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With many of us still cooped up at home in coronavirus limbo, some genius YouTube accounts have allowed us to revisit the graffitied laneways of Melbourne, explore bustling Vancouver, or the idyllic Amalfi Coast on (virtual) foot can you buy diflucan over the counter in canada. Enter the world of online walking tours. It’s travel without can you buy diflucan over the counter in canada leaving your house. Walking is a wonderful and pretty effortless physical exercise, but its benefits for your mental wellbeing can’t be understated.

Breathing in the fresh air and getting lost in the rhythm of placing one foot in front of the other can be restorative, even meditative.Studies have shown a brisk, 30-minute walk just three times a week can increase quality of sleep, improve your mood, decrease anxiety, and even restore your sex drive.It’s something we also can you buy diflucan over the counter in canada tend to do a LOT of when we’re travelling. Public transport in a foreign country can sometimes be intimidating, plus lazily meandering around the streets can lead to some truly memorable meals and discoveries.Travelling itself is also mentally beneficial, with studies showing it can strengthen your relationships, broaden your horizons by making you step outside your comfort zone, and lower cortisol levels, making you feel calm and content.Like what you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like this.But with almost the entire world on pause right now, venturing can you buy diflucan over the counter in canada out (further than 5km from home) has become a lot more difficult, even on foot.Take a walk, digitallyEnter the world of virtual walking. An increasingly popular community of YouTubers taking viewers on tours of some of the world’s most beautiful and energised locations all from the comfort of your own home.Search ‘walking tour’ on YouTube and the video streaming site will produce thousands of results.

The most popular account is ProWalk Tours with 182,000 subscribers, which have actually been making can you buy diflucan over the counter in canada videos of this kind for three years. They take viewers through the ruins of Pompeii, Cairo’s famous Khan el-Khalili bazaar, and the streets of Vancouver, all shot from first-person perspective so you could feel like you’re actually there.Now, especially for the Melbournians experiencing the harshest restrictions in the country, you can still visit some of your favourite city haunts, like the Fitzroy Gardens, Queen Vic Market, even Federation Square at Christmas time where hordes of people (remember people?. ) gather to watch children’s stories on the big screen while can you buy diflucan over the counter in canada Flinders St Station glimmers with festive twinkle lights. All in glorious 4K.In videos shot by The First Person, it's rather soothing to return to normalcy and a recording of everyday history.

These videos aren't can you buy diflucan over the counter in canada escapism necessarily, but more of a reliving of the mundane moments that made up life before quarantine. The walk along Bourke St in peak hour, or a quiet stroll through the rolling hills of Cape Schank on the Mornington Peninsula. Basic moments of existence that have been temporarily stripped away.As good as the real can you buy diflucan over the counter in canada thing?. Of course, this sort of faux escapism isn’t a complete substitute for the real thing, though the videos do offer some calming benefits at a time when we have no choice but to stay in one place.

They're almost nostalgic.Clinical psychologist Amanda Gordon, Director at can you buy diflucan over the counter in canada Armchair Psychology, says virtual walking and touring offers a chance for people to plan, to dream, and build a sense of optimism through nostalgia for the good ol’ days.It’s a Band-Aid solution in extraordinary times, for sure, but it just isn’t the same as actually being there.“People will always need to move around,” she says.“When we are actually in the place we not only see and hear, we smell the smells, touch the surfaces, connect with other people on our journey. The physical is not just the exercise we get, it is an all-round experience.”Stephanie Nuzzo was inspired when actress Hilary Duff shared her iso fitness regimen - and when she tried it herself, the flexibility and structured routine left her feeling better than ever.I don't know about you guys, but 2020 has thrown a wrench into my fitness plans. Back in February, I was feeling great can you buy diflucan over the counter in canada. I was training regularly.

Building strength—all that jazz.Then COVID can you buy diflucan over the counter in canada happened, and my gym days stopped. While I recognise that a dip in fitness is nothing compared to the tragic circumstances people are living through right now, it was a part of my life that changed. And finding an alternative regime that gives can you buy diflucan over the counter in canada me the same mental and physical satisfaction has been tricky.For context, I was living in New York when corona kicked off. As a result, I was stuck in my apartment for four months.

Space was can you buy diflucan over the counter in canada limited, and there was nary a dumbbell to be found. Considering the world was on fire, I let go of fitness goals and began working out in a more laid-back fashion.Fast forward a few months, I was back in Australia when I noticed an interesting Instagram post. Hilary Duff had shared a photo of her can you buy diflucan over the counter in canada rig, commemorating the progress she'd made on her fitness journey in iso. She looked lean as ever.Now, I've attempted to follow Duff's health plan in the past, and it was a positive experience for me.

So, when I saw she had found an at-home can you buy diflucan over the counter in canada program that was maintaining her fitness, I was intrigued. Could I do the same?. I wanted to find out.Like what can you buy diflucan over the counter in canada you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like this.What did it involve?.

In her post, Duff credited can you buy diflucan over the counter in canada her success to two things. Counting her macros and training with Novo Body Fitness. I gave both a whirl for a week.First, I consulted the team at Novo Body for some can you buy diflucan over the counter in canada insight into the workouts Duff was doing at home. They were kind enough to share a few workout videos with me and explained that Duff completed their strength-training sessions four to five times a week.I then reached out to Dietitian Nicola Moore of Lifeshape about counting my macros.

If you're new to can you buy diflucan over the counter in canada this term, allow me to offer a quick intro. Macros, or macronutrients, include carbohydrates, fats and proteins. This style of eating involves can you buy diflucan over the counter in canada counting how many grams you consume of each food group. The amounts depend on you and your goals.When I last mirrored Duff's health routine, Moore advised I eat five times a day.

She gave me meal examples to work from and suggested I eat five cups of can you buy diflucan over the counter in canada veggies daily with smaller servings of meat, dairy and grains. Nothing was off-limits, however, I just needed to balance what I was eating to keep my number of macros the same.This time, I asked if I should shift my diet to account for our more sedentary reality (#covidlife). Moore recommended the same plan but said I should move regularly while working from home, and that it would be best to set structured meal breaks.How did I go?. I hadn't touched a dumbbell in five months, so my first attempt left me feeling like a can you buy diflucan over the counter in canada baby deer.

While I found the workouts exhilarating, I had to make allowances for the fact that I'd lost strength.This, according to Louise Hazel – Olympian, Fitness Expert and owner of Slay Gym in L.A – is something we need to pay attention to at the moment."In our haste to get back to training again, sometimes we overlook a number of things. Where strength training is concerned, the most important thing can you buy diflucan over the counter in canada is foundation. You have to start thinking about your body as if you are building a house. If you try and stack bricks on sand, then the foundation caves in and that's where injury occurs," she explained to me."I've seen it so many times, people taking on strength training programs that they've seen from celebrities, or can you buy diflucan over the counter in canada been given from influencers, and they're quite simply not yet prepared for them."She recommended, "starting off at a beginner level, whether you've been training for a long time or not."I adapted the routines to avoid overextendingWith that considered, I made sure not to overextend myself with the weight I was lifting.

I worked hard but was able to complete five workouts without cursing myself for signing up to this experiment.When it comes to food, I mostly felt comfortable with my plan. I usually stuck to the meals that Moore gave me, however, because measuring an item to swap it can you buy diflucan over the counter in canada out for another felt too time-consuming.Then there was the fact that I somehow forgot I'd agreed to do this diet over my birthday. Attempting to count the macros in cake and making allowances for that was near impossible for me. It's safe to say I failed at least once can you buy diflucan over the counter in canada.

Sorry, Hilary!. What were can you buy diflucan over the counter in canada the results?. This might be the best thing I've done for my health since quarantine kicked off.I was able to approach my diet and fitness with a consistency that I'd lost for months. It became easier to make healthier choices, but I didn't cut anything out of my diet, so I wasn't longing can you buy diflucan over the counter in canada for a cheat meal.Getting up in the mornings became easier, and my energy levels lasted throughout the day.

I even started looking forward to my workouts (what?. ). Lastly, I saw changes in my body, too. I lost about a kilo, I felt less bloated, and my clothes fit better.

Most importantly, the program worked for my body and didn't leave me wanting to punch a wall.In a year like this one especially, the ultimate goal is finding a routine that leaves you feeling great. If you end up with a bod like Duff, that’s a brilliant bonus, but nothing quite compares to a positive headspace, a strong body… and the occasional slice of birthday cake.With many of us still cooped up at home in coronavirus limbo, some genius YouTube accounts have allowed us to revisit the graffitied laneways of Melbourne, explore bustling Vancouver, or the idyllic Amalfi Coast on (virtual) foot. Enter the world of online walking tours. It’s travel without leaving your house.

Walking is a wonderful and pretty effortless physical exercise, but its benefits for your mental wellbeing can’t be understated. Breathing in the fresh air and getting lost in the rhythm of placing one foot in front of the other can be restorative, even meditative.Studies have shown a brisk, 30-minute walk just three times a week can increase quality of sleep, improve your mood, decrease anxiety, and even restore your sex drive.It’s something we also tend to do a LOT of when we’re travelling. Public transport in a foreign country can sometimes be intimidating, plus lazily meandering around the streets can lead to some truly memorable meals and discoveries.Travelling itself is also mentally beneficial, with studies showing it can strengthen your relationships, broaden your horizons by making you step outside your comfort zone, and lower cortisol levels, making you feel calm and content.Like what you see?. Sign up to our bodyandsoul.com.au newsletter for more stories like this.But with almost the entire world on pause right now, venturing out (further than 5km from home) has become a lot more difficult, even on foot.Take a walk, digitallyEnter the world of virtual walking.

An increasingly popular community of YouTubers taking viewers on tours of some of the world’s most beautiful and energised locations all from the comfort of your own home.Search ‘walking tour’ on YouTube and the video streaming site will produce thousands of results. The most popular account is ProWalk Tours with 182,000 subscribers, which have actually been making videos of this kind for three years. They take viewers through the ruins of Pompeii, Cairo’s famous Khan el-Khalili bazaar, and the streets of Vancouver, all shot from first-person perspective so you could feel like you’re actually there.Now, especially for the Melbournians experiencing the harshest restrictions in the country, you can still visit some of your favourite city haunts, like the Fitzroy Gardens, Queen Vic Market, even Federation Square at Christmas time where hordes of people (remember people?. ) gather to watch children’s stories on the big screen while Flinders St Station glimmers with festive twinkle lights.

All in glorious 4K.In videos shot by The First Person, it's rather soothing to return to normalcy and a recording of everyday history. These videos aren't escapism necessarily, but more of a reliving of the mundane moments that made up life before quarantine. The walk along Bourke St in peak hour, or a quiet stroll through the rolling hills of Cape Schank on the Mornington Peninsula. Basic moments of existence that have been temporarily stripped away.As good as the real thing?.

Of course, this sort of faux escapism isn’t a complete substitute for the real thing, though the videos do offer some calming benefits at a time when we have no choice but to stay in one place. They're almost nostalgic.Clinical psychologist Amanda Gordon, Director at Armchair Psychology, says virtual walking and touring offers a chance for people to plan, to dream, and build a sense of optimism through nostalgia for the good ol’ days.It’s a Band-Aid solution in extraordinary times, for sure, but it just isn’t the same as actually being there.“People will always need to move around,” she says.“When we are actually in the place we not only see and hear, we smell the smells, touch the surfaces, connect with other people on our journey. The physical is not just the exercise we get, it is an all-round experience.”Stephanie Nuzzo was inspired when actress Hilary Duff shared her iso fitness regimen - and when she tried it herself, the flexibility and structured routine left her feeling better than ever.I don't know about you guys, but 2020 has thrown a wrench into my fitness plans. Back in February, I was feeling great.

I was training regularly. Building strength—all that jazz.Then COVID happened, and my gym days stopped. While I recognise that a dip in fitness is nothing compared to the tragic circumstances people are living through right now, it was a part of my life that changed. And finding an alternative regime that gives me the same mental and physical satisfaction has been tricky.For context, I was living in New York when corona kicked off.

As a result, I was stuck in my apartment for four months. Space was limited, and there was nary a dumbbell to be found. Considering the world was on fire, I let go of fitness goals and began working out in a more laid-back fashion.Fast forward a few months, I was back in Australia when I noticed an interesting Instagram post. Hilary Duff had shared a photo of her rig, commemorating the progress she'd made on her fitness journey in iso.

She looked lean as ever.Now, I've attempted to follow Duff's health plan in the past, and it was a positive experience for me. So, when I saw she had found an at-home program that was maintaining her fitness, I was intrigued. Could I do the same?. I wanted to find out.Like what you see?.

Sign up to our bodyandsoul.com.au newsletter for more stories like this.What did it involve?. In her post, Duff credited her success to two things. Counting her macros and training with Novo Body Fitness. I gave both a whirl for a week.First, I consulted the team at Novo Body for some insight into the workouts Duff was doing at home.

They were kind enough to share a few workout videos with me and explained that Duff completed their strength-training sessions four to five times a week.I then reached out to Dietitian Nicola Moore of Lifeshape about counting my macros. If you're new to this term, allow me to offer a quick intro. Macros, or macronutrients, include carbohydrates, fats and proteins. This style of eating involves counting how many grams you consume of each food group.

The amounts depend on you and your goals.When I last mirrored Duff's health routine, Moore advised I eat five times a day. She gave me meal examples to work from and suggested I eat five cups of veggies daily with smaller servings of meat, dairy and grains. Nothing was off-limits, however, I just needed to balance what I was eating to keep my number of macros the same.This time, I asked if I should shift my diet to account for our more sedentary reality (#covidlife). Moore recommended the same plan but said I should move regularly while working from home, and that it would be best to set structured meal breaks.How did I go?.

I hadn't touched a dumbbell in five months, so my first attempt left me feeling like a baby deer. While I found the workouts exhilarating, I had to make allowances for the fact that I'd lost strength.This, according to Louise Hazel – Olympian, Fitness Expert and owner of Slay Gym in L.A – is something we need to pay attention to at the moment."In our haste to get back to training again, sometimes we overlook a number of things. Where strength training is concerned, the most important thing is foundation. You have to start thinking about your body as if you are building a house.

If you try and stack bricks on sand, then the foundation caves in and that's where injury occurs," she explained to me."I've seen it so many times, people taking on strength training programs that they've seen from celebrities, or been given from influencers, and they're quite simply not yet prepared for them."She recommended, "starting off at a beginner level, whether you've been training for a long time or not."I adapted the routines to avoid overextendingWith that considered, I made sure not to overextend myself with the weight I was lifting. I worked hard but was able to complete five workouts without cursing myself for signing up to this experiment.When it comes to food, I mostly felt comfortable with my plan. I usually stuck to the meals that Moore gave me, however, because measuring an item to swap it out for another felt too time-consuming.Then there was the fact that I somehow forgot I'd agreed to do this diet over my birthday. Attempting to count the macros in cake and making allowances for that was near impossible for me.

It's safe to say I failed at least once. Sorry, Hilary!. What were the results?. This might be the best thing I've done for my health since quarantine kicked off.I was able to approach my diet and fitness with a consistency that I'd lost for months.

It became easier to make healthier choices, but I didn't cut anything out of my diet, so I wasn't longing for a cheat meal.Getting up in the mornings became easier, and my energy levels lasted throughout the day. I even started looking forward to my workouts (what?. ). Lastly, I saw changes in my body, too.

