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€‚For the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This Focus Issue on arrhythmias contains a State of the kamagra tablets online Art Review entitled ‘Tilt testing remains a valuable asset’, authored by Richard Sutton from Imperial College in London, UK, and colleagues.1 The authors note that head-up test (TT) has been used for >50 years to study heart rate/blood pressure adaptation to positional changes, to model responses to haemorrhage, to assess orthostatic hypotension, and to evaluate haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension.2–4 During these studies, some subjects were syncopal http://cz.keimfarben.de/kamagra-oral-jelly-online-shop/ with vasovagal reflex. As a result, tilt testing was incorporated into clinical assessment of syncope when the origin was unknown. Subsequently, clinical experience supported TT’s diagnostic value kamagra tablets online. This is highlighted in evidence-based professional practice guidelines which provide advice for tilt test methodology and interpretation, while concurrently identifying its limitations.

Thus, TT is held to be valuable in clinical diagnostics, in contrast to the limited active standing test but kamagra tablets online complementary to ECG-loop recorders. TT has added importantly to appreciation of pathophysiology of syncope/collapse and, thereby, has improved care of syncopal patients.Medicine evolves steadily, but sometimes new ideas or discoveries lead to either sudden turns or abrupt jumps forward. It happened with the discovery of blood kamagra tablets online typing and with the realization that invisible forms of life identifiable by a microscope could cause fatal s. What followed was the introduction of safe blood transfusions and of specific antibiotics against different types of bacteria.

Progressively, these highly selective approaches favoured kamagra tablets online the development of the term ‘Precision Medicine’ (still often used interchangeably with the older term ‘Personalized Medicine’), which gained favour because it is objectively attractive and also conveys the reassuring feeling that doctors have therapies that are just ‘right for us’.5 In a State of the Art Review article entitled ‘Precision Medicine and cardiac channelopathies. When dreams meet reality’, Massimiliano Gnecchi from the University of Pavia in Italy, and colleagues note that cardiac channelopathies are being progressively involved in the evolution brought by Precision Medicine and some of them are benefiting from these novel approaches, especially the long QT syndrome.6 The authors explore the main layers that should be considered when developing a Precision Medicine approach for cardiac channelopathies, with a focus on modern in vitro strategies based on patient-specific human-induced pluripotent stem cells and on in silico models. Precision Medicine is where scientists and clinicians must meet, and integrate their expertise, in order to improve medical care in an innovative way but without losing common sense. They have indeed tried to provide the cardiologist’s point of view by kamagra tablets online comparing state-of-the-art techniques and approaches, including revolutionary discoveries, with current practice.

This point matters because the new approaches may, or may not, exceed the efficacy and safety of established therapies. Thus, the eagerness to implement the most recent translational strategies for cardiac channelopathies must be tempered by kamagra tablets online an objective assessment to verify whether the Precision Medicine approaches are indeed making a difference for the patients.7–9 Gnecchi and colleagues believe that Precision Medicine may shape the diagnosis and treatment of cardiac channelopathies for years to come (Figure 1). Nonetheless, its potential superiority over standard therapies should be constantly monitored and assessed before translating intellectually rewarding new discoveries into clinical practice. Figure 1Precision Medicine kamagra tablets online layers.

Layers that constitute a Precision Medicine pipeline for a dynamic patient risk stratification. SNV, single nucleotide variants (from Gnecchi M, Sala L, kamagra tablets online Schwartz PJ. Precision Medicine and cardiac channelopathies. When dreams kamagra tablets online meet reality.

See pages 1661–1675).Figure 1Precision Medicine layers. Layers that constitute a Precision Medicine pipeline for a dynamic patient risk stratification. SNV, single nucleotide variants (from Gnecchi M, kamagra tablets online Sala L, Schwartz PJ. Precision Medicine and cardiac channelopathies.

When dreams meet reality kamagra tablets online. See pages 1661–1675).The benefit of prophylactic implantable cardioverter-defibrillator (ICD) use is not uniform due to differences in the risk of life-threatening ventricular tachycardia (VT)/fibrillation (VF) and non-arrhythmic mortality.10,11 In a clinical research article entitled ‘Predicted benefit of an implantable cardioverter-defibrillator. The MADIT-ICD benefit score’, Arwa Younis from the University of Rochester Medical Center in New York, USA, and colleagues aimed to develop an ICD Benefit Prediction Score that integrates the competing risks.12 The study population comprised kamagra tablets online all 4531 patients enrolled in the MADIT trials. Best subsets Fine and Gray regression analysis was used to develop prognostic models for VT (≥200 b.p.m.)/VF vs.

Non-arrhythmic mortality kamagra tablets online (defined as death without prior sustained VT/VF). Eight predictors of VT/VF (male, age <75years, prior non-sustained VT, heart rate >75 b.p.m., systolic blood pressure <140 mmHg, ejection fraction ≤25%, myocardial infarction, and atrial arrhythmia) and seven predictors of non-arrhythmic mortality (age ≥75 years, diabetes mellitus, body mass index <23 kg/m2, ejection fraction ≤25%, NYHA class ≥II, ICD vs. CRT-D, and kamagra tablets online atrial arrhythmia) were identified. The two scores were combined to create three MADIT-ICD benefit groups.

In the highest benefit group, the 3-year predicted risk of VT/VF was three-fold higher than the risk of non-arrhythmic mortality (20% vs. 7%, P < kamagra tablets online. 0.001). In the intermediate kamagra tablets online benefit group, the difference in the corresponding predicted risks was attenuated (15% vs.

9%, P <. 0.01). In the lowest benefit group, the 3-year predicted risk of VT/VF was similar to the risk of non-arrhythmic mortality (11% vs. 12%, P = 0.41).

A personalized ICD Benefit Score was developed based on the distribution of the two competing risks scores in the study population (https://is.gd/madit). Internal and external validation confirmed model stability.Thus, the authors propose the novel MADIT-ICD Benefit Score that predicts the likelihood of prophylactic ICD benefit through personalized assessment of the risk of VT/VF weighed against the risk of non-arrhythmic mortality. The manuscript is accompanied by an Editorial by Hugh Calkins and David Okada from the Johns Hopkins University School of Medicine in Baltimore, MD, USA.13 The authors note that overall, Younis and colleagues are to be congratulated for taking an important step towards precision management in the primary prevention ICD population by proving an elegant, easy to use, validated scoring system that incorporates both arrhythmic and non-arrhythmic competing risk. The Editorialists would urge all cardiologists and electrophysiologists to utilize this tool in their risk/benefit discussions with patients regarding whether or not to implant an ICD.Risk stratification of sudden cardiac arrest (SCA) in Brugada syndrome (Brs) remains the main challenge for physicians.14–16 Several scores have been suggested to improve risk stratification, but have never been replicated.

In a clinical research article entitled ‘Robustness and relevance of predictive score in sudden cardiac death for patients with Brugada syndrome’, Vincent Probst from UNIV Nantes in France, and colleagues aimed to investigate the accuracy of the Brs risk scores.17 A total of 1613 patients were prospectively enrolled from 1993 to 2016 in a multicentric database. Among them, all patients were evaluated with the Shanghai score and 461 (29%) with the Sieira score. After a mean follow-up of 6.5 years, an arrhythmic event occurred in 75 (5%) patients including 16 SCAs, 11 symptomatic ventricular arrhythmias, and 48 appropriate therapies. Predictive capacities of the Shanghai and the Sieira scores estimated by an area under the curve were 0.73 and 0.71, respectively.

No statistical difference was found in intermediate risk patients.Probst et al. Conclude that in the largest cohort of Brs patients ever described, risk scores do not allow stratifying the risk of an arrhythmic event in intermediate risk patients. The manuscript is accompanied by an Editorial by Pietro Delise from the Hospital Pederzoli in Mestre, Italy.18 The author notes that the final lesson is that, in the clinical setting, the decision-making of physicians cannot be replaced by a calculating machine alone.The prediction of ischaemic and bleeding risk in patients with atrial fibrillation (AF) is currently predominantly based on clinical predictors.19,20 In a clinical research article entitled ‘Serial assessment of biomarkers and the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in the ENGAGE AF-TIMI 48 trial’, K. Oyama from Harvard Medical School in Boston, MA, USA, and colleagues investigated whether patients with AF demonstrate detectable changes in biomarkers including hsTnT (high-sensitivity troponin T), NT-proBNP (N-terminal probrain natriuretic peptide), and GDF-15 (growth differentiation factor-15) over 12 months and whether such changes from baseline to 12 months are associated with the subsequent risk of stroke or systemic embolic events and bleeding.21 ENGAGE AF-TIMI 48 was a randomized trial of the oral factor Xa inhibitor edoxaban in patients with AF and a CHADS2 score ≥2.

