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Credit. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia in this population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb.

Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition.

In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the two conditions remains unclear,” she says.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition. The other authors on this paper were Ginette A.

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

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

As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an . These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow.

Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear. To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types.

Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer. €œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

It’s one of those things that doesn’t sound right when you hear it,” says Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a renova, which seems to encourage a strong immune response despite the cancer’s lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs.

€œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says. Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

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MAYAGÜEZ, PUERTO RICO – Abigail Matos-Pagán llegó a una casa de color azul brillante en Mayagüez, renova care en donde la recibió Beatriz Gastón, quien en silencio la condujo a la pequeña habitación de su madre. Matos-Pagán llevaba una vacuna contra skin care products para Wildelma Gastón, de 88 años, quien está confinada en una cama por su artritis y otros problemas de salud. Wildelma Gastón pidió que le pusieran su rosario en el pecho y señaló su “brazo bueno”, donde Matos-Pagán renova care le inyectó la primera dosis de la vacuna de Moderna.

La familia Gastón, compuesta por cinco miembros, respiró con alivio. Aunque la vacuna estaba disponible desde hacía meses, Wildelma no había podido ir a un centro de vacunación. Según el rastreador de datos de skin care products de los Centros para renova care el Control y la Prevención de Enfermedades (CDC), la tasa de vacunación de Puerto Rico en marzo fue una de las más bajas entre los estados y territorios de Estados Unidos, a pesar de haber recibido más de 1,3 millones de dosis de vacunas.

El despliegue puso de manifiesto las disparidades en el acceso a los servicios médicos, y los retos que supone el seguimiento y la comunicación con ciudadanos que viven en lugares lejanos, como Wildelma. Cada vez que regresaban de la escuela o del trabajo, a los familiares les preocupaba la posibilidad de llevar el renova a su hogar, y la amenaza que suponía para la vida de Wildelma. Durante su visita, Matos-Pagán renova care también vacunó a dos de los hijos de Beatriz, que son estudiantes de la Universidad de Puerto Rico-Mayaqüez.

€œLlevamos mucho tiempo esperando este momento”, dijo Beatriz Gastón mientras se despedía con un abrazo de Matos-Pagán, expresando su gratitud por la visita a domicilio. Para ella la vacuna renova care es algo más que una protección contra el skin care. Le permite a la familia estar junto a su madre.

Para Matos-Pagán, es una nueva misión. La enfermera, que ha liderado tareas de ayuda tras los huracanes y terremotos en Puerto Rico y otros lugares, se ha propuesto vacunar al mayor renova care número posible de personas contra skin care products en este territorio estadounidense. Algunos residentes de Mayagüez, ciudad situada en la costa occidental de la isla principal, la llaman cariñosamente “La reina de la vacunación” y se presentan en su casa pidiendo ayuda para vacunarse.

Según el rastreador de casos de The New York Times, hasta el 5 de agosto, Puerto Rico suma cerca de 182,000 casos dSegún el rastreador de casos de The New York Times, hasta el 5 de agosto, Puerto Rico suma cerca de 182,000 casos de skin care products y 2,594 muertes. Algo más del 59% de la población está totalmente vacunada, pero muchos de los que no están vacunados son difíciles de renova care localizar porque viven en comunidades montañosas alejadas, o tienen enfermedades crónicas que les obligan a quedarse en casa. Hasta ahora, Matos-Pagán ha vacunado a unas 1,800 personas en Puerto Rico, incluidas 1,000 con enfermedades crónicas o postradas en cama.

En los primeros días de la pandemia, la salud de Carmen Blas empeoró y empezó a utilizar una silla de ruedas. Blas, de 78 años, estaba confinada en su casa, en el tercer piso de un edificio renova care de apartamentos, lo que la mantenía a salvo de contraer skin care products, pero más tarde no pudo encontrar transporte para ir a vacunarse. En junio, sus dos hijos, Lisette y Raymond, vinieron desde Wisconsin para ayudar y llamaron inmediatamente a funcionarios de salud pública para que Blas se vacunara.

€œSuelo volver todos renova care los años y esta ha sido la vez que más tiempo he estado fuera. Fue especialmente duro porque la salud de mi madre empeoró y me preocupaba no volver a verla”, contó Raymond, que pensaba prolongar su visita todo el tiempo que fuera necesario. Matos-Pagán fue a la casa de Blas, en Aguadilla, para administrarle la vacuna.

La familia renova care celebró con alegría la vacunación. €œHa sido muy especial tener momentos personales en la casa de alguien durante la vacunación. Se nota lo mucho que significa para toda la familia”, comentó Matos-Pagán.

La movilización durante una crisis no es algo nuevo para renova care Matos-Pagán. Tras el paso del huracán María, que cortó el agua y la electricidad en toda la isla y se cobró más de 3,000 vidas, Matos-Pagán llevó a cabo evaluaciones comunitarias iniciales en las ciudades más remotas y afectadas de Puerto Rico. Muchas carreteras eran inaccesibles debido a las inundaciones y a los escombros, lo que impedía a estas comunidades satisfacer necesidades básicas como alimentos, agua, recetas médicas y transporte.

Después, tras una serie de terremotos que sacudieron la isla en 2020, dejando a más personas sin vivienda o en estructuras deficientes, Matos-Pagán organizó a las enfermeras locales para que renova care prestaran atención sanitaria a la comunidad. Suministraron a las poblaciones en riesgo sus medicamentos cuando las farmacias cerraron y los equipos instalaron tiendas médicas móviles junto a hospitales que estaban saturados. €œSoy hiperactiva y estoy renova care siempre ocupada en mi vida diaria, pero cuando hay una crisis, estoy tranquila y calmada.

Con los pies en la tierra. Siento que estoy donde debo estar”, expresó. Matos-Pagán nació en Nueva renova care York.

Se interesó por la medicina después de ver cómo las enfermeras ayudaban a su madre, que murió por complicaciones de un aneurisma cuando Matos-Pagán tenía 9 años. La muerte de su madre le enseñó que “nada era permanente”, dijo, lo que la ha inspirado a actuar cuando ocurre un desastre y a apoyar a las personas ante la tragedia y la pérdida. Abigail Matos-Pagán le administra la vacuna contra renova care skin care products a Wildelma Gastón, en su casa de Mayagüez, en Puerto Rico.

Gastón está confinada en su cama por la artritis y otros problemas de salud. (Alicia Carter) Matos-Pagán regresó a Puerto Rico para estudiar enfermería y posteriormente obtuvo un máster y un doctorado en la Universidad de Puerto Rico-Mayagüez. Gracias a su trabajo, renova care ostenta varios títulos.

Primera comandante del Equipo de Respuesta a Desastres de Puerto Rico, y directora y fundadora de la Coalición de Enfermeras para Comunidades en Desastre. Su experiencia en la gestión de profesionales y recursos médicos durante los huracanes la ha llevado a lugares renova care de la costa atlántica estadounidense y del Caribe. Durante la pandemia de skin care products, fue contratada para ayudar a dirigir el triage (sistema para seleccionar a los pacientes prioritarios que llegan a urgencias) de una unidad de cuidados intensivos, escasa de recursos, en El Paso, Texas, y en una residencia de mayores muy afectada en Maryland.

€œNo todo el mundo está hecho para esto. Es un trabajo realmente triste y deprimente”, señaló Matos-Pagán renova care. €œPero incluso cuando hay miles de víctimas, se pueden salvar vidas y satisfacer las necesidades básicas de las personas.

He visto a las comunidades unirse de manera increíble. Es un reto, pero eso es lo que renova care me hace seguir adelante”. Y mientras trabaja para inyectar con rapidez más vacunas contra skin care products en los brazos de los residentes de Puerto Rico, Matos-Pagán se prepara para la próxima crisis.

La temporada de huracanes comenzó oficialmente en junio, y estará en alerta para otro posible desafío sanitario hasta finales de noviembre. Related Topics Contact Us renova care Submit a Story Tip[UPDATED at 6:15 p.m. ET] SACRAMENTO, Calif.

€” A proposal sailing through the California renova care legislature that aims to stop people from getting harassed outside of vaccination sites is raising alarms among some First Amendment experts. If it becomes law, SB 742 would make it punishable by up to six months in jail and/or a maximum fine of $1,000 to intimidate, threaten, harass or prevent people from getting a skin care products — or any other — treatment on their way to a vaccination site. The measure was introduced after protesters briefly shut down a mass vaccination clinic at Los Angeles’ Dodger Stadium in January.

Now that mass vaccination clinics have mostly folded renova care up, lawmakers worry that vaccination sites with less security than Dodger Stadium — like pharmacies and mobile clinics in parks or fast-food parking lots — are vulnerable. It’s a sign of how toxic the issue of vaccination has become in a state with a long history of intense and divisive treatment wars. State Sen.

Richard Pan (D-Sacramento), a pediatrician who administers treatments to his renova care patients, wrote the bill. He has been the target of anti-vaccination harassment since writing and championing laws that made it harder for parents to refuse routine treatments for their children by eliminating personal belief exemptions and tightening rules around medical ones. He was shoved by someone who opposed the medical exemption bill in 2019, the same year in which an anti-treatment protester threw menstrual blood onto the state Senate floor.

Pan was also among the lawmakers threatened at a committee hearing earlier this year renova care. Last month, Pan volunteered at a vaccination clinic at a Sacramento park that he said was disrupted by anti-treatment protesters with a bullhorn who made it hard for medical personnel to converse with patients and answer their questions. And while he said renova care he can handle threats, ordinary citizens “shouldn’t have to run a gauntlet to get vaccinated.” That includes walking through a group likely made up of unvaccinated protesters and possibly getting exposed to skin care products to get protected, he said.

His measure prohibits obstructing, injuring, harassing, intimidating or interfering with people “in connection with any vaccination services.” The bill passed the state Senate with just four no votes and faces one more committee hurdle before it heads to the Assembly floor. The bill defines harassment as getting within 30 feet of someone to hand them a leaflet, display a sign, participate in any kind of verbal protesting like singing or chanting, or conduct any education or counseling with that person. Blocking someone or impeding them from getting a treatment is an obvious problem, and it’s good that the proposal would try to stop that, said Glen Smith, litigation renova care director for the First Amendment Coalition, a California-based nonprofit that promotes the First Amendment, which guarantees rights such as free speech and assembly.

But he thinks the proposal goes too far with its definition of harassment. €œTo say you can’t get within 30 feet of them just to hand them a pamphlet or ask them a question?. That seems to be overkill for me,” Smith renova care said.

It’s worse than overkill, said Eugene Volokh, a professor of First Amendment law at the UCLA School of Law. €œThat law is clearly unconstitutional,” Volokh said. He has two primary renova care concerns with the proposal.

First, though it’s modeled on similar laws that create zones around abortion clinics to protect patients from harassment, this bill goes beyond what courts have upheld in the past, he said. In 2000, the renova care U.S. Supreme Court upheld a Colorado law that created an 8-foot “bubble zone” around a person entering or exiting an abortion clinic, but in 2014 the high court struck down a Massachusetts law that created a 35-foot “buffer zone” around clinics.

A 30-foot zone around a person getting a treatment is bigger than the court would allow, Volokh believes. His second concern is that the bill specifically prohibits someone from leafletting or talking to someone only renova care about treatments. That violates the First Amendment, Volokh said, because it targets certain content.

Someone could hand out an anti-war or anti-fur leaflet and not run afoul of the law, he said. €œI think it’s pretty shocking renova care that a state legislature would try to enact this kind of restriction on fully protected speech this way,” Volokh said. The Right to Life League, which has opposed the measure from the start, advocated to get “in connection with vaccination services” added to the bill language.

Once the bill was amended to include that phrase, that limited “the negative impact of the bill on pro-life activities,” like anti-abortion sidewalk counseling outside Planned Parenthood clinics, which provide abortions and treatments, Elisabeth Beall, media coordinator for the Right to Life League, wrote in a statement. The group still renova care believes the bill is unconstitutional. Not all free speech advocates share Volokh’s interpretation of the bill.

The American Civil Liberties renova care Union said it has no issues with it as written. €œIt’s not necessarily the case that the freedom to express our views is unrestricted,” said Kevin Baker, director of governmental relations at ACLU California Action. €œThey can be balanced with important governmental objectives” like letting people get vaccinated in peace.

Part of renova care that objective is stopping disinformation about treatments, which Pan said is the primary reason people are not getting the shots. €œFrankly, any gains we make to try to get more people vaccinated are going to be incremental because of disinformation,” Pan said. And when protesters show up claiming they’re there to educate patients, “they’re talking about disinformation.” Joshua Coleman, co-founder of the group V is for treatment, which advocates for informed consent before vaccinations and says treatments carry risk, said he brought the bullhorn to Pan’s clinic to “educate those coming to receive the treatment on important facts they deserve to know” and object to Pan’s bill.

€œThe intent in attending Senator Pan’s vaccination clinic was to protest the censorship of important information and his egregious and renova care erroneous attack on free speech,” he said via email. Pan said his bill was “carefully crafted” to stop the “obstruction, harassment and intimidation” of people seeking treatments, and is confident that it is well within the bounds of the First Amendment. €œThere’s precedent for saying you can protest.