I lost about a kilo, I felt less bloated, and my clothes fit better. Most importantly, the program worked for my body and didn't leave me wanting to punch a wall.In a year like this one especially, the ultimate goal is finding a routine that leaves you feeling great. If you end up with a bod like Duff, that’s a brilliant bonus, but nothing quite compares to a positive headspace, a strong body… and the occasional slice of birthday cake..

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

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

Doi:10.1093/cid/ciz294.A new 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 diflucan one breastfeeding on the HIV-1 envelope, it prevents viral interaction with the CD4 receptor. No cross-resistance has been described with other antiretroviral agents, including those that target viral entry by other modalities.

In the phase III BRIGHTE trial, 371 highly treatment-experienced patients who …BackgroundCumbria Sexual Health Services (CSHS) in collaboration with Cumbria Public Health and local authorities have established a COVID-19 contact tracing pathway for Cumbria. The local system was live 10 days prior to the national system on diflucan one breastfeeding 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 hop over to here that Cumbria needed to act fast to prevent the transmission of COVID-19 and Matt knew that sexual health had the skills to help.ProcessDespite over 90% of the diflucan one breastfeeding 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 diflucan one breastfeeding 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 COVID-19 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 diflucan one breastfeeding 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 diflucan one breastfeeding 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 diflucan one breastfeeding 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 diflucan one breastfeeding. There are six boroughs in Cumbria with different teams of EHOs working in each. With so many people involved, diflucan one breastfeeding 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 COVID-19. 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 diflucan one breastfeeding 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 diflucan one breastfeeding our local PH team, PHE, Cumbria Council, EHOs and both CCGs.Cumbria has the infrastructure to meet the demands of a second wave of COVID-19. 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.

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High burden of antibiotic-resistant Mycoplasma genitalium in symptomatic urethritisMycoplasma site here genitalium is an aetiological agent of can you buy diflucan over the counter in canada sexually transmitted urethritis. A cohort study investigated M. Genitalium prevalence, antibiotic resistance and association with previous macrolide exposure among 1816 Chinese men who presented can you buy diflucan over the counter in canada with symptomatic urethritis between 2011 and 2015. Infection was diagnosed by PCR, and sequencing was used to detect mutations that confer resistance to macrolides and fluoroquinolones. In 11% of men, M can you buy diflucan over the counter in canada.

Genitalium was the sole pathogen identified. Nearly 90% of infections were resistant to macrolides and fluoroquinolones. Previous macrolide exposure was associated with higher can you buy diflucan over the counter in canada prevalence of resistance (97%). The findings point to the need for routine screening for M. Genitalium in can you buy diflucan over the counter in canada symptomatic men with urethritis.

Treatment strategies to overcome antibiotic resistance in M. Genitalium are needed.Yang L, Xiaohong S, can you buy diflucan over the counter in canada Wenjing L, et al. Mycoplasma genitalium in symptomatic male urethritis. Macrolide use is associated with increased resistance. Clin Infect Dis 2020;5:805–10 can you buy diflucan over the counter in canada.

Doi:10.1093/cid/ciz294.A new 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 can you buy diflucan over the counter in canada the CD4 receptor. No cross-resistance has been described with other antiretroviral agents, including those that target viral entry by other modalities. In the phase III BRIGHTE trial, 371 highly treatment-experienced patients who …BackgroundCumbria Sexual Health Services (CSHS) in collaboration with Cumbria Public Health and local authorities have established a COVID-19 contact tracing pathway for Cumbria. The local can you buy diflucan over the counter in canada 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 COVID-19 and Matt knew that sexual health had the skills to can you buy diflucan over the counter in canada help.ProcessDespite over 90% of the staff from CSHS being redeployed in March 2020, CSHS maintained urgent sexual healthcare discharge after diflucan 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 can you buy diflucan over the counter in canada 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 COVID-19 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 can you buy diflucan over the counter in canada 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 can you buy diflucan over the counter in canada 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 can you buy diflucan over the counter in canada 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 can you buy diflucan over the counter in canada 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 can you buy diflucan over the counter in canada 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 COVID-19. 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 can you buy diflucan over the counter in canada 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 can you buy diflucan over the counter in canada PH team, PHE, Cumbria Council, EHOs and both CCGs.Cumbria has the infrastructure to meet the demands of a second wave of COVID-19. 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..

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Visit your doctor or health care professional for regular checkups. If you are taking Diflucan for a long time you may need blood work. Tell your doctor if your symptoms do not improve. Some fungal infections need many weeks or months of treatment to cure.

Alcohol can increase possible damage to your liver. Avoid alcoholic drinks.

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Here are eight ways how many diflucan pills can i take to help minimize meat processing workers’ exposure to the coronavirus. Screen workers before they enter the workplace. If a worker becomes sick, send them home and disinfect their workstation and any tools they used.

Move workstations how many diflucan pills can i take farther apart. Install partitions between workstations using strip curtains, plexiglass, or similar materials. To limit spread between groups, assign the same workers to the same shifts with the same coworkers.

Prevent workers from using other workers’ how many diflucan pills can i take equipment. Allow workers to wear face coverings when entering, inside, and exiting the facility. Encourage workers to report any safety and health concerns to their supervisors.

OSHA is committed to ensuring that workers and employers in essential industries have clear guidance to keep workers safe and healthy from the how many diflucan pills can i take coronavirus—including guidance for essential workers in construction, manufacturing, package delivery, and retail. Workers and employers who have questions or concerns about workplace safety can contact OSHA online or by phone at 1-800-321-6742 (OSHA). You can find additional resources and learn more about OSHA’s response to the coronavirus at www.osha.gov/coronavirus.

Loren Sweatt is how many diflucan pills can i take the Principal Deputy Assistant Secretary for the U.S. Department of Labor’s Occupation Safety and Health Administration Editor’s Note. It is important to note that information and guidance about COVID-19 continually evolve as conditions change.

Workers and employers are encouraged to regularly refer to the resources below for updates:One in 10 people in the United States will get the flu in a how many diflucan pills can i take given season, according to estimates from the Centers for Disease Control and Prevention. And while viruses can live all year round, flu activity tends to rise in October and then peak between December and February. With COVID-19 a factor this year, it's even more important to take precautions to prevent the flu from spreading.

Here are how many diflucan pills can i take 10 ways to keep workers safe. Recommend all workers get vaccinated. Vaccination is the most important way to prevent the spread of the flu.

It takes about two weeks for flu antibodies how many diflucan pills can i take to develop, so the time to get a shot is before peak flu season. Encourage workers to stay home if they are sick. The Centers for Disease Control and Prevention recommend that workers who have a fever and respiratory symptoms stay at home until 24 hours after their fever ends (100 degrees Fahrenheit or lower) without the use of medication.

Not everyone diflucan 1 tableta cena who has the how many diflucan pills can i take flu will have a fever. Other symptoms can include a runny nose, body aches, headache, fatigue, diarrhea or vomiting. Wash hands frequently with soap and water for 20 seconds.

Use an alcohol-based hand rub if soap how many diflucan pills can i take and water are not available. When using soap and water, rub soapy hands together for at least 20 seconds, rinse with water, and dry completely. If soap and water are not available, use an alcohol-based hand rub until you can wash your hands.

Continue practicing how many diflucan pills can i take social distancing. Staying at least 6 feet apart from co-workers, whenever possible, can help prevent the spread of the flu. Cover coughs and sneezes with a tissue or upper sleeve.

Tissues should go into a "no-touch" wastebasket and wash your hands after how many diflucan pills can i take coughing, sneezing or blowing your nose. Avoid touching your face. Keep frequently touched surfaces clean.

Commonly used surfaces how many diflucan pills can i take such as counters, door handles, phones, computer keyboards and touchpads should be cleaned after each use. Limit shared equipment or clean equipment before others use it. Avoid using a co-worker's phone, desk, office, computer or other equipment unless they are cleaned with an EPA-approved disinfectant.

Training is how many diflucan pills can i take knowledge. Make sure all workers understand how to stay healthy at work during flu season, including new and temporary workers. Wear a face covering.

These can help limit the flu's how many diflucan pills can i take spread. Consider alternate work arrangements. If feasible, offer options such as telework or staggered shifts for workers considered high risk for seasonal flu (such as older workers, pregnant women, and those with asthma).

Learn more about workplace safety and how many diflucan pills can i take the flu on OSHA's website. You can find additional resources and learn more about OSHA's response to the coronavirus at osha.gov/coronavirus. Workers and employers who have questions or concerns about workplace safety can contact OSHA online or by phone at 1-800-321-6742 (OSHA).

Loren Sweatt is the Principal Deputy Assistant Secretary for the U.S how many diflucan pills can i take. Department of Labor's Occupational Safety and Health Administration. Follow OSHA on Twitter at @OSHA_DOL..

Protecting the safety can you buy diflucan over the counter in canada and health of essential workers who how long should you wait to take diflucan after antibiotics support America’s food security—including the meat, poultry, and pork processing industries—is a top priority for the Occupational Safety and Health Administration (OSHA). OSHA and the Centers for Disease Control and Prevention issued additional guidance to reduce the risk of exposure to the coronavirus and keep workers safe and healthy in the meatpacking and meat processing industries —including those involved in beef, pork, and poultry operations. This new guidance provides specific recommendations for employers to meet their obligations to protect workers in these facilities, where people normally work closely together and share workspaces and equipment. Here are can you buy diflucan over the counter in canada eight ways to help minimize meat processing workers’ exposure to the coronavirus. Screen workers before they enter the workplace.

If a worker becomes sick, send them home and disinfect their workstation and any tools they used. Move workstations can you buy diflucan over the counter in canada farther apart. Install partitions between workstations using strip curtains, plexiglass, or similar materials. To limit spread between groups, assign the same workers to the same shifts with the same coworkers. Prevent workers from using other can you buy diflucan over the counter in canada workers’ equipment.

Allow workers to wear face coverings when entering, inside, and exiting the facility. Encourage workers to report any safety and health concerns to their supervisors. OSHA is can you buy diflucan over the counter in canada committed to ensuring that workers and employers in essential industries have clear guidance to keep workers safe and healthy from the coronavirus—including guidance for essential workers in construction, manufacturing, package delivery, and retail. Workers and employers who have questions or concerns about workplace safety can contact OSHA online or by phone at 1-800-321-6742 (OSHA). You can find additional resources and learn more about OSHA’s response to the coronavirus at www.osha.gov/coronavirus.

Loren Sweatt is the Principal Deputy Assistant Secretary for the can you buy diflucan over the counter in canada U.S. Department of Labor’s Occupation Safety and Health Administration Editor’s Note. It is important to note that information and guidance about COVID-19 continually evolve as conditions change. Workers and employers are encouraged to regularly refer to the resources below for updates:One in 10 people in the United can you buy diflucan over the counter in canada States will get the flu in a given season, according to estimates from the Centers for Disease Control and Prevention. And while viruses can live all year round, flu activity tends to rise in October and then peak between December and February.

With COVID-19 a factor this year, it's even more important to take precautions to prevent the flu from spreading. Here are can you buy diflucan over the counter in canada 10 ways to keep workers safe. Recommend all workers get vaccinated. Vaccination is the most important way to prevent the spread of the flu. It takes about two weeks for flu antibodies to can you buy diflucan over the counter in canada develop, so the time to get a shot is before peak flu season.

Encourage workers to stay home if they are sick. The Centers for Disease Control and Prevention recommend that workers who have a fever and respiratory symptoms stay at home until 24 hours after their fever ends (100 degrees Fahrenheit or lower) without the use of medication. Not everyone can you buy diflucan over the counter in canada who has the flu will have a fever. Other symptoms can include a runny nose, body aches, headache, fatigue, diarrhea or vomiting. Wash hands frequently with soap and water for 20 seconds.

Use an alcohol-based hand can you buy diflucan over the counter in canada rub if soap and water are not available. When using soap and water, rub soapy hands together for at least 20 seconds, rinse with water, and dry completely. If soap and water are not available, use an alcohol-based hand rub until you can wash your hands. Continue practicing social distancing can you buy diflucan over the counter in canada. Staying at least 6 feet apart from co-workers, whenever possible, can help prevent the spread of the flu.

Cover coughs and sneezes with a tissue or upper sleeve. Tissues should go into a "no-touch" wastebasket and can you buy diflucan over the counter in canada wash your hands after coughing, sneezing or blowing your nose. Avoid touching your face. Keep frequently touched surfaces clean. Commonly used surfaces such as counters, can you buy diflucan over the counter in canada door handles, phones, computer keyboards and touchpads should be cleaned after each use.

Limit shared equipment or clean equipment before others use it. Avoid using a co-worker's phone, desk, office, computer or other equipment unless they are cleaned with an EPA-approved disinfectant. Training is knowledge can you buy diflucan over the counter in canada. Make sure all workers understand how to stay healthy at work during flu season, including new and temporary workers. Wear a face covering.

These can help limit the flu's can you buy diflucan over the counter in canada spread. Consider alternate work arrangements. If feasible, offer options such as telework or staggered shifts for workers considered high risk for seasonal flu (such as older workers, pregnant women, and those with asthma). Learn more about workplace safety and the can you buy diflucan over the counter in canada flu on OSHA's website. You can find additional resources and learn more about OSHA's response to the coronavirus at osha.gov/coronavirus.

Workers and employers who have questions or concerns about workplace safety can contact OSHA online or by phone at 1-800-321-6742 (OSHA). Loren Sweatt is the Principal can you buy diflucan over the counter in canada Deputy Assistant Secretary for the U.S. Department of Labor's Occupational Safety and Health Administration. Follow OSHA on Twitter at @OSHA_DOL..

How fast does diflucan work

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A key consideration in timing of aortic valve replacement (AVR) for patients with aortic stenosis (AS) is how fast does diflucan work whether there is an increased risk of sudden cardiac death (SCD) that might be reduced these details by relief of outflow obstruction. Minners and colleagues1 addressed this issue in a retrospective analysis of outcomes in 1840 patients with how fast does diflucan work mild to moderate AS (aortic maximum velocity 2.5–4.0 m/s) in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Overall the annualised rate of SCD was 0.39% per year with 27 events in asymptomatic patients. The most recent echocardiogram prior to SCD showed mild–moderate AS in most (80%) of these patients with no difference in SCD event rates in those who progressed to severe AS compared to those who how fast does diflucan work did not develop severe valve obstruction.

On Cox regression analysis, the only independent risk factors for SCD were age (HR 1.06, 95% CI 1.01 to 1.11 per year, p=0.02), increased left ventricular mass index (HR 1.20, 95% CI 1.10 to 1.32 per 10 g/m2, p<0.001) and lower body mass index (HR 0.87, 95% CI 0.79 how fast does diflucan work to 0.97 per kg/m2, p=0.01) but not the severity of valve obstruction (figure 1).Univariate (top) and multivariate (bottom) Cox regression analyses for SCD during 46.1±14.6 months of follow-up in the Simvastatin and Ezetimibe in Aortic Stenosis study. The number of events for each variable is reflected by the dark, horizontal bars with separation at the median for continuous variables. A forest how fast does diflucan work plot visualisation of HRs for SCD is provided on the right. LVED, left ventricular enddiastolic diameter.

LVES, left how fast does diflucan work ventricular endsystolic diameter. LVM, left how fast does diflucan work ventricular mass. SCD, sudden cardiac death." data-icon-position data-hide-link-title="0">Figure 1 Univariate (top) and multivariate (bottom) Cox regression analyses for SCD during 46.1±14.6 months of follow-up in the Simvastatin and Ezetimibe in Aortic Stenosis study. The number how fast does diflucan work of events for each variable is reflected by the dark, horizontal bars with separation at the median for continuous variables.