The authors performed a nested prospective biomarker study in ∼6300 patients, analysing hsTnT, NT-proBNP, and GDF-15 at baseline and 12 months. HsTnT was dynamic in 47% (≥2 ng/L change), NT-proBNP in 52% (≥200 pg/L change), and GDF-15 in 46% (≥300 pg/L change) during 12 months. In a Cox regression model, upward changes in log2-transformed hsTnT and NT-proBNP changes were associated with increased risk of stroke or systemic embolic events (adjusted hazard ratios 1.74 and 1.27, respectively) and log2-transformed GDF-15 level changes with bleeding (adjusted hazard ratio 1.40) (Figure 2). Reassessment of ABC-stroke (age, prior stroke/transient ischaemic attack, hsTnT, and NT-proBNP) and ABC-bleeding (age, prior bleeding, haemoglobin, hsTnT, and GDF-15) risk scores at 12 months accurately reclassified a significant proportion of patients compared with their baseline risk.

Figure 2Graphical Abstract (from Oyama K, Giugliano RP, Berg DD, Ruff CT, Jarolim P, Tang M, Murphy SA, Lanz HJ, Grosso MA, Antman EM, Braunwald E, Morrow DA. Serial assessment of biomarkers and the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in the ENGAGE AF-TIMI-48 trial. See pages 1698–1706).Figure 2Graphical Abstract (from Oyama K, Giugliano RP, Berg DD, Ruff CT, Jarolim P, Tang M, Murphy SA, Lanz HJ, Grosso MA, Antman EM, Braunwald E, Morrow DA. Serial assessment of biomarkers and the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in the ENGAGE AF-TIMI-48 trial.

See pages 1698–1706).Oyama et al. Conclude that serial assessment of hsTnT, NT-proBNP, and GDF-15 reveals that a substantial proportion of patients with AF exhibit dynamic values. Greater increases in these biomarkers measured over 1 year are associated with important clinical outcomes in anticoagulated patients with AF. The manuscript is accompanied by an Editorial by Christoph Bode from the Universitätsklinikum Freiburg in Germany.22 The author notes that the current study by Oyama et al.

Is likely to be an important step forward to tailoring the current prediction models for patients with AF to a better correlation with stroke, embolic as well as bleeding events. Literacy is a prerequisite to understand the world. Learning the ABC will enable us to identify individual risk and consequently personalize therapy for our most vulnerable patients.The issue is complemented by two Discussion Forum articles. In a contribution entitled ‘Effectiveness of closed loop stimulation pacing in patients with cardio-inhibitory vasovagal reflex syncope is questionable’, Wouter Wieling from the University of Amsterdam in the Netherlands, and David Jardine from the University of Otago in Christchurch, New Zealand comment on the contribution also published in this issue entitled ‘Cardiac pacing in severe recurrent reflex syncope and tilt-induced asystole’ by Michele Brignole from the Ospedale San Luca, and colleagues.3,23 Brignole et al.

Respond in a separate comment.24The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article. References1Sutton R, Fedorowski A, Olshansky B, Gert van Dijk J, Abe H, Brignole M, de Lange F, Kenny RA, Lim PB, Moya A, Rosen SD, Russo V, Stewart JM, Thijs RD, Benditt DG. Tilt testing remains a valuable asset. Eur Heart J 2021;42:1654–1660.2Sutton R, Brignole M.

Twenty-eight years of research permit reinterpretation of tilt-testing. Hypotensive susceptibility rather than diagnosis. Eur Heart J 2014;35:2211–2212.3Brignole M, Russo V, Arabia F, Oliveira M, Pedrote A, Aerts A, Rapacciuolo A, Boveda S, Deharo JC, Maglia G, Nigro G, Giacopelli D, Gargaro A, Tomaino M. Cardiac pacing in severe recurrent reflex syncope and tilt-induced asystole.

Eur Heart J 2021;42:508–516.4Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018;39:1883–1948.5Corral-Acero J, Margara F, Marciniak M, Rodero C, Loncaric F, Feng Y, Gilbert A, Fernandes JF, Bukhari HA, Wajdan A, Martinez MV, Santos MS, Shamohammdi M, Luo H, Westphal P, Leeson P, DiAchille P, Gurev V, Mayr M, Geris L, Pathmanathan P, Morrison T, Cornelussen R, Prinzen F, Delhaas T, Doltra A, Sitges M, Vigmond EJ, Zacur E, Grau V, Rodriguez B, Remme EW, Niederer S, Mortier P, McLeod K, Potse M, Pueyo E, Bueno-Orovio A, Lamata P. The ‘Digital Twin’ to enable the vision of precision cardiology.

Eur Heart J 2020;41:4556–4564.6Gnecchi M, Sala L, Schwartz PJ. Precision Medicine and cardiac channelopathies. When dreams meet reality. Eur Heart J 2021;42:1661–1675.7Mehta A, Ramachandra CJA, Singh P, Chitre A, Lua CH, Mura M, Crotti L, Wong P, Schwartz PJ, Gnecchi M, Shim W.

Identification of a targeted and testable antiarrhythmic therapy for long-QT syndrome type 2 using a patient-specific cellular model. Eur Heart J 2018;39:1446–1455.8Schwartz PJ, Gnecchi M, Dagradi F, Castelletti S, Parati G, Spazzolini C, Sala L, Crotti L. From patient-specific induced pluripotent stem cells to clinical translation in long QT syndrome Type 2. Eur Heart J 2019;40:1832–1836.9Schwartz PJ.

1970–2020. 50 years of research on the long QT syndrome—from almost zero knowledge to precision medicine. Eur Heart J 2021;42:1063–1072.10Zabel M, Willems R, Lubinski A, Bauer A, Brugada J, Conen D, Flevari P, Hasenfuβ G, Svetlosak M, Huikuri HV, Malik M, Pavlović N, Schmidt G, Sritharan R, Schlögl S, Szavits-Nossan J, Traykov V, Tuinenburg AE, Willich SN, Harden M, Friede T, Svendsen JH, Sticherling C, Merkely B. Clinical effectiveness of primary prevention implantable cardioverter-defibrillators.

Results of the EU-CERT-ICD controlled multicentre cohort study. Eur Heart J 2020;41:3437–3447.11Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekvål TM, Spaulding C, Van Veldhuisen DJ. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC).

Endorsed by. Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015;36:2793–2867.12Younis A, Goldberger JJ, Kutyifa V, Zareba W, Polonsky B, Klein H, Aktas MK, Huang D, Daubert J, Estes M, Cannom D, McNitt S, Stein K, Goldenberg I. Predicted benefit of an implantable cardioverter-defibrillator.

The MADIT-ICD benefit score. Eur Heart J 2021;42:1676–1684.13Okada DR, Calkins H. Precision prevention with ICDs. Can a simple score improve patient selection?.

Eur Heart J 2021;42:1685–1686.14Pappone C, Ciconte G, Micaglio E, Monasky MM. Common modulators of Brugada syndrome phenotype do not affect SCN5A prognostic value. Eur Heart J 2021;42:1273–1274.15El-Battrawy I, Lang S, Zhou X, Akin I. Different genotypes of Brugada syndrome may present different clinical phenotypes.

Electrophysiology from bench to bedside. Eur Heart J 2021;42:1270–1272.16Postema PG, Walsh R, Bezzina CR. Illuminating the path from genetics to clinical outcome in Brugada syndrome. Eur Heart J 2021;42:1091–1093.17Probst V, Goronflot T, Anys S, Tixier R, Briand J, Berthome P, Geoffroy O, Clementy N, Mansourati J, Jesel L, Dupuis JM, Bru P, Kyndt F, Wargny M, Guyomarch B, Thollet A, Mabo P, Gourraud PA, Behar N, Sacher F, Gourraud JB.

Robustness and relevance of predictive score in sudden cardiac death for patients with Brugada syndrome. Eur Heart J 2021;42:1687–1695.18Delise P. Risk stratification in Brugada syndrome. The challenge of the grey zone.