This law doesn’t say you can’t renova care protest. There’s certain rules around the protest,” Pan said. €œEspecially as we’re trying to deal with this renova, we need to do what we can to be sure people feel safe getting themselves vaccinated.” This story was produced by KHN, which publishes California Healthline, an editorially independent service renova care of the California Health Care Foundation.

[Correction. This article was revised at 6:15 p.m. ET on Aug renova care.

9, 2021, to correct the Right to Life League’s position on SB 742. A previous version of the story implied the group had changed its stance to support the bill, but it still opposes it.] Rachel Bluth. rbluth@kff.org, @RachelHBluth Related Topics Contact renova care Us Submit a Story TipCristina Martinez’s spinal operation in Houston was expected to be routine.

But after destabilizing her spine, the surgeon discovered the implant he was ready to put in her back was larger than he wanted to use — and the device company’s sales rep didn’t have a smaller size on hand, according to a report he filed about the operation. Dr. Ra’Kerry Rahman went ahead with renova care the operation, and Martinez awoke feeling pain and some numbness, she alleges.

When Rahman removed the plastic device four days later and replaced it with a smaller one, Martinez suffered nerve damage and loss of feeling in her left leg, she claims. Martinez is suing the surgeon, implant maker Life Spine Inc., and its distributor and sales representatives, alleging their negligence led to her injuries because the right part renova care wasn’t available during her first surgery. All deny wrongdoing.

The case is set for trial in November. The lawsuit takes aim at the bustling sales networks that orthopedic device manufacturers have renova care built to market ever-growing lines of costly surgical hardware — from spinal implants to replacement knees and artificial hips commonly used in operations. Sales in 2019 topped $20 billion, though skin care products forced many hospitals to suspend elective surgeries for much of last year.

Device makers train sales reps to offer surgeons technical guidance in the operating room on the use of their products. They pay prominent surgeons to tout their implants at medical conferences — and athletes to offer celebrity renova care endorsements. The industry says these practices help ensure that patients receive the highest-quality care.

But a KHN investigation found these practices also have been blamed for contributing to serious patient harm in thousands of medical malpractice, product liability and whistleblower lawsuits filed over the past decade. Some patients allege they were injured after sales reps sold or delivered wrong-size or defective implants, while others accuse device makers renova care of misleading doctors about the safety and durability of their products. Six multi-district federal cases have consolidated more than 28,000 suits by patients seeking compensation for injuries involving hip implants, including painful redo operations.

In other court renova care actions, patients and whistleblowers repeatedly have accused device companies of failing to report injury-causing defects to federal regulators as required — or of doling out millions of dollars in illegal kickbacks to surgeons who agreed to use their products. Device makers have denied the allegations and many such cases are settled under confidential terms. At least 250 companies sell surgical hardware, and many more distribute it to doctors and hospitals across the country.

Spine companies renova care alone obtained more than 1,200 patents for devices in 2018, according to an industry report. Many come to market through a streamlined Food and Drug Administration process that approves their use because they are essentially the same as what is already being sold. €œIn orthopedics, we are inundated with a multitude of new implants that debut each year,” Dr.

James Kang, chairman of the orthopedic surgery department at Brigham and Women’s Hospital, remarked at renova care a Harvard Medical School roundtable discussion published in 2019. Dr. James Kang, chairman of the orthopedic surgery department at Brigham and Women’s Hospital, discusses hip-spine syndrome in a 2016 YouTube video.

(Screenshot from YouTube) Kang said surgeons often rely on industry “reps” in the operating room renova care for guidance because it is “usually burdensome and difficult” for surgeons to know “all of the intricate details and nuances” of so many products. Martinez’s lawsuit says the process went awry during her May 2018 spinal fusion in Houston, an operation in which an implant is inserted into the spinal column to replace a worn or damaged disc. Martinez was under anesthesia, with her spine destabilized, when Rahman discovered the Life Spine surgical kit did not renova care contain any implants shorter than 50 millimeters, or about 2 inches.

That was too large, according to the complaint. Martinez, a former day care worker, blames her injuries on the redo operation, which replaced the implant with a 40 mm version Life Spine supplied later. Through his lawyer, Rahman declined to renova care comment.

In court filings, the surgeon has denied responsibility. His operating notes, according to court pleadings, say he had ordered “all lengths available” of the implant through a Life Spine distributor and its sales reps. In a June court filing, Rahman contends the “small area of renova care leg numbness experienced by Ms.

Martinez was a known complication of the first surgery … and was not the result of any alleged negligence.” In the court filing, Rahman also argues it was “appropriate” for him to rely on the sales reps and hospital staff to “inform him as to whether all materials and equipment needed for surgery were available.” Illinois-based Life Spine also denies blame. In court filings, it says the sales reps initially ordered a sterile kit that included only implants from 50 mm to 55 mm long, which it duly shipped to Houston. At the time of Martinez’s operation, Life Spine was the target of a sealed whistleblower lawsuit accusing it of paying improper consulting fees and other kickbacks to more than 60 surgeons who renova care agreed to use its wares.

Court records in the whistleblower case identify Rahman as one of the company’s paid consultants, although he and the other surgeons were not named as defendants. Life Spine and two of its executives settled the matter in November 2019 by paying a total of nearly $6 renova care million. An orthopedic surgery expert hired by Martinez for her suit faulted Rahman for not making sure he had the right gear “prior to the start of surgery,” according to his report.

The expert also criticized the sales rep for failing to bring “all available lengths to the procedure or to inform Dr. Rahman that the necessary implants renova care were not available,” court records show. The sales rep and distributor denied any blame, arguing in court filings that they “met all applicable standards of care.” Frenzied Competition for Sales Major device makers train a corps of sales agents, some recruited right out of college, to cultivate and work closely with surgeons — one likened the relationship to a caddy and an avid golfer.

Duties can include lugging 20-pound sets of surgical hardware to the operating room, assuring it is sterile and knowing its specifications, though the reps are not required to have medical training or credentials. Stryker, one of the nation’s top four spine implant manufacturers, spends what it calls “a significant amount of time renova care and money” to train reps. When hired, they typically “shadow” other reps for three to six months, then attend a 10-day intensive “Spine School” and other training.

In all, the company said in a court filing, it typically takes eight to 18 months, often longer, to develop “long-term relationships” with customers. For those renova care who do, the jobs can pay handsomely. Veteran reps who influence which brands of hardware surgeons select command salaries and bonuses that can stretch into the low six figures and beyond, court records show.

The market is so hotly competitive that device makers typically require reps to sign contracts that prohibit them from working for a rival company in the same territory for a year or more — and aren’t shy about suing to fend off raids on their renova care staffs, court records show. In 2019, DePuy Synthes sued an Alabama sales rep who jumped ship, blaming him for stealing away accounts “worth millions of dollars practically overnight.” An arm of health care giant Johnson &. Johnson, DePuy Synthes filed at least two dozen similar suits from 2014 through the end of 2020, court records show.

Most, including the case of the Alabama sales rep, have renova care been settled under confidential terms. Some companies have spent lavishly to poach experienced sales agents — practices that can violate business conduct laws. One allegedly paid a New York sales pro a “staggering, seven-figure signing bonus.” Another is said to have dangled an $800,000-a-year job as “director of surgeon education,” while a gambit to make inroads in the Phoenix market dubbed “Sun Devil” guaranteed a branch manager a $500,000 annual salary, court records show.

Another promised a sales agent $900,000 renova care paid out over three years. Whistleblowers and government investigators have argued for years that so much money changing hands can lead to kickbacks or other marketing schemes that corrupt medical judgment and endanger patients. Some injury suits also have blamed sales reps and distributors for staying mum about product renova care deficiencies they observed in the operating room.

These cases often are settled with no admission of wrongdoing. Sometimes, surgeons help promote implants at medical meetings and other gatherings. Orthopedic surgeons and neurosurgeons received a total of about $511 million in industry consulting fees from 2013 through 2019 and renova care nearly $300 million more for “serving as faculty or speaker” at industry-sponsored events, a KHN analysis of government data found.

AdvaMed, the device industry’s trade group, says doctors often take “primary responsibility” for training other doctors to use new devices. €œUnlike a pill or injection, procedures to implant or equip medical devices for patients can be extremely technical and complex,” said Scott Whitaker, the group’s president and CEO. A court exhibit shows two screws that a Georgia man alleged broke apart about renova care two years after his spinal operation.

The 2013 lawsuit has since been settled. (U.S. District Court renova care filing) Some prominent surgeons who touted products that later were recalled, or who helped train surgeons to use implants, have been criticized in pending injury lawsuits.

One is Dr. Brad Penenberg, an orthopedic surgeon in Beverly Hills, California, paid by Wright Medical Technology as a “key renova care opinion leader,” according to court filings. Multiple lawsuits cite a webinar for orthopedic surgeons that featured Penenberg and said hip surgery patients could resume “activities and lifestyles that include such things as tennis, horseback riding and snow skiing.” Injured patients are arguing in court filings that Penenberg and several other experts paid by the company knew of significant failures of the hip device.

Penenberg did not respond to numerous requests for comment but in court papers denied the allegations. Hundreds of patients are claiming injuries they blame at least partly on overly renova care aggressive marketing by Wright Medical. In one 2020 lawsuit, a Montana man who had received a hip implant said he was taking a walk while in Arizona on vacation when he “felt a severe jolt in his groin and fell.” He was out of cell range and could not get up or call for help.

A “good Samaritan” called for an ambulance, which took him to a hospital in Gilbert, Arizona, where X-rays showed a fracture of the implant. It was removed and renova care replaced. Wright Medical has denied the allegations.

In 1984, Mary Lou Retton won an individual all-around Olympic gold medal in gymnastics, the first American woman to do so. (David Madison / Getty Images) Retired California psychologist Herb Glazeroff is suing Penenberg and Wright Medical renova care Technology over a hip replacement that allegedly failed about five years after the surgeon installed it. In May 2019, Glazeroff was walking when he “suddenly dropped to his knees as his left leg gave out on him,” according to the suit.

He alleges that the hip had fractured, which required a painful second operation and “a long and arduous rehabilitation program” from which he has “yet to fully recover.” Glazeroff argues renova care that Penenberg failed to warn him about the implant’s dangers even though the surgeon had been named in “multiple lawsuits” alleging device defects. Penenberg has denied the allegations. Dozens of lawsuits have taken aim at Indiana device maker Biomet’s advertising a hip replacement for “younger, more active patients” that showcased Olympic gold medal gymnast Mary Lou Retton.

One ad says “Mary Lou lives pain-free, and so should you.” Yet Retton suffered painful heavy-metal poisoning renova care requiring the implant’s removal and sued the company for damages, according to court records. In a January 2020 court filing in Houston, Retton tried to block a subpoena seeking her deposition in a product liability lawsuit filed against Biomet by two patients in King County, Washington. The Washington case has since been settled and the deposition did not occur.

But in a court filing opposing the subpoena, Retton confirmed she had a Biomet implant put in her left hip in 2005 and one on her right side about six renova care years later. She said she promoted Biomet products from April 2006 through April 2013 and sued the company in January 2018, alleging the implants were defective. Retton said she and Biomet settled the suit in early 2019 “under confidential terms the parties find favorable to their respective positions.

[Ms. Retton] values her long relationship with Biomet and her continued use of her [Biomet hip implants] and [Biomet] appreciates the support it has received over the years from [Ms. Retton].” In 2011, Olympic gymnastics gold medalist Mary Lou Retton shared patient testimony for device company Biomet and her orthopedic surgeon.

(Screenshot from YouTube) Defects Ignored, Downplayed Whether touted by renowned surgeons or celebrities, orthopedic surgery marketing materials stress quick improvement in a person’s quality of life. That proves true for most patients. Yet researching how often implants fail or cause life-changing injuries — and which brands have the best safety records — can be daunting.

The FDA requires device makers to advise the agency of information “that reasonably suggests” a device they sell “may have caused or contributed to a death or serious injury or has malfunctioned” in a way that could recur. The FDA posts the reports on a public website, with the caveat that they may convey “incomplete, inaccurate, untimely, unverified, or biased data.” KHN found that thousands of malpractice and product liability lawsuits have accused device marketers of concealing or downplaying hardware defects, leaving patients and their doctors in the dark about possible risks. In many cases, these claims are bolstered by company records, or actions by state or federal regulators.

In 2019, for instance, DePuy Synthes paid $120 million to settle a lawsuit filed by 46 state attorneys general. The suit accused the company of advertising that a replacement hip it sold lasted three years in 99.2% of operations, when it knew of data showing that 7% had failed within that time. The company did not admit wrongdoing in settling the case.

British device company Smith &. Nephew faces a federal civil proceeding comprising nearly 1,000 injury suits, including one that says the company “underreported and withheld” notices of malfunctions and “willfully ignored the existence of numerous complaints about [its] failures.” An expert hired by the patients cites a company audit showing “significant adverse events” were logged from two days to 142 days late, while a corporate memo circulated among executives to push sales was titled “Milk the Cash Cow,” according to court records. Smith &.

