientist at the CDC in Atlanta who is part of its hypertension medications Response Team."We found that from March through October, the proportion of mental health-related emergency department visits increased 24% for children aged 5 to 11, and 31% among teenagers aged 12 to 17 years, compared to 2019," Leeb said.Pediatric mental health visits actually dropped off dramatically from mid-March to mid-April, when stay-at-home orders were in effect in much of the country. Since then, however, such visits have steadily increased, according to the report.But Leeb said interpreting the numbers is not straightforward.On the one hand, she said even the large how to buy cheap lasix online jumps seen in the report likely underestimate the total number of pediatric mental health emergencies.

"Many mental health care encounters occur outside of emergency departments," Leeb explained.But additional research indicates emergency department visits as a whole dropped significantly between January and October. And that, Leeb said, might mean that "the relative proportion of emergency department visits for children's mental health-related concerns may be inflated."Regardless, Leeb said the findings show that many kids' mental health was sufficiently concerning to prompt ER visits at a time when the public was being discouraged from using emergency departments for anything but the most critical how to buy cheap lasix online care.As such, the findings "highlight the importance of continuing to monitor children's mental health during the lasix to ensure access to mental health services during public health crises," Leeb said.The study did not set out to identify specific reasons for emergency visits and Leeb said figuring that out requires more study.But past research shows that the lost sense of safety and disruption to daily living that often accompanies disasters is a common trigger for stress. And that stress, in turn, can lead to isolation and trigger mental health emergencies, Leeb said.This is not surprising, according to psychologist Lynn Bufka, senior director for practice, research and policy at the American Psychological Association."These are stressful times for many and stress can exacerbate mental health concerns," Bufka noted. "Previous research indicates that a portion of children do have adverse outcomes from traumatic events, and this lasix is no different."Bufka pointed to the wholesale uprooting of kids' routines and structure, both in terms of school and socializing."Children's play is one way children explore and understand their world, so not being able to play with friends gives them fewer outlets for fun, but also just fewer general opportunities to cope and explore," she explained.Kids may also pick up on how to buy cheap lasix online parents' stress, which can magnify their own fears."All of this has an impact on children and how they understand their world and interpret the events around them," Bufka said.

Some kids adapt how to buy cheap lasix online more easily. Others will struggle. For youngsters with existing mental health problems, the current stresses will add to them.But parents and other adults can do a lot to support kids how to buy cheap lasix online and help those who are struggling.On that front, Leeb advised parents to foster a supportive environment and learn about behavior that signals kids are under mounting stress. The CDC has a number of helpful resources, she said, including an online primer on talking with your child about the hypertension.Leeb and how to buy cheap lasix online her colleagues published their findings in the Nov.

13 issue of the CDC's Morbidity and Mortality Weekly Report.More informationGet tips on talking with your child about hypertension at the U.S. Centers for Disease Control and how to buy cheap lasix online Prevention. SOURCES. Rebecca Leeb, PhD, health scientist, U.S.

Centers for Disease Control and Prevention, Atlanta. Lynn Bufka, senior director for practice, research and policy, American Psychological Association, Washington, D.C.. Morbidity and Mortality Weekly Report, Nov. 13, 2020Copyright © 2020 HealthDay.

All rights reserved. QUESTION Laughter feels good because… See AnswerLatest hypertension News MONDAY, Nov. 16, 2020 (HealthDay News) -- BioNTech and Pfizer's experimental hypertension treatment could cut transmission of the lasix in half, leading to a "dramatic" curb of its spread, according to a company executive."I'm very confident that transmission between people will be reduced by such a highly effective treatment -- maybe not 90% but maybe 50%," said Ugur Sahin, chief executive of Germany's BioNTech, the Associated Press reported.Last week, the companies claimed the treatment was 90% effective in protecting people from the new hypertension."If everything continues to go well, we will start to deliver the treatment end of this year, beginning next year," Sahin said. "Our goal is to deliver more than 300 million of treatment doses until April next year, which could allow us to already start to make an impact."Researchers are gathering more information on safety and manufacturing quality of the treatment, the AP reported.Copyright © 2020 HealthDay.