Eur Heart J 2021;42:1696–1697.19Sulzgruber P, Doehner W, Niessner A. Valvular atrial fibrillation and a CHA2DS2-VASc score of 1—a statement of the ESC working group on cardiovascular pharmacotherapy and ESC council on stroke. Eur Heart J 2021;42:541–543.20Nielsen PB, Soegaard M, Skjoeth F, Larsen TB, Lip GYH, PRESTIGE-AF investigators. Risk of ischemic stroke and recurrent ICH in patients with atrial fibrillation presenting with incident ICH.

An analysis from the Danish Stroke Registry. Eur Heart J 2020;41(Suppl_2):ehaa946.0521.21Oyama K, Giugliano RP, Berg DD, Ruff CT, Jarolim P, Tang M, Murphy SA, Lanz HJ, Grosso MA, Antman EM, Braunwald E, Morrow DA. Serial assessment of biomarkers and the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in the ENGAGE AF-TIMI-48 trial. Eur Heart J 2021;42:1698–1706.22Krohn-Grimberghe M, Duerschmied D, Bode C.

What do we learn by repeating the ABC?. Eur Heart J 2021;42:1707–1709.23Wieling W, Jardine DL. Effectiveness of closed loop stimulation pacing in patients with cardio-inhibitory vasovagal reflex syncope is questionable. Eur Heart J 2021;42:1710.24Brignole M, Sutton R, Fedorowski A.

Are convictions more dangerous enemies of truth than lies?. Eur Heart J 2021;42:1711–1712. Published on behalf of the European Society of Cardiology. All rights reserved.

© The Author(s) 2021. For permissions, please email. Journals.permissions@oup.com..

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More than Buy cipro no prescription 2,900 U.S kamagra 100mg oral jelly side effects. Health care workers have died in the erectile dysfunction treatment kamagra since March, a far higher number than that reported by the government, according to a new analysis by KHN and The Guardian. Fatalities from kamagra 100mg oral jelly side effects the erectile dysfunction have skewed young, with the majority of victims under age 60 in the cases for which there is age data. People of color have been disproportionately affected, accounting for about 65% of deaths in cases in which there is race and ethnicity data.

After conducting interviews with relatives and friends of around 300 victims, KHN and The Guardian learned that one-third of the fatalities involved concerns over inadequate personal protective equipment. Many of the deaths — about 680 — occurred in New York and New Jersey, which kamagra 100mg oral jelly side effects were hit hard early in the kamagra. Significant numbers also died in Southern and Western states in the ensuing months. The findings are part of “Lost on the Frontline,” a nine-month data and investigative project by KHN and The Guardian to track every health care worker who dies of erectile dysfunction treatment.

One of those lost, Vincent DeJesus, 39, told his brother Neil that he’d be in deep trouble if he spent much time with a erectile dysfunction treatment-positive patient while wearing the surgical mask provided to him by the Las kamagra 100mg oral jelly side effects Vegas hospital where he worked. DeJesus died on Aug. 15. Another fatality was Sue Williams-Ward, a 68-year-old home health aide kamagra 100mg oral jelly side effects who earned $13 an hour in Indianapolis, and bathed, dressed and fed clients without wearing any PPE, her husband said.

She was intubated for six weeks before she died May 2. €œLost on the Frontline” is prompting new government action to explore the root cause of health care worker deaths and take steps to track them better. Officials at the Department of Health and Human Services recently asked the National Academy of kamagra 100mg oral jelly side effects Sciences for a “rapid expert consultation” on why so many health care workers are dying in the U.S., citing the count of fallen workers by The Guardian and KHN. €œThe question is, where are they becoming infected?.

€ asked Michael Osterholm, a member of President-elect Joe Biden’s erectile dysfunction treatment advisory team and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. €œThat is clearly a critical issue we need to answer and we don’t kamagra 100mg oral jelly side effects have that.” [embedded content] The Dec. 10 report by the national academies suggests a new federal tracking system and specially trained contact tracers who would take PPE policies and availability into consideration. Doing so would add critical knowledge that could inform generations to come and give meaning to the lives lost.

€œThose [health care workers] are people who walked into places of work every day because they cared about patients, putting food on the kamagra 100mg oral jelly side effects table for families, and every single one of those lives matter,” said Sue Anne Bell, a University of Michigan assistant professor of nursing and co-author of the national academies report. The recommendations come at a fraught moment for health care workers, as some are getting the erectile dysfunction treatment while others are fighting for their lives amid the highest levels of the nation has seen. The toll continues to mount. In Indianapolis, for example, 41-year-old nurse practitioner Kindra Irons kamagra 100mg oral jelly side effects died Dec.

1. She saw seven or kamagra 100mg oral jelly side effects eight home health patients per week while wearing full PPE, including an N95 mask and a face shield, according to her husband, Marcus Irons. The kamagra destroyed her lungs so badly that six weeks on the most aggressive life support equipment, ECMO, couldn’t save her, he said. Marcus Irons said he is now struggling financially to support their two youngest children, ages 12 and 15.

€œNobody should have to kamagra 100mg oral jelly side effects go through what we’re going through,” he said. In Massachusetts, 43-year-old Mike “Flynnie” Flynn oversaw transportation and laundry services at North Shore Medical Center, a hospital in Salem, Massachusetts. He and his wife were also raising young children, ages 8, 10 and 11. Flynn, who shone at father-daughter dances, fell kamagra 100mg oral jelly side effects ill in late November and died Dec.

8. He had a heart attack at home on the couch, according to his father, Paul Flynn. A hospital spokesperson said he had full access to PPE and free testing kamagra 100mg oral jelly side effects on-site. Since the first months of the kamagra, more than 70 reporters at The Guardian and KHN have scrutinized numerous governmental and public data sources, interviewed the bereaved and spoken with health care experts to build a count.

The total number includes fatalities identified by labor unions, obituaries and news outlets and in online postings by the bereaved, as well as by relatives of the deceased. The previous total announced by The Guardian kamagra 100mg oral jelly side effects and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments. These deaths include the facility names but not worker names.

Reporters cross-checked kamagra 100mg oral jelly side effects each record to ensure fatalities did not appear in the database twice. The tally has been widely cited by other media as well as by members of Congress. Rep. Norma Torres (D-Calif.) referenced the data citing the need kamagra 100mg oral jelly side effects for a pending bill that would provide compensation to the families of health care workers who died or sustained long-term disabilities from erectile dysfunction treatment.

Sen. Ron Wyden (D-Ore.) mentioned the tally in a Senate Finance Committee hearing about the medical supply chain. €œThe fact is,” he said, “the shortages of PPE have put our doctors and nurses and caregivers in grave danger.” This story is part of “Lost on the Frontline,” an ongoing project from kamagra 100mg oral jelly side effects The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. Who die from erectile dysfunction treatment, and to investigate why so many are victims of the disease.

If you kamagra 100mg oral jelly side effects have a colleague or loved one we should include, please share their story. Christina Jewett. ChristinaJ@kff.org, @by_cjewett Melissa Bailey. @mmbaily Related Topics Contact Us Submit a Story kamagra 100mg oral jelly side effects TipWorkers at Garfield Medical Center in suburban Los Angeles were on edge as the kamagra ramped up in March and April.

Staffers in a 30-patient unit were rationing a single tub of sanitizing wipes all day. A May memo from the CEO said N95 masks could be cleaned up to 20 times before replacement. Patients showed kamagra 100mg oral jelly side effects up erectile dysfunction treatment-negative but some still developed symptoms a few days later. Contact tracing took the form of texts and whispers about exposures.

By summer, frustration gave way to fear. At least 60 staff members at the 210-bed community hospital caught erectile dysfunction treatment, according to records obtained kamagra 100mg oral jelly side effects by KHN and interviews with eight staff members and others familiar with hospital operations. The first to die was Dawei Liang, 60, a quiet radiology technician who never said no when a colleague needed help. A cardiology technician became infected and changed his final wishes — agreeing to intubation — hoping for more years to dote on his grandchildren.

Few felt safe kamagra 100mg oral jelly side effects. Ten months into the kamagra, it has become far clearer why tens of thousands of health care workers have been infected by the kamagra and why so many have died. Dire PPE shortages. Limited erectile dysfunction treatment kamagra 100mg oral jelly side effects tests.

Sparse tracking of viral spread. Layers of flawed policies handed down by health care executives and politicians, and lax enforcement by government regulators. All of those breakdowns, across cities and states, have contributed to the deaths of more kamagra 100mg oral jelly side effects than 2,900 health care workers, a nine-month investigation by over 70 reporters at KHN and The Guardian has found. This number is far higher than that reported by the U.S.