Nephew has denied the allegations and in one court paper called the expert’s opinions “speculative.” A cluster of Florida injury cases pertaining to a knee implant from German manufacturer Aesculap alleges that the FDA cited the company for failing to report 25 adverse incidents — in some cases for a year or more — as a result of an inspection at its Hazelwood, Missouri, plant in September 2015. Aesculap has denied the allegations and the suits are pending in Florida’s Indian River County Circuit Court. John Saltis is suing spinal device company NuVasive over its handling of his complaint that a screw holding his spinal implant in place snapped in May 2016, about 17 months after his operation.

Saltis, 68, was two hours into his workday as a toolmaker at General Electric in Rutland, Vermont, when he felt sharp pain in his neck and shoulder, bad enough to send him to the hospital emergency room. A few days later, X-rays revealed the screw had broken and, according to Saltis, fractured vertebrae in the process. Saltis said the San Diego-based device company told the FDA the incident caused no harm.

But Saltis said he has lingering numbness and pain in his right hand. As a result, he said, his lifestyle has “changed dramatically.” He sold his motorcycle and stopped biking and now relies on his left hand for simple tasks like opening doors and shaking hands — even plucking chips out of a bag. €œI miss things like bowling and playing toss with my grandkids,” he said.

A few days after feeling a sharp pain in his neck and shoulder, X-rays revealed the screw holding John Saltis’ spinal implant had broken and, Saltis says, fractured vertebrae in the process. (Hans Pennink for KHN) “I was pain-free for a few months and would have stayed that way if the screw hadn’t broken,” he says. €œThis can change somebody’s life completely.” (Hans Pennink for KHN) In 2019, Saltis sued NuVasive without a lawyer, hoping to show the $600 screw was defective.

In a court filing, NuVasive said Saltis is arguing “the screw is defective because it broke.” That’s not good enough, according to NuVasive, which argues that Saltis must show the screw was “unreasonably dangerous” to press his claim. In late June, a federal judge agreed and dismissed the suit, though she allowed Saltis to amend his complaint, which he is pursuing. The case is pending.

€œI was pain-free for a few months and would have stayed that way if the screw hadn’t broken,” Saltis said. €œThis can change somebody’s life completely.” A Push for Change as renova Eases As hospitals resume elective operations stalled by the skin care, some industry critics see an opportunity to rethink orthopedic surgery practices — from sales to tracking of injuries. Some want to keep industry reps out of operating rooms and place tighter restrictions on their access to hospitals.

They say the current system needlessly drives up health care costs and exposes patients to risks such as from extra people in the operating room. Reps counter that their incomes have been dropping due to global purchasing arrangements that give hospitals greater say over prices for surgical equipment. Sales reps say their technical knowledge and skills make operations safer for patients and note that many surgeons enjoy the security of having them present in the operating room.

Reps also say they perform tasks that hospitals would need to hire additional personnel to do, such as keeping track of device inventories. €œThe industry has embedded reps into the supply chain, and it is a hard culture to break,” said Itai Nemovicher, president of the Orthopaedic Implant Co., which seeks to produce lower-cost implants. Yet guidelines for “reentry” after skin care products put out by AdvaMed and the American Hospital Association say medical device reps should deliver “services, information and support remotely whenever possible.” The guidelines advise hospitals to use videoconferencing gear when it “does not compromise patient safety or privacy.” Dr.

Adriane Fugh-Berman, a professor of pharmacology and physiology at Georgetown University, said device reps are viewed as part of the operating room team even though they are there “to sell products. That is pretty horrifying from a patient’s point of view.” She said hospitals should train staff to perform these functions. €œRelying on sales reps in the OR is appalling.

We need to come up with a better system.” Greater transparency might have helped Little Rock, Arkansas, resident Christopher Paul Bills. He sued Consensus Orthopedics, the maker of a hip implant system that he alleged failed and sent metal through his hip joint that his surgeon said in 2016 looked “as if a bomb had gone off.” An Australian registry that tracks outcomes of operations had in September 2014 identified the implant as having a “higher number” of hip failures compared with other manufacturers, according to the suit. Bills underwent four operations and spent more than a year in the hospital and in rehabilitation, costs borne by Medicare and private insurance.

€œMr. Bills was left with no right hip at all and his surgeon does not plan to install a replacement hip,” the suit says. Bills uses an electric scooter to get around and hopes to graduate to hand-held crutches.

€œSince his right leg is useless, he will require a vehicle with hand-controls to drive,” according to the suit. The company disputed Bills’ claims and denied its hip system had any defects. The case ended in 2019 when Bills died of cancer unrelated to his operations, said his lawyer, Joseph Saunders.

€œHe never did get justice,” Saunders said. Fred Schulte. fschulte@kff.org, @fredschulte Related Topics Contact Us Submit a Story TipMAYAGÜEZ, PUERTO RICO — Abigail Matos-Pagán entered a bright-blue house in Mayagüez earlier this summer and was met by Beatriz Gastón, who quietly led the way to her mother’s small room.

Matos-Pagán had come to provide a skin care products treatment for Wildelma Gastón, 88, whose arthritis and other health concerns confine her to bed. Wildelma Gastón asked for her rosary to be placed on her chest and motioned to her “good arm,” where Matos-Pagán injected a first dose of the Moderna treatment. The Gastón household, made up of five family members, breathed a collective sigh of relief.

Though the treatment had been available for months, Wildelma had been unable to reach a vaccination site. According to the Centers for Disease Control and Prevention’s skin care products Data Tracker, Puerto Rico’s vaccination rate in March was one of the lowest among U.S. States and territories despite receiving more than 1.3 million treatment doses.

The rollout highlighted disparities in access to medical services, and the challenges of tracking and reaching remote citizens, such as Wildelma. With each trip to school or work, family members worried about bringing the renova into their home and the threat to Wildelma’s life. Matos-Pagán also vaccinated two of Beatriz’s children, who are students at the University of Puerto Rico-Mayaqüez, during her visit.

€œWe have been waiting a long time for this moment,” Beatriz Gastón said as she hugged Matos-Pagán goodbye, expressing gratitude for the home visit. To her, the treatment is more than protection from the skin care — it clears the way for the family to be together with her mother. To Matos-Pagán, it is her latest calling.

The nurse practitioner, who has guided relief efforts after hurricanes and earthquakes in Puerto Rico and elsewhere, has made it her mission in the U.S. Territory to vaccinate as many people as possible against skin care products. Some residents of Mayagüez, a city on the western shore of the main island, candidly call her “The Vaccination Queen” and show up at her home asking for help in getting a shot.

According to The New York Times’ case tracker, as of Friday, Puerto Rico has had more than 182,000 skin care products cases and at least 2,594 deaths. About 57% of the population is fully vaccinated, but many of the unvaccinated are hard to reach because they live in remote mountainous communities or have chronic illnesses that leave them homebound. Matos-Pagán has vaccinated around 1,800 people in Puerto Rico so far, including 1,000 who have chronic illnesses or are bedridden.

In the renova’s early days, Carmen Blas’ health declined, and she began using a wheelchair. Blas, 78, was confined to her home, on the third story of an apartment building, which kept her safe from contracting skin care products, but later she couldn’t find transportation to a vaccination site. In June, her two children, Lisette and Raymond, visited from Wisconsin to help and immediately called the public health officials to get Blas inoculated.

€œI usually come back every year and this was the longest I’ve ever been away. It was especially hard as my mother’s health worsened, and I worried I might never see her again,” said Raymond, who planned to extend his visit for as long as he was needed. Matos-Pagán came to Blas’ home in Aguadilla, Puerto Rico, to give her the treatment.

The family cheered the moment the vaccination was over. €œIt’s been really special to have intimate moments in someone’s home during vaccinations. You can tell how much it means to their entire family,” Matos-Pagán said afterward.

Mobilizing during a crisis is nothing new for Matos-Pagán. In the aftermath of Hurricane Maria, which cut off water and electricity to the entire island and claimed more than 3,000 lives, Matos-Pagán conducted initial community assessments in Puerto Rico’s remotest and hardest-hit cities. Flooding and debris made many roads inaccessible, blocking these communities from basic needs such as food, water, prescription medications and transportation.

Then, after a series of earthquakes in 2020 rocked the island, leaving even more people without housing or in substandard structures, Matos-Pagán organized local nurse practitioners to provide community health care. They supplied at-risk populations with their medicines when pharmacies closed, and teams set up mobile medical tents near overcrowded hospitals. €œI’m hyper and busy in my daily life, but when there is a crisis, I am calm and still.

Grounded. I feel like I’m where I belong,” she said. Abigail Matos-Pagán gives Wildelma Gastón a skin care products treatment at her home in Mayagüez, Puerto Rico.

Gastón is confined to bed because of arthritis and other health problems.(Alicia Carter) Matos-Pagán was born in New York City. She became interested in medicine after watching nurses support her mother, who died of complications from an aneurysm when Matos-Pagán was 9. Her mother’s death taught her “nothing was permanent,” she said, which has inspired her to act when disaster strikes and support people through personal tragedy and loss.

Matos-Pagán returned to Puerto Rico to study nursing and later earned a master’s degree and a doctorate at the University of Puerto Rico-Mayagüez. Through her work, she holds various titles. First commander of the Puerto Rican Disaster Response Team, and director and founder of the Coalition of Nurses for Communities in Disaster.

Her experiences managing medical professionals and resources during hurricanes have taken her to locations across the U.S. Atlantic coast and the Caribbean. During the skin care products renova, she was recruited to assist in triage leadership for an ICU floor short on resources in El Paso, Texas, and a hard-hit senior living facility in Maryland.

€œNot everyone is built for this. It’s really sad, depressing work,” Matos-Pagán said. €œBut even when there are mass casualties, you can still save lives and get people’s basic needs met.

I’ve seen communities come together in the most incredible ways. It’s a challenge, but that’s what keeps me going.” And, even as she is rapidly trying to get more skin care products shots into the arms of Puerto Ricans, Matos-Pagán is preparing for the next crisis. Hurricane season officially began in June, and she will be on disaster-ready duty until the end of November.

Related Topics Contact Us Submit a Story TipKHN freelancer Mark Kreidler discussed why professional athletes are not taking a more affirmative role in pushing skin care products treatments on Newsy on Tuesday. KHN Midwest correspondent Cara Anthony discussed masking mandates, treatment efficacy and breakthrough skin care products cases on Illinois Public Media’s “The 21st Show” on Monday. KHN chief Washington correspondent Julie Rovner discussed the recent surge in skin care products cases on Axios’ “Axios Today” podcast and WAMU/NPR’s “1A” on Monday and July 30, respectively.

KHN Montana correspondent Katheryn Houghton explored the phenomenon of folks visiting radon mines in Montana as a treatment for various ills on “Voices of Montana” on July 30. Related Topics Contact Us Submit a Story Tip.

MAYAGÜEZ, PUERTO RICO – Abigail Matos-Pagán llegó a una casa de color azul brillante en Mayagüez, en donde la recibió Beatriz Gastón, quien where can i buy renova over the counter en silencio la condujo a la pequeña habitación de su madre. Matos-Pagán llevaba una vacuna contra skin care products para Wildelma Gastón, de 88 años, quien está confinada en una cama por su artritis y otros problemas de salud. Wildelma Gastón pidió where can i buy renova over the counter que le pusieran su rosario en el pecho y señaló su “brazo bueno”, donde Matos-Pagán le inyectó la primera dosis de la vacuna de Moderna. La familia Gastón, compuesta por cinco miembros, respiró con alivio.

Aunque la vacuna estaba disponible desde hacía meses, Wildelma no había podido ir a un centro de vacunación. Según el rastreador de datos de skin care products de los Centros para el Control y la Prevención de Enfermedades (CDC), la tasa de vacunación de Puerto Rico en marzo where can i buy renova over the counter fue una de las más bajas entre los estados y territorios de Estados Unidos, a pesar de haber recibido más de 1,3 millones de dosis de vacunas. El despliegue puso de manifiesto las disparidades en el acceso a los servicios médicos, y los retos que supone el seguimiento y la comunicación con ciudadanos que viven en lugares lejanos, como Wildelma. Cada vez que regresaban de la escuela o del trabajo, a los familiares les preocupaba la posibilidad de llevar el renova a su hogar, y la amenaza que suponía para la vida de Wildelma.

Durante su visita, Matos-Pagán where can i buy renova over the counter también vacunó a dos de los hijos de Beatriz, que son estudiantes de la Universidad de Puerto Rico-Mayaqüez. €œLlevamos mucho tiempo esperando este momento”, dijo Beatriz Gastón mientras se despedía con un abrazo de Matos-Pagán, expresando su gratitud por la visita a domicilio. Para ella la vacuna es algo más que una protección contra where can i buy renova over the counter el skin care. Le permite a la familia estar junto a su madre.

Para Matos-Pagán, es una nueva misión. La enfermera, que ha liderado tareas where can i buy renova over the counter de ayuda tras los huracanes y terremotos en Puerto Rico y otros lugares, se ha propuesto vacunar al mayor número posible de personas contra skin care products en este territorio estadounidense. Algunos residentes de Mayagüez, ciudad situada en la costa occidental de la isla principal, la llaman cariñosamente “La reina de la vacunación” y se presentan en su casa pidiendo ayuda para vacunarse. Según el rastreador de casos de The New York Times, hasta el 5 de agosto, Puerto Rico suma cerca de 182,000 casos dSegún el rastreador de casos de The New York Times, hasta el 5 de agosto, Puerto Rico suma cerca de 182,000 casos de skin care products y 2,594 muertes.