All rights reserved. SLIDESHOW Whooping Cough (Pertussis) Symptoms, treatment Facts See SlideshowLatest Infectious Disease News By Dennis Thompson HealthDay ReporterMONDAY, Nov. 16, 2020 (HealthDay News)A deadly South American lasix that causes Ebola-like bleeding can spread human-to-human, public health officials have learned from its second-ever outbreak.Public health investigators have reconstructed the path by which the Chapare lasix spread from person to person during a 2019 outbreak in Bolivia, leaping from the initial patient to several health care workers.But while the rodent-borne Chapare lasix is highly lethal -- killing three of the five confirmed patients in the latest outbreak -- the pathogen poses very little risk to people in North America, experts said."This lasix is not one we think is going to really be a major threat to the United States," said Dr. Dan Bausch, president-elect of the American Society of Tropical Medicine and Hygiene.

"The lasix is important to understand for people who might be traveling in this area of Bolivia, important to understand for people living in that area of the world, and to our greater understanding of these types of lasixes, but not something your average person in the U.S. Needs to be worried about."The lasix first emerged in 2004, in the Chapare province of Bolivia, about 370 miles east of the country's capital city, La Paz. There was a small cluster of illnesses in that first outbreak, but only a single confirmed case, researchers said in background notes.The Chapare lasix belongs to a different viral family from Ebola, but both can cause hemorrhagic fever in the infected.In the case of Chapare lasix, symptoms can include fever, headache, abdominal pain, rash, and bleeding of the gums, researchers noted. Hemorrhagic fevers ultimately can cause life-threatening organ failure and bleeding.There is no treatment for Chapare lasix, outside of IV fluids and supportive care.The second outbreak started with a 65-year-old rice farmer who likely caught Chapare lasix through contact with rat urine or droppings, said lead researcher Dr.

Caitlin Cossaboom, an epidemiologist with the U.S. Centers for Disease Control and Prevention's Division of High Consequence Pathogens and Pathology.Cossaboom reported on the new outbreak Monday at the American Society of Tropical Medicine and Hygiene's annual meeting. Such research is considered preliminary until published in a peer-reviewed journal.A 25-year-old doctor caring for the farmer at a hospital in the village of Caranavi was next infected, the investigation revealed."The night before he died, she suctioned saliva from his mouth, and then she fell ill nine days later," Cossaboom explained.A 48-year-old paramedic working in an ambulance that transported the doctor to a La Paz hospital then became the next person in the chain of ."When she was in the ambulance, she needed CPR," Cossaboom said of the doctor. "The ambulance worker that performed CPR on her 16 days later developed symptoms."When the doctor arrived in La Paz, a gastroenterologist performed an endoscopy on her as part of her treatment -- a procedure in which a small camera is snaked into the mouth to examine a person's upper GI tract.The gastroenterologist developed symptoms 14 days later, Cossaboom said."In all of those cases, we have definitive evidence of exposure to bodily fluids," Cossaboom said.The initial patient, the village doctor and the gastroenterologist all died from Chapare lasix.

The ambulance medic and a fifth patient -- a farm worker also from Caranavi -- survived their .Bolivian health officials investigating the outbreak trapped rats in Caranavi, and genetic testing showed that the rats carry the Chapare lasix, Cossaboom said.The species are the pygmy rice rat and the small-eared pygmy rice rat, and they are found across Bolivia and several neighboring countries, researchers said.South American countries adjacent to Bolivia should be on the lookout for potential Chapare lasix outbreaks where these mouse species are common, Cossaboom said.Scientists suspect Chapare lasix might have been circulating in Bolivia for years now, but infected patients may have been wrongly diagnosed with dengue, a mosquito-borne viral that is common in the region."This really raises the importance of improving surveillance for Chapare lasix and other arenalasixes in South America, because they look like other very common diseases like dengue," Cossaboom said. "In these cases, the initial patients were assumed to have dengue, because their clinical signs looked just like dengue. The difference is that dengue can't be transmitted human-to-human." QUESTION Bowel regularity means a bowel movement every day. See Answer Arenalasixes are very vulnerable to heat and disinfectants like alcohol, Bausch said."It might be in the rice before you cook it, and if you're the preparer of rice that's contaminated with rodent urine you can get infected, but if you're the consumer of the hot rice once it's cooked, that's really not the risk," Bausch said.Other known arenalasixes include dangerous pathogens such as Lassa lasix, which causes thousands of deaths annually in West Africa, and Machupo lasix, which has caused deadly outbreaks in Bolivia, researchers said.Outside of someone contracting Chapare lasix in South America and then traveling home, there's not much risk of an outbreak in the United States anytime soon, Bausch and Cossaboom said.That's because the pygmy rice rats that harbor Chapare lasix are not typically located as far north as the United States, they said.More InformationThe U.S.