A forest plot visualisation of HRs for SCD is provided on the right. LVED, left ventricular enddiastolic how fast does diflucan work diameter. LVES, left ventricular how fast does diflucan work endsystolic diameter. LVM, left ventricular mass.

SCD, sudden cardiac death.The lack of association between AS severity and the risk of SCD in the SEAS study is thought-provoking and challenges the conventional wisdom that early AVR would prevent SCD in asymptomatic patients with AS.2 In the past, syncope and SCD in patients with AS were thought to be due to mechanisms such as left ventricle (LV) baroreceptor malfunction, hypotension secondary to peripheral vasodilation in the face of fixed valve obstruction, or a shortened diastolic filling interval at high how fast does diflucan work heart rates leading to a reduced stroke volume. However, it is doubtful that any of these mechanisms would account for SCD when AS is only how fast does diflucan work mild to moderate in severity. €˜It is increasingly recognised that that AS is not simply a mechanical problem of the valve leaflets not opening fully. Instead, AS compromises a complex interplay between the valve, how fast does diflucan work ventricle and vasculature with abnormal function of all three components of the disease process.’ As I conclude in an editorial, ‘It is unlikely that early AVR will reduce the risk of sudden death when severe valve obstruction is not present.

Perhaps it is time to turn our attention to mitigating the non-valvular disease processes in adults with calcific valve disease.’In another interesting paper in this issue of Heart, Williams and Brown3 hypothesised that the apparent benefit of fractional flow reserve (FFR) guidance of percutaneous coronary intervention (PCI) in patients with chronic coronary syndromes (CCS) might simply be due to utilisation of fewer stents rather than to knowledge about the physiological severity of the coronary lesions. In a Monte Carlo simulation using data from the PCI strata of the Bypass Angioplasty Revascularization Investigation 2 Diabetes study, random deferral of PCI progressively reduced the risk of death and myocardial infarction at 1 year, suggesting that FFR-guided deferral of PCI improves outcomes simply because fewer stents are placed.In an editorial, Weintraub and Boden4 put this data into the context of 30 years of clinical trials comparing PCI with optimal medical therapy from CCS and conclude ‘In contrast how fast does diflucan work to patients with acute coronary syndrome, there remains no convincing evidence that PCI will prevent events in patients with stable angina and chronic ischaemic heart disease. We know that, if needed, PCI will how fast does diflucan work ameliorate severe angina, but we also know that this may not be a durable effect. By contrast, for the great majority of patients who are not disabled by angina, PCI can be safely deferred in both diabetic and non-diabetic patients, with revascularisation reserved only for those with unacceptable angina or who develop an acute coronary syndrome during follow-up.

The role of FFR remains uncertain at best and need not be performed routinely in all patients with CCS, though it may be useful how fast does diflucan work where http://cz.keimfarben.de/buy-diflucan-tablets/ the visual estimation of angiographical severity is uncertain.’Cardiac involvement in patients with sepsis contributes to adverse outcomes with most previous studies focusing on left ventricular dysfunction. In order to assess the impact of right ventricular involvement on outcomes in sepsis Kim and colleagues5 performed a retrospective cohort study of 778 patients with septic shock with echocardiographic imaging. Sepsis-induced cardiac dysfunction was present in 34.7% of the entire cohort, affecting the LV how fast does diflucan work in 67.3% and the right ventricle (RV) in 40.7% of these patients. Any type of how fast does diflucan work sepsis-induced cardiac dysfunction was associated with a significantly higher 28-day mortality (35.9 vs 26.8%.

P<0.01), longer intensive care unit length of stay and longer duration of mechanical ventilator, compared with those without cardiac dysfunction. Isolated RV dysfunction was how fast does diflucan work rare (24/270, 8.9%) but was associated with a higher risk of 28-day mortality (adjusted OR 2.77, 95% CI 1.20 to 6.40, p=0.02) (figure 2).Comparisons of survival curves between each type of dysfunction. LV, left ventricle. RV, right ventricle." data-icon-position data-hide-link-title="0">Figure 2 Comparisons of survival curves between each type of dysfunction how fast does diflucan work.

LV, left how fast does diflucan work ventricle. RV, right ventricle.The mechanisms of cardiac dysfunction in patients with sepsis are summarised in an editorial by Dugar and Vallabhajosyula6 (figure 3). They also how fast does diflucan work point out the challenges in understanding cardiac involvement in patients with sepsis including the effect of timing of imaging on detection, difficulties in measuring RV systolic performance, and differing definitions of RV dysfunction. They conclude how fast does diflucan work.

€˜there is a crucial need to understand the how to identify RV dysfunction in sepsis and the causative mechanisms associated with higher mortality in this population, which will significantly influence how we prevent and manage this disease process.’Mechanism of RV dysfunction associated organ failure and mortality in sepsis. RV, right ventricular." data-icon-position data-hide-link-title="0">Figure 3 how fast does diflucan work Mechanism of RV dysfunction associated organ failure and mortality in sepsis. RV, right ventricular.The Education-in-Heart article in this issue by Steiner and Kirkpatrick7 focuses on palliative care in management of pateints with cardiovascular disease. Palliative care now encompasses much how fast does diflucan work more than end-of-life comfort measures.

Instead, ‘Palliative care is a specialised type of medical care that focuses on improving communication about goals of care, maximising quality of life and reducing symptoms’ and thus applies to many how fast does diflucan work of our patients at many time points in their disease course. Each of you will want to read the entire article yourself which includes several useful tools, such as the one shown in figure 4, to improve conversations with patients about treatment options, goals of care and planning for adverse outcomes.Ask-Tell-Ask tool to guide difficult conversations." data-icon-position data-hide-link-title="0">Figure 4 Ask-Tell-Ask tool to guide difficult conversations.Be sure to try the two Image Challenge questions in this issue.8 9 Over 150 board-review format multiple choice questions based on all types of cardiac images can be found in our online archive on the Heart homepage (https://heart.bmj.com/pages/collections/image_challenges/).In symptomatic patients with severe aortic stenosis (AS), there is no question that aortic valve replacement (AVR) relieves symptoms and prolongs life. In asymptomatic patients, clinical decision making is less clear because of the need to balance the risks of intervention and a prosthetic valve against the risks of how fast does diflucan work continued watchful waiting. On the other hand, symptom onset is inevitable in patients with severe AS—the decision is not whether but rather when to replace the valve.The primary rationale for deferring AVR until a later date is the lack of evidence that AVR before symptom onset would improve longevity.

In addition, the risks, discomfort and disability associated with a surgical or how fast does diflucan work transcatheter procedure are postponed until a later date. Furthermore, if a mechanical AVR is chosen, delaying intervention reduces the length of time the patient is exposed to the risks and inconvenience of warfarin anticoagulation how fast does diflucan work. If a bioprosthetic AVR is chosen, implantation later in life increases the likelihood that the valve will not deteriorate to the point of reintervention during the patient’s lifetime. Unfortunately, patients with AS how fast does diflucan work do not have the option of a normal aortic valve.

Instead the diseased native valve is replaced with an imperfect prosthetic valve.On the other hand, accumulating evidence from advanced imaging studies shows that aortic valve obstruction is associated with adverse changes in left ventricular (LV) structure and function, even in the absence of symptoms, which may not resolve after AVR.1 In addition, observational studies suggest that there may be an increased risk of sudden cardiac death in apparently asymptomatic patients with severe AS, although the magnitude and predictors of risk remain unclear.In order to provide clarity about the risk of sudden death in asymptomatic adults with AS, Minners and colleagues examined the data from the Simvastatin and Ezetimibe in Aortic ….

A key consideration in timing of aortic valve replacement (AVR) for patients with aortic stenosis (AS) is whether there is an increased risk of sudden can you buy diflucan over the counter in canada cardiac death (SCD) that might be reduced by relief of outflow obstruction. Minners and colleagues1 addressed this issue in a retrospective analysis of outcomes in 1840 patients with mild to moderate AS (aortic maximum velocity 2.5–4.0 m/s) in the Simvastatin and Ezetimibe in Aortic Stenosis can you buy diflucan over the counter in canada (SEAS) study. Overall the annualised rate of SCD was 0.39% per year with 27 events in asymptomatic patients.

The most recent echocardiogram prior to SCD showed mild–moderate AS in most (80%) of these patients with no difference in SCD event rates in those who progressed to severe AS compared to those who did not can you buy diflucan over the counter in canada develop severe valve obstruction. On Cox regression analysis, the only independent risk factors for SCD were can you buy diflucan over the counter in canada age (HR 1.06, 95% CI 1.01 to 1.11 per year, p=0.02), increased left ventricular mass index (HR 1.20, 95% CI 1.10 to 1.32 per 10 g/m2, p<0.001) and lower body mass index (HR 0.87, 95% CI 0.79 to 0.97 per kg/m2, p=0.01) but not the severity of valve obstruction (figure 1).Univariate (top) and multivariate (bottom) Cox regression analyses for SCD during 46.1±14.6 months of follow-up in the Simvastatin and Ezetimibe in Aortic Stenosis study. The number of events for each variable is reflected by the dark, horizontal bars with separation at the median for continuous variables.

A forest plot visualisation of HRs for SCD can you buy diflucan over the counter in canada is provided on the right. LVED, left ventricular enddiastolic diameter. LVES, left ventricular can you buy diflucan over the counter in canada endsystolic diameter.

LVM, left can you buy diflucan over the counter in canada ventricular mass. SCD, sudden cardiac death." data-icon-position data-hide-link-title="0">Figure 1 Univariate (top) and multivariate (bottom) Cox regression analyses for SCD during 46.1±14.6 months of follow-up in the Simvastatin and Ezetimibe in Aortic Stenosis study. The number of events for can you buy diflucan over the counter in canada each variable is reflected by the dark, horizontal bars with separation at the median for continuous variables.

A forest plot visualisation of HRs for SCD is provided on the right. LVED, left can you buy diflucan over the counter in canada ventricular enddiastolic diameter. LVES, left can you buy diflucan over the counter in canada ventricular endsystolic diameter.

LVM, left ventricular mass. SCD, sudden cardiac death.The lack of association between AS severity and the risk of SCD in the SEAS study is thought-provoking and challenges the conventional wisdom that early AVR would prevent SCD in asymptomatic patients with AS.2 In the past, syncope and SCD in patients with AS were thought to be due to mechanisms such as left ventricle (LV) baroreceptor malfunction, hypotension secondary to peripheral vasodilation in can you buy diflucan over the counter in canada the face of fixed valve obstruction, or a shortened diastolic filling interval at high heart rates leading to a reduced stroke volume. However, it is doubtful that any of these mechanisms would account for SCD when AS is only mild to moderate in can you buy diflucan over the counter in canada severity.

€˜It is increasingly recognised that that AS is not simply a mechanical problem of the valve leaflets not opening fully. Instead, AS compromises a complex interplay between the valve, ventricle and vasculature with can you buy diflucan over the counter in canada abnormal function of all three components of the disease process.’ As I conclude in an editorial, ‘It is unlikely that early AVR will reduce the risk of sudden death when severe valve obstruction is not present. Perhaps it is time to turn our attention to mitigating the non-valvular disease processes in adults with calcific valve disease.’In another interesting paper in this issue of Heart, Williams and Brown3 hypothesised that the apparent benefit of fractional flow reserve (FFR) guidance of percutaneous coronary intervention (PCI) in patients with chronic coronary syndromes (CCS) might simply be due to utilisation of fewer stents rather than to knowledge about the physiological severity of the coronary lesions.

In a Monte Carlo simulation using data from the PCI strata of the Bypass Angioplasty Revascularization Investigation 2 Diabetes study, random deferral of PCI progressively reduced the risk of death and myocardial infarction at 1 year, suggesting that FFR-guided deferral of PCI improves outcomes simply because fewer stents are placed.In an editorial, Weintraub and Boden4 put this data into the context of 30 years of clinical trials comparing PCI with optimal medical therapy from CCS and conclude ‘In contrast to patients with acute coronary syndrome, there can you buy diflucan over the counter in canada remains no convincing evidence that PCI will prevent events in patients with stable angina and chronic ischaemic heart disease. We know that, if needed, PCI will ameliorate severe angina, but we also know that this may not be a can you buy diflucan over the counter in canada durable effect. By contrast, for the great majority of patients who are not disabled by angina, PCI can be safely deferred in both diabetic and non-diabetic patients, with revascularisation reserved only for those with unacceptable angina or who develop an acute coronary syndrome during follow-up.

The role of FFR remains uncertain at best and need not be performed routinely in all patients can you buy diflucan over the counter in canada with CCS, though it may be useful where the visual estimation of angiographical severity is uncertain.’Cardiac involvement in patients with sepsis contributes to adverse outcomes with most previous studies focusing on left ventricular dysfunction. In order to assess the impact of right ventricular involvement on outcomes in sepsis Kim and colleagues5 performed a retrospective cohort study of 778 patients with septic shock with echocardiographic imaging. Sepsis-induced cardiac dysfunction was present in 34.7% of the entire cohort, affecting the LV in 67.3% and the right ventricle (RV) in can you buy diflucan over the counter in canada 40.7% of these patients.

Any type of sepsis-induced cardiac dysfunction was can you buy diflucan over the counter in canada associated with a significantly higher 28-day mortality (35.9 vs 26.8%. P<0.01), longer intensive care unit length of stay and longer duration of mechanical ventilator, compared with those without cardiac dysfunction. Isolated RV dysfunction was rare (24/270, 8.9%) but was associated with a higher risk of can you buy diflucan over the counter in canada 28-day mortality (adjusted OR 2.77, 95% CI 1.20 to 6.40, p=0.02) (figure 2).Comparisons of survival curves between each type of dysfunction.

LV, left ventricle. RV, right ventricle." data-icon-position data-hide-link-title="0">Figure can you buy diflucan over the counter in canada 2 Comparisons of survival curves between each type of dysfunction. LV, left can you buy diflucan over the counter in canada ventricle.

RV, right ventricle.The mechanisms of cardiac dysfunction in patients with sepsis are summarised in an editorial by Dugar and Vallabhajosyula6 (figure 3). They also point out the challenges in understanding cardiac involvement in patients with sepsis including the effect of timing of imaging on detection, difficulties in measuring RV systolic performance, and differing definitions of RV can you buy diflucan over the counter in canada dysfunction. They conclude can you buy diflucan over the counter in canada.

€˜there is a crucial need to understand the how to identify RV dysfunction in sepsis and the causative mechanisms associated with higher mortality in this population, which will significantly influence how we prevent and manage this disease process.’Mechanism of RV dysfunction associated organ failure and mortality in sepsis. RV, right ventricular." data-icon-position data-hide-link-title="0">Figure 3 Mechanism of RV dysfunction associated organ failure and mortality can you buy diflucan over the counter in canada in sepsis. RV, right ventricular.The Education-in-Heart article in this issue by Steiner and Kirkpatrick7 focuses on palliative care in management of pateints with cardiovascular disease.