Government, which does not have a comprehensive national count of health care workers who’ve died of erectile dysfunction treatment. The fatalities have skewed young, with the majority of victims under age 60 in the cases for which there is kamagra 100mg oral jelly side effects age data. People of color have been disproportionately affected, accounting for about 65% of deaths in cases in which there is race and ethnicity data. After conducting interviews with relatives and friends of around 300 victims, KHN and The Guardian learned that one-third of the fatalities involved concerns over inadequate kamagra 100mg oral jelly side effects personal protective equipment.

Many of the deaths occurred in New York and New Jersey, and significant numbers also died in Southern and Western states as the kamagra wore on. Workers at well-funded academic medical centers — hubs of policymaking clout and prestigious research — were largely spared. Those who died tended to work in less prestigious community kamagra 100mg oral jelly side effects hospitals like Garfield, nursing homes and other health centers in roles in which access to critical information was low and patient contact was high. Garfield Medical Center and its parent company, AHMC Healthcare, did not respond to multiple calls or emails regarding workers’ concerns and circumstances leading to the worker deaths.

So as 2020 draws to a close, we ask. Did so many of kamagra 100mg oral jelly side effects the nation’s health care workers have to die?. New York’s Warning for the Nation The seeds of the crisis can be found in New York and the surrounding cities and suburbs. It was the region where the profound risks facing medical staff became clear.

And it was here where kamagra 100mg oral jelly side effects the most died. As the kamagra began its U.S. Surge, city paramedics were out in force, their sirens cutting through eerily empty streets as they rushed patients to hospitals. Carlos Lizcano, a blunt Queens kamagra 100mg oral jelly side effects native who had been with the New York City Fire Department (FDNY) for two decades, was one of them.

He was answering four to five cardiac arrest calls every shift. Normally he would have fielded that many in a month. He remembered kamagra 100mg oral jelly side effects being stretched so thin he had to enlist a dying man’s son to help with CPR. On another call, he did chest compressions on a 33-year-old woman as her two small children stood in the doorway of a small apartment.

€œI just have this memory of those kids looking at us like, ‘What’s going on?. €™â€ After the young woman died, Lizcano went outside and punched kamagra 100mg oral jelly side effects the ambulance in frustration and grief. The personal risks paramedics faced were also grave. More than 40% of emergency medical service workers in the FDNY went on leave for confirmed or suspected erectile dysfunction during the first three months of the kamagra, according to a study by the department’s chief medical officer and others.

In fact, health care workers were kamagra 100mg oral jelly side effects three times more likely than the general public to get erectile dysfunction treatment, other researchers found. And the risks were not equally spread among medical professions. Initially, CDC guidelines were written to afford the highest protection to workers in a hospital’s erectile dysfunction treatment unit. Yet months later, it was clear that the doctors initially thought to be at most risk — anesthesiologists and those working kamagra 100mg oral jelly side effects in the intensive care unit — were among the least likely to die.

This could be due to better personal protective equipment or patients being less infectious by the time they reach the ICU. Instead, scientists discovered that “front door” health workers like paramedics and those in acute-care “receiving” roles — such as in the emergency kamagra 100mg oral jelly side effects room — were twice as likely as other health care workers to be hospitalized with erectile dysfunction treatment. [embedded content] For FDNY’s first responders, part of the problem was having to ration and reuse masks. Workers were blind to an invisible threat that would be recognized months later.

The kamagra spread rapidly from pre-symptomatic people and among those with kamagra 100mg oral jelly side effects no symptoms at all. In mid-March, Lizcano was one of thousands of FDNY first responders infected with erectile dysfunction treatment. At least four of them died, city records show. They were among the kamagra 100mg oral jelly side effects 679 health care workers who have died in New York and New Jersey to date, most at the height of the terrible first wave of the kamagra.

€œInitially, we didn’t think it was this bad,” Lizcano said, recalling the confusion and chaos of the early kamagra. €œThis city wasn’t prepared.” Neither was the rest of the country. An Elusive Enemy The kamagra continued to spread like a ghost through the nation and proved deadly to kamagra 100mg oral jelly side effects workers who were among the first to encounter sick patients in their hospital or nursing home. One government agency had a unique vantage point into the problem but did little to use its power to cite employers — or speak out about the hazards.

Health employers had a mandate to report worker deaths and hospitalizations to the Occupational Safety and Health Administration. When they did so, the report went to an agency headed by Eugene Scalia, son of conservative Supreme Court kamagra 100mg oral jelly side effects Justice Antonin Scalia who died in 2016. The younger Scalia had spent part of his career as a corporate lawyer fighting the very agency he was charged with leading. Its inspectors have documented instances in which some of the most vulnerable workers — those with low information and high patient contact — faced incredible hazards, but OSHA’s staff did little to hold employers to account.

Beaumont, Texas, kamagra 100mg oral jelly side effects a town near the Louisiana border, was largely untouched by the kamagra in early April. That’s when a 56-year-old physical therapy assistant at Christus Health’s St. Elizabeth Hospital named Danny Marks called in sick with a fever and body aches, federal OSHA records show. He told a human resources employee that he’d been in the room of a patient who was receiving a breathing treatment — the type known as kamagra 100mg oral jelly side effects the most hazardous to health workers.

The CDC advises that N95 respirators be used by all in the room for the so-called aerosol-generating procedures. (A facility spokesperson said the patient was not known or suspected to have erectile dysfunction treatment at the time Marks entered the room.) Marks went home to self-isolate. By April 17, he kamagra 100mg oral jelly side effects was dead. The patient whose room Marks entered later tested positive for erectile dysfunction treatment.

And an OSHA investigation into Marks’ death found there was no sign kamagra 100mg oral jelly side effects on the door to warn him that a potentially infected patient was inside, nor was there a cart outside the room where he could grab protective gear. The facility did not have a universal masking policy in effect when Marks went in the room, and it was more than likely that he was not wearing any respiratory protection, according to a copy of the report obtained through a public records request. Twenty-one more employees contracted erectile dysfunction treatment by the time he died. €œHe was a beloved gentleman and friend and he kamagra 100mg oral jelly side effects is missed very much,” Katy Kiser, Christus’ public relations director, told KHN.

OSHA did not issue a citation to the facility, instead recommending safety changes. The agency logged nearly 8,700 complaints from health care workers in 2020. Yet Harvard researchers found that some of those desperate pleas for help, often decrying shortages of PPE, did little to forestall kamagra 100mg oral jelly side effects harm. In fact, they concluded that surges in those complaints preceded increases in deaths among working-age adults 16 days later.

One report author, Peg Seminario, blasted OSHA for failing to use its power to get employers’ attention about the danger facing health workers. She said issuing big fines in high-profile cases can have a broad impact — except OSHA has kamagra 100mg oral jelly side effects not done so. €œThere’s no accountability for failing to protect workers from exposure to this deadly kamagra,” said Seminario, a former union health and safety official. Desperate for Safety Gear There was little outward sign this summer that Garfield Medical Center was struggling to contain erectile dysfunction treatment.

While Medicare has forced nursing homes to report staff s and deaths, no such requirement applies kamagra 100mg oral jelly side effects to hospitals. More 'Lost on the Frontline' Stories Dying Young. The Health Care Workers in Their 20s Killed by erectile dysfunction treatment By Alastair Gee, The Guardian | August 13, 2020A database of deaths compiled by KHN and The Guardian includes a significant minority under 30, leaving shattered dreams and devastated families.(Photo Credit. The Obra family)Most Home Health Aides ‘Can’t Afford Not to Work’ — Even When Lacking PPEBy Eli Cahan | October 16, 2020Home kamagra 100mg oral jelly side effects health aides flattened the curve by keeping the most vulnerable patients — seniors, the disabled, the infirm — out of hospitals.

But they’ve done it mostly at poverty wages and without overtime pay, hazard pay, sick leave or health insurance.(Photo Credit. Tamarya Burnett)They Cared for Some of New York’s Most Vulnerable Communities. Then 12 kamagra 100mg oral jelly side effects Died.By Danielle Renwick, The Guardian | August 27, 2020Immigrant health workers help keep the U.S. Health system afloat — and they’re dying of erectile dysfunction treatment at high rates.(Photo Credit.