National Institutes of Health has more about hemorrhagic fevers.SOURCES. Caitlin Cossaboom, DVM, PhD, MPH, epidemiologist, U.S. Centers for her response Disease Control and Prevention's Division of High Consequence Pathogens and Pathology. Dan Bausch, MD, scientific program chair and president-elect, American Society of Tropical Medicine and Hygiene.

Virtual annual meeting, American Society of Tropical Medicine and Hygiene, Nov. 16, 2020Copyright © 2020 HealthDay. All rights reserved. From Infectious Disease Resources Featured Centers Health Solutions From Our SponsorsLatest Heart News By Steven Reinberg and Ernie Mundell HealthDay ReportersMONDAY, Nov.

16, 2020Does high-strength fish oil help the heart or doesn't it?. Prior research into a prescription medicine derived from fish called Vascepa, announced earlier this year, suggested it might be of real value for heart patients.But the results from a trial of another such drug called Epanova, released Sunday, are disappointing. Researchers found no benefit from taking the medicine for a wide range of heart health outcomes, compared to taking a placebo pill containing only corn oil."Many people continue to take fish oil supplements to prevent heart disease. However, the fish oil medication we tested in the [new] trial was not effective for that purpose," co-researcher Dr.

A. Michael Lincoff said in a news release from the American Heart Association.He's vice chairman for research in the department of cardiovascular medicine at the Cleveland Clinic's Heart, Vascular and Thoracic Institute.The research was presented Sunday at the AHA's virtual annual meeting. It was also published simultaneously in the Journal of the American Medical Association.The new study was funded by AstraZeneca, which makes Epanova. AstraZeneca announced Friday that it was halting the phase III trial, based on disappointing results.The conflicting results from trials of the two different prescription-strength medicines, Vascepa and Epanova, throws confusion on whether or not heart patients really benefit from the nutrient."The question of whether omega-3 fatty acids improve health is important to patients, physicians, and the health care system," noted Dr.

Gregory Curfman, who penned an editorial on the trial. "Even in the hypertension medications era, cardiovascular disease is the leading cause of death in the U.S.""Given the current uncertain state of knowledge, neither patients nor physicians can be confident that omega-3 fatty acids have any health benefits ," he said.That probably won't stop Americans from buying the supplements. "In 2019, the global market for omega-3 fatty acids reached $4.1 billion and is expected to double by 2025," Curfman noted.The new study focused on Epanova, which contains a combination of two omega-3 carboxylic acids — eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA].More than 13,000 patients, treated at centers around the world, were given either Epanova or a placebo pill containing corn oil. All patients had conditions putting them at at "high cardiovascular risk." For example, they were being treated with cholesterol-lowering statins and had either blockages of the coronary arteries, or arteries in the brain or legs, or were at risk for heart disease because of conditions such as diabetes or lifestyle risk factors like smoking.Enrollment into the trial began in 2014.

The trial was terminated in January of 2020, Lincoff's group said.Over that period of time, over 1,600 patients experienced some kind of cardiac event. But the use of Epanova did not decrease deaths from heart disease, heart attack, stroke, the need for stents or bypass surgery, or being hospitalized for angina. IMAGES Heart Illustration Browse through our medical image collection to see illustrations of human anatomy and physiology See Images There was even one downside to the treatment. Researchers say that use of the prescription-strength fish oil appeared tied to a rise in the risk for the common abnormal heart rhythm called atrial fibrillation.But if Epanova appears to confer no benefit, why did heart patients given another omega-3 prescription drug, Vascepa, seemingly get a health boost?.

According to Curfman, the answer may lie in trial design.Vascepa contains a form of purified EPA known as icosapent ethyl. The clinical trial which appeared to validate Vascepa's effectiveness lasted 5 years. Researchers found that use of the drug was tied to a 25% reduction in a variety of cardiac events when compared to placebo — in this case, mineral oil."Why did these 2 high-quality clinical trials, both using the same high dose of omega-3 fatty acids, come to opposite conclusions?. ," Curfman asked.The choice of placebo -- mineral oil or corn oil -- might help explain the discrepancy, he said.