Palliative care can you buy diflucan over the counter in canada now encompasses much more than end-of-life comfort measures. Instead, ‘Palliative care is a specialised type of medical care that focuses on improving communication about goals of care, maximising quality of life and reducing can you buy diflucan over the counter in canada symptoms’ and thus applies to many of our patients at many time points in their disease course. Each of you will want to read the entire article yourself which includes several useful tools, such as the one shown in figure 4, to improve conversations with patients about treatment options, goals of care and planning for adverse outcomes.Ask-Tell-Ask tool to guide difficult conversations." data-icon-position data-hide-link-title="0">Figure 4 Ask-Tell-Ask tool to guide difficult conversations.Be sure to try the two Image Challenge questions in this issue.8 9 Over 150 board-review format multiple choice questions based on all types of cardiac images can be found in our online archive on the Heart homepage (https://heart.bmj.com/pages/collections/image_challenges/).In symptomatic patients with severe aortic stenosis (AS), there is no question that aortic valve replacement (AVR) relieves symptoms and prolongs life.

In asymptomatic patients, clinical decision making is less clear because of the need to balance the risks of intervention and a prosthetic valve against can you buy diflucan over the counter in canada the risks of continued watchful waiting. On the other hand, symptom onset is inevitable in patients with severe AS—the decision is not whether but rather when to replace the valve.The primary rationale for deferring AVR until a later date is the lack of evidence that AVR before symptom onset would improve longevity. In addition, the risks, discomfort and disability associated with a surgical or transcatheter procedure are postponed until a later can you buy diflucan over the counter in canada date.

Furthermore, if a mechanical AVR is chosen, delaying intervention reduces the length of time the patient is exposed to the risks and inconvenience of can you buy diflucan over the counter in canada warfarin anticoagulation. If a bioprosthetic AVR is chosen, implantation later in life increases the likelihood that the valve will not deteriorate to the point of reintervention during the patient’s lifetime. Unfortunately, patients with AS do not have the option of a normal can you buy diflucan over the counter in canada aortic valve.

Instead the diseased native valve is replaced with an imperfect prosthetic valve.On the other hand, accumulating evidence from advanced imaging studies shows that aortic valve obstruction is associated with adverse changes in left ventricular (LV) structure and function, even in the absence of symptoms, which may not resolve after AVR.1 In addition, observational studies suggest that there may be an increased risk of sudden cardiac death in apparently asymptomatic patients with severe AS, although the magnitude and predictors of risk remain unclear.In order to provide clarity about the risk of sudden death in asymptomatic adults with AS, Minners and colleagues examined the data from the Simvastatin and Ezetimibe in Aortic ….

Diflucan 1

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NCHS Data diflucan 1 Brief No. 286, September 2017PDF Versionpdf icon (374 KB)Anjel Vahratian, Ph.D.Key findingsData from the National Health Interview Survey, 2015Among those aged 40–59, perimenopausal women (56.0%) were more likely than postmenopausal (40.5%) and premenopausal (32.5%) women to sleep less than 7 hours, on average, in a 24-hour period.Postmenopausal women aged 40–59 were more likely than premenopausal women aged 40–59 to have trouble falling asleep (27.1% compared with 16.8%, respectively), and staying asleep (35.9% compared with 23.7%), four times or more in the past week.Postmenopausal women aged 40–59 (55.1%) were more likely than premenopausal women aged 40–59 (47.0%) to not wake up feeling well rested 4 days or more in the past week.Sleep duration and quality are important contributors to health and wellness. Insufficient sleep is associated with an increased risk for chronic conditions such as diflucan 1 cardiovascular disease (1) and diabetes (2).

Women may be particularly vulnerable to sleep problems during times of reproductive hormonal change, such as after the menopausal transition. Menopause is diflucan 1 “the permanent cessation of menstruation that occurs after the loss of ovarian activity” (3). This data brief describes sleep duration and sleep quality among nonpregnant women aged 40–59 by menopausal status.

The age range selected for this analysis reflects the focus on midlife sleep health. In this analysis, 74.2% of women are diflucan 1 premenopausal, 3.7% are perimenopausal, and 22.1% are postmenopausal. Keywords.

Insufficient sleep, menopause, National Health Interview Survey Perimenopausal women were more likely than premenopausal and postmenopausal women to sleep less than 7 hours, on average, in a 24-hour period.More than one in three diflucan 1 nonpregnant women aged 40–59 slept less than 7 hours, on average, in a 24-hour period (35.1%) (Figure 1). Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period (56.0%), compared with 32.5% of premenopausal and 40.5% of postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to sleep less than 7 hours, on average, in a 24-hour period.

Figure 1 diflucan 1. Percentage of nonpregnant women aged 40–59 who slept less than 7 hours, on average, in a 24-hour period, by menopausal status. United States, 2015image icon1Significant diflucan 1 quadratic trend by menopausal status (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their diflucan 1 last menstrual cycle was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data table diflucan 1 for Figure 1pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

The percentage of women aged 40–59 who had trouble falling asleep four times or more in the past week varied by menopausal status.Nearly one in five nonpregnant women aged 40–59 had trouble falling asleep four times or more diflucan 1 in the past week (19.4%) (Figure 2). The percentage of women in this age group who had trouble falling asleep four times or more in the past week increased from 16.8% among premenopausal women to 24.7% among perimenopausal and 27.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble falling asleep four times or more in the past week.

Figure 2 diflucan 1. Percentage of nonpregnant women aged 40–59 who had trouble falling asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal diflucan 1 status (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal diflucan 1 if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data diflucan 1 table for Figure 2pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week varied by menopausal status.More than one in four nonpregnant women aged diflucan 1 40–59 had trouble staying asleep four times or more in the past week (26.7%) (Figure 3). The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week increased from 23.7% among premenopausal, to 30.8% among perimenopausal, and to 35.9% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble staying asleep four times or more in the past week.

Figure 3 diflucan 1. Percentage of nonpregnant women aged 40–59 who had trouble staying asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal status diflucan 1 (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle diflucan 1 was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data table for diflucan 1 Figure 3pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

The percentage of women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week varied by menopausal status.Nearly one in two nonpregnant women aged 40–59 did not wake up feeling well rested 4 days or more in the past week (48.9%) (Figure 4). The percentage of women in this age group who did not wake up feeling well rested 4 days or more in the past week increased diflucan 1 from 47.0% among premenopausal women to 49.9% among perimenopausal and 55.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to not wake up feeling well rested 4 days or more in the past week.

Figure 4 diflucan 1. Percentage of nonpregnant women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal status (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data table for Figure 4pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015.

SummaryThis report describes sleep duration and sleep quality among U.S. Nonpregnant women aged 40–59 by menopausal status. Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period compared with premenopausal and postmenopausal women.

In contrast, postmenopausal women were most likely to have poor-quality sleep. A greater percentage of postmenopausal women had frequent trouble falling asleep, staying asleep, and not waking well rested compared with premenopausal women. The percentage of perimenopausal women with poor-quality sleep was between the percentages for the other two groups in all three categories.

Sleep duration changes with advancing age (4), but sleep duration and quality are also influenced by concurrent changes in women’s reproductive hormone levels (5). Because sleep is critical for optimal health and well-being (6), the findings in this report highlight areas for further research and targeted health promotion. DefinitionsMenopausal status.

A three-level categorical variable was created from a series of questions that asked women. 1) “How old were you when your periods or menstrual cycles started?. €.

2) “Do you still have periods or menstrual cycles?. €. 3) “When did you have your last period or menstrual cycle?.

€. And 4) “Have you ever had both ovaries removed, either as part of a hysterectomy or as one or more separate surgeries?. € Women were postmenopausal if they a) had gone without a menstrual cycle for more than 1 year or b) were in surgical menopause after the removal of their ovaries.

Women were perimenopausal if they a) no longer had a menstrual cycle and b) their last menstrual cycle was 1 year ago or less. Premenopausal women still had a menstrual cycle.Not waking feeling well rested. Determined by respondents who answered 3 days or less on the questionnaire item asking, “In the past week, on how many days did you wake up feeling well rested?.

€Short sleep duration. Determined by respondents who answered 6 hours or less on the questionnaire item asking, “On average, how many hours of sleep do you get in a 24-hour period?. €Trouble falling asleep.

Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble falling asleep?. €Trouble staying asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble staying asleep?.

€ Data source and methodsData from the 2015 National Health Interview Survey (NHIS) were used for this analysis. NHIS is a multipurpose health survey conducted continuously throughout the year by the National Center for Health Statistics. Interviews are conducted in person in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone.

Data for this analysis came from the Sample Adult core and cancer supplement sections of the 2015 NHIS. For more information about NHIS, including the questionnaire, visit the NHIS website.All analyses used weights to produce national estimates. Estimates on sleep duration and quality in this report are nationally representative of the civilian, noninstitutionalized nonpregnant female population aged 40–59 living in households across the United States.

The sample design is described in more detail elsewhere (7). Point estimates and their estimated variances were calculated using SUDAAN software (8) to account for the complex sample design of NHIS. Linear and quadratic trend tests of the estimated proportions across menopausal status were tested in SUDAAN via PROC DESCRIPT using the POLY option.

Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. About the authorAnjel Vahratian is with the National Center for Health Statistics, Division of Health Interview Statistics. The author gratefully acknowledges the assistance of Lindsey Black in the preparation of this report.

ReferencesFord ES. Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled cohort risk equations among US adults. J Am Heart Assoc 3(6):e001454.

2014.Ford ES, Wheaton AG, Chapman DP, Li C, Perry GS, Croft JB. Associations between self-reported sleep duration and sleeping disorder with concentrations of fasting and 2-h glucose, insulin, and glycosylated hemoglobin among adults without diagnosed diabetes. J Diabetes 6(4):338–50.

2014.American College of Obstetrics and Gynecology. ACOG Practice Bulletin No. 141.

Management of menopausal symptoms. Obstet Gynecol 123(1):202–16. 2014.Black LI, Nugent CN, Adams PF.

Tables of adult health behaviors, sleep. National Health Interview Survey, 2011–2014pdf icon. 2016.Santoro N.

Perimenopause. From research to practice. J Women’s Health (Larchmt) 25(4):332–9.

2016.Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al. Recommended amount of sleep for a healthy adult. A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society.

J Clin Sleep Med 11(6):591–2. 2015.Parsons VL, Moriarity C, Jonas K, et al. Design and estimation for the National Health Interview Survey, 2006–2015.

National Center for Health Statistics. Vital Health Stat 2(165). 2014.RTI International.

SUDAAN (Release 11.0.0) [computer software]. 2012. Suggested citationVahratian A.

Sleep duration and quality among women aged 40–59, by menopausal status. NCHS data brief, no 286. Hyattsville, MD.

National Center for Health Statistics. 2017.Copyright informationAll material appearing in this report is in the public domain and may be reproduced or copied without permission. Citation as to source, however, is appreciated.National Center for Health StatisticsCharles J.

Rothwell, M.S., M.B.A., DirectorJennifer H. Madans, Ph.D., Associate Director for ScienceDivision of Health Interview StatisticsMarcie L. Cynamon, DirectorStephen J.

Blumberg, Ph.D., Associate Director for Science.

NCHS Data Brief No can you buy diflucan over the counter in canada. 286, September 2017PDF Versionpdf icon (374 KB)Anjel Vahratian, Ph.D.Key findingsData from the National Health Interview Survey, 2015Among those aged 40–59, perimenopausal women (56.0%) were more likely than postmenopausal (40.5%) and premenopausal (32.5%) women to sleep less than 7 hours, on average, in a 24-hour period.Postmenopausal women aged 40–59 were more likely than premenopausal women aged 40–59 to have trouble falling asleep (27.1% compared with 16.8%, respectively), and staying asleep (35.9% compared with 23.7%), four times or more in the past week.Postmenopausal women aged 40–59 (55.1%) were more likely than premenopausal women aged 40–59 (47.0%) to not wake up feeling well rested 4 days or more in the past week.Sleep duration and quality are important contributors to health and wellness. Insufficient sleep is associated with an can you buy diflucan over the counter in canada increased risk for chronic conditions such as cardiovascular disease (1) and diabetes (2). Women may be particularly vulnerable to sleep problems during times of reproductive hormonal change, such as after the menopausal transition. Menopause is “the permanent cessation of menstruation that occurs after the loss of can you buy diflucan over the counter in canada ovarian activity” (3).

This data brief describes sleep duration and sleep quality among nonpregnant women aged 40–59 by menopausal status. The age range selected for this analysis reflects the focus on midlife sleep health. In this analysis, 74.2% of women are premenopausal, 3.7% are perimenopausal, and 22.1% are can you buy diflucan over the counter in canada postmenopausal. Keywords. Insufficient sleep, menopause, National Health Interview Survey Perimenopausal women were more likely than premenopausal and postmenopausal women to sleep less than 7 hours, on average, in a 24-hour period.More than one in three nonpregnant women aged 40–59 slept less than 7 hours, on can you buy diflucan over the counter in canada average, in a 24-hour period (35.1%) (Figure 1).

Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period (56.0%), compared with 32.5% of premenopausal and 40.5% of postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to sleep less than 7 hours, on average, in a 24-hour period. Figure 1 can you buy diflucan over the counter in canada. Percentage of nonpregnant women aged 40–59 who slept less than 7 hours, on average, in a 24-hour period, by menopausal status. United States, 2015image icon1Significant quadratic trend by menopausal status can you buy diflucan over the counter in canada (p <.

0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or can you buy diflucan over the counter in canada less. Women were premenopausal if they still had a menstrual cycle. Access data table for Figure 1pdf icon.SOURCE can you buy diflucan over the counter in canada.

NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had trouble falling asleep four times or more in the past week varied by menopausal status.Nearly one in five nonpregnant women aged 40–59 had trouble falling can you buy diflucan over the counter in canada asleep four times or more in the past week (19.4%) (Figure 2). The percentage of women in this age group who had trouble falling asleep four times or more in the past week increased from 16.8% among premenopausal women to 24.7% among perimenopausal and 27.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble falling asleep four times or more in the past week. Figure 2 can you buy diflucan over the counter in canada.

Percentage of nonpregnant women aged 40–59 who had trouble falling asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by can you buy diflucan over the counter in canada menopausal status (p <. 0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and can you buy diflucan over the counter in canada their last menstrual cycle was 1 year ago or less.

Women were premenopausal if they still had a menstrual cycle. Access data can you buy diflucan over the counter in canada table for Figure 2pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week varied by menopausal status.More can you buy diflucan over the counter in canada than one in four nonpregnant women aged 40–59 had trouble staying asleep four times or more in the past week (26.7%) (Figure 3). The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week increased from 23.7% among premenopausal, to 30.8% among perimenopausal, and to 35.9% among postmenopausal women.

Postmenopausal women were significantly more likely than premenopausal women to have trouble staying asleep four times or more in the past week. Figure 3 can you buy diflucan over the counter in canada. Percentage of nonpregnant women aged 40–59 who had trouble staying asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal status (p < can you buy diflucan over the counter in canada. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if can you buy diflucan over the counter in canada they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table for Figure 3pdf icon.SOURCE can you buy diflucan over the counter in canada. NCHS, National Health Interview Survey, 2015.

The percentage of women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week varied by menopausal status.Nearly one in two nonpregnant women aged 40–59 did not wake up feeling well rested 4 days or more in the past week (48.9%) (Figure 4). The percentage can you buy diflucan over the counter in canada of women in this age group who did not wake up feeling well rested 4 days or more in the past week increased from 47.0% among premenopausal women to 49.9% among perimenopausal and 55.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to not wake up feeling well rested 4 days or more in the past week. Figure 4 can you buy diflucan over the counter in canada. Percentage of nonpregnant women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week, by menopausal status.