Pablo Monsalve/VIEWpress via Getty Images)These Front-Line Workers Could Have Retired. They Risked Their Lives Instead kamagra 100mg oral jelly side effects. By Shoshana Dubnow | November 20, 2020 An investigation by KHN and The Guardian shows that 329 health care workers age 65 or older have reportedly died of erectile dysfunction treatment.(Photo Credits. Tom Miles, David Brown, Bethany MacDonald) kamagra 100mg oral jelly side effects Yet as the focus of the kamagra moved from the East Coast in the spring to Southern and Western states, health care worker deaths climbed.

And behind the scenes at Garfield, workers were dealing with a lack of equipment meant to keep them safe. Complaints to state worker-safety officials filed in March and April said Garfield Medical Center workers were asked to reuse the same N95 respirator for a week. Another complaint said workers ran out kamagra 100mg oral jelly side effects of medical gowns and were directed to use less-protective gowns typically provided to patients. Staffers were shaken by the death of Dawei Liang.

And only after his death and a rash of s did Garfield provide N95 masks to more workers and put up plastic tarps to block a erectile dysfunction treatment unit from an adjacent ward. Yet this may have kamagra 100mg oral jelly side effects been too late. The erectile dysfunction can easily spread to every corner of a hospital. Researchers in South Africa traced a single ER patient to 119 cases in a hospital — 80 among staff members.

Those included 62 nurses from neurology, surgical kamagra 100mg oral jelly side effects and general medical units that typically would not have housed erectile dysfunction treatment patients. By late July, Garfield cardiac and respiratory technician Thong Nguyen, 73, learned he was erectile dysfunction treatment-positive days after he collapsed at work. Nguyen loved his job and was typically not one to complain, said his youngest daughter, Dinh Kozuki. A 34-year veteran at the hospital, he was known for conducting medical tests in multiple languages kamagra 100mg oral jelly side effects.

His colleagues teased him, saying he was never going to retire. Kozuki said her father spoke up in March about the rationing of protective gear, but his concerns were not allayed. Dinh Kozuki’s father, Thong Nguyen, died of erectile dysfunction treatment-related complications after nearly 35 years of service at Garfield Medical kamagra 100mg oral jelly side effects Center in Los Angeles. Nguyen’s supervisor told him he’d have to reuse personal protective equipment.

€œHe definitely should not have passed [away],” Kozuki said.(Heidi de Marco / KHN) The PPE problems at Garfield were a symptom of a broader problem. As the kamagra spread around the nation, chronic shortages of protective gear left many workers in community-based settings fatally kamagra 100mg oral jelly side effects exposed. Nearly 1 in 3 family members or friends of around 300 health care workers interviewed by KHN or The Guardian expressed concerns about a fallen workers’ PPE. Health care workers’ labor unions asked for the more-protective N95 respirators when the kamagra began.

But Centers for Disease Control and Prevention guidelines said the unfitted surgical masks worn by workers who feed, bathe and lift kamagra 100mg oral jelly side effects erectile dysfunction treatment patients were adequate amid supply shortages. Mary Turner, an ICU nurse and president of the Minnesota Nurses Association, said she protested alongside nurses all summer demanding better protective gear, which she said was often kept from workers because of supply-chain shortages and the lack of political will to address them. €œIt shouldn’t kamagra 100mg oral jelly side effects have to be that way,” Turner said. €œWe shouldn’t have to beg on the streets for protection during a kamagra.” At Garfield, it was even hard to get tested.

Critical care technician Tony Ramirez said he started feeling ill on July 12. He had an idea of how kamagra 100mg oral jelly side effects he might have been exposed. He’d cleaned up urine and feces of a patient suspected of having erectile dysfunction treatment and worked alongside two staffers who also turned out to be erectile dysfunction treatment-positive. At the time, he’d been wearing a surgical mask and was worried it didn’t protect him.

Yet he kamagra 100mg oral jelly side effects was denied a free test at the hospital, and went on his own time to Dodger Stadium to get one. His positive result came back a few days later. As Ramirez rested at home, he texted Alex Palomo, 44, a Garfield medical secretary who was also at home with erectile dysfunction treatment, to see how he was doing. Palomo was the kind of man who came kamagra 100mg oral jelly side effects to many family parties but would often slip away unseen.

A cousin finally asked him about it. Palomo said he just hated to say goodbye. Palomo would wear only a surgical mask kamagra 100mg oral jelly side effects when he would go into the rooms of patients with flashing call lights, chat with them and maybe bring them a refill of water, Ramirez said. Paramedics work behind an ambulance at the Garfield Medical Center in Monterey Park, California, on March 19.

(Frederic J. Brown / AFP kamagra 100mg oral jelly side effects via Getty Images) Ramirez said Palomo had no access to patient charts, so he would not have known which patients had erectile dysfunction treatment. €œIn essence, he was helping blindly.” Palomo never answered the text. He died of erectile dysfunction treatment on Aug.

14. And Thong Nguyen had fared no better. His daughter, a hospital pharmacist in Fresno, had pressed him to go on a ventilator after seeing other patients survive with the treatment. It might mean he could retire and watch his grandkids grow up.

But it made no difference. €œHe definitely should not have passed [away],” Kozuki said. Nursing Homes Devastated During the summer, as nursing homes recovered from their spring surge, Heather Pagano got a new assignment. The Doctors Without Borders adviser on humanitarianism had been working in cholera clinics in Nigeria.

In May, she arrived in southeastern Michigan to train nursing home staffers on optimal -control techniques. Federal officials required worker death reports from nursing homes, which by December tallied more than 1,100 fatalities. Researchers in Minnesota found particular hazards for these health workers, concluding they were the ones most at risk of getting erectile dysfunction treatment. Pagano learned that staffers were repurposing trash bin liners and going to the local Sherwin-Williams store for painting coveralls to backfill shortages of medical gowns.

The least-trained clinical workers — nursing assistants — were doing the most hazardous jobs, turning and cleaning patients, and brushing their teeth. She said nursing home leaders were shuffling reams of federal, state and local guidelines yet had little understanding of how to stop the kamagra from spreading. €œNo one sent trainers to show people what to do, practically speaking,” she said. As the kamagra wore on, nursing homes reported staff shortages getting worse by the week.

Few wanted to put their lives on the line for $13 an hour, the wage for nursing assistants in many parts of the U.S. The organization GetusPPE, formed by doctors to address shortages, saw almost all requests for help were coming from nursing homes, doctors’ offices and other non-hospital facilities. Only 12% of the requests could be fulfilled, its October report said. And a kamagra-weary and science-wary public has fueled the kamagra’s spread.

In fact, whether or not a nursing home was properly staffed played only a small role in determining its susceptibility to a lethal outbreak, University of Chicago public health professor Tamara Konetzka found. The crucial factor was whether there was widespread viral transmission in the surrounding community. €œIn the end, the story has pretty much stayed the same,” Konetzka said. €œNursing homes in kamagra hot spots are at high risk and there’s very little they can do to keep the kamagra out.” The treatment Arrives From March through November, 40 complaints were filed about the Garfield Medical Center with the California Department of Public Health, nearly three times the statewide average for the time.

State officials substantiated 11 complaints and said they are part of an ongoing inspection. For Thanksgiving, AHMC Healthcare Chairman Jonathan Wu sent hospital staffers a letter thanking “frontline healthcare workers who continue to serve, selflessly exposing themselves to the kamagra so that others may cope, recover and survive.” The letter made no mention of the workers who had died. €œA lot of people were upset by that,” said critical care technician Melissa Ennis. €œI was upset.” By December, all workers were required to wear an N95 respirator in every corner of the hospital, she said.

Ennis said she felt unnerved taking it off. She took breaks to eat and drink in her car. Garfield said on its website that it is screening patients for the kamagra and will “implement prevention and control practices to protect our patients, visitors, and staff.” On Dec. 9, Ennis received notice that the treatment was on its way to Garfield.

Nationwide, the treatment brought health workers relief from months of tension. Nurses and doctors posted photos of themselves weeping and holding their small children. At the same time, it proved too late for some. A new surge of deaths drove the toll among health workers to more than 2,900.

And before Ennis could get the shot, she learned she would have to wait at least a few more days, until she could get a erectile dysfunction treatment test. She found out she’d been exposed to the kamagra by a colleague. Shoshana Dubnow and Anna Sirianni contributed to this report. Video by Hannah Norman.

Web production by Lydia Zuraw. This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. Who die from erectile dysfunction treatment, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Christina Jewett. ChristinaJ@kff.org, @by_cjewett Related Topics Contact Us Submit a Story TipJournalists from KHN and The Guardian have identified 2,921 workers who reportedly died of complications from erectile dysfunction treatment after they contracted it on the job. Reporters are working to confirm the cause of death and workplace conditions in each case. They are also writing about the people behind the statistics — their personalities, passions and quirks — and telling the story of every life lost.Explore the new interactive tool tracking those health worker deaths.(Note.