Algo más del 59% de la población está totalmente vacunada, pero muchos de los que no están vacunados son difíciles where can i buy renova over the counter de localizar porque viven en comunidades montañosas alejadas, o tienen enfermedades crónicas que les obligan a quedarse en casa. Hasta ahora, Matos-Pagán ha vacunado a unas 1,800 personas en Puerto Rico, incluidas 1,000 con enfermedades crónicas o postradas en cama. En los primeros días de la pandemia, la salud de Carmen Blas empeoró y empezó a utilizar una silla de ruedas. Blas, de where can i buy renova over the counter 78 años, estaba confinada en su casa, en el tercer piso de un edificio de apartamentos, lo que la mantenía a salvo de contraer skin care products, pero más tarde no pudo encontrar transporte para ir a vacunarse.

En junio, sus dos hijos, Lisette y Raymond, vinieron desde Wisconsin para ayudar y llamaron inmediatamente a funcionarios de salud pública para que Blas se vacunara. €œSuelo volver todos los años y esta ha sido la vez que where can i buy renova over the counter más tiempo he estado fuera. Fue especialmente duro porque la salud de mi madre empeoró y me preocupaba no volver a verla”, contó Raymond, que pensaba prolongar su visita todo el tiempo que fuera necesario. Matos-Pagán fue a la casa de Blas, en Aguadilla, para administrarle la vacuna.

La familia where can i buy renova over the counter celebró con alegría la vacunación. €œHa sido muy especial tener momentos personales en la casa de alguien durante la vacunación. Se nota lo mucho que significa para toda la familia”, comentó Matos-Pagán. La movilización durante una crisis no es algo nuevo para where can i buy renova over the counter Matos-Pagán.

Tras el paso del huracán María, que cortó el agua y la electricidad en toda la isla y se cobró más de 3,000 vidas, Matos-Pagán llevó a cabo evaluaciones comunitarias iniciales en las ciudades más remotas y afectadas de Puerto Rico. Muchas carreteras eran inaccesibles debido a las inundaciones y a los escombros, lo que impedía a estas comunidades satisfacer necesidades básicas como alimentos, agua, recetas médicas y transporte. Después, tras una serie de terremotos que where can i buy renova over the counter sacudieron la isla en 2020, dejando a más personas sin vivienda o en estructuras deficientes, Matos-Pagán organizó a las enfermeras locales para que prestaran atención sanitaria a la comunidad. Suministraron a las poblaciones en riesgo sus medicamentos cuando las farmacias cerraron y los equipos instalaron tiendas médicas móviles junto a hospitales que estaban saturados.

€œSoy hiperactiva y estoy siempre ocupada en mi vida diaria, where can i buy renova over the counter pero cuando hay una crisis, estoy tranquila y calmada. Con los pies en la tierra. Siento que estoy donde debo estar”, expresó. Matos-Pagán nació en Nueva York where can i buy renova over the counter.

Se interesó por la medicina después de ver cómo las enfermeras ayudaban a su madre, que murió por complicaciones de un aneurisma cuando Matos-Pagán tenía 9 años. La muerte de su madre le enseñó que “nada era permanente”, dijo, lo que la ha inspirado a actuar cuando ocurre un desastre y a apoyar a las personas ante la tragedia y la pérdida. Abigail Matos-Pagán le administra la vacuna contra skin care products a Wildelma where can i buy renova over the counter Gastón, en su casa de Mayagüez, en Puerto Rico. Gastón está confinada en su cama por la artritis y otros problemas de salud.

(Alicia Carter) Matos-Pagán regresó a Puerto Rico para estudiar enfermería y posteriormente obtuvo un máster y un doctorado en la Universidad de Puerto Rico-Mayagüez. Gracias a su trabajo, where can i buy renova over the counter ostenta varios títulos. Primera comandante del Equipo de Respuesta a Desastres de Puerto Rico, y directora y fundadora de la Coalición de Enfermeras para Comunidades en Desastre. Su experiencia en la gestión de profesionales y recursos médicos durante los huracanes la ha llevado a lugares where can i buy renova over the counter de la costa atlántica estadounidense y del Caribe.

Durante la pandemia de skin care products, fue contratada para ayudar a dirigir el triage (sistema para seleccionar a los pacientes prioritarios que llegan a urgencias) de una unidad de cuidados intensivos, escasa de recursos, en El Paso, Texas, y en una residencia de mayores muy afectada en Maryland. €œNo todo el mundo está hecho para esto. Es un where can i buy renova over the counter trabajo realmente triste y deprimente”, señaló Matos-Pagán. €œPero incluso cuando hay miles de víctimas, se pueden salvar vidas y satisfacer las necesidades básicas de las personas.

He visto a las comunidades unirse de manera increíble. Es un reto, pero eso es where can i buy renova over the counter lo que me hace seguir adelante”. Y mientras trabaja para inyectar con rapidez más vacunas contra skin care products en los brazos de los residentes de Puerto Rico, Matos-Pagán se prepara para la próxima crisis. La temporada de huracanes comenzó oficialmente en junio, y estará en alerta para otro posible desafío sanitario hasta finales de noviembre.

Related Topics Contact Us Submit a Story Tip[UPDATED where can i buy renova over the counter at 6:15 p.m. ET] SACRAMENTO, Calif. €” A proposal sailing through the California legislature that aims to stop people from getting harassed outside of vaccination sites is raising alarms where can i buy renova over the counter among some First Amendment experts. If it becomes law, SB 742 would make it punishable by up to six months in jail and/or a maximum fine of $1,000 to intimidate, threaten, harass or prevent people from getting a skin care products — or any other — treatment on their way to a vaccination site.

The measure was introduced after protesters briefly shut down a mass vaccination clinic at Los Angeles’ Dodger Stadium in January. Now that mass vaccination clinics have mostly folded up, lawmakers worry that vaccination sites with less security where can i buy renova over the counter than Dodger Stadium — like pharmacies and mobile clinics in parks or fast-food parking lots — are vulnerable. It’s a sign of how toxic the issue of vaccination has become in a state with a long history of intense and divisive treatment wars. State Sen.

Richard Pan (D-Sacramento), a pediatrician where can i buy renova over the counter who administers treatments to his patients, wrote the bill. He has been the target of anti-vaccination harassment since writing and championing laws that made it harder for parents to refuse routine treatments for their children by eliminating personal belief exemptions and tightening rules around medical ones. He was shoved by someone who opposed the medical exemption bill in 2019, the same year in which an anti-treatment protester threw menstrual blood onto the state Senate floor. Pan was where can i buy renova over the counter also among the lawmakers threatened at a committee hearing earlier this year.

Last month, Pan volunteered at a vaccination clinic at a Sacramento park that he said was disrupted by anti-treatment protesters with a bullhorn who made it hard for medical personnel to converse with patients and answer their questions. And while he said he can handle threats, ordinary citizens “shouldn’t have to run a gauntlet to get vaccinated.” That includes walking through a group likely made up of where can i buy renova over the counter unvaccinated protesters and possibly getting exposed to skin care products to get protected, he said. His measure prohibits obstructing, injuring, harassing, intimidating or interfering with people “in connection with any vaccination services.” The bill passed the state Senate with just four no votes and faces one more committee hurdle before it heads to the Assembly floor. The bill defines harassment as getting within 30 feet of someone to hand them a leaflet, display a sign, participate in any kind of verbal protesting like singing or chanting, or conduct any education or counseling with that person.

Blocking someone or impeding them from getting a treatment is an obvious problem, and it’s good that the proposal would try to stop that, said Glen Smith, litigation director for the First Amendment Coalition, a California-based nonprofit that promotes the First Amendment, which guarantees rights such as free speech and assembly where can i buy renova over the counter. But he thinks the proposal goes too far with its definition of harassment. €œTo say you can’t get within 30 feet of them just to hand them a pamphlet or ask them a question?. That seems to be overkill for me,” Smith said where can i buy renova over the counter.

It’s worse than overkill, said Eugene Volokh, a professor of First Amendment law at the UCLA School of Law. €œThat law is clearly unconstitutional,” Volokh said. He has two primary concerns where can i buy renova over the counter with the proposal. First, though it’s modeled on similar laws that create zones around abortion clinics to protect patients from harassment, this bill goes beyond what courts have upheld in the past, he said.

In 2000, where can i buy renova over the counter the U.S. Supreme Court upheld a Colorado law that created an 8-foot “bubble zone” around a person entering or exiting an abortion clinic, but in 2014 the high court struck down a Massachusetts law that created a 35-foot “buffer zone” around clinics. A 30-foot zone around a person getting a treatment is bigger than the court would allow, Volokh believes. His second concern is that the bill specifically prohibits someone from leafletting or talking to someone only about treatments where can i buy renova over the counter.

That violates the First Amendment, Volokh said, because it targets certain content. Someone could hand out an anti-war or anti-fur leaflet and not run afoul of the law, he said. €œI think it’s pretty shocking that a state legislature would try to enact this kind of restriction on where can i buy renova over the counter fully protected speech this way,” Volokh said. The Right to Life League, which has opposed the measure from the start, advocated to get “in connection with vaccination services” added to the bill language.

Once the bill was amended to include that phrase, that limited “the negative impact of the bill on pro-life activities,” like anti-abortion sidewalk counseling outside Planned Parenthood clinics, which provide abortions and treatments, Elisabeth Beall, media coordinator for the Right to Life League, wrote in a statement. The group still believes the bill where can i buy renova over the counter is unconstitutional. Not all free speech advocates share Volokh’s interpretation of the bill. The American where can i buy renova over the counter Civil Liberties Union said it has no issues with it as written.

€œIt’s not necessarily the case that the freedom to express our views is unrestricted,” said Kevin Baker, director of governmental relations at ACLU California Action. €œThey can be balanced with important governmental objectives” like letting people get vaccinated in peace. Part of that objective is stopping disinformation about treatments, which Pan said is the primary reason people are where can i buy renova over the counter not getting the shots. €œFrankly, any gains we make to try to get more people vaccinated are going to be incremental because of disinformation,” Pan said.

And when protesters show up claiming they’re there to educate patients, “they’re talking about disinformation.” Joshua Coleman, co-founder of the group V is for treatment, which advocates for informed consent before vaccinations and says treatments carry risk, said he brought the bullhorn to Pan’s clinic to “educate those coming to receive the treatment on important facts they deserve to know” and object to Pan’s bill. €œThe intent in attending Senator Pan’s vaccination clinic where can i buy renova over the counter was to protest the censorship of important information and his egregious and erroneous attack on free speech,” he said via email. Pan said his bill was “carefully crafted” to stop the “obstruction, harassment and intimidation” of people seeking treatments, and is confident that it is well within the bounds of the First Amendment. €œThere’s precedent for saying you can protest.

This law doesn’t say where can i buy renova over the counter you can’t protest. There’s certain rules around the protest,” Pan said. €œEspecially as we’re trying to deal with this renova, we need to do what we can to be sure people feel safe getting themselves vaccinated.” This story was where can i buy renova over the counter produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. [Correction.

This article was revised at 6:15 p.m. ET on Aug where can i buy renova over the counter. 9, 2021, to correct the Right to Life League’s position on SB 742. A previous version of the story implied the group had changed its stance to support the bill, but it still opposes it.] Rachel Bluth.

rbluth@kff.org, @RachelHBluth Related Topics Contact where can i buy renova over the counter Us Submit a Story TipCristina Martinez’s spinal operation in Houston was expected to be routine. But after destabilizing her spine, the surgeon discovered the implant he was ready to put in her back was larger than he wanted to use — and the device company’s sales rep didn’t have a smaller size on hand, according to a report he filed about the operation. Dr. Ra’Kerry Rahman went ahead with the operation, and where can i buy renova over the counter Martinez awoke feeling pain and some numbness, she alleges.

When Rahman removed the plastic device four days later and replaced it with a smaller one, Martinez suffered nerve damage and loss of feeling in her left leg, she claims. Martinez is suing the surgeon, implant maker Life Spine Inc., where can i buy renova over the counter and its distributor and sales representatives, alleging their negligence led to her injuries because the right part wasn’t available during her first surgery. All deny wrongdoing. The case is set for trial in November.

The lawsuit takes aim at the bustling sales networks that orthopedic device manufacturers have where can i buy renova over the counter built to market ever-growing lines of costly surgical hardware — from spinal implants to replacement knees and artificial hips commonly used in operations. Sales in 2019 topped $20 billion, though skin care products forced many hospitals to suspend elective surgeries for much of last year. Device makers train sales reps to offer surgeons technical guidance in the operating room on the use of their products. They pay prominent surgeons to tout their implants at medical conferences — and athletes to offer celebrity where can i buy renova over the counter endorsements.

The industry says these practices help ensure that patients receive the highest-quality care. But a KHN investigation found these practices also have been blamed for contributing to serious patient harm in thousands of medical malpractice, product liability and whistleblower lawsuits filed over the past decade. Some patients allege they were injured after sales reps sold or delivered wrong-size or defective implants, while others accuse device where can i buy renova over the counter makers of misleading doctors about the safety and durability of their products. Six multi-district federal cases have consolidated more than 28,000 suits by patients seeking compensation for injuries involving hip implants, including painful redo operations.