United States, 2015image icon1Significant linear trend by menopausal status (p <. 0.05).NOTES. Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle.

Access data table for Figure 4pdf icon.SOURCE. NCHS, National Health Interview Survey, 2015. SummaryThis report describes sleep duration and sleep quality among U.S. Nonpregnant women aged 40–59 by menopausal status. Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period compared with premenopausal and postmenopausal women.

In contrast, postmenopausal women were most likely to have poor-quality sleep. A greater percentage of postmenopausal women had frequent trouble falling asleep, staying asleep, and not waking well rested compared with premenopausal women. The percentage of perimenopausal women with poor-quality sleep was between the percentages for the other two groups in all three categories. Sleep duration changes with advancing age (4), but sleep duration and quality are also influenced by concurrent changes in women’s reproductive hormone levels (5). Because sleep is critical for optimal health and well-being (6), the findings in this report highlight areas for further research and targeted health promotion.

DefinitionsMenopausal status. A three-level categorical variable was created from a series of questions that asked women. 1) “How old were you when your periods or menstrual cycles started?. €. 2) “Do you still have periods or menstrual cycles?.

€. 3) “When did you have your last period or menstrual cycle?. €. And 4) “Have you ever had both ovaries removed, either as part of a hysterectomy or as one or more separate surgeries?. € Women were postmenopausal if they a) had gone without a menstrual cycle for more than 1 year or b) were in surgical menopause after the removal of their ovaries.

Women were perimenopausal if they a) no longer had a menstrual cycle and b) their last menstrual cycle was 1 year ago or less. Premenopausal women still had a menstrual cycle.Not waking feeling well rested. Determined by respondents who answered 3 days or less on the questionnaire item asking, “In the past week, on how many days did you wake up feeling well rested?. €Short sleep duration. Determined by respondents who answered 6 hours or less on the questionnaire item asking, “On average, how many hours of sleep do you get in a 24-hour period?.

€Trouble falling asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble falling asleep?. €Trouble staying asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble staying asleep?. € Data source and methodsData from the 2015 National Health Interview Survey (NHIS) were used for this analysis.

NHIS is a multipurpose health survey conducted continuously throughout the year by the National Center for Health Statistics. Interviews are conducted in person in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone. Data for this analysis came from the Sample Adult core and cancer supplement sections of the 2015 NHIS. For more information about NHIS, including the questionnaire, visit the NHIS website.All analyses used weights to produce national estimates. Estimates on sleep duration and quality in this report are nationally representative of the civilian, noninstitutionalized nonpregnant female population aged 40–59 living in households across the United States.

The sample design is described in more detail elsewhere (7). Point estimates and their estimated variances were calculated using SUDAAN software (8) to account for the complex sample design of NHIS. Linear and quadratic trend tests of the estimated proportions across menopausal status were tested in SUDAAN via PROC DESCRIPT using the POLY option. Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. About the authorAnjel Vahratian is with the National Center for Health Statistics, Division of Health Interview Statistics.

The author gratefully acknowledges the assistance of Lindsey Black in the preparation of this report. ReferencesFord ES. Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled cohort risk equations among US adults. J Am Heart Assoc 3(6):e001454. 2014.Ford ES, Wheaton AG, Chapman DP, Li C, Perry GS, Croft JB.

Associations between self-reported sleep duration and sleeping disorder with concentrations of fasting and 2-h glucose, insulin, and glycosylated hemoglobin among adults without diagnosed diabetes. J Diabetes 6(4):338–50. 2014.American College of Obstetrics and Gynecology. ACOG Practice Bulletin No. 141.

Management of menopausal symptoms. Obstet Gynecol 123(1):202–16. 2014.Black LI, Nugent CN, Adams PF. Tables of adult health behaviors, sleep. National Health Interview Survey, 2011–2014pdf icon.

2016.Santoro N. Perimenopause. From research to practice. J Women’s Health (Larchmt) 25(4):332–9. 2016.Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al.

Recommended amount of sleep for a healthy adult. A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. J Clin Sleep Med 11(6):591–2. 2015.Parsons VL, Moriarity C, Jonas K, et al. Design and estimation for the National Health Interview Survey, 2006–2015.

National Center for Health Statistics. Vital Health Stat 2(165). 2014.RTI International. SUDAAN (Release 11.0.0) [computer software]. 2012.

Suggested citationVahratian A. Sleep duration and quality among women aged 40–59, by menopausal status. NCHS data brief, no 286. Hyattsville, MD. National Center for Health Statistics.

2017.Copyright informationAll material appearing in this report is in the public domain and may be reproduced or copied without permission. Citation as to source, however, is appreciated.National Center for Health StatisticsCharles J. Rothwell, M.S., M.B.A., DirectorJennifer H. Madans, Ph.D., Associate Director for ScienceDivision of Health Interview StatisticsMarcie L. Cynamon, DirectorStephen J.

Blumberg, Ph.D., Associate Director for Science.

Diflucan 150mg how long does it take to work

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Start Preamble diflucan 150mg how long does it take to work Federal Transit http://cz.keimfarben.de/can-you-get-diflucan-over-the-counter-in-canada/ Administration (FTA), DOT. Notice of funding opportunity. The Coronavirus diflucan 150mg how long does it take to work Disease 2019 (COVID-19) public health emergency Start Printed Page 63654has had a significant impact on transit operations.

During a series of FTA listening sessions held over the last three months, transit agencies asked FTA to support research to identify solutions to address the operational challenges that they are facing as a result of COVID-19. In response, FTA makes available through this Notice of Funding Opportunity (NOFO) funding to support research demonstration grants to public transit agencies to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the COVID-19 public health emergency. Demonstration grants under this NOFO are authorized under FTA's Public Transportation Innovation diflucan 150mg how long does it take to work Program (49 U.S.C.

5312). Eligible projects will demonstrate innovative solutions to improve the operational efficiencies of transit systems and enhance mobility for their communities in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning diflucan 150mg how long does it take to work and disinfection.

(2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in diflucan 150mg how long does it take to work transit services.

The total funding available for awards under this NOFO is $10,000,000. FTA may diflucan 150mg how long does it take to work supplement this amount if additional funding becomes available. Applicants must submit completed proposals for funding opportunity FTA-2020-015-TRI through the GRANTS.GOV “APPLY” function by 11:59 p.m.

Eastern Time on November 2, 2020. Prospective applicants should register as soon as diflucan 150mg how long does it take to work possible on the GRANTS.GOV website to ensure they can complete the application process before the submission deadline. Application instructions are available on FTA's website at http://transit.dot.gov/​howtoapply and in the “FIND” module of GRANTS.GOV.

FTA will not accept mail and fax submissions. Start Further Info Please send any diflucan 150mg how long does it take to work questions on this notice to Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone.

2020-366-8985. A Telecommunication Device diflucan 150mg how long does it take to work for the Deaf (TDD) is available for individuals who are deaf or hard of hearing at 1-800-877-8339. End Further Info End Preamble Start Supplemental Information Table of Contents A.

Program Description B. Federal Award Information diflucan 150mg how long does it take to work C. Eligibility Information D.

Application and Submission diflucan 150mg how long does it take to work Information E. Application Review Information F. Federal Award Administration Information G.

Federal Awarding diflucan 150mg how long does it take to work Agency Contact Information A. Program Description The Public Transportation COVID-19 Research Demonstration Grant Program is funded through the Public Transportation Innovation Program (49 U.S.C. 5312), with the goal to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the COVID-19 public health emergency.

Eligible projects will propose to develop and deploy innovative diflucan 150mg how long does it take to work solutions in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and disinfection. (2) exposure mitigation measures.

(3) innovative diflucan 150mg how long does it take to work mobility such as contactless payments. And (4) measures that strengthen public confidence in transit. As required diflucan 150mg how long does it take to work by 49 U.S.C.

5312(e)(4), projects funded under this NOFO must participate in an evaluation by an independent outside entity that will conduct a comprehensive evaluation of the success or failure of the projects funded under this subsection and any plan for broad-based implementation of the innovation promoted by successful projects. B. Federal Award Information FTA diflucan 150mg how long does it take to work makes available $10,000,000 in fiscal year (FY) 2020 funds under the Public Transportation Innovation Program (49 U.S.C.

5312) to finance the Public Transportation COVID-19 Research Demonstration Grant Program. FTA may supplement the total funds available if additional funding becomes available at the time project selections are made. FTA will grant pre-award authority starting on the date of the project award announcement for selected projects and should be completed within 24 months from diflucan 150mg how long does it take to work the date of award.

Funds are available only for eligible expenses incurred after the announcement of project selections. C. Eligibility Information (1) Eligible Applicants Eligible applicants include State and local governmental authorities, diflucan 150mg how long does it take to work direct recipients of Urbanized Area (49 U.S.C.

5307) and Rural Area (49 U.S.C. 5311) formula funds, and Indian tribes. Eligible applicants are limited to FTA diflucan 150mg how long does it take to work grantees or subrecipients who would be the primary beneficiaries of the innovative products and services that are developed—typically public transit agencies.

Except for projects proposed by Indian tribes, proposals for projects in rural (non-urbanized) areas must be submitted as part of a consolidated State proposal. States and other eligible applicants also may diflucan 150mg how long does it take to work submit consolidated proposals for projects in urbanized areas. The submission of the Statewide application will not preclude the submission and consideration of any application from other eligible recipients in an urbanized area in a State.

Proposals may contain projects to be implemented by the recipient or its subrecipients. Eligible subrecipients include public agencies, private nonprofit organizations, and private providers engaged in public diflucan 150mg how long does it take to work transportation. Eligible applicants may submit consolidated proposals for projects.

(2) Cost Sharing or Matching The maximum Federal share of project costs is 100 percent. FTA may diflucan 150mg how long does it take to work give additional consideration to applicants that propose a local share and may view these applicants as more competitive. The applicant must document the source(s) of the local match, if any, in the grant application.

For any applicants proposing match, eligible local match sources include the following. Cash from non-Government diflucan 150mg how long does it take to work sources other than revenues from providing public transportation services. Revenues derived from the sale of advertising and concessions.

Revenues generated from value capture financing mechanisms. Funds from diflucan 150mg how long does it take to work an undistributed cash surplus. Replacement or depreciation cash fund or reserve.

New capital diflucan 150mg how long does it take to work. Or in-kind contributions. (3) Eligible Projects Eligible projects will propose innovative solutions to improve operational efficiencies of transit agencies and enhance the mobility of transit users, through projects that demonstrate innovative solutions for.

Vehicle, facility, diflucan 150mg how long does it take to work equipment and infrastructure cleaning and disinfection. Exposure mitigation measures such a real-time notification of rail and bus passenger loads. New multi-modal payment innovative mobility systems such as contactless payments.

And measures that strengthen public diflucan 150mg how long does it take to work confidence in transit. Each applicant may only submit one proposal.Start Printed Page 63655 D. Application and Submission Information (1) Address and Form of Application Submission Applications must be submitted through GRANTS.GOV.

Applicants can find general information for submitting applications through GRANTS.GOV at www.fta.dot.gov/​howtoapply, along with specific instructions diflucan 150mg how long does it take to work for the forms and attachments required for submission. Mail and fax submissions will not be accepted. (2) Content and Form of Application Submission a.

Proposal Submission A complete proposal submission consists diflucan 150mg how long does it take to work of at least two forms. 1. The SF-424 Mandatory Form (downloadable diflucan 150mg how long does it take to work from GRANTS.GOV) and 2.

The supplemental form for the FY 2020 COVID-19 Demonstration Program (downloadable from GRANTS.GOV), which is available on FTA's website at (placeholder for FTA COVID-19 Demonstration Program). The application must include responses to all sections of the SF-424 mandatory form and the supplemental form unless a section is indicated as optional. FTA will use the information on the supplemental form to determine applicant and project eligibility for the program and to evaluate the proposal against the selection criteria described in diflucan 150mg how long does it take to work part E of this notice.

FTA will accept only one supplemental form per SF-424 submission. FTA encourages applicants to consider submitting a single supplemental form that includes multiple activities to be evaluated as a consolidated proposal. Applicants may attach additional diflucan 150mg how long does it take to work supporting information to the SF-424 submission, including but not limited to letters of support, project budgets, or excerpts from relevant planning documents.

Supporting documentation must be described and referenced by file name in the appropriate response section of the supplemental form, or it may not be reviewed. Information such as applicant name, Federal amount requested, local match amount, description of areas served, etc., may be requested in varying degrees of detail on both the SF-424 form and supplemental form. Applicants must fill in all fields unless stated otherwise diflucan 150mg how long does it take to work on the forms.

If applicants copy information into the supplemental form from another source, they should verify that the supplemental form has fully captured pasted text and that it has not truncated the text due to character limits built into the form. Applicants should use both the “Check Package for Errors” and the “Validate Form” validation diflucan 150mg how long does it take to work buttons on both forms to check all required fields. Applicants should also ensure that the Federal and local amounts specified are consistent.

Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S diflucan 150mg how long does it take to work. Initiative, the Department encourages applicants to consider how the project will address the challenges faced by rural areas.

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Applicant Name ii. Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number iii diflucan 150mg how long does it take to work. Key contact information (contact name, address, email address, and phone number) iv.

Congressional district(s) where project will take place v. Project Information (title, executive summary, and type) diflucan 150mg how long does it take to work vi. A detailed description of the need for the project vii.

A detailed diflucan 150mg how long does it take to work description of how the project will support the Program objectives viii. Evidence that the applicant can provide the local cost shares ix. A description of the technical, legal, and financial capacity of the applicant x.

A detailed project budget xi diflucan 150mg how long does it take to work. Details on the local matching funds xii. A detailed project timeline xiii.

Whether the project diflucan 150mg how long does it take to work impacts an Opportunity Zone (3) Unique Entity Identifier and System for Award Management (SAM) Each applicant is required to. (1) Be registered in SAM before submitting an application. (2) provide a valid unique entity identifier in its application.

And (3) continue diflucan 150mg how long does it take to work to maintain an active SAM registration with current information at all times during which the applicant has an active Federal award or an application or plan under consideration by FTA. These requirements do not apply if the applicant. (1) Is excepted from the requirements under 2 CFR 25.110(b) or (c).

Or (2) has diflucan 150mg how long does it take to work an exception approved by FTA under 2 CFR 25.110(d). FTA may not make an award until the applicant has complied with all applicable unique entity identifier and SAM requirements. If an applicant has not fully complied with diflucan 150mg how long does it take to work the requirements by the time FTA is ready to make an award, FTA may determine that the applicant is not qualified to receive an award and use that determination as a basis for making a Federal award to another applicant.

All applicants must provide a unique entity identifier provided by SAM. Registration in SAM may take as little as 3-5 business days, but there can be unexpected steps or delays. For example, the applicant may need to obtain an Employer diflucan 150mg how long does it take to work Identification Number.

FTA recommends allowing ample time, up to several weeks, to complete all steps. For additional information on obtaining a unique entity identifier, please visit www.sam.gov. (4) Submission Dates and Times Project proposals must be submitted electronically through GRANTS.GOV by 11:59 p.m diflucan 150mg how long does it take to work.

Eastern on November 2, 2020. Mail and fax submissions will not be accepted. FTA urges applicants to submit applications diflucan 150mg how long does it take to work at least 72 hours prior to the due date to allow time to correct any problems that may have caused either GRANTS.GOV or FTA systems to reject the submission.