The previous total announced by The Guardian and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments. These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure fatalities did not appear in the database twice.) More From This Series.

Related Topics Health Industry erectile dysfunction treatment Doctors Investigation Lost On The Frontline Nursing HomesCan’t see the audio player?. Click here to listen on SoundCloud. erectile dysfunction treatment was the dominant — but not the only — health policy story of 2020. In this special year-in-review episode of KHN’s “What the Health?.

€ podcast, panelists look back at some of the biggest non-erectile dysfunction stories. Those included Supreme Court cases on the Affordable Care Act, Medicaid work requirements and abortion, as well as a year-end surprise ending to the “surprise bill” saga. This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Sarah Karlin-Smith of Pink Sheet. Among the takeaways from this week’s podcast.

The erectile dysfunction kamagra strengthened the hand of ACA supporters, even as the Trump administration sought to get the Supreme Court to overturn the federal health law. Many people felt it was an inopportune time to get rid of that safety valve while so many Americans were losing their jobs — and their health insurance — due to the economic chaos from the kamagra.Preliminary enrollment numbers released by federal officials last week suggest that more people were taking advantage of the option to buy coverage for 2021 through the ACA marketplaces than for 2020, even in the absence of enrollment encouragement from the federal government.The ACA’s Medicaid expansion had a bit of a roller-coaster ride this year. Voters in two more states — Oklahoma and Missouri — approved the expansion in ballot measures, but the Trump administration continued its support of state plans that require many adults to prove they are working in order to continue their coverage. The Supreme Court has agreed to hear a challenge to that policy.

Although lower courts have ruled that the Medicaid law does not allow such restrictions, it’s not clear how the new conservative majority on the court will view this issue.Concerns are beginning to grow in Washington about the near-term prospect of the Medicare trust fund going insolvent. That can likely be fixed only with a remedy adopted by Congress, and that may not happen unless lawmakers feel a crisis is very near.The Trump administration has sought to bring down drug out-of-pocket expenses for Medicare beneficiaries. Among those initiatives is a demonstration project to lower the cost of insulin. About a third of Medicare beneficiaries will be enrolled in plans that offer reduced prices in 2021.

But the effort could have a hidden consequence. Higher insurance premiums.Many members of Congress began this session two years ago with grand promises of working to lower drug prices — but they never reached an agreement on how to do it.President Donald Trump, however, was strongly motivated by the issue and late this year issued an order to set many Medicare drug prices based on what is paid in other industrialized nations. Drugmakers detest the idea and have vowed to fight it in court. Although some Democrats endorse the concept, it seems unlikely that President-elect Joe Biden would want to spend much capital in a legal battle for a plan that hasn’t been carefully vetted.The gigantic spending and erectile dysfunction treatment relief bill that Congress finally approved Monday includes a provision to protect consumers from surprise medical bills when they are unknowingly treated by doctors or hospitals outside their insurance network.

The law sets up a mediation process to resolve the charges, but the process favors the doctors. Insurers are likely to pass along any extra costs to consumers through higher premiums. To hear all our podcasts, click here. And subscribe to What the Health?.

on iTunes, Stitcher, Google Play, Spotify, or Pocket Casts. Related Topics Contact Us Submit a Story Tip.

More than Buy cipro no prescription 2,900 kamagra tablets online U.S. Health care workers have died in the erectile dysfunction treatment kamagra since March, a far higher number than that reported by the government, according to a new analysis by KHN and The Guardian. Fatalities from the erectile dysfunction have skewed young, with the majority of victims under age kamagra tablets online 60 in the cases for which there is age data.

People of color have been disproportionately affected, accounting for about 65% of deaths in cases in which there is race and ethnicity data. After conducting interviews with relatives and friends of around 300 victims, KHN and The Guardian learned that one-third of the fatalities involved concerns over inadequate personal protective equipment. Many of the deaths — about 680 — occurred in New York kamagra tablets online and New Jersey, which were hit hard early in the kamagra.

Significant numbers also died in Southern and Western states in the ensuing months. The findings are part of “Lost on the Frontline,” a nine-month data and investigative project by KHN and The Guardian to track every health care worker who dies of erectile dysfunction treatment. One of those lost, Vincent DeJesus, 39, told his brother Neil that he’d be in kamagra tablets online deep trouble if he spent much time with a erectile dysfunction treatment-positive patient while wearing the surgical mask provided to him by the Las Vegas hospital where he worked.

DeJesus died on Aug. 15. Another fatality was Sue Williams-Ward, a 68-year-old home health aide who earned $13 an hour in Indianapolis, kamagra tablets online and bathed, dressed and fed clients without wearing any PPE, her husband said.

She was intubated for six weeks before she died May 2. €œLost on the Frontline” is prompting new government action to explore the root cause of health care worker deaths and take steps to track them better. Officials at the Department of Health and Human Services recently asked the National Academy of Sciences for a “rapid expert consultation” on why so many health care workers are dying in the U.S., citing the count of kamagra tablets online fallen workers by The Guardian and KHN.

€œThe question is, where are they becoming infected?. € asked Michael Osterholm, a member of President-elect Joe Biden’s erectile dysfunction treatment advisory team and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. €œThat is clearly a critical issue we need to answer and we don’t have that.” [embedded content] The kamagra tablets online Dec.

10 report by the national academies suggests a new federal tracking system and specially trained contact tracers who would take PPE policies and availability into consideration. Doing so would add critical knowledge that could inform generations to come and give meaning to the lives lost. €œThose [health care workers] are people who walked into places of work every day because they cared about patients, putting food on kamagra tablets online the table for families, and every single one of those lives matter,” said Sue Anne Bell, a University of Michigan assistant professor of nursing and co-author of the national academies report.

The recommendations come at a fraught moment for health care workers, as some are getting the erectile dysfunction treatment while others are fighting for their lives amid the highest levels of the nation has seen. The toll continues to mount. In Indianapolis, for example, 41-year-old nurse practitioner Kindra Irons died kamagra tablets online Dec.

1. She saw seven kamagra tablets online or eight home health patients per week while wearing full PPE, including an N95 mask and a face shield, according to her husband, Marcus Irons. The kamagra destroyed her lungs so badly that six weeks on the most aggressive life support equipment, ECMO, couldn’t save her, he said.

Marcus Irons said he is now struggling financially to support their two youngest children, ages 12 and 15. €œNobody should kamagra tablets online have to go through what we’re going through,” he said. In Massachusetts, 43-year-old Mike “Flynnie” Flynn oversaw transportation and laundry services at North Shore Medical Center, a hospital in Salem, Massachusetts.

He and his wife were also raising young children, ages 8, 10 and 11. Flynn, who shone at father-daughter dances, fell ill in late November kamagra tablets online and died Dec. 8.

He had a heart attack at home on the couch, according to his father, Paul Flynn. A hospital kamagra tablets online spokesperson said he had full access to PPE and free testing on-site. Since the first months of the kamagra, more than 70 reporters at The Guardian and KHN have scrutinized numerous governmental and public data sources, interviewed the bereaved and spoken with health care experts to build a count.

The total number includes fatalities identified by labor unions, obituaries and news outlets and in online postings by the bereaved, as well as by relatives of the deceased. The previous total announced by The Guardian and KHN was approximately 1,450 health care kamagra tablets online worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments.

These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure kamagra tablets online fatalities did not appear in the database twice. The tally has been widely cited by other media as well as by members of Congress.

Rep. Norma Torres (D-Calif.) referenced the data citing the need for a pending bill that kamagra tablets online would provide compensation to the families of health care workers who died or sustained long-term disabilities from erectile dysfunction treatment. Sen.

Ron Wyden (D-Ore.) mentioned the tally in a Senate Finance Committee hearing about the medical supply chain. €œThe fact is,” he said, “the shortages of PPE have put our doctors and nurses and caregivers in grave danger.” This kamagra tablets online story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. Who die from erectile dysfunction treatment, and to investigate why so many are victims of the disease.

If you have a colleague or loved one we should include, please share kamagra tablets online their story. Christina Jewett. ChristinaJ@kff.org, @by_cjewett Melissa Bailey.