In other court where can i buy renova over the counter actions, patients and whistleblowers repeatedly have accused device companies of failing to report injury-causing defects to federal regulators as required — or of doling out millions of dollars in illegal kickbacks to surgeons who agreed to use their products. Device makers have denied the allegations and many such cases are settled under confidential terms. At least 250 companies sell surgical hardware, and many more distribute it to doctors and hospitals across the country. Spine companies alone obtained more than 1,200 patents for devices in 2018, according to where can i buy renova over the counter an industry report.

Many come to market through a streamlined Food and Drug Administration process that approves their use because they are essentially the same as what is already being sold. €œIn orthopedics, we are inundated with a multitude of new implants that debut each year,” Dr. James Kang, chairman of the orthopedic surgery department at Brigham and Women’s Hospital, remarked at where can i buy renova over the counter a Harvard Medical School roundtable discussion published in 2019. Dr.

James Kang, chairman of the orthopedic surgery department at Brigham and Women’s Hospital, discusses hip-spine syndrome in a 2016 YouTube video. (Screenshot from YouTube) Kang said surgeons often rely on industry “reps” in the operating room for guidance because it is “usually burdensome and difficult” for surgeons to know “all of where can i buy renova over the counter the intricate details and nuances” of so many products. Martinez’s lawsuit says the process went awry during her May 2018 spinal fusion in Houston, an operation in which an implant is inserted into the spinal column to replace a worn or damaged disc. Martinez was under anesthesia, with her spine destabilized, when Rahman discovered the Life Spine surgical kit where can i buy renova over the counter did not contain any implants shorter than 50 millimeters, or about 2 inches.

That was too large, according to the complaint. Martinez, a former day care worker, blames her injuries on the redo operation, which replaced the implant with a 40 mm version Life Spine supplied later. Through his lawyer, where can i buy renova over the counter Rahman declined to comment. In court filings, the surgeon has denied responsibility.

His operating notes, according to court pleadings, say he had ordered “all lengths available” of the implant through a Life Spine distributor and its sales reps. In a June court filing, Rahman where can i buy renova over the counter contends the “small area of leg numbness experienced by Ms. Martinez was a known complication of the first surgery … and was not the result of any alleged negligence.” In the court filing, Rahman also argues it was “appropriate” for him to rely on the sales reps and hospital staff to “inform him as to whether all materials and equipment needed for surgery were available.” Illinois-based Life Spine also denies blame. In court filings, it says the sales reps initially ordered a sterile kit that included only implants from 50 mm to 55 mm long, which it duly shipped to Houston.

At the time of Martinez’s operation, Life Spine was the target of a sealed whistleblower lawsuit accusing where can i buy renova over the counter it of paying improper consulting fees and other kickbacks to more than 60 surgeons who agreed to use its wares. Court records in the whistleblower case identify Rahman as one of the company’s paid consultants, although he and the other surgeons were not named as defendants. Life Spine and two of its executives where can i buy renova over the counter settled the matter in November 2019 by paying a total of nearly $6 million. An orthopedic surgery expert hired by Martinez for her suit faulted Rahman for not making sure he had the right gear “prior to the start of surgery,” according to his report.

The expert also criticized the sales rep for failing to bring “all available lengths to the procedure or to inform Dr. Rahman that the necessary implants were not available,” court where can i buy renova over the counter records show. The sales rep and distributor denied any blame, arguing in court filings that they “met all applicable standards of care.” Frenzied Competition for Sales Major device makers train a corps of sales agents, some recruited right out of college, to cultivate and work closely with surgeons — one likened the relationship to a caddy and an avid golfer. Duties can include lugging 20-pound sets of surgical hardware to the operating room, assuring it is sterile and knowing its specifications, though the reps are not required to have medical training or credentials.

Stryker, one of the nation’s top four spine implant manufacturers, spends what it calls “a significant amount of time and money” where can i buy renova over the counter to train reps. When hired, they typically “shadow” other reps for three to six months, then attend a 10-day intensive “Spine School” and other training. In all, the company said in a court filing, it typically takes eight to 18 months, often longer, to develop “long-term relationships” with customers. For those who where can i buy renova over the counter do, the jobs can pay handsomely.

Veteran reps who influence which brands of hardware surgeons select command salaries and bonuses that can stretch into the low six figures and beyond, court records show. The market is so hotly competitive that device makers typically require reps to sign contracts that prohibit where can i buy renova over the counter them from working for a rival company in the same territory for a year or more — and aren’t shy about suing to fend off raids on their staffs, court records show. In 2019, DePuy Synthes sued an Alabama sales rep who jumped ship, blaming him for stealing away accounts “worth millions of dollars practically overnight.” An arm of health care giant Johnson &. Johnson, DePuy Synthes filed at least two dozen similar suits from 2014 through the end of 2020, court records show.

Most, including the case of the Alabama sales rep, have been where can i buy renova over the counter settled under confidential terms. Some companies have spent lavishly to poach experienced sales agents — practices that can violate business conduct laws. One allegedly paid a New York sales pro a “staggering, seven-figure signing bonus.” Another is said to have dangled an $800,000-a-year job as “director of surgeon education,” while a gambit to make inroads in the Phoenix market dubbed “Sun Devil” guaranteed a branch manager a $500,000 annual salary, court records show. Another promised a sales agent $900,000 paid out over where can i buy renova over the counter three years.

Whistleblowers and government investigators have argued for years that so much money changing hands can lead to kickbacks or other marketing schemes that corrupt medical judgment and endanger patients. Some injury suits also have blamed sales reps and where can i buy renova over the counter distributors for staying mum about product deficiencies they observed in the operating room. These cases often are settled with no admission of wrongdoing. Sometimes, surgeons help promote implants at medical meetings and other gatherings.

Orthopedic surgeons and neurosurgeons received a total of about $511 million in industry consulting fees from 2013 through 2019 and nearly $300 million more for “serving as where can i buy renova over the counter faculty or speaker” at industry-sponsored events, a KHN analysis of government data found. AdvaMed, the device industry’s trade group, says doctors often take “primary responsibility” for training other doctors to use new devices. €œUnlike a pill or injection, procedures to implant or equip medical devices for patients can be extremely technical and complex,” said Scott Whitaker, the group’s president and CEO. A court exhibit shows two screws that a Georgia where can i buy renova over the counter man alleged broke apart about two years after his spinal operation.

The 2013 lawsuit has since been settled. (U.S. District Court filing) Some where can i buy renova over the counter prominent surgeons who touted products that later were recalled, or who helped train surgeons to use implants, have been criticized in pending injury lawsuits. One is Dr.

Brad Penenberg, an orthopedic surgeon in Beverly Hills, California, paid by Wright Medical Technology as a “key opinion where can i buy renova over the counter leader,” according to court filings. Multiple lawsuits cite a webinar for orthopedic surgeons that featured Penenberg and said hip surgery patients could resume “activities and lifestyles that include such things as tennis, horseback riding and snow skiing.” Injured patients are arguing in court filings that Penenberg and several other experts paid by the company knew of significant failures of the hip device. Penenberg did not respond to numerous requests for comment but in court papers denied the allegations. Hundreds of patients are claiming where can i buy renova over the counter injuries they blame at least partly on overly aggressive marketing by Wright Medical.

In one 2020 lawsuit, a Montana man who had received a hip implant said he was taking a walk while in Arizona on vacation when he “felt a severe jolt in his groin and fell.” He was out of cell range and could not get up or call for help. A “good Samaritan” called for an ambulance, which took him to a hospital in Gilbert, Arizona, where X-rays showed a fracture of the implant. It was where can i buy renova over the counter removed and replaced. Wright Medical has denied the allegations.

In 1984, Mary Lou Retton won an individual all-around Olympic gold medal in gymnastics, the first American woman to do so. (David Madison / Getty Images) Retired California psychologist Herb where can i buy renova over the counter Glazeroff is suing Penenberg and Wright Medical Technology over a hip replacement that allegedly failed about five years after the surgeon installed it. In May 2019, Glazeroff was walking when he “suddenly dropped to his knees as his left leg gave out on him,” according to the suit. He alleges that the hip had fractured, which required a painful second operation and “a long and arduous rehabilitation program” from which he has “yet to fully recover.” Glazeroff argues that Penenberg failed to warn him about the implant’s dangers even though the surgeon had where can i buy renova over the counter been named in “multiple lawsuits” alleging device defects.

Penenberg has denied the allegations. Dozens of lawsuits have taken aim at Indiana device maker Biomet’s advertising a hip replacement for “younger, more active patients” that showcased Olympic gold medal gymnast Mary Lou Retton. One ad says “Mary Lou lives pain-free, and so should you.” where can i buy renova over the counter Yet Retton suffered painful heavy-metal poisoning requiring the implant’s removal and sued the company for damages, according to court records. In a January 2020 court filing in Houston, Retton tried to block a subpoena seeking her deposition in a product liability lawsuit filed against Biomet by two patients in King County, Washington.

The Washington case has since been settled and the deposition did not occur. But in a court filing opposing the subpoena, Retton confirmed she had a Biomet implant put in her left hip in 2005 and where can i buy renova over the counter one on her right side about six years later. She said she promoted Biomet products from April 2006 through April 2013 and sued the company in January 2018, alleging the implants were defective. Retton said she and Biomet settled the suit in early 2019 “under confidential terms the parties find favorable to their respective positions.

[Ms. Retton] values her long relationship with Biomet and her continued use of her [Biomet hip implants] and [Biomet] appreciates the support it has received over the years from [Ms. Retton].” In 2011, Olympic gymnastics gold medalist Mary Lou Retton shared patient testimony for device company Biomet and her orthopedic surgeon. (Screenshot from YouTube) Defects Ignored, Downplayed Whether touted by renowned surgeons or celebrities, orthopedic surgery marketing materials stress quick improvement in a person’s quality of life.

That proves true for most patients. Yet researching how often implants fail or cause life-changing injuries — and which brands have the best safety records — can be daunting. The FDA requires device makers to advise the agency of information “that reasonably suggests” a device they sell “may have caused or contributed to a death or serious injury or has malfunctioned” in a way that could recur. The FDA posts the reports on a public website, with the caveat that they may convey “incomplete, inaccurate, untimely, unverified, or biased data.” KHN found that thousands of malpractice and product liability lawsuits have accused device marketers of concealing or downplaying hardware defects, leaving patients and their doctors in the dark about possible risks.

In many cases, these claims are bolstered by company records, or actions by state or federal regulators. In 2019, for instance, DePuy Synthes paid $120 million to settle a lawsuit filed by 46 state attorneys general. The suit accused the company of advertising that a replacement hip it sold lasted three years in 99.2% of operations, when it knew of data showing that 7% had failed within that time. The company did not admit wrongdoing in settling the case.

British device company Smith &. Nephew faces a federal civil proceeding comprising nearly 1,000 injury suits, including one that says the company “underreported and withheld” notices of malfunctions and “willfully ignored the existence of numerous complaints about [its] failures.” An expert hired by the patients cites a company audit showing “significant adverse events” were logged from two days to 142 days late, while a corporate memo circulated among executives to push sales was titled “Milk the Cash Cow,” according to court records. Smith &. Nephew has denied the allegations and in one court paper called the expert’s opinions “speculative.” A cluster of Florida injury cases pertaining to a knee implant from German manufacturer Aesculap alleges that the FDA cited the company for failing to report 25 adverse incidents — in some cases for a year or more — as a result of an inspection at its Hazelwood, Missouri, plant in September 2015.

Aesculap has denied the allegations and the suits are pending in Florida’s Indian River County Circuit Court. John Saltis is suing spinal device company NuVasive over its handling of his complaint that a screw holding his spinal implant in place snapped in May 2016, about 17 months after his operation. Saltis, 68, was two hours into his workday as a toolmaker at General Electric in Rutland, Vermont, when he felt sharp pain in his neck and shoulder, bad enough to send him to the hospital emergency room. A few days later, X-rays revealed the screw had broken and, according to Saltis, fractured vertebrae in the process.

Saltis said the San Diego-based device company told the FDA the incident caused no harm. But Saltis said he has lingering numbness and pain in his right hand. As a result, he said, his lifestyle has “changed dramatically.” He sold his motorcycle and stopped biking and now relies on his left hand for simple tasks like opening doors and shaking hands — even plucking chips out of a bag. €œI miss things like bowling and playing toss with my grandkids,” he said.

A few days after feeling a sharp pain in his neck and shoulder, X-rays revealed the screw holding John Saltis’ spinal implant had broken and, Saltis says, fractured vertebrae in the process. (Hans Pennink for KHN) “I was pain-free for a few months and would have stayed that way if the screw hadn’t broken,” he says. €œThis can change somebody’s life completely.” (Hans Pennink for KHN) In 2019, Saltis sued NuVasive without a lawyer, hoping to show the $600 screw was defective. In a court filing, NuVasive said Saltis is arguing “the screw is defective because it broke.” That’s not good enough, according to NuVasive, which argues that Saltis must show the screw was “unreasonably dangerous” to press his claim.