Perhaps Vascepa "did not reduce the risk of cardiovascular events, but instead, the comparator, mineral oil, increased the risk of cardiovascular events," Curfman theorized. That might create the illusion that Vascepa helped patients, he reasoned.There is some evidence that mineral oil can boost levels of LDL 'bad" cholesterol, Curfman noted.But right now, the theory that the choice of placebo influenced the Vascepa trial results has not been tested, he stressed."Only a new clinical trial of icosapent ethyl versus corn oil would settle the question definitively, but this is unlikely to be undertaken" by private industry, Curfman said.Therefore, he added, "the FDA should require a post-marketing clinical trial of high-dose icosapent ethyl versus corn oil in patients at risk for cardiovascular events."More informationThere's more about the benefits of fish oil supplements at the American Heart Association.SOURCE. American Heart Association annual meeting, news release, Nov. 15, 2020.

Journal of the American Medical Association, Nov. 15, 2020Copyright © 2020 HealthDay. All rights reserved. From Healthy Heart Resources Featured Centers Health Solutions From Our SponsorsLatest Prevention &.

Wellness News MONDAY, Nov. 16, 2020 (HealthDay News)Despite skyrocketing hypertension rates, many Americans plan to attend large holiday gatherings, a nationwide survey finds.Nearly two in five respondents said they will likely gather with more than 10 people, according to the Ohio State University Wexner Medical Center poll.And while many plan to take precautions -- such as social distancing and asking those with hypertension medications symptoms not to attend holiday gatherings -- one-third of respondents said they won't ask guests to wear masks.The United States is seeing record numbers of hypertension s, and colder weather is leading to more get-togethers indoors, where the lasix can more easily spread."We're going to look back at what happened during this holiday season and ask ourselves, 'Were we part of the solution or were we part of the problem?. '" said Dr. Iahn Gonsenhauser, chief quality and patient safety officer at the Wexner Medical Center."When you're gathered together around the table, engaged in conversation, sitting less than six feet apart with your masks down, even in a small group, that's when the spread of this lasix can really happen," he warned in a university news release.The safest way to mark the holidays is to cancel in-person plans with family and friends, and connect virtually instead, Gonsenhauser advised.If you do decide to host a gathering, it's crucial to create a safety plan and outline it to all your guests, he added.Measures could include having everyone wear masks at all times.

Separating seating arrangements by household. And assigning one or two people to serve the food. The same precautions should be used even if your holiday event is held outdoors, Gonsenhauser said.If you plan to travel or host out-of-town guests, monitor hypertension medications rates and restrictions in both locations."If you have someone in your household who's high risk and you're in a low-incidence area, you're going to want to think twice about having a celebration where people are coming from an area where there's a lot of lasix in the community," Gonsenhauser said.More informationFor more on hypertension medications, go to the U.S. Centers for Disease Control and Prevention.SOURCE.

Ohio State University, news release, Nov. 12, 2020Robert PreidtCopyright © 2020 HealthDay. All rights reserved. QUESTION Bowel regularity means a bowel movement every day.

Lasix dosaggio

NYC applicants lasix dosaggio should How to get diflucan otc no longer use DOH-4220. See more information here about Jan. 2021 changes for NYC applicants regarding Supplement A. This supplement collects information about the applicant's current resources and past resources (for lasix dosaggio nursing home coverage). Do not use the DOH-4220 application for Medicaid applicants in the MAGI category (generally those under age 65 or, if younger and disabled, not receiving Medicare).

All MAGI applicants should go through the NYS Health Benefits Exchange to apply for Medicaid. They can contact a Navigator lasix dosaggio or Community Health Advocates for assistance. All local districts in New York State are required to accept the revised DOH-4220 for non-MAGI Medicaid applicants (Aged 65+, Blind, Disabled) (including for coverage of long-term care services), Medicare Savings Program, the Medicaid Buy-In Program fr Working People with Disabilities. The DOH-4220 - Access NY Health Care application can be used for all Medicaid benefits -- including for those who want to apply for coverage of Medicaid long-term care -- whether through home care or for those in a nursing home (with the addition of the Supplement Aform, described below). Applicants who only want a lasix dosaggio Medicare Savings Program (MSP) may continue to use the MSP-only application (and this is recommended).

Districts must also continue to accept the LDSS-2921, although it only makes sense to use this when someone is applying for both Medicaid and some other public benefit covered by the Common Application, such as the income benefits such as Safety Net Assistance. See this article for more about these different Medicaid categories, and these charts of the different rules for counting income and resources for the different categories. There are several other online resources relating to the new lasix dosaggio application - check here for changes English Spanish This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.Heads Up - Changes Coming April 2021 Once again, NYS is changing the way people without Medicare access prescription drugs. Since October 2011, most people who do not have Medicare obtained their drugs throug their Medicaid managed care plan. At that time, this drug benefit was "carved into" the Medicaid managed care benefit package.

Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a "fee for service" lasix dosaggio basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans. That means that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers. How Prescription Drugs are Obtained through Managed Care plans No - Until April 2020 lasix dosaggio HOW DO MANAGED CARE PLANS DEFINE THE PHARMACY BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies.

Under Medicaid managed care. Plan formularies will be comparable to but not the same as the Medicaid formulary lasix dosaggio. Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs. The Pharmacy Benefit will vary by plan lasix dosaggio.

Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan to plan. Prescriber Prevails applies lasix dosaggio in certain drug classes. Prescriber prevails applys to medically necessary precription drugs in the following classes. atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics.

Prescribers will need to demonstrate reasonable profession judgment and supply plans witht requested information and/or clinical documentation lasix dosaggio. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies. The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future. Standardized Prior Autorization (PA) Form -- The Department of Health worked with managed care plans, provider organizations and other lasix dosaggio state agencies to develop a standard prior authorization form for the pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013.

Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price. CAN CONSUMERS SWITCH PLANS IN ORDER TO lasix dosaggio GAIN ACCESS TO DRUGS?. Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care. Medicaid managed care enrollees can only leave and join another plan within the first 90 days of joining a health plan.

After the 90 days lasix dosaggio has expired, enrollees are “locked in” to the plan for the rest of the year. Consumers can switch plans during the “lock in” period only for good cause. The pharmacy benefit changes are not considered good cause. After the lasix dosaggio first 12 months of enrollment, Medicaid managed care enrollees can switch plans at any time. STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements.

If the plan still denies access, consumers can pursue review processes specific to managed care while at the same time pursuing a fair hearing. All plans are required to maintain an internal and external review process for lasix dosaggio complaints and appeals of service denials. Some plans may develop special procedures for drug denials. Information on these procedures should be provided in member handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend lasix dosaggio or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision.

An adverse decision is called a 'FInal Adverse Determination" or FAD. See model Denial FAD Notice and FAD Notice to Reduce, Suspend or Stop Services. The enroll has the right to request a fair hearing lasix dosaggio to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals. The plan may extend the time to decide both standard and expedited appeals by up to 14 days if more information is needed and it is in the enrollee's interest.

AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal lasix dosaggio and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time. See more about the changes in Managed Care appeals here. Even though that article is focused on Managed lasix dosaggio Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care. Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications.

Consumers who experience problems with access to prescription drugs should always file a complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE lasix dosaggio FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees. Certain drugs/drug categories require the prescribers to obtain prior authorization. These include brand name drugs that have a generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list. The lasix dosaggio full Medicaid formulary can be searched on the eMedNY website.

Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated. Prior authorization is required for original prescriptions, not refills. A prior authorization is effective for the original dispensing and up to five refills of lasix dosaggio that prescription within the next six months. Click here for more information on NY's prior authorization process. The New York State Board of Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities.

The State Department of Health collects retail price lasix dosaggio information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs. Click here to view New York State Medicaid’s Pharmacy Provider Manual. WHO YOU CAN CALL FOR HELP Community Health Advocates Hotline lasix dosaggio. 1-888-614-5400 NY State Department of Health's Managed Care Hotline.

1-800-206-8125 (Mon. - Fri lasix dosaggio. 8:30 am - 4:30 pm) NY State Department of Insurance. 1-800-400-8882 NY State Attorney General's Health Care Bureau. 1-800-771-7755.

Download the form at how to buy cheap lasix online this link (As of January 2021, the form was last updated in https://really-delicious.com/how-to-get-diflucan-otc/ March 2015). For those age 65+ or who are disabled or blind, a second form is also required - Supplement A - As of Jan. 2021 the same Supplement A form is used statewide - DOH-5178A (English). NYC how to buy cheap lasix online applicants should no longer use DOH-4220. See more information here about Jan.

2021 changes for NYC applicants regarding Supplement A. This supplement collects information about the how to buy cheap lasix online applicant's current resources and past resources (for nursing home coverage). Do not use the DOH-4220 application for Medicaid applicants in the MAGI category (generally those under age 65 or, if younger and disabled, not receiving Medicare). All MAGI applicants should go through the NYS Health Benefits Exchange to apply for Medicaid. They can contact how to buy cheap lasix online a Navigator or Community Health Advocates for assistance.