@mmbaily Related Topics Contact Us Submit a Story TipWorkers at Garfield Medical Center in suburban Los Angeles were kamagra tablets online on edge as the kamagra ramped up in March and April. Staffers in a 30-patient unit were rationing a single tub of sanitizing wipes all day. A May memo from the CEO said N95 masks could be cleaned up to 20 times before replacement.

Patients showed up erectile dysfunction treatment-negative but some kamagra tablets online still developed symptoms a few days later. Contact tracing took the form of texts and whispers about exposures. By summer, frustration gave way to fear.

At least 60 staff members at the 210-bed community hospital caught erectile dysfunction treatment, according to records obtained by KHN and interviews with eight staff members and kamagra tablets online others familiar with hospital operations. The first to die was Dawei Liang, 60, a quiet radiology technician who never said no when a colleague needed help. A cardiology technician became infected and changed his final wishes — agreeing to intubation — hoping for more years to dote on his grandchildren.

Few felt safe kamagra tablets online. Ten months into the kamagra, it has become far clearer why tens of thousands of health care workers have been infected by the kamagra and why so many have died. Dire PPE shortages.

Limited erectile dysfunction treatment tests kamagra tablets online. Sparse tracking of viral spread. Layers of flawed policies handed down by health care executives and politicians, and lax enforcement by government regulators.

All of those breakdowns, across cities and states, have contributed to the deaths of more than 2,900 health care workers, a nine-month investigation by over 70 reporters at KHN and The Guardian kamagra tablets online has found. This number is far higher than that reported by the U.S. Government, which does not have a comprehensive national count of health care workers who’ve died of erectile dysfunction treatment.

The fatalities kamagra tablets online have skewed young, with the majority of victims under age 60 in the cases for which there is age data. People of color have been disproportionately affected, accounting for about 65% of deaths in cases in which there is race and ethnicity data. After conducting interviews with relatives and friends of around 300 victims, KHN and The Guardian learned that one-third of the fatalities involved concerns over inadequate personal protective kamagra tablets online equipment.

Many of the deaths occurred in New York and New Jersey, and significant numbers also died in Southern and Western states as the kamagra wore on. Workers at well-funded academic medical centers — hubs of policymaking clout and prestigious research — were largely spared. Those who died tended to work in less prestigious community hospitals like Garfield, nursing homes and kamagra tablets online other health centers in roles in which access to critical information was low and patient contact was high.

Garfield Medical Center and its parent company, AHMC Healthcare, did not respond to multiple calls or emails regarding workers’ concerns and circumstances leading to the worker deaths. So as 2020 draws to a close, we ask. Did so many of the nation’s kamagra tablets online health care workers have to die?.

New York’s Warning for the Nation The seeds of the crisis can be found in New York and the surrounding cities and suburbs. It was the region where the profound risks facing medical staff became clear. And it was here kamagra tablets online where the most died.

As the kamagra began its U.S. Surge, city paramedics were out in force, their sirens cutting through eerily empty streets as they rushed patients to hospitals. Carlos Lizcano, a blunt Queens native who had been with the New York City Fire Department (FDNY) for kamagra tablets online two decades, was one of them.

He was answering four to five cardiac arrest calls every shift. Normally he would have fielded that many in a month. He remembered being stretched so thin he had to enlist a dying man’s kamagra tablets online son to help with CPR.

On another call, he did chest compressions on a 33-year-old woman as her two small children stood in the doorway of a small apartment. €œI just have this memory of those kids looking at us like, ‘What’s going on?. €™â€ After the young kamagra tablets online woman died, Lizcano went outside and punched the ambulance in frustration and grief.

The personal risks paramedics faced were also grave. More than 40% of emergency medical service workers in the FDNY went on leave for confirmed or suspected erectile dysfunction during the first three months of the kamagra, according to a study by the department’s chief medical officer and others. In fact, health care workers were three times more likely than the general public kamagra tablets online to get erectile dysfunction treatment, other researchers found.

And the risks were not equally spread among medical professions. Initially, CDC guidelines were written to afford the highest protection to workers in a hospital’s erectile dysfunction treatment unit. Yet months later, it was clear that the doctors initially thought to be at most risk — anesthesiologists and those working in the intensive care unit — were among the kamagra tablets online least likely to die.

This could be due to better personal protective equipment or patients being less infectious by the time they reach the ICU. Instead, scientists kamagra tablets online discovered that “front door” health workers like paramedics and those in acute-care “receiving” roles — such as in the emergency room — were twice as likely as other health care workers to be hospitalized with erectile dysfunction treatment. [embedded content] For FDNY’s first responders, part of the problem was having to ration and reuse masks.

Workers were blind to an invisible threat that would be recognized months later. The kamagra spread rapidly from pre-symptomatic people and among those with no kamagra tablets online symptoms at all. In mid-March, Lizcano was one of thousands of FDNY first responders infected with erectile dysfunction treatment.

At least four of them died, city records show. They were among the 679 health kamagra tablets online care workers who have died in New York and New Jersey to date, most at the height of the terrible first wave of the kamagra. €œInitially, we didn’t think it was this bad,” Lizcano said, recalling the confusion and chaos of the early kamagra.

€œThis city wasn’t prepared.” Neither was the rest of the country. An Elusive kamagra tablets online Enemy The kamagra continued to spread like a ghost through the nation and proved deadly to workers who were among the first to encounter sick patients in their hospital or nursing home. One government agency had a unique vantage point into the problem but did little to use its power to cite employers — or speak out about the hazards.

Health employers had a mandate to report worker deaths and hospitalizations to the Occupational Safety and Health Administration. When they did so, the report went to an agency headed by Eugene Scalia, son of conservative Supreme Court Justice Antonin Scalia who died in kamagra tablets online 2016. The younger Scalia had spent part of his career as a corporate lawyer fighting the very agency he was charged with leading.

Its inspectors have documented instances in which some of the most vulnerable workers — those with low information and high patient contact — faced incredible hazards, but OSHA’s staff did little to hold employers to account. Beaumont, Texas, a town near the Louisiana border, was largely untouched by the kamagra in early April kamagra tablets online. That’s when a 56-year-old physical therapy assistant at Christus Health’s St.

Elizabeth Hospital named Danny Marks called in sick with a fever and body aches, federal OSHA records show. He told a human resources employee that he’d been in the room of a patient who was receiving a breathing treatment — the type known as the most hazardous to health kamagra tablets online workers. The CDC advises that N95 respirators be used by all in the room for the so-called aerosol-generating procedures.

(A facility spokesperson said the patient was not known or suspected to have erectile dysfunction treatment at the time Marks entered the room.) Marks went home to self-isolate. By April 17, he kamagra tablets online was dead. The patient whose room Marks entered later tested positive for erectile dysfunction treatment.

And an OSHA investigation into Marks’ death found there was no sign on the door to warn him that a potentially infected patient was inside, nor was there a cart outside the room where he could grab protective gear kamagra tablets online. The facility did not have a universal masking policy in effect when Marks went in the room, and it was more than likely that he was not wearing any respiratory protection, according to a copy of the report obtained through a public records request. Twenty-one more employees contracted erectile dysfunction treatment by the time he died.

€œHe was a beloved gentleman and friend and he is missed very much,” Katy Kiser, Christus’ public relations director, told kamagra tablets online KHN. OSHA did not issue a citation to the facility, instead recommending safety changes. The agency logged nearly 8,700 complaints from health care workers in 2020.

Yet Harvard researchers found that some of those desperate pleas for help, often decrying shortages kamagra tablets online of PPE, did little to forestall harm. In fact, they concluded that surges in those complaints preceded increases in deaths among working-age adults 16 days later. One report author, Peg Seminario, blasted OSHA for failing to use its power to get employers’ attention about the danger facing health workers.

She said issuing big fines in high-profile cases can have a broad impact — except OSHA has not done so kamagra tablets online. €œThere’s no accountability for failing to protect workers from exposure to this deadly kamagra,” said Seminario, a former union health and safety official. Desperate for Safety Gear There was little outward sign this summer that Garfield Medical Center was struggling to contain erectile dysfunction treatment.

While Medicare has forced nursing homes to report staff s and deaths, kamagra tablets online no such requirement applies to hospitals. More 'Lost on the Frontline' Stories Dying Young. The Health Care Workers in Their 20s Killed by erectile dysfunction treatment By Alastair Gee, The Guardian | August 13, 2020A database of deaths compiled by KHN and The Guardian includes a significant minority under 30, leaving shattered dreams and devastated families.(Photo Credit.