In late June, a federal judge agreed and dismissed the suit, though she allowed Saltis to amend his complaint, which he is pursuing. The case is pending. €œI was pain-free for a few months and would have stayed that way if the screw hadn’t broken,” Saltis said. €œThis can change somebody’s life completely.” A Push for Change as renova Eases As hospitals resume elective operations stalled by the skin care, some industry critics see an opportunity to rethink orthopedic surgery practices — from sales to tracking of injuries.

Some want to keep industry reps out of operating rooms and place tighter restrictions on their access to hospitals. They say the current system needlessly drives up health care costs and exposes patients to risks such as from extra people in the operating room. Reps counter that their incomes have been dropping due to global purchasing arrangements that give hospitals greater say over prices for surgical equipment. Sales reps say their technical knowledge and skills make operations safer for patients and note that many surgeons enjoy the security of having them present in the operating room.

Reps also say they perform tasks that hospitals would need to hire additional personnel to do, such as keeping track of device inventories. €œThe industry has embedded reps into the supply chain, and it is a hard culture to break,” said Itai Nemovicher, president of the Orthopaedic Implant Co., which seeks to produce lower-cost implants. Yet guidelines for “reentry” after skin care products put out by AdvaMed and the American Hospital Association say medical device reps should deliver “services, information and support remotely whenever possible.” The guidelines advise hospitals to use videoconferencing gear when it “does not compromise patient safety or privacy.” Dr. Adriane Fugh-Berman, a professor of pharmacology and physiology at Georgetown University, said device reps are viewed as part of the operating room team even though they are there “to sell products.

That is pretty horrifying from a patient’s point of view.” She said hospitals should train staff to perform these functions. €œRelying on sales reps in the OR is appalling. We need to come up with a better system.” Greater transparency might have helped Little Rock, Arkansas, resident Christopher Paul Bills. He sued Consensus Orthopedics, the maker of a hip implant system that he alleged failed and sent metal through his hip joint that his surgeon said in 2016 looked “as if a bomb had gone off.” An Australian registry that tracks outcomes of operations had in September 2014 identified the implant as having a “higher number” of hip failures compared with other manufacturers, according to the suit.

Bills underwent four operations and spent more than a year in the hospital and in rehabilitation, costs borne by Medicare and private insurance. €œMr. Bills was left with no right hip at all and his surgeon does not plan to install a replacement hip,” the suit says. Bills uses an electric scooter to get around and hopes to graduate to hand-held crutches.

€œSince his right leg is useless, he will require a vehicle with hand-controls to drive,” according to the suit. The company disputed Bills’ claims and denied its hip system had any defects. The case ended in 2019 when Bills died of cancer unrelated to his operations, said his lawyer, Joseph Saunders. €œHe never did get justice,” Saunders said.

Fred Schulte. fschulte@kff.org, @fredschulte Related Topics Contact Us Submit a Story TipMAYAGÜEZ, PUERTO RICO — Abigail Matos-Pagán entered a bright-blue house in Mayagüez earlier this summer and was met by Beatriz Gastón, who quietly led the way to her mother’s small room. Matos-Pagán had come to provide a skin care products treatment for Wildelma Gastón, 88, whose arthritis and other health concerns confine her to bed. Wildelma Gastón asked for her rosary to be placed on her chest and motioned to her “good arm,” where Matos-Pagán injected a first dose of the Moderna treatment.

The Gastón household, made up of five family members, breathed a collective sigh of relief. Though the treatment had been available for months, Wildelma had been unable to reach a vaccination site. According to the Centers for Disease Control and Prevention’s skin care products Data Tracker, Puerto Rico’s vaccination rate in March was one of the lowest among U.S. States and territories despite receiving more than 1.3 million treatment doses.

The rollout highlighted disparities in access to medical services, and the challenges of tracking and reaching remote citizens, such as Wildelma. With each trip to school or work, family members worried about bringing the renova into their home and the threat to Wildelma’s life. Matos-Pagán also vaccinated two of Beatriz’s children, who are students at the University of Puerto Rico-Mayaqüez, during her visit. €œWe have been waiting a long time for this moment,” Beatriz Gastón said as she hugged Matos-Pagán goodbye, expressing gratitude for the home visit.

To her, the treatment is more than protection from the skin care — it clears the way for the family to be together with her mother. To Matos-Pagán, it is her latest calling. The nurse practitioner, who has guided relief efforts after hurricanes and earthquakes in Puerto Rico and elsewhere, has made it her mission in the U.S. Territory to vaccinate as many people as possible against skin care products.

Some residents of Mayagüez, a city on the western shore of the main island, candidly call her “The Vaccination Queen” and show up at her home asking for help in getting a shot. According to The New York Times’ case tracker, as of Friday, Puerto Rico has had more than 182,000 skin care products cases and at least 2,594 deaths. About 57% of the population is fully vaccinated, but many of the unvaccinated are hard to reach because they live in remote mountainous communities or have chronic illnesses that leave them homebound. Matos-Pagán has vaccinated around 1,800 people in Puerto Rico so far, including 1,000 who have chronic illnesses or are bedridden.

In the renova’s early days, Carmen Blas’ health declined, and she began using a wheelchair. Blas, 78, was confined to her home, on the third story of an apartment building, which kept her safe from contracting skin care products, but later she couldn’t find transportation to a vaccination site. In June, her two children, Lisette and Raymond, visited from Wisconsin to help and immediately called the public health officials to get Blas inoculated. €œI usually come back every year and this was the longest I’ve ever been away.

It was especially hard as my mother’s health worsened, and I worried I might never see her again,” said Raymond, who planned to extend his visit for as long as he was needed. Matos-Pagán came to Blas’ home in Aguadilla, Puerto Rico, to give her the treatment. The family cheered the moment the vaccination was over. €œIt’s been really special to have intimate moments in someone’s home during vaccinations.

You can tell how much it means to their entire family,” Matos-Pagán said afterward. Mobilizing during a crisis is nothing new for Matos-Pagán. In the aftermath of Hurricane Maria, which cut off water and electricity to the entire island and claimed more than 3,000 lives, Matos-Pagán conducted initial community assessments in Puerto Rico’s remotest and hardest-hit cities. Flooding and debris made many roads inaccessible, blocking these communities from basic needs such as food, water, prescription medications and transportation.

Then, after a series of earthquakes in 2020 rocked the island, leaving even more people without housing or in substandard structures, Matos-Pagán organized local nurse practitioners to provide community health care. They supplied at-risk populations with their medicines when pharmacies closed, and teams set up mobile medical tents near overcrowded hospitals. €œI’m hyper and busy in my daily life, but when there is a crisis, I am calm and still. Grounded.

I feel like I’m where I belong,” she said. Abigail Matos-Pagán gives Wildelma Gastón a skin care products treatment at her home in Mayagüez, Puerto Rico. Gastón is confined to bed because of arthritis and other health problems.(Alicia Carter) Matos-Pagán was born in New York City. She became interested in medicine after watching nurses support her mother, who died of complications from an aneurysm when Matos-Pagán was 9.

Her mother’s death taught her “nothing was permanent,” she said, which has inspired her to act when disaster strikes and support people through personal tragedy and loss. Matos-Pagán returned to Puerto Rico to study nursing and later earned a master’s degree and a doctorate at the University of Puerto Rico-Mayagüez. Through her work, she holds various titles. First commander of the Puerto Rican Disaster Response Team, and director and founder of the Coalition of Nurses for Communities in Disaster.

Her experiences managing medical professionals and resources during hurricanes have taken her to locations across the U.S. Atlantic coast and the Caribbean. During the skin care products renova, she was recruited to assist in triage leadership for an ICU floor short on resources in El Paso, Texas, and a hard-hit senior living facility in Maryland. €œNot everyone is built for this.

It’s really sad, depressing work,” Matos-Pagán said. €œBut even when there are mass casualties, you can still save lives and get people’s basic needs met. I’ve seen communities come together in the most incredible ways. It’s a challenge, but that’s what keeps me going.” And, even as she is rapidly trying to get more skin care products shots into the arms of Puerto Ricans, Matos-Pagán is preparing for the next crisis.

Hurricane season officially began in June, and she will be on disaster-ready duty until the end of November. Related Topics Contact Us Submit a Story TipKHN freelancer Mark Kreidler discussed why professional athletes are not taking a more affirmative role in pushing skin care products treatments on Newsy on Tuesday. KHN Midwest correspondent Cara Anthony discussed masking mandates, treatment efficacy and breakthrough skin care products cases on Illinois Public Media’s “The 21st Show” on Monday. KHN chief Washington correspondent Julie Rovner discussed the recent surge in skin care products cases on Axios’ “Axios Today” podcast and WAMU/NPR’s “1A” on Monday and July 30, respectively.

KHN Montana correspondent Katheryn Houghton explored the phenomenon of folks visiting radon mines in Montana as a treatment for various ills on “Voices of Montana” on July 30. Related Topics Contact Us Submit a Story Tip.

What should I watch for while taking Renova?

It may take 2 to 12 weeks before you see the full effect. Do not use the following products on the same areas that you are treating with Renova, unless otherwise directed by your doctor or health care professional: other topical agents with a strong skin drying effect such as products with a high alcohol content, astringents, spices, the peel of lime or other citrus, medicated soaps or shampoos, permanent wave solutions, electrolysis, hair removers or waxes, or any other preparations or processes that might dry or irritate your skin.

Renova can make you more sensitive to the sun. Keep out of the sun. If you cannot avoid being in the sun, wear protective clothing and use sunscreen. Do not use sun lamps or tanning beds/booths. Avoid cold weather and wind as much as possible, and use clothing to protect you from the weather. Skin treated with Renova may dry out or get wind burned more easily.

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Mine was Cathy Freeman.Even now, she’s the one person who makes me nervous if I’m in the same room as her, but it makes me so proud that these days we have so many more female role models to look to.Sam Kerr’s debut children’s novel Kicking Goals. The Flip renova 31 resenha Out (Simon &. Schuster, $14.99), is out now.Any products featured in this article are selected by our editors, who don’t play favourites. If you renova 31 resenha buy something, we may get a cut of the sale.

A positive outlook is just around the corner, Kerr says these simple pointers can lead you there.1 where can i buy renova over the counter. Do what makes you happy where can i buy renova over the counter and do it for the right reasonsMy motto ever since I was a kid has been to do what makes me happy. My mum and dad always allowed me to do whatever made me happy, and that has had a big influence on me, on and off the field.That can be tough at times with injuries and also everything that goes on with social media. Sometimes I also might get stressed at where can i buy renova over the counter things I should be doing.But now I ask myself, if it’s not going to make me happy, why would I do it?. It’s tough to make those decisions and it sounds selfish but if it’s not good for my soul, I know I shouldn’t do it.Like what you see?.

Sign up to where can i buy renova over the counter our bodyandsoul.com.au newsletter for more stories like this.2. Set goals I’m a big goal setter. I write them down before the start where can i buy renova over the counter of a season. I used to write them down in a journal but now I keep them in my phone. I have short- and long-term goals, but I where can i buy renova over the counter always make sure I include goals that are easy to smash because I feel this helps me along the way.Before the Olympics, I was struggling with an injury, but being able to tick off some little goals along the way enabled me to feel good about myself.

Other long-term goals are about a process – like winning the Champions League this year.3. Be flexible in your thinking – because not everything will go your wayDisappointment and setbacks don’t where can i buy renova over the counter just happen on the sports field. They happen in life. There’s an element of rolling with the punches and that’s very much how I am but I also now realise that the key is to just keep going.It’s about having the resilience and perspective that not everything will go your way where can i buy renova over the counter but this doesn’t mean it’s catastrophic.4. Realise that you can’t please everyoneI’ve only really learnt this over the past few years because it has become relevant to me.

Some people will love you and some people will hate you no matter what, especially now with social media.You’re never where can i buy renova over the counter going to please everyone.5. Take time off social mediaI love social media but I think there’s a time and place for it. Twitter can where can i buy renova over the counter be quite hostile at times, but I love Instagram because it’s great to share experiences and show your life.The messages [on Instagram] are more supportive than other social media. But I’ve learnt there are times when I must tune out.During the Olympics, I was posting but not reading anything because [the Games] is such a roller-coaster. I’m sure where can i buy renova over the counter when I missed the penalty, people were slamming me, but when I scored against Great Britain, people were saying how amazing it was.

I don’t want one moment to define me as a player.6. Know that there’s no room for racism on the sports field or in lifeI feel as if I’ve grown up in a time when we’re calling out racism [as] unacceptable – although I’m often mistaken for being Aboriginal, where can i buy renova over the counter and I don’t know if that’s acceptable, either?. My dad moved to Australia from India and he speaks about being subjected to racism.Thankfully, I haven’t been subjected to the comments Dad faced. But I also know that it’s something we can’t be complacent about where can i buy renova over the counter. In the Matildas, it’s all about respect and inclusion.That’s why we held up the Indigenous flag before our first game at the Olympics.