All local districts in New York State are required to accept the revised DOH-4220 for non-MAGI Medicaid applicants (Aged 65+, Blind, Disabled) (including for coverage of long-term care services), Medicare Savings Program, the Medicaid Buy-In Program fr Working People with Disabilities. The DOH-4220 - Access NY Health Care application can be used for all Medicaid benefits -- including for those who want to apply for coverage of Medicaid long-term care -- whether through home care or for those in a nursing home (with the addition of the Supplement Aform, described below). Applicants who only want how to buy cheap lasix online a Medicare Savings Program (MSP) may continue to use the MSP-only application (and this is recommended). Districts must also continue to accept the LDSS-2921, although it only makes sense to use this when someone is applying for both Medicaid and some other public benefit covered by the Common Application, such as the income benefits such as Safety Net Assistance. See this article for more about these different Medicaid categories, and these charts of the different rules for counting income and resources for the different categories.

There are several other online resources relating to the new application how to buy cheap lasix online - check here for changes English Spanish This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.Heads Up - Changes Coming April 2021 Once again, NYS is changing the way people without Medicare access prescription drugs. Since October 2011, most people who do not have Medicare obtained their drugs throug their Medicaid managed care plan. At that time, this drug benefit was "carved into" the Medicaid managed care benefit package. Before that date, people enrolled in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on how to buy cheap lasix online a "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans.

That means that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers. How Prescription Drugs are Obtained through Managed Care plans No - Until April 2020 HOW how to buy cheap lasix online DO MANAGED CARE PLANS DEFINE THE PHARMACY BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies. Under Medicaid managed care. Plan formularies will be how to buy cheap lasix online comparable to but not the same as the Medicaid formulary.

Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs. The Pharmacy Benefit will vary by plan how to buy cheap lasix online. Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan to plan.

Prescriber Prevails how to buy cheap lasix online applies in certain drug classes. Prescriber prevails applys to medically necessary precription drugs in the following classes. atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics. Prescribers will need to demonstrate reasonable profession how to buy cheap lasix online judgment and supply plans witht requested information and/or clinical documentation. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies.

The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future. Standardized Prior Autorization (PA) Form -- The Department of how to buy cheap lasix online Health worked with managed care plans, provider organizations and other state agencies to develop a standard prior authorization form for the pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013. Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price. CAN CONSUMERS SWITCH PLANS IN ORDER TO GAIN ACCESS TO DRUGS?.

Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed how to buy cheap lasix online to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care. Medicaid managed care enrollees can only leave and join another plan within the first 90 days of joining a health plan. After the 90 days has expired, enrollees are “locked in” to the how to buy cheap lasix online plan for the rest of the year. Consumers can switch plans during the “lock in” period only for good cause.

The pharmacy benefit changes are not considered good cause. After the first 12 months of enrollment, Medicaid managed how to buy cheap lasix online care enrollees can switch plans at any time. STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements. If the plan still denies access, consumers can pursue review processes specific to managed care while at the same time pursuing a fair hearing. All plans how to buy cheap lasix online are required to maintain an internal and external review process for complaints and appeals of service denials.

Some plans may develop special procedures for drug denials. Information on these procedures should be provided in member handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, how to buy cheap lasix online or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision. An adverse decision is called a 'FInal Adverse Determination" or FAD. See model Denial FAD Notice and FAD Notice to Reduce, Suspend or Stop Services.

The enroll has the right to request a fair how to buy cheap lasix online hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals. The plan may extend the time to decide both standard and expedited appeals by up to 14 days if more information is needed and it is in the enrollee's interest. AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the how to buy cheap lasix online right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time.

See more about the changes in Managed Care appeals here. Even though that article is focused on Managed Long how to buy cheap lasix online Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care. Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications. Consumers who experience problems with access to prescription drugs should always file a complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers how to buy cheap lasix online most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees.

Certain drugs/drug categories require the prescribers to obtain prior authorization. These include brand name drugs that have a generic alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list. The full Medicaid formulary can be searched on the how to buy cheap lasix online eMedNY website. Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated. Prior authorization is required for original prescriptions, not refills.

A prior authorization is effective for the original dispensing and up to five refills of how to buy cheap lasix online that prescription within the next six months. Click here for more information on NY's prior authorization process. The New York State Board of Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities. The State Department of Health collects retail price information on these how to buy cheap lasix online drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs.

Click here to view New York State Medicaid’s Pharmacy Provider Manual. WHO YOU how to buy cheap lasix online CAN CALL FOR HELP Community Health Advocates Hotline. 1-888-614-5400 NY State Department of Health's Managed Care Hotline. 1-800-206-8125 (Mon. - Fri.