Proposals submitted after the deadline will only be considered under extraordinary circumstances not within the applicant's control. Deadlines will not be extended due diflucan 150mg how long does it take to work to scheduled website maintenance. GRANTS.GOV scheduled maintenance and outage times are announced on the GRANTS.GOV website.

Within 48 hours after submitting an electronic application, the applicant should receive two email messages from GRANTS.GOV. (1) Confirmation of successful transmission to GRANTS.GOV diflucan 150mg how long does it take to work. And (2) confirmation of successful validation by GRANTS.GOV.

If the applicant does not receive confirmation of successful validation or receives a notice of failed validation or incomplete materials, the applicant must address the reason for the failed validation, as described in the email notice, and resubmit before the submission deadline. If making a resubmission for any diflucan 150mg how long does it take to work reason, applicants must include all original attachments regardless of which attachments were updated and check the box on the supplemental form indicating this is a resubmission. Applicants are encouraged to begin the process of registration on the GRANTS.GOV site well in advance of the submission deadline.

Registration is Start Printed Page 63656a multi-step process, which may take several weeks to complete before an application can be submitted. Registered applicants may still be required to update their diflucan 150mg how long does it take to work registration before submitting an application. Registration in SAM is renewed annually and persons making submissions on behalf of the Authorized Organization Representative (AOR) must be authorized in GRANTS.GOV by the AOR to make submissions.

(5) Funding Restrictions Funds may be used for post-award expenditures only. Funds under this NOFO cannot be used to reimburse projects diflucan 150mg how long does it take to work for otherwise eligible expenses incurred prior to the date of project award announcements. (6) Other Submission Requirements FTA encourages applicants to identify scaled funding options in case insufficient funding is available to fund a project at the full requested amount.

If an applicant indicates that a project is scalable, the applicant must provide an appropriate minimum funding diflucan 150mg how long does it take to work amount that will fund an eligible project that achieves the objectives of the program and meets all relevant program requirements. The applicant must provide a clear explanation of how a reduced award would affect the project budget and scope. FTA may award a lesser amount whether or not the applicant provides a scalable option.

E. Application Review Information (1) Project Evaluation Criteria Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S.

Initiative, the Department will consider how the project will address the challenges faced by rural areas. In addition, the Department will review and consider applications for funding pursuant to this Notice in accordance with the President's September 2, 2020 memorandum, entitled Memorandum on Reviewing Funding to State and Local Government Recipients of Federal Funds that Are Permitting Anarchy, Violence, and Destruction in American Cities, consistent with guidance from the Office of Management and Budget and the Attorney General and with all applicable laws. FTA will evaluate proposals submitted according to the following criteria.

(a) Project Innovation and Impact. (b) Project Approach. (c) National Applicability.

(d) Commercialization and/or Knowledge Transfer. And (e) Technical, Legal and Financial Capacity. FTA encourages each applicant to demonstrate how a project supports all criteria with the most relevant information the applicant can provide, regardless of whether such information has been specifically requested or identified in this notice.

A. Project Innovation and Impact i. Effectiveness of the project in achieving and demonstrating the specific objectives of this program.

Ii. Demonstration of benefits in addressing the needs of the transit agency and industry and impacts to infrastructure, equipment, transit workforce, and riders. Iii.

Degree of improvement over current and existing technologies, designs, and/or practices applicable to the transit industry. B. Project Approach i.

Quality of the project approach such as existing partnerships, collaboration strategies and level of commitment of the project partners. Ii. Proposal is realistic in its approach to fulfill the milestones/deliverables, schedule and goals.

C. National Applicability i. Degree to which the project could be replicated by other transit agencies regionally or nationally.

Ii. Ability to evaluate technologies, http://cz.keimfarben.de/buy-diflucan-tablets/ designs and/or practices in a wide variety of conditions and locales. Iii.

Degree to which the technology, designs and/or practices can be replicated by other transportation modes. D. Commercialization and/or Knowledge Transfer i.

Demonstrates a realistic plan for moving the results of the project into the transit marketplace (patents, conferences, articles in trade magazines, webinar, site visits, etc.). Ii. How the project team plans to work with the industry on improving best practices, guidance and/or standards, if applicable.

Iii. Demonstrate a clear understanding and robust approach to data collection, access and management. E.

Technical, Legal and Financial Capacity Capacity of the applicant and any partners to successfully execute the project effort. There should be no outstanding legal, technical, or financial issues with the applicant that would make this a high-risk project. (2) Review and Selection Process An FTA technical evaluation committee will evaluate proposals based on the published project evaluation criteria.

Members of the technical evaluation committee will rate the applications and may seek clarification about any statement in an application. The FTA Administrator will determine the final selection and amount of funding for each project after consideration of the findings of the technical evaluation committee. Geographic diversity, diversity of the project type, the amount of local match to be provided, and the applicant's receipt and management of other Federal transit funds may be considered in FTA's award decisions.

Prior fare payment innovation efforts may receive priority consideration. The FTA Administrator will consider the following key DOT objectives. A.

Utilizing alternative funding sources and innovative financing models to attract non-Federal sources of investment. B. Whether the project is located in or supports public transportation service in a qualified opportunity zone designated pursuant to 26.U.S.C.

1400Z-1. And c. The extent to which the project addresses challenges specific to the provision of rural public transportation.

(3) FAPIIS Review Prior to making a grant award, FTA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS) accessible through SAM. An applicant may review and comment on information about itself that a Federal awarding agency previously entered. FTA will consider any comments by the applicant, in addition to the other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 2 CFR 200.205 Federal Awarding Agency Review of Risk Posed by Applicants.

F. Federal Award Administration Information (1) Federal Award Notices FTA will announce the final project selections on the FTA website. Project recipients should contact their FTA Regional Office for additional information regarding allocations for Start Printed Page 63657projects.

At the time project selections are announced, FTA will extend pre-award authority for the selected projects. There is no blanket pre-award authority for these projects before announcement. There is no minimum or maximum grant award amount, but FTA intends to fund as many meritorious projects as possible.

FTA only will consider proposals from eligible recipients for eligible activities. Due to funding limitations, projects selected for funding may receive less than the amount originally requested. In those cases, applicants must be able to demonstrate that the proposed projects are still viable and can be completed with the amount awarded.

(2) Administrative and National Policy Requirements a. Pre-Award Authority FTA will issue specific guidance to recipients regarding pre-award authority at the time of selection. FTA does not provide pre-award authority for competitive funds until projects are selected, and there are Federal requirements that must be met before costs are incurred.

For more information about FTA's policy on pre-award authority, see the FY 2020 Apportionments Notice published on June 3, 2020, at https://www.govinfo.gov/​content/​pkg/​FR-2020-06-03/​pdf/​2020-11946.pdf. b. Grant Requirements Selected applicants will submit a grant application through FTA's electronic grant management system and adhere to the customary FTA grant requirements for research project (insert Circular name).

All competitive grants, regardless of award amount, will be subject to the Congressional notification and release process. FTA emphasizes that third-party procurement applies to all funding awards, as described in FTA Circular 4220.1F, “Third Party Contracting Guidance.” However, FTA may approve applications that include a specifically identified partnering organization(s) (2 CFR 200.302(f)). When included, the application, budget, and budget narrative should provide a clear understanding of how the selection of these organizations is critical for the project and give sufficient detail about the costs involved.

C. Planning FTA encourages applicants to engage the appropriate State Departments of Transportation, Regional Transportation Planning Organizations, or Metropolitan Planning Organizations in areas to be served by the project funds available under this program. D.

Standard Assurances The applicant assures that it will comply with all applicable Federal statutes, regulations, executive orders, FTA circulars, and other Federal administrative requirements in carrying out any project supported by the FTA grant. The applicant acknowledges that it is under a continuing obligation to comply with the terms and conditions of the grant agreement issued for its project with FTA. The applicant understands that Federal laws, regulations, policies, and administrative practices might be modified from time to time and may affect the implementation of the project.

The applicant agrees that the most recent Federal requirements will apply to the project unless FTA issues a written determination otherwise. The applicant must submit the Certifications and Assurances before receiving a grant if it does not have current certifications on file. E.

Free Speech and Religious Liberty In connection with any program or activity conducted with or benefiting from funds awarded under this notice, recipients of funds must comply with all applicable requirements of Federal law, including, without limitation, the Constitution of the United States. Statutory, regulatory, and public policy requirements, including without limitation, those protecting free speech, religious liberty, public welfare, the environment, and prohibiting discrimination. The conditions of performance, non-discrimination requirements, and other assurances made applicable to the award of funds in accordance with regulations of the Department of Transportation.

And applicable Federal financial assistance and contracting principles promulgated by the Office of Management and Budget. In complying with these requirements, recipients must ensure that no concession agreements are denied or other contracting decisions made on the basis of speech or other activities protected by the First Amendment. If the Department determines that a recipient has failed to comply with applicable Federal requirements, the Department may terminate the award of funds and disallow previously incurred costs, requiring the recipient to reimburse any expended award funds.

(3) Reporting The post-award reporting requirements include submission of the Federal Financial Report (FFR) and Milestone Progress Report in TrAMS. An evaluation of the grant will occur at various points in the demonstration process and at the end of the project. In addition, FTA is responsible for producing an Annual Report to Congress that compiles evaluation of selected projects, including an evaluation of the performance measures identified by the applicants.

All applicants must develop an evaluation plan to measure the success or failure of their projects and describe any plans for broad-based implementation of successful projects. FTA may request data and reports to support the evaluation and Annual Report. A.

Independent Evaluation To achieve a comprehensive understanding of the impacts and implications of each proposed COVID-19 Research Demonstration Program, projects funded under this announcement will require the recipient to conduct a third party independent evaluation of their project. Recipients will be required to contract with a third party independent evaluator to assist in developing an evaluation plan, and collecting, storing and managing data required to fulfill the evaluation requirement. No more than 10 percent of the Federal share of the project may be used to hire the third-party independent evaluator and the inclusion of a third-party independent evaluation should be described in the grant application.

If the project duration is more than two years, an interim evaluation report would need to be submitted to FTA, otherwise the evaluation report should be included as part of the final project report. B. COVID-19 Research Demonstration Grant Program Evaluation Projects funded under this announcement will be required to establish a set of performance metrics set by the third-party independent evaluator and shared with FTA.

G. Federal Awarding Agency Contacts Information For questions about applying, please contact Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone.

202-366-8985. A TDD is available at 1-800-877-8339 (TDDFIRS). To ensure that applicants receive accurate information about eligibility or the program, applicants are encouraged to contact FTA directly with questions, rather than through intermediaries or third parties.Start Printed Page 63658 FTA staff also may conduct briefings on the competitive grants selection and award process upon request.

Start Signature K. Jane Williams, Deputy Administrator. End Signature End Supplemental Information [FR Doc.

2020-22316 Filed 10-7-20. 8:45 am]BILLING CODE 4910-57-PStart Preamble Office of the Secretary, Department of Health and Human Services. Notice.

The Department of Health and Human Services (HHS) Office of Infectious Disease and HIV/AIDS Policy (OIDP) in the Office of the Assistant Secretary for Health (OASH) announces the draft Viral Hepatitis National Strategic Plan. A Roadmap to Elimination (2021-2025) (Hepatitis Plan) available for public comment. The draft Hepatitis Plan may be reviewed at www.hhs.gov/​hepatitis.

All comments must be received by 5:00 p.m. ET on October 8, 2020 to ensure consideration. All comments must be submitted electronically to HepatitisPlanComments@hhs.gov.

Start Further Info Carol Jimenez, OIDP, Carol.Jimenez@hhs.gov. 202-401-5131. End Further Info End Preamble Start Supplemental Information Viral hepatitis is a significant public health threat that puts people who are infected at increased risk for serious disease and death.

In the United States, new hepatitis A and hepatitis C infections have increased dramatically in recent years, little progress has been made on preventing hepatitis B infections, and, as of 2016, an estimated 3.3 million people were chronically infected with hepatitis B and hepatitis C.1-3 Collectively, viral hepatitis costs people, health systems, states, and the federal government billions of dollars each year 4 5 and contributes to substantial health disparities, stigma, and discrimination. Reversing the rates of viral hepatitis, preventing new infections, and improving care and treatment require a strategic and coordinated approach by federal partners in collaboration with state and local health departments, tribal communities, community-based organizations, and other nonfederal partners and stakeholders. To spur action to reduce new viral hepatitis infections and their adverse public health impact, OASH through OIDP, in collaboration with federal partners throughout HHS and other departments, led and coordinated development of the Hepatitis Plan.

Opportunities for public input were provided, and public comments received were reviewed and analyzed and helped inform the components of the Hepatitis Plan. The Hepatitis Plan focuses on hepatitis A, hepatitis B, and hepatitis C—the hepatitis viruses that most significantly affect the health of the nation. It is an elimination plan, with the overarching goal of eliminating viral hepatitis as a public health threat in the United States by 2030.

The Hepatitis Plan is intended to serve as a roadmap for all stakeholders at all levels to eliminate hepatitis in this nation. The Hepatitis Plan presents a strategic framework for integrating and leveraging synergistic policies, programs, and resources. It sets forth a vision and five goals for the nation, with objectives and strategies for each goal.

The objectives and strategies offered in this plan are interrelated and may be used to make progress toward more than one goal. The Hepatitis Plan identifies disproportionately impacted populations based on national hepatitis incidence, prevalence, and mortality data, to help federal and other stakeholders focus their efforts to realize the greatest impact. The Hepatitis Plan also includes indicators to measure progress and quantitative targets for each indicator.

Although it is a 5-year plan, it sets 10-year quantitative targets for each indicator—reflecting the reality that it will take more than 5 years to eliminate viral hepatitis as a public health threat. The order in which the goals, objectives, strategies, and indicators are presented is not associated with any prioritization. The following are the Hepatitis Plan's vision and goals.

Vision. The United States will be a place where new viral hepatitis infections are prevented, every person knows their status, and every person with viral hepatitis has high-quality health care and treatment and lives free from stigma and discrimination. This vision includes all people, regardless of age, sex, gender identity, sexual orientation, race, ethnicity, geographic location, or socioeconomic circumstance.

Goals. 1. Prevent New Viral Hepatitis Infections 2.

Improve Viral Hepatitis—Related Health Outcomes of People with Viral Hepatitis 3. Reduce Viral Hepatitis—Related Disparities and Health Inequities 4. Improve Viral Hepatitis Surveillance and Data Usage 5.

Achieve Integrated, Coordinated Efforts That Address the Viral Hepatitis Epidemics among All Partners and Stakeholders A roadmap for stakeholders at all levels and sectors, the Hepatitis Plan envisions a whole-of-nation response to preventing and controlling viral hepatitis in the United States. The Hepatitis Plan assumes the active participation of state, local, and tribal health departments and organizations, health plans and health care providers, schools and other academic institutions, community- and faith-based organizations, scientists, researchers, and the public in this effort. The priority populations, indicators, and quantitative targets, especially the methods used to determine them, are intended to help focus efforts and limited resources to realize the most impact.

Stakeholders are encouraged to focus on activities that resonate the most with the needs of the populations they serve and services they provide, and, using the Hepatitis Plan as a framework, develop their own plans to eliminate viral hepatitis and improve the health of their communities, states, tribal nations, and the nation. Information Needs The draft Hepatitis Plan may be reviewed at. Www.hhs.gov/​hepatitis.