We want to represent the people in our team, in our community and in our fan base, and we want to feel connected.We want to feel as if we’re representing where can i buy renova over the counter all people who are part of the Matildas. It was a moment that drew our team closer, and hopefully people in Australia saw that as a moment of coming together.Why it’s important to have role modelsGrowing up, you never stop and analyse diversity, bullying and inclusion but I wanted to write a book for kids that addressed these issues to show them “you’re not alone”.Everyone goes through their own experiences but talking about these issues and sharing stories helps.I never thought about being a role model and it’s something I don’t take lightly but I also value that I can be a role model. I felt that when I was where can i buy renova over the counter growing up, young female athletes didn’t have many role models. Mine was Cathy Freeman.Even now, she’s the one person who makes me nervous if I’m in the same room as her, but it makes me so proud that these days we have so many more female role models to look to.Sam Kerr’s debut children’s novel Kicking Goals. The Flip where can i buy renova over the counter Out (Simon &.

Schuster, $14.99), is out now.Any products featured in this article are selected by our editors, who don’t play favourites. If you buy something, we may get a cut of the where can i buy renova over the counter sale. Learn more..

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WASHINGTON, DC – Last week, anna lotan renova the U.S generic renova online. Department of Labor took a range of actions to aid American workers and employers as our nation combats the skin care renova. Reopening America’s Economy anna lotan renova. Statement by U.S.

Secretary of Labor Scalia on the August Jobs anna lotan renova Report – “Today’s jobs report is encouraging news for American workers heading into Labor Day. The report significantly beat expectations, with the unemployment rate dropping to 8.4 percent even as more Americans entered the labor force. Unemployment fell across all demographics, and the 1.4 million jobs added showed increases across most industry sectors. This follows a string of other reports showing a strong anna lotan renova recovery underway.

The Administration remains focused on returning millions more Americans to work, and providing additional support to the unemployed through the Lost Wages Assistance Program authorized by the President when Congress failed to act on enhanced unemployment benefits.” Secretary Scalia also joined Fox News, Fox Business and CNN to discuss the report. Defending Workers’ Rights to Paid Leave and Wages anna lotan renova Earned. U.S. Department of Labor Offers Webinar for Ohio Employers – The Wage and Hour Division and the Occupational Safety and Health Administration presented a webinar for Ohio area employers and human resources professionals on the paid leave requirements of the Families First skin care Response Act and safety guidance for returning to work and maintaining a safe and healthy working environment.During the skin care renova, the Department of Labor is focused on protecting the safety and health of American workers, assisting our state partners as they deliver traditional unemployment and expanded unemployment benefits, ensuring Americans know their rights to new paid sick leave and expanded family and medical leave, providing guidance and assistance to employers, and carrying out the mission of the Department anna lotan renova.

The mission of the Department of Labor is to foster, promote and develop the welfare of the wage earners, job seekers and retirees of the United States. Improve working conditions. Advance opportunities for profitable employment anna lotan renova. And assure work-related benefits and rights.WASHINGTON, DC – U.S.

Secretary of Labor Eugene Scalia issued the following statement on the August 2020 Employment Situation Report:“Today’s jobs report anna lotan renova is encouraging news for American workers heading into Labor Day. The report significantly beat expectations, with the unemployment rate dropping to 8.4 percent even as more Americans entered the labor force. Unemployment fell across all demographics, and the 1.4 million jobs added showed increases across most industry anna lotan renova sectors. This follows a string of other reports showing a strong recovery underway.

The Administration remains focused on returning millions more Americans to work, and providing additional support to the unemployed through the Lost Wages Assistance Program authorized by the President when Congress failed to act on enhanced unemployment benefits.”.

WASHINGTON, DC – Last week, where can i buy renova over the counter the U.S best place to buy renova. Department of Labor took a range of actions to aid American workers and employers as our nation combats the skin care renova. Reopening America’s where can i buy renova over the counter Economy. Statement by U.S. Secretary of Labor Scalia on the August Jobs Report – “Today’s jobs report is encouraging where can i buy renova over the counter news for American workers heading into Labor Day.

The report significantly beat expectations, with the unemployment rate dropping to 8.4 percent even as more Americans entered the labor force. Unemployment fell across all demographics, and the 1.4 million jobs added showed increases across most industry sectors. This follows where can i buy renova over the counter a string of other reports showing a strong recovery underway. The Administration remains focused on returning millions more Americans to work, and providing additional support to the unemployed through the Lost Wages Assistance Program authorized by the President when Congress failed to act on enhanced unemployment benefits.” Secretary Scalia also joined Fox News, Fox Business and CNN to discuss the report. Defending Workers’ Rights to Paid Leave and Wages where can i buy renova over the counter Earned.

U.S. Department of Labor Offers Webinar for Ohio Employers – The Wage and Hour Division and where can i buy renova over the counter the Occupational Safety and Health Administration presented a webinar for Ohio area employers and human resources professionals on the paid leave requirements of the Families First skin care Response Act and safety guidance for returning to work and maintaining a safe and healthy working environment.During the skin care renova, the Department of Labor is focused on protecting the safety and health of American workers, assisting our state partners as they deliver traditional unemployment and expanded unemployment benefits, ensuring Americans know their rights to new paid sick leave and expanded family and medical leave, providing guidance and assistance to employers, and carrying out the mission of the Department. The mission of the Department of Labor is to foster, promote and develop the welfare of the wage earners, job seekers and retirees of the United States. Improve working conditions. Advance opportunities for where can i buy renova over the counter profitable employment.

And assure work-related benefits and rights.WASHINGTON, DC – U.S. Secretary of Labor Eugene Scalia issued the following statement on the August 2020 Employment Situation Report:“Today’s jobs report is encouraging news for where can i buy renova over the counter American workers heading into Labor Day. The report significantly beat expectations, with the unemployment rate dropping to 8.4 percent even as more Americans entered the labor force. Unemployment fell where can i buy renova over the counter across all demographics, and the 1.4 million jobs added showed increases across most industry sectors. This follows a string of other reports showing a strong recovery underway.

The Administration remains focused on returning millions more Americans to work, and providing additional support to the unemployed through the Lost Wages Assistance Program authorized by the President when Congress failed to act on enhanced unemployment benefits.”.

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High burden of antibiotic-resistant Mycoplasma genitalium in renova tu personal symptomatic urethritisMycoplasma genitalium is an aetiological agent of sexually transmitted urethritis. A cohort study investigated M. Genitalium prevalence, antibiotic resistance and association with previous macrolide exposure among 1816 Chinese men who presented with symptomatic urethritis between 2011 and 2015 renova tu personal.

was diagnosed by PCR, and sequencing was used to detect mutations that confer resistance to macrolides and fluoroquinolones. In 11% renova tu personal of men, M. Genitalium was the sole pathogen identified.

Nearly 90% of s were renova tu personal resistant to macrolides and fluoroquinolones. Previous macrolide exposure was associated with higher prevalence of resistance (97%). The findings renova tu personal point to the need for routine screening for M.

Genitalium in symptomatic men with urethritis. Treatment strategies renova tu personal to overcome antibiotic resistance in M. Genitalium are needed.Yang L, Xiaohong S, Wenjing L, et al.

Mycoplasma genitalium in symptomatic male renova tu personal urethritis. Macrolide use is associated with increased resistance. Clin Infect Dis 2020;5:805–10.

Doi:10.1093/cid/ciz294.A new renova tu personal entry inhibitor offers promise for treatment-experienced patients with multidrug-resistant HIVFostemsavir, the prodrug of temsavir, is an attachment inhibitor. By targeting the gp120 protein on the HIV-1 envelope, it prevents viral interaction with the CD4 receptor. No cross-resistance has been described with renova tu personal other antiretroviral agents, including those that target viral entry by other modalities.

In the phase III BRIGHTE trial, 371 highly treatment-experienced patients who had exhausted ≥4 classes of antiretrovirals received fostemsavir with an optimised regimen. After 48 weeks, 54% of renova tu personal those with 1–2 additional active drugs achieved viral load suppression <40 copies/mL. Response rates were 38% among patients lacking other active agents.

Drug-related adverse renova tu personal events included nausea (4%) and diarrhoea (3%). As gp120 substitutions reduced fostemsavir susceptibility in up to 70% of patients with virological failure, fostemsavir offers the most valuable salvage option in partnership with other active drugs.Kozal M, Aberg J, Pialoux G, et al. Fostemsavir in renova tu personal adults with multidrug-resistant HIV-1 .

N Engl J Med 2020;382:1232–43. Doi. 10.1056/NEJMoa1902493Novel tools to aid identification of hepatitis C in primary careHepatitis C can now be cured with oral antiviral treatment, and improving diagnosis is a key element of elimination strategies.1 A cluster randomised controlled trial in South West England tested performance and cost-effectiveness of an electronic algorithm that identified at-risk patients in primary care according to national recommendations,2 coupled with educational activities and interventions to increase patients’ awareness.

Outcomes were testing uptake, diagnosis and referral to specialist care. Practices in the intervention arm had an increase in all outcome measures, with adjusted risk ratios of 1.59 (1.21–2.08) for uptake, 2.24 (1.47–3.42) for diagnosis and 5.78 (1.60–21.6) for referral. The intervention was highly cost-effective.

Electronic algorithms applied to practice systems could enhance testing and diagnosis of hepatitis C in primary care, contributing to global elimination goals.Roberts K, Macleod J, Metcalfe C, et al. Cost-effectiveness of an intervention to increase uptake of hepatitis C renova testing and treatment (HepCATT). Cluster randomised controlled trial in primary care.

BMJ 2020;368:m322. Doi:10.1136/bmj.m322Low completion rates for antiretroviral postexposure prophylaxis (PEP) after sexual assaultA 4-week course of triple-agent postexposure prophylaxis (PEP) is recommended following a high-risk sexual assault.3 4 A retrospective study in Barcelona identified 1695 victims attending an emergency room (ER) between 2006 and 2015. Overall, 883 (52%) started prophylaxis in ER, which was mostly (43%) lopinavir/ritonavir based.

Follow-up appointments were arranged for those living in Catalonia (631, 71.5%), and of these, only 183 (29%) completed treatment. Loss to follow-up was more prevalent in those residing outside Barcelona. PEP non-completion was associated with a low perceived risk, previous assaults, a known aggressor and a positive cocaine test.

Side effects were common, occurring in up to 65% of those taking lopinavir/ritonavir and accounting for 15% of all discontinuations. More tolerable PEP regimens, accessible follow-up and provision of 1-month supply may improve completion rates.Inciarte A, Leal L, Masfarre L, et al. Postexposure prophylaxis for HIV in sexual assault victims.

HIV Med 2020;21:43–52. Doi:10.1111/hiv.12797.Effective antiretroviral therapy reduces anal high-risk HPV and cancer riskAmong people with HIV, effective antiretroviral therapy (ART) is expected to improve control of anal with high-risk human papillomarenova (HR-HPV) and reduce the progression of HPV-associated anal lesions. The magnitude of the effect is not well established.

By meta-analysis, people on established ART (vs ART-naive) had a 35% lower prevalence of HR-HPV , and those with undetectable viral load (vs detectable viral load) had a 27% and 16% reduced risk of low and high-grade anal lesions, respectively. Sustained virological suppression on ART reduced by 44% the risk of anal cancer. The role of effective ART in reducing anal HR-HPV and cancer risks is especially salient given current limitations in anal cancer screening, high rates of anal lesion recurrence and access to vaccination.Kelly H, Chikandiwa A, Alemany Vilches L, et al.

Association of antiretroviral therapy with anal high-risk human papillomarenova, anal intraepithelial neoplasia and anal cancer in people living with HIV. A systematic review and meta-analysis. Lancet HIV.

2020;7:e262–78. Doi:10.1016/S2352-3018(19)30434-5.The impact of sex work laws and stigma on HIV prevention among female sex workersSex work laws and stigma have been established as structural risk factors for HIV acquisition among female sex workers (FSWs). However, individual-level data assessing these relationships are limited.

A study examined individual-level data collected in 2011–2018 from 7259 FSWs across 10 sub-Saharan African countries. An association emerged between HIV prevalence and increasingly punitive and non-protective laws. HIV prevalence among FSWs was 11.6%, 19.6% and 39.4% in contexts where sex work was partly legalised, not recognised or criminalised, respectively.

Stigma measures such as fear of seeking health services, mistreatment in healthcare settings, lack of police protection, blackmail and violence were associated with higher HIV prevalence and more punitive settings. Sex work laws that protect sex workers and reduce structural risks are needed.Lyons CE, Schwartz SR, Murray SM, et al. The role of sex work laws and stigmas in increasing HIV risks among sex workers.

Nat Commun 2020;11:773. Doi:10.1038/s41467-020-14593-6.BackgroundCumbria Sexual Health Services (CSHS) in collaboration with Cumbria Public Health and local authorities have established a skin care products contact tracing pathway for Cumbria. The local system was live 10 days prior to the national system on 18 May 2020.

It was designed to interface and dovetail with the government’s track and trace programme.Our involvement in this initiative was due to a chance meeting between Professor Matt Phillips, Consultant in Sexual Health and HIV, and the Director of Public Health Cumbria, Colin Cox. Colin knew that Cumbria needed to act fast to prevent the transmission of skin care products and Matt knew that sexual health had the skills to help.ProcessDespite over 90% of the staff from CSHS being redeployed in March 2020, CSHS maintained urgent sexual healthcare for the county and a phone line for advice and guidance. As staff began to return to the service in May 2020 we had capacity to spare seven staff members, whose hours were the equivalent of four full-time staff.