OIDP seeks to obtain feedback from external stakeholders on the following. 1. Do the draft plan's goals, objectives, and strategies appropriately address the viral hepatitis epidemics?.

2. Are there any critical gaps in the Hepatitis Plan's goals, objectives, and strategies?. If so, please specify the gaps.

3. Do any of the Hepatitis Plan's goals, objectives and strategies cause concern?. If so, please specify the goal, objective or strategy, and describe the concern regarding it.

Each commenter is limited to a maximum of seven pages. Start Authority 77 FR 15761 (March 16, 2012). End Authority Start Signature Dated.

September 22, 2020. B. Kaye Hayes, Acting Director, Office of Infectious Disease and HIV/AIDS Policy.

End Signature Footnotes 1. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance—Start Printed Page 60814United States, 2018.

U.S. Department of Health and Human Services. 2020.

Accessed August 9, 2020. Https://www.cdc.gov/​hepatitis/​statistics/​2018surveillance/​index.htm. 2.

Hofmeister MG, Rosenthal EM, Barker LK, et al. Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016. Hepatology.

2019 Mar;69(3):1020-1031. Doi. 10.1002/hep.30297.

3. LeFevre ML. Screening for hepatitis B virus infection in nonpregnant adolescents and adults.

US Preventive Services Task Force recommendation statement. Annals Internal Med. 2014;161(1):58-66.

4. Morey RJ, Collier MG, Nelson NP. The financial burden of public health responses to hepatitis A cases among food handlers, 2012-2014.

Public Health Rep. 2017;132(4):443-447. Doi:10.1177/0033354917710947.

5. Wittenborn J, Brady J, Dougherty M, Rein D. Potential epidemiologic, economic, and budgetary impacts of current rates of hepatitis C treatment in Medicare and non-Medicare populations.

Hepatol Commun. 2017;1(2):99-109. Doi:10.1002/hep4.1031.

End Supplemental Information [FR Doc. 2020-21288 Filed 9-25-20. 8:45 am]BILLING CODE 4150-43-P.

Start Preamble Federal Transit can you buy diflucan over the counter in canada Administration (FTA), DOT http://cz.keimfarben.de/can-you-get-diflucan-over-the-counter-in-canada/. Notice of funding opportunity. The Coronavirus Disease 2019 (COVID-19) public health emergency Start Printed Page 63654has had a significant impact on transit can you buy diflucan over the counter in canada operations.

During a series of FTA listening sessions held over the last three months, transit agencies asked FTA to support research to identify solutions to address the operational challenges that they are facing as a result of COVID-19. In response, FTA makes available through this Notice of Funding Opportunity (NOFO) funding to support research demonstration grants to public transit agencies to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the COVID-19 public health emergency. Demonstration grants under this NOFO are authorized under FTA's can you buy diflucan over the counter in canada Public Transportation Innovation Program (49 U.S.C.

5312). Eligible projects will demonstrate innovative solutions to improve the operational efficiencies of transit systems and enhance mobility for their communities in four major areas. (1) Vehicle, facility, equipment and infrastructure cleaning and can you buy diflucan over the counter in canada disinfection.

(2) exposure mitigation measures. (3) innovative mobility such as contactless payments. And (4) measures that strengthen public confidence in transit can you buy diflucan over the counter in canada services.

The total funding available for awards under this NOFO is $10,000,000. FTA may supplement can you buy diflucan over the counter in canada this amount if additional funding becomes available. Applicants must submit completed proposals for funding opportunity FTA-2020-015-TRI through the GRANTS.GOV “APPLY” function by 11:59 p.m.

Eastern Time on November 2, 2020. Prospective applicants should register as soon as possible on the GRANTS.GOV website to ensure they can complete the application process before the submission can you buy diflucan over the counter in canada deadline. Application instructions are available on FTA's website at http://transit.dot.gov/​howtoapply and in the “FIND” module of GRANTS.GOV.

FTA will not accept mail and fax submissions. Start Further Info Please send any questions on this notice to Jamel can you buy diflucan over the counter in canada El-Hamri email. Jamel.El-Hamri@dot.gov phone.

2020-366-8985. A Telecommunication Device for the Deaf can you buy diflucan over the counter in canada (TDD) is available for individuals who are deaf or hard of hearing at 1-800-877-8339. End Further Info End Preamble Start Supplemental Information Table of Contents A.

Program Description B. Federal Award Information C can you buy diflucan over the counter in canada. Eligibility Information D.

Application and Submission Information E can you buy diflucan over the counter in canada. Application Review Information F. Federal Award Administration Information G.

Federal Awarding Agency can you buy diflucan over the counter in canada Contact Information A. Program Description The Public Transportation COVID-19 Research Demonstration Grant Program is funded through the Public Transportation Innovation Program (49 U.S.C. 5312), with the goal to develop, deploy, and demonstrate innovative solutions that improve the operational efficiency of transit agencies, as well as enhance the mobility of transit users affected by the COVID-19 public health emergency.

Eligible projects will propose to develop and deploy innovative solutions in four major areas can you buy diflucan over the counter in canada. (1) Vehicle, facility, equipment and infrastructure cleaning and disinfection. (2) exposure mitigation measures.

(3) innovative mobility can you buy diflucan over the counter in canada such as contactless payments. And (4) measures that strengthen public confidence in transit. As required by can you buy diflucan over the counter in canada 49 U.S.C.

5312(e)(4), projects funded under this NOFO must participate in an evaluation by an independent outside entity that will conduct a comprehensive evaluation of the success or failure of the projects funded under this subsection and any plan for broad-based implementation of the innovation promoted by successful projects. B. Federal Award Information FTA makes available $10,000,000 in fiscal year (FY) 2020 funds under the Public can you buy diflucan over the counter in canada Transportation Innovation Program (49 U.S.C.

5312) to finance the Public Transportation COVID-19 Research Demonstration Grant Program. FTA may supplement the total funds available if additional funding becomes available at the time project selections are made. FTA will grant pre-award authority starting on the date of the project award announcement for selected projects and should be completed within 24 months can you buy diflucan over the counter in canada from the date of award.

Funds are available only for eligible expenses incurred after the announcement of project selections. C. Eligibility Information (1) Eligible Applicants Eligible can you buy diflucan over the counter in canada applicants include State and local governmental authorities, direct recipients of Urbanized Area (49 U.S.C.

5307) and Rural Area (49 U.S.C. 5311) formula funds, and Indian tribes. Eligible applicants are limited to FTA grantees or subrecipients who would be the primary can you buy diflucan over the counter in canada beneficiaries of the innovative products and services that are developed—typically public transit agencies.

Except for projects proposed by Indian tribes, proposals for projects in rural (non-urbanized) areas must be submitted as part of a consolidated State proposal. States and other eligible can you buy diflucan over the counter in canada applicants also may submit consolidated proposals for projects in urbanized areas. The submission of the Statewide application will not preclude the submission and consideration of any application from other eligible recipients in an urbanized area in a State.

Proposals may contain projects to be implemented by the recipient or its subrecipients. Eligible subrecipients include public agencies, private nonprofit organizations, and private providers engaged in can you buy diflucan over the counter in canada public transportation. Eligible applicants may submit consolidated proposals for projects.

(2) Cost Sharing or Matching The maximum Federal share of project costs is 100 percent. FTA may give additional consideration to applicants that propose a local share and may view these applicants as more can you buy diflucan over the counter in canada competitive. The applicant must document the source(s) of the local match, if any, in the grant application.

For any applicants proposing match, eligible local match sources include the following. Cash from can you buy diflucan over the counter in canada non-Government sources other than revenues from providing public transportation services. Revenues derived from the sale of advertising and concessions.

Revenues generated from value capture financing mechanisms. Funds from an undistributed can you buy diflucan over the counter in canada cash surplus. Replacement or depreciation cash fund or reserve.

New capital can you buy diflucan over the counter in canada. Or in-kind contributions. (3) Eligible Projects Eligible projects will propose innovative solutions to improve operational efficiencies of transit agencies and enhance the mobility of transit users, through projects that demonstrate innovative solutions for.

Vehicle, facility, equipment can you buy diflucan over the counter in canada and infrastructure cleaning and disinfection. Exposure mitigation measures such a real-time notification of rail and bus passenger loads. New multi-modal payment innovative mobility systems such as contactless payments.

And measures that strengthen public confidence in can you buy diflucan over the counter in canada transit. Each applicant may only submit one proposal.Start Printed Page 63655 D. Application and Submission Information (1) Address and Form of Application Submission Applications must be submitted through GRANTS.GOV.

Applicants can can you buy diflucan over the counter in canada find general information for submitting applications through GRANTS.GOV at www.fta.dot.gov/​howtoapply, along with specific instructions for the forms and attachments required for submission. Mail and fax submissions will not be accepted. (2) Content and Form of Application Submission a.

Proposal Submission A complete proposal submission consists of can you buy diflucan over the counter in canada at least two forms. 1. The SF-424 can you buy diflucan over the counter in canada Mandatory Form (downloadable from GRANTS.GOV) and 2.

The supplemental form for the FY 2020 COVID-19 Demonstration Program (downloadable from GRANTS.GOV), which is available on FTA's website at (placeholder for FTA COVID-19 Demonstration Program). The application must include responses to all sections of the SF-424 mandatory form and the supplemental form unless a section is indicated as optional. FTA will use the information on the supplemental form to determine applicant and project eligibility for the program and to evaluate the proposal against can you buy diflucan over the counter in canada the selection criteria described in part E of this notice.

FTA will accept only one supplemental form per SF-424 submission. FTA encourages applicants to consider submitting a single supplemental form that includes multiple activities to be evaluated as a consolidated proposal. Applicants may attach additional can you buy diflucan over the counter in canada supporting information to the SF-424 submission, including but not limited to letters of support, project budgets, or excerpts from relevant planning documents.

Supporting documentation must be described and referenced by file name in the appropriate response section of the supplemental form, or it may not be reviewed. Information such as applicant name, Federal amount requested, local match amount, description of areas served, etc., may be requested in varying degrees of detail on both the SF-424 form and supplemental form. Applicants must fill in all fields unless stated otherwise on the forms can you buy diflucan over the counter in canada.

If applicants copy information into the supplemental form from another source, they should verify that the supplemental form has fully captured pasted text and that it has not truncated the text due to character limits built into the form. Applicants should use both the “Check Package for Errors” and the “Validate Form” validation buttons on both forms to check all required can you buy diflucan over the counter in canada fields. Applicants should also ensure that the Federal and local amounts specified are consistent.

Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with can you buy diflucan over the counter in canada the R.O.U.T.E.S. Initiative, the Department encourages applicants to consider how the project will address the challenges faced by rural areas.

B. Application Content can you buy diflucan over the counter in canada The SF-424 Mandatory Form and the supplemental form will prompt applicants for the required information, including. I.

Applicant Name ii. Dun and can you buy diflucan over the counter in canada Bradstreet (D&B) Data Universal Numbering System (DUNS) number iii. Key contact information (contact name, address, email address, and phone number) iv.

Congressional district(s) where project will take place v. Project Information can you buy diflucan over the counter in canada (title, executive summary, and type) vi. A detailed description of the need for the project vii.

A detailed can you buy diflucan over the counter in canada description of how the project will support the Program objectives viii. Evidence that the applicant can provide the local cost shares ix. A description of the technical, legal, and financial capacity of the applicant x.

A detailed project can you buy diflucan over the counter in canada budget xi. Details on the local matching funds xii. A detailed project timeline xiii.

Whether the project impacts an Opportunity can you buy diflucan over the counter in canada Zone (3) Unique Entity Identifier and System for Award Management (SAM) Each applicant is required to. (1) Be registered in SAM before submitting an application. (2) provide a valid unique entity identifier in its application.

And (3) continue to maintain an can you buy diflucan over the counter in canada active SAM registration with current information at all times during which the applicant has an active Federal award or an application or plan under consideration by FTA. These requirements do not apply if the applicant. (1) Is excepted from the requirements under 2 CFR 25.110(b) or (c).

Or (2) has an exception approved by FTA under 2 CFR 25.110(d) can you buy diflucan over the counter in canada. FTA may not make an award until the applicant has complied with all applicable unique entity identifier and SAM requirements. If an applicant has not fully complied with the requirements by the time FTA is ready to make an award, FTA may determine that the applicant is not qualified to receive an award and use that determination as a basis for can you buy diflucan over the counter in canada making a Federal award to another applicant.

All applicants must provide a unique entity identifier provided by SAM. Registration in SAM may take as little as 3-5 business days, but there can be unexpected steps or delays. For example, the applicant may can you buy diflucan over the counter in canada need to obtain an Employer Identification Number.

FTA recommends allowing ample time, up to several weeks, to complete all steps. For additional information on obtaining a unique entity identifier, please visit www.sam.gov. (4) Submission Dates can you buy diflucan over the counter in canada and Times Project proposals must be submitted electronically through GRANTS.GOV by 11:59 p.m.

Eastern on November 2, 2020. Mail and fax submissions will not be accepted. FTA urges applicants to submit applications at can you buy diflucan over the counter in canada least 72 hours prior to the due date to allow time to correct any problems that may have caused either GRANTS.GOV or FTA systems to reject the submission.

Proposals submitted after the deadline will only be considered under extraordinary circumstances not within the applicant's control. Deadlines will not be extended due to can you buy diflucan over the counter in canada scheduled website maintenance. GRANTS.GOV scheduled maintenance and outage times are announced on the GRANTS.GOV website.

Within 48 hours after submitting an electronic application, the applicant should receive two email messages from GRANTS.GOV. (1) Confirmation of successful transmission to GRANTS.GOV can you buy diflucan over the counter in canada. And (2) confirmation of successful validation by GRANTS.GOV.

If the applicant does not receive confirmation of successful validation or receives a notice of failed validation or incomplete materials, the applicant must address the reason for the failed validation, as described in the email notice, and resubmit before the submission deadline. If making a resubmission for any reason, applicants must include all original attachments regardless of which attachments were updated and check the box can you buy diflucan over the counter in canada on the supplemental form indicating this is a resubmission. Applicants are encouraged to begin the process of registration on the GRANTS.GOV site well in advance of the submission deadline.

Registration is Start Printed Page 63656a multi-step process, which may take several weeks to complete before an application can be submitted. Registered applicants may can you buy diflucan over the counter in canada still be required to update their registration before submitting an application. Registration in SAM is renewed annually and persons making submissions on behalf of the Authorized Organization Representative (AOR) must be authorized in GRANTS.GOV by the AOR to make submissions.

(5) Funding Restrictions Funds may be used for post-award expenditures only. Funds under this NOFO cannot be used to reimburse projects for otherwise eligible expenses incurred prior to can you buy diflucan over the counter in canada the date of project award announcements. (6) Other Submission Requirements FTA encourages applicants to identify scaled funding options in case insufficient funding is available to fund a project at the full requested amount.

If an applicant indicates that can you buy diflucan over the counter in canada a project is scalable, the applicant must provide an appropriate minimum funding amount that will fund an eligible project that achieves the objectives of the program and meets all relevant program requirements. The applicant must provide a clear explanation of how a reduced award would affect the project budget and scope. FTA may award a lesser amount whether or not the applicant provides a scalable option.

E. Application Review Information (1) Project Evaluation Criteria Addressing the deteriorating conditions and disproportionately high fatality rates on our rural transportation infrastructure is of critical interest to the Department, as rural transportation networks face unique challenges in safety, infrastructure condition, and passenger and freight usage. Consistent with the R.O.U.T.E.S.

Initiative, the Department will consider how the project will address the challenges faced by rural areas. In addition, the Department will review and consider applications for funding pursuant to this Notice in accordance with the President's September 2, 2020 memorandum, entitled Memorandum on Reviewing Funding to State and Local Government Recipients of Federal Funds that Are Permitting Anarchy, Violence, and Destruction in American Cities, consistent with guidance from the Office of Management and Budget and the Attorney General and with all applicable laws. FTA will evaluate proposals submitted according to the following criteria.

(a) Project Innovation and Impact. (b) Project Approach. (c) National Applicability.

(d) Commercialization and/or Knowledge Transfer. And (e) Technical, Legal and Financial Capacity. FTA encourages each applicant to demonstrate how a project supports all criteria with the most relevant information the applicant can provide, regardless of whether such information has been specifically requested or identified in this notice.

A. Project Innovation and Impact i. Effectiveness of the project in achieving and demonstrating the specific objectives of this program.

Ii. Demonstration of benefits in addressing the needs of the transit agency and industry and impacts to infrastructure, equipment, transit workforce, and riders. Iii.

Degree of improvement over current and existing technologies, designs, and/or practices applicable to the transit industry. B. Project Approach i.

Quality of the project approach such as existing partnerships, collaboration strategies and level of commitment of the project partners. Ii. Proposal is realistic in its approach to fulfill the milestones/deliverables, schedule and goals.

C. National Applicability i. Degree to which the project could be replicated by other transit agencies regionally or nationally.

Ii. Ability to evaluate technologies, designs and/or practices in a wide variety of conditions and locales. Iii.

Degree to which the technology, designs and/or practices can be replicated by other transportation modes. D. Commercialization and/or Knowledge Transfer i.

Demonstrates a realistic plan for moving the results of the project into the transit marketplace (patents, conferences, articles in trade magazines, webinar, site visits, etc.). Ii. How the project team plans to work with the industry on improving best practices, guidance and/or standards, if applicable.

Iii. Demonstrate a clear understanding and robust approach to data collection, access and management. E.

Technical, Legal and Financial Capacity Capacity of the applicant and any partners to successfully execute the project effort. There should be no outstanding legal, technical, or financial issues with the applicant that would make this a high-risk project. (2) Review and Selection Process An FTA technical evaluation committee will evaluate proposals based on the published project evaluation criteria.

Members of the technical evaluation committee will rate the applications and may seek clarification about any statement in an application. The FTA Administrator will determine the final selection and amount of funding for each project after consideration of the findings of the technical evaluation committee. Geographic diversity, diversity of the project type, the amount of local match to be provided, and the applicant's receipt and management of other Federal transit funds may be considered in FTA's award decisions.

Prior fare payment innovation efforts may receive priority consideration. The FTA Administrator will consider the following key DOT objectives. A.

Utilizing alternative funding sources and innovative financing models to attract non-Federal sources of investment. B. Whether the project is located in or supports public transportation service in a qualified opportunity zone designated pursuant to 26.U.S.C.

1400Z-1. And c. The extent to which the project addresses challenges specific to the provision of rural public transportation.

(3) FAPIIS Review Prior to making a grant award, FTA is required to review and consider any information about the applicant that is in the Federal Awardee Performance and Integrity Information System (FAPIIS) accessible through SAM. An applicant may review and comment on information about itself that a Federal awarding agency previously entered. FTA will consider any comments by the applicant, in addition to the other information in FAPIIS, in making a judgment about the applicant's integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 2 CFR 200.205 Federal Awarding Agency Review of Risk Posed by Applicants.

F. Federal Award Administration Information (1) Federal Award Notices FTA will announce the final project selections on the FTA website. Project recipients should contact their FTA Regional Office for additional information regarding allocations for Start Printed Page 63657projects.

At the time project selections are announced, FTA will extend pre-award authority for the selected projects. There is no blanket pre-award authority for these projects before announcement. There is no minimum or maximum grant award amount, but FTA intends to fund as many meritorious projects as possible.

FTA only will consider proposals from eligible recipients for eligible activities. Due to funding limitations, projects selected for funding may receive less than the amount originally requested. In those cases, applicants must be able to demonstrate that the proposed projects are still viable and can be completed with the amount awarded.

(2) Administrative and National Policy Requirements a. Pre-Award Authority FTA will issue specific guidance to recipients regarding pre-award authority at the time of selection. FTA does not provide pre-award authority for competitive funds until projects are selected, and there are Federal requirements that must be met before costs are incurred.

For more information about FTA's policy on pre-award authority, see the FY 2020 Apportionments Notice published on June 3, 2020, at https://www.govinfo.gov/​content/​pkg/​FR-2020-06-03/​pdf/​2020-11946.pdf. b. Grant Requirements Selected applicants will submit a grant application through FTA's electronic grant management system and adhere to the customary FTA grant requirements for research project (insert Circular name).

All competitive grants, regardless of award amount, will be subject to the Congressional notification and release process. FTA emphasizes that third-party procurement applies to all funding awards, as described in FTA Circular 4220.1F, “Third Party Contracting Guidance.” However, FTA may approve applications that include a specifically identified partnering organization(s) (2 CFR 200.302(f)). When included, the application, budget, and budget narrative should provide a clear understanding of how the selection of these organizations is critical for the project and give sufficient detail about the costs involved.

C. Planning FTA encourages applicants to engage the appropriate State Departments of Transportation, Regional Transportation Planning Organizations, or Metropolitan Planning Organizations in areas to be served by the project funds available under this program. D.

Standard Assurances The applicant assures that it will comply with all applicable Federal statutes, regulations, executive orders, FTA circulars, and other Federal administrative requirements in carrying out any project supported by the FTA grant. The applicant acknowledges that it is under a continuing obligation to comply with the terms and conditions of the grant agreement issued for its project with FTA. The applicant understands that Federal laws, regulations, policies, and administrative practices might be modified from time to time and may affect the implementation of the project.

The applicant agrees that the most recent Federal requirements will apply to the project unless FTA issues a written determination otherwise. The applicant must submit the Certifications and Assurances before receiving a grant if it does not have current certifications on file. E.

Free Speech and Religious Liberty In connection with any program or activity conducted with or benefiting from funds awarded under this notice, recipients of funds must comply with all applicable requirements of Federal law, including, without limitation, the Constitution of the United States. Statutory, regulatory, and public policy requirements, including without limitation, those protecting free speech, religious liberty, public welfare, the environment, and prohibiting discrimination. The conditions of performance, non-discrimination requirements, and other assurances made applicable to the award of funds in accordance with regulations of the Department of Transportation.

And applicable Federal financial assistance and contracting principles promulgated by the Office of Management and Budget. In complying with these requirements, recipients must ensure that no concession agreements are denied or other contracting decisions made on the basis of speech or other activities protected by the First Amendment. If the Department determines that a recipient has failed to comply with applicable Federal requirements, the Department may terminate the award of funds and disallow previously incurred costs, requiring the recipient to reimburse any expended award funds.

(3) Reporting The post-award reporting requirements include submission of the Federal Financial Report (FFR) and Milestone Progress Report in TrAMS. An evaluation of the grant will occur at various points in the demonstration process and at the end of the project. In addition, FTA is responsible for producing an Annual Report to Congress that compiles evaluation of selected projects, including an evaluation of the performance measures identified by the applicants.

All applicants must develop an evaluation plan to measure the success or failure of their projects and describe any plans for broad-based implementation of successful projects. FTA may request data and reports to support the evaluation and Annual Report. A.

Independent Evaluation To achieve a comprehensive understanding of the impacts and implications of each proposed COVID-19 Research Demonstration Program, projects funded under this announcement will require the recipient to conduct a third party independent evaluation of their project. Recipients will be required to contract with a third party independent evaluator to assist in developing an evaluation plan, and collecting, storing and managing data required to fulfill the evaluation requirement. No more than 10 percent of the Federal share of the project may be used to hire the third-party independent evaluator and the inclusion of a third-party independent evaluation should be described in the grant application.

If the project duration is more than two years, an interim evaluation report would need to be submitted to FTA, otherwise the evaluation report should be included as part of the final project report. B. COVID-19 Research Demonstration Grant Program Evaluation Projects funded under this announcement will be required to establish a set of performance metrics set by the third-party independent evaluator and shared with FTA.

G. Federal Awarding Agency Contacts Information For questions about applying, please contact Jamel El-Hamri email. Jamel.El-Hamri@dot.gov phone.

202-366-8985. A TDD is available at 1-800-877-8339 (TDDFIRS). To ensure that applicants receive accurate information about eligibility or the program, applicants are encouraged to contact FTA directly with questions, rather than through intermediaries or third parties.Start Printed Page 63658 FTA staff also may conduct briefings on the competitive grants selection and award process upon request.

Start Signature K. Jane Williams, Deputy Administrator. End Signature End Supplemental Information [FR Doc.

2020-22316 Filed 10-7-20. 8:45 am]BILLING CODE 4910-57-PStart Preamble Office of the Secretary, Department of Health and Human Services. Notice.

The Department of Health and Human Services (HHS) Office of Infectious Disease and HIV/AIDS Policy (OIDP) in the Office of the Assistant Secretary for Health (OASH) announces the draft Viral Hepatitis National Strategic Plan. A Roadmap to Elimination (2021-2025) (Hepatitis Plan) available for public comment. The draft Hepatitis Plan may be reviewed at www.hhs.gov/​hepatitis.

All comments must be received by 5:00 p.m. ET on October 8, 2020 to ensure consideration. All comments must be submitted electronically to HepatitisPlanComments@hhs.gov.

Start Further Info Carol Jimenez, OIDP, Carol.Jimenez@hhs.gov. 202-401-5131. End Further Info End Preamble Start Supplemental Information Viral hepatitis is a significant public health threat that puts people who are infected at increased risk for serious disease and death.

In the United States, new hepatitis A and hepatitis C infections have increased dramatically in recent years, little progress has been made on preventing hepatitis B infections, and, as of 2016, an estimated 3.3 million people were chronically infected with hepatitis B and hepatitis C.1-3 Collectively, viral hepatitis costs people, health systems, states, and the federal government billions of dollars each year 4 5 and contributes to substantial health disparities, stigma, and discrimination. Reversing the rates of viral hepatitis, preventing new infections, and improving care and treatment require a strategic and coordinated approach by federal partners in collaboration with state and local health departments, tribal communities, community-based organizations, and other nonfederal partners and stakeholders. To spur action to reduce new viral hepatitis infections and their adverse public health impact, OASH through OIDP, in collaboration with federal partners throughout HHS and other departments, led and coordinated development of the Hepatitis Plan.

Opportunities for public input were provided, and public comments received were reviewed and analyzed and helped inform the components of the Hepatitis Plan. The Hepatitis Plan focuses on hepatitis A, hepatitis B, and hepatitis C—the hepatitis viruses that most significantly affect the health of the nation. It is an elimination plan, with the overarching goal of eliminating viral hepatitis as a public health threat in the United States by 2030.

The Hepatitis Plan is intended to serve as a roadmap for all stakeholders at all levels to eliminate hepatitis in this nation. The Hepatitis Plan presents a strategic framework for integrating and leveraging synergistic policies, programs, and resources. It sets forth a vision and five goals for the nation, with objectives and strategies for each goal.

The objectives and strategies offered in this plan are interrelated and may be used to make progress toward more than one goal. The Hepatitis Plan identifies disproportionately impacted populations based on national hepatitis incidence, prevalence, and mortality data, to help federal and other stakeholders focus their efforts to realize the greatest impact. The Hepatitis Plan also includes indicators to measure progress and quantitative targets for each indicator.

Although it is a 5-year plan, it sets 10-year quantitative targets for each indicator—reflecting the reality that it will take more than 5 years to eliminate viral hepatitis as a public health threat. The order in which the goals, objectives, strategies, and indicators are presented is not associated with any prioritization. The following are the Hepatitis Plan's vision and goals.

Vision. The United States will be a place where new viral hepatitis infections are prevented, every person knows their status, and every person with viral hepatitis has high-quality health care and treatment and lives free from stigma and discrimination. This vision includes all people, regardless of age, sex, gender identity, sexual orientation, race, ethnicity, geographic location, or socioeconomic circumstance.

Goals. 1. Prevent New Viral Hepatitis Infections 2.

Improve Viral Hepatitis—Related Health Outcomes of People with Viral Hepatitis 3. Reduce Viral Hepatitis—Related Disparities and Health Inequities 4. Improve Viral Hepatitis Surveillance and Data Usage 5.

Achieve Integrated, Coordinated Efforts That Address the Viral Hepatitis Epidemics among All Partners and Stakeholders A roadmap for stakeholders at all levels and sectors, the Hepatitis Plan envisions a whole-of-nation response to preventing and controlling viral hepatitis in the United States. The Hepatitis Plan assumes the active participation of state, local, and tribal health departments and organizations, health plans and health care providers, schools and other academic institutions, community- and faith-based organizations, scientists, researchers, and the public in this effort. The priority populations, indicators, and quantitative targets, especially the methods used to determine them, are intended to help focus efforts and limited resources to realize the most impact.

Stakeholders are encouraged to focus on activities that resonate the most with the needs of the populations they serve and services they provide, and, using the Hepatitis Plan as a framework, develop their own plans to eliminate viral hepatitis and improve the health of their communities, states, tribal nations, and the nation. Information Needs The draft Hepatitis Plan may be reviewed at. Www.hhs.gov/​hepatitis.

OIDP seeks to obtain feedback from external stakeholders on the following. 1. Do the draft plan's goals, objectives, and strategies appropriately address the viral hepatitis epidemics?.

2. Are there any critical gaps in the Hepatitis Plan's goals, objectives, and strategies?. If so, please specify the gaps.

3. Do any of the Hepatitis Plan's goals, objectives and strategies cause concern?. If so, please specify the goal, objective or strategy, and describe the concern regarding it.

Each commenter is limited to a maximum of seven pages. Start Authority 77 FR 15761 (March 16, 2012). End Authority Start Signature Dated.

September 22, 2020. B. Kaye Hayes, Acting Director, Office of Infectious Disease and HIV/AIDS Policy.

End Signature Footnotes 1. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance—Start Printed Page 60814United States, 2018.

U.S. Department of Health and Human Services. 2020.

Accessed August 9, 2020. Https://www.cdc.gov/​hepatitis/​statistics/​2018surveillance/​index.htm. 2.

Hofmeister MG, Rosenthal EM, Barker LK, et al. Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016. Hepatology.

2019 Mar;69(3):1020-1031. Doi. 10.1002/hep.30297.

3. LeFevre ML. Screening for hepatitis B virus infection in nonpregnant adolescents and adults.

US Preventive Services Task Force recommendation statement. Annals Internal Med. 2014;161(1):58-66.

4. Morey RJ, Collier MG, Nelson NP. The financial burden of public health responses to hepatitis A cases among food handlers, 2012-2014.

Public Health Rep. 2017;132(4):443-447. Doi:10.1177/0033354917710947.

5. Wittenborn J, Brady J, Dougherty M, Rein D. Potential epidemiologic, economic, and budgetary impacts of current rates of hepatitis C treatment in Medicare and non-Medicare populations.

Hepatol Commun. 2017;1(2):99-109. Doi:10.1002/hep4.1031.

End Supplemental Information [FR Doc. 2020-21288 Filed 9-25-20. 8:45 am]BILLING CODE 4150-43-P.