We had one system administrator, three healthcare assistants, one nurse, Health Advisor Helen Musker and myself.CSHS were paramount to the speed with which the local system began. Following approval from the Trust’s chief executive officer we had adapted our electronic patient records (EPR) system, developed a standard operating procedure and trained staff, using a stepwise competency model, within just 1 day.In collaboration with the local laboratories we developed methods for the input of positive skin care products results into our EPR derivative. We ensured that labs would be able to cope with the increase in testing and that testing hubs had additional capacity.

Testing sites and occupational health were asked to inform patients that if they tested positive they would be contacted by our teams.This initiative involved a multiagency system including local public health (PH) teams, local authority, North Cumbria and Morecambe Bay CCGs, Public Health England (PHE) and the military. If CSHS recognise more than one positive result in the same area/organisation, they flag this with PH at the daily incident management meeting and environmental health officers (EHOs) provide advice and guidance for the organisation. We have had an active role in the contact tracing for clusters in local general practices, providing essential information to PH to enable them to initiate outbreak control and provide accurate advice to the practices.

We are an integral part in recognising cases in large organisations and ensuring prompt action is taken to stem the spread of the disease. The team have provided out-of-hours work to ensure timely and efficient action is taken for all contacts.The local contact tracing pilot has evolved and a database was established by local authorities. Our data fed directly into this from the end of May 2020.

This enables the multiagency team to record data in one place, improving recognition of patterns of transmission.DiscussionCumbria is covered by three National Health Service Trusts, which meant accessing data outside of our Trust was challenging and took more time to establish. There are two CCGs for Cumbria, which meant discussions regarding testing were needed with both North and South CCGs and variations in provision had to be accounted for. There are six boroughs in Cumbria with different teams of EHOs working in each.

With so many people involved, not only is there need for large-scale frequent communication across a multisystem team, there is also inevitable duplication of work.Lockdown is easing and sexual health clinics are increasing capacity in a new world of virtual appointments and reduced face-to-face consultations. Staff within the contact tracing team are now balancing their commitments across both teams to maintain their skills and keep abreast of the rapid developments within our service due to skin care products. We are currently applying for funding from PH in order to second staff and backfill posts in sexual health.ConclusionCSHS have been able to lend our skills effectively to the local contact tracing efforts.

We have expedited the contact tracing in Cumbria and provided crucial information to help contain outbreaks. It has had a positive effect on staff morale within the service and we have gained national recognition for our work. We have developed excellent relationships with our local PH team, PHE, Cumbria Council, EHOs and both CCGs.Cumbria has the infrastructure to meet the demands of a second wave of skin care products.

The beauty of this model is that if we are faced with a second lockdown, sexual health staff will inevitably be available to help with the increased demand for contact tracing. Our ambition is that this model will be replicated nationally..

High burden of antibiotic-resistant where can i buy renova over the counter Mycoplasma genitalium in see it here symptomatic urethritisMycoplasma genitalium is an aetiological agent of sexually transmitted urethritis. A cohort study investigated M. Genitalium prevalence, where can i buy renova over the counter antibiotic resistance and association with previous macrolide exposure among 1816 Chinese men who presented with symptomatic urethritis between 2011 and 2015. was diagnosed by PCR, and sequencing was used to detect mutations that confer resistance to macrolides and fluoroquinolones.

In 11% where can i buy renova over the counter of men, M. Genitalium was the sole pathogen identified. Nearly 90% of s were resistant to macrolides and where can i buy renova over the counter fluoroquinolones. Previous macrolide exposure was associated with higher prevalence of resistance (97%).

The findings point to the need for routine where can i buy renova over the counter screening for M. Genitalium in symptomatic men with urethritis. Treatment strategies where can i buy renova over the counter to overcome antibiotic resistance in M. Genitalium are needed.Yang L, Xiaohong S, Wenjing L, et al.

Mycoplasma genitalium where can i buy renova over the counter in symptomatic male urethritis. Macrolide use is associated with increased resistance. Clin Infect Dis 2020;5:805–10. Doi:10.1093/cid/ciz294.A new entry inhibitor offers promise for treatment-experienced patients with multidrug-resistant where can i buy renova over the counter HIVFostemsavir, the prodrug of temsavir, is an attachment inhibitor.

By targeting the gp120 protein on the HIV-1 envelope, it prevents viral interaction with the CD4 receptor. No cross-resistance has been described with other where can i buy renova over the counter antiretroviral agents, including those that target viral entry by other modalities. In the phase III BRIGHTE trial, 371 highly treatment-experienced patients who had exhausted ≥4 classes of antiretrovirals received fostemsavir with an optimised regimen. After 48 where can i buy renova over the counter weeks, 54% of those with 1–2 additional active drugs achieved viral load suppression <40 copies/mL.

Response rates were 38% among patients lacking other active agents. Drug-related adverse events included nausea (4%) and where can i buy renova over the counter diarrhoea (3%). As gp120 substitutions reduced fostemsavir susceptibility in up to 70% of patients with virological failure, fostemsavir offers the most valuable salvage option in partnership with other active drugs.Kozal M, Aberg J, Pialoux G, et al. Fostemsavir in adults with multidrug-resistant where can i buy renova over the counter HIV-1 .

N Engl J Med 2020;382:1232–43. Doi. 10.1056/NEJMoa1902493Novel tools to aid identification of hepatitis C in primary careHepatitis C can now be cured with oral antiviral treatment, and improving diagnosis is a key element of elimination strategies.1 A cluster randomised controlled trial in South West England tested performance and cost-effectiveness of an electronic algorithm that identified at-risk patients in primary care according to national recommendations,2 coupled with educational activities and interventions to increase patients’ awareness. Outcomes were testing uptake, diagnosis and referral to specialist care.

Practices in the intervention arm had an increase in all outcome measures, with adjusted risk ratios of 1.59 (1.21–2.08) for uptake, 2.24 (1.47–3.42) for diagnosis and 5.78 (1.60–21.6) for referral. The intervention was highly cost-effective. Electronic algorithms applied to practice systems could enhance testing and diagnosis of hepatitis C in primary care, contributing to global elimination goals.Roberts K, Macleod J, Metcalfe C, et al. Cost-effectiveness of an intervention to increase uptake of hepatitis C renova testing and treatment (HepCATT).

Cluster randomised controlled trial in primary care. BMJ 2020;368:m322. Doi:10.1136/bmj.m322Low completion rates for antiretroviral postexposure prophylaxis (PEP) after sexual assaultA 4-week course of triple-agent postexposure prophylaxis (PEP) is recommended following a high-risk sexual assault.3 4 A retrospective study in Barcelona identified 1695 victims attending an emergency room (ER) between 2006 and 2015. Overall, 883 (52%) started prophylaxis in ER, which was mostly (43%) lopinavir/ritonavir based.

Follow-up appointments were arranged for those living in Catalonia (631, 71.5%), and of these, only 183 (29%) completed treatment. Loss to follow-up was more prevalent in those residing outside Barcelona. PEP non-completion was associated with a low perceived risk, previous assaults, a known aggressor and a positive cocaine test. Side effects were common, occurring in up to 65% of those taking lopinavir/ritonavir and accounting for 15% of all discontinuations.

More tolerable PEP regimens, accessible follow-up and provision of 1-month supply may improve completion rates.Inciarte A, Leal L, Masfarre L, et al. Postexposure prophylaxis for HIV in sexual assault victims. HIV Med 2020;21:43–52. Doi:10.1111/hiv.12797.Effective antiretroviral therapy reduces anal high-risk HPV and cancer riskAmong people with HIV, effective antiretroviral therapy (ART) is expected to improve control of anal with high-risk human papillomarenova (HR-HPV) and reduce the progression of HPV-associated anal lesions.

The magnitude of the effect is not well established. By meta-analysis, people on established ART (vs ART-naive) had a 35% lower prevalence of HR-HPV , and those with undetectable viral load (vs detectable viral load) had a 27% and 16% reduced risk of low and high-grade anal lesions, respectively. Sustained virological suppression on ART reduced by 44% the risk of anal cancer. The role of effective ART in reducing anal HR-HPV and cancer risks is especially salient given current limitations in anal cancer screening, high rates of anal lesion recurrence and access to vaccination.Kelly H, Chikandiwa A, Alemany Vilches L, et al.

Association of antiretroviral therapy with anal high-risk human papillomarenova, anal intraepithelial neoplasia and anal cancer in people living with HIV. A systematic review and meta-analysis. Lancet HIV. 2020;7:e262–78.

Doi:10.1016/S2352-3018(19)30434-5.The impact of sex work laws and stigma on HIV prevention among female sex workersSex work laws and stigma have been established as structural risk factors for HIV acquisition among female sex workers (FSWs). However, individual-level data assessing these relationships are limited. A study examined individual-level data collected in 2011–2018 from 7259 FSWs across 10 sub-Saharan African countries. An association emerged between HIV prevalence and increasingly punitive and non-protective laws.

HIV prevalence among FSWs was 11.6%, 19.6% and 39.4% in contexts where sex work was partly legalised, not recognised or criminalised, respectively. Stigma measures such as fear of seeking health services, mistreatment in healthcare settings, lack of police protection, blackmail and violence were associated with higher HIV prevalence and more punitive settings. Sex work laws that protect sex workers and reduce structural risks are needed.Lyons CE, Schwartz SR, Murray SM, et al. The role of sex work laws and stigmas in increasing HIV risks among sex workers.

Nat Commun 2020;11:773. Doi:10.1038/s41467-020-14593-6.BackgroundCumbria Sexual Health Services (CSHS) in collaboration with Cumbria Public Health and local authorities have established a skin care products contact tracing pathway for Cumbria. The local system was live 10 days prior to the national system on 18 May 2020. It was designed to interface and dovetail with the government’s track and trace programme.Our involvement in this initiative was due to a chance meeting between Professor Matt Phillips, Consultant in Sexual Health and HIV, and the Director of Public Health Cumbria, Colin Cox.

Colin knew that Cumbria needed to act fast to prevent the transmission of skin care products and Matt knew that sexual health had the skills to help.ProcessDespite over 90% of the staff from CSHS being redeployed in March 2020, CSHS maintained urgent sexual healthcare for the county and a phone line for advice and guidance. As staff began to return to the service in May 2020 we had capacity to spare seven staff members, whose hours were the equivalent of four full-time staff. We had one system administrator, three healthcare assistants, one nurse, Health Advisor Helen Musker and myself.CSHS were paramount to the speed with which the local system began. Following approval from the Trust’s chief executive officer we had adapted our electronic patient records (EPR) system, developed a standard operating procedure and trained staff, using a stepwise competency model, within just 1 day.In collaboration with the local laboratories we developed methods for the input of positive skin care products results into our EPR derivative.

We ensured that labs would be able to cope with the increase in testing and that testing hubs had additional capacity. Testing sites and occupational health were asked to inform patients that if they tested positive they would be contacted by our teams.This initiative involved a multiagency system including local public health (PH) teams, local authority, North Cumbria and Morecambe Bay CCGs, Public Health England (PHE) and the military. If CSHS recognise more than one positive result in the same area/organisation, they flag this with PH at the daily incident management meeting and environmental health officers (EHOs) provide advice and guidance for the organisation. We have had an active role in the contact tracing for clusters in local general practices, providing essential information to PH to enable them to initiate outbreak control and provide accurate advice to the practices.

We are an integral part in recognising cases in large organisations and ensuring prompt action is taken to stem the spread of the disease. The team have provided out-of-hours work to ensure timely and efficient action is taken for all contacts.The local contact tracing pilot has evolved and a database was established by local authorities. Our data fed directly into this from the end of May 2020. This enables the multiagency team to record data in one place, improving recognition of patterns of transmission.DiscussionCumbria is covered by three National Health Service Trusts, which meant accessing data outside of our Trust was challenging and took more time to establish.

There are two CCGs for Cumbria, which meant discussions regarding testing were needed with both North and South CCGs and variations in provision had to be accounted for. There are six boroughs in Cumbria with different teams of EHOs working in each. With so many people involved, not only is there need for large-scale frequent communication across a multisystem team, there is also inevitable duplication of work.Lockdown is easing and sexual health clinics are increasing capacity in a new world of virtual appointments and reduced face-to-face consultations. Staff within the contact tracing team are now balancing their commitments across both teams to maintain their skills and keep abreast of the rapid developments within our service due to skin care products.

We are currently applying for funding from PH in order to second staff and backfill posts in sexual health.ConclusionCSHS have been able to lend our skills effectively to the local contact tracing efforts. We have expedited the contact tracing in Cumbria and provided crucial information to help contain outbreaks. It has had a positive effect on staff morale within the service and we have gained national recognition for our work. We have developed excellent relationships with our local PH team, PHE, Cumbria Council, EHOs and both CCGs.Cumbria has the infrastructure to meet the demands of a second wave of skin care products.

The beauty of this model is that if we are faced with a second lockdown, sexual health staff will inevitably be available to help with the increased demand for contact tracing. Our ambition is that this model will be replicated nationally..