The Obra family)Most Home Health Aides ‘Can’t Afford Not to Work’ — Even When Lacking PPEBy Eli kamagra tablets online Cahan | October 16, 2020Home health aides flattened the curve by keeping the most vulnerable patients — seniors, the disabled, the infirm — out of hospitals. But they’ve done it mostly at poverty wages and without overtime pay, hazard pay, sick leave or health insurance.(Photo Credit. Tamarya Burnett)They Cared for Some of New York’s Most Vulnerable Communities.

Then 12 Died.By Danielle Renwick, The kamagra tablets online Guardian | August 27, 2020Immigrant health workers help keep the U.S. Health system afloat — and they’re dying of erectile dysfunction treatment at high rates.(Photo Credit. Pablo Monsalve/VIEWpress via Getty Images)These Front-Line Workers Could Have Retired.

They Risked kamagra tablets online Their Lives Instead. By Shoshana Dubnow | November 20, 2020 An investigation by KHN and The Guardian shows that 329 health care workers age 65 or older have reportedly died of erectile dysfunction treatment.(Photo Credits. Tom Miles, David Brown, Bethany MacDonald) Yet as the focus of the kamagra moved from the East Coast kamagra tablets online in the spring to Southern and Western states, health care worker deaths climbed.

And behind the scenes at Garfield, workers were dealing with a lack of equipment meant to keep them safe. Complaints to state worker-safety officials filed in March and April said Garfield Medical Center workers were asked to reuse the same N95 respirator for a week. Another complaint kamagra tablets online said workers ran out of medical gowns and were directed to use less-protective gowns typically provided to patients.

Staffers were shaken by the death of Dawei Liang. And only after his death and a rash of s did Garfield provide N95 masks to more workers and put up plastic tarps to block a erectile dysfunction treatment unit from an adjacent ward. Yet this may have kamagra tablets online been too late.

The erectile dysfunction can easily spread to every corner of a hospital. Researchers in South Africa traced a single ER patient to 119 cases in a hospital — 80 among staff members. Those included 62 nurses kamagra tablets online from neurology, surgical and general medical units that typically would not have housed erectile dysfunction treatment patients.

By late July, Garfield cardiac and respiratory technician Thong Nguyen, 73, learned he was erectile dysfunction treatment-positive days after he collapsed at work. Nguyen loved his job and was typically not one to complain, said his youngest daughter, Dinh Kozuki. A 34-year veteran at the hospital, he was known for conducting medical tests in multiple kamagra tablets online languages.

His colleagues teased him, saying he was never going to retire. Kozuki said her father spoke up in March about the rationing of protective gear, but his concerns were not allayed. Dinh Kozuki’s father, Thong Nguyen, died of erectile dysfunction treatment-related complications after nearly kamagra tablets online 35 years of service at Garfield Medical Center in Los Angeles.

Nguyen’s supervisor told him he’d have to reuse personal protective equipment. €œHe definitely should not have passed [away],” Kozuki said.(Heidi de Marco / KHN) The PPE problems at Garfield were a symptom of a broader problem. As the kamagra spread around the nation, chronic shortages of protective gear left kamagra tablets online many workers in community-based settings fatally exposed.

Nearly 1 in 3 family members or friends of around 300 health care workers interviewed by KHN or The Guardian expressed concerns about a fallen workers’ PPE. Health care workers’ labor unions asked for the more-protective N95 respirators when the kamagra began. But Centers for Disease Control and Prevention guidelines said the unfitted surgical masks worn by workers who feed, bathe and lift kamagra tablets online erectile dysfunction treatment patients were adequate amid supply shortages.

Mary Turner, an ICU nurse and president of the Minnesota Nurses Association, said she protested alongside nurses all summer demanding better protective gear, which she said was often kept from workers because of supply-chain shortages and the lack of political will to address them. €œIt shouldn’t have kamagra tablets online to be that way,” Turner said. €œWe shouldn’t have to beg on the streets for protection during a kamagra.” At Garfield, it was even hard to get tested.

Critical care technician Tony Ramirez said he started feeling ill on July 12. He had an idea of how he might have kamagra tablets online been exposed. He’d cleaned up urine and feces of a patient suspected of having erectile dysfunction treatment and worked alongside two staffers who also turned out to be erectile dysfunction treatment-positive.

At the time, he’d been wearing a surgical mask and was worried it didn’t protect him. Yet he was denied a free test kamagra tablets online at the hospital, and went on his own time to Dodger Stadium to get one. His positive result came back a few days later.

As Ramirez rested at home, he texted Alex Palomo, 44, a Garfield medical secretary who was also at home with erectile dysfunction treatment, to see how he was doing. Palomo was the kind kamagra tablets online of man who came to many family parties but would often slip away unseen. A cousin finally asked him about it.

Palomo said he just hated to say goodbye. Palomo would wear only a surgical mask when he would go into the rooms of patients with flashing call lights, chat with them and maybe bring them kamagra tablets online a refill of water, Ramirez said. Paramedics work behind an ambulance at the Garfield Medical Center in Monterey Park, California, on March 19.

(Frederic J. Brown / AFP via Getty Images) Ramirez said Palomo had no access to patient charts, so he would not have known kamagra tablets online which patients had erectile dysfunction treatment. €œIn essence, he was helping blindly.” Palomo never answered the text.

He died of erectile dysfunction treatment on Aug. 14. And Thong Nguyen had fared no better.

His daughter, a hospital pharmacist in Fresno, had pressed him to go on a ventilator after seeing other patients survive with the treatment. It might mean he could retire and watch his grandkids grow up. But it made no difference.

€œHe definitely should not have passed [away],” Kozuki said. Nursing Homes Devastated During the summer, as nursing homes recovered from their spring surge, Heather Pagano got a new assignment. The Doctors Without Borders adviser on humanitarianism had been working in cholera clinics in Nigeria.

In May, she arrived in southeastern Michigan to train nursing home staffers on optimal -control techniques. Federal officials required worker death reports from nursing homes, which by December tallied more than 1,100 fatalities. Researchers in Minnesota found particular hazards for these health workers, concluding they were the ones most at risk of getting erectile dysfunction treatment.

Pagano learned that staffers were repurposing trash bin liners and going to the local Sherwin-Williams store for painting coveralls to backfill shortages of medical gowns. The least-trained clinical workers — nursing assistants — were doing the most hazardous jobs, turning and cleaning patients, and brushing their teeth. She said nursing home leaders were shuffling reams of federal, state and local guidelines yet had little understanding of how to stop the kamagra from spreading.

€œNo one sent trainers to show people what to do, practically speaking,” she said. As the kamagra wore on, nursing homes reported staff shortages getting worse by the week. Few wanted to put their lives on the line for $13 an hour, the wage for nursing assistants in many parts of the U.S.

The organization GetusPPE, formed by doctors to address shortages, saw almost all requests for help were coming from nursing homes, doctors’ offices and other non-hospital facilities. Only 12% of the requests could be fulfilled, its October report said. And a kamagra-weary and science-wary public has fueled the kamagra’s spread.

In fact, whether or not a nursing home was properly staffed played only a small role in determining its susceptibility to a lethal outbreak, University of Chicago public health professor Tamara Konetzka found. The crucial factor was whether there was widespread viral transmission in the surrounding community. €œIn the end, the story has pretty much stayed the same,” Konetzka said.

€œNursing homes in kamagra hot spots are at high risk and there’s very little they can do to keep the kamagra out.” The treatment Arrives From March through November, 40 complaints were filed about the Garfield Medical Center with the California Department of Public Health, nearly three times the statewide average for the time. State officials substantiated 11 complaints and said they are part of an ongoing inspection. For Thanksgiving, AHMC Healthcare Chairman Jonathan Wu sent hospital staffers a letter thanking “frontline healthcare workers who continue to serve, selflessly exposing themselves to the kamagra so that others may cope, recover and survive.” The letter made no mention of the workers who had died.

€œA lot of people were upset by that,” said critical care technician Melissa Ennis. €œI was upset.” By December, all workers were required to wear an N95 respirator in every corner of the hospital, she said. Ennis said she felt unnerved taking it off.

She took breaks to eat and drink in her car. Garfield said on its website that it is screening patients for the kamagra and will “implement prevention and control practices to protect our patients, visitors, and staff.” On Dec. 9, Ennis received notice that the treatment was on its way to Garfield.

Nationwide, the treatment brought health workers relief from months of tension. Nurses and doctors posted photos of themselves weeping and holding their small children. At the same time, it proved too late for some.

A new surge of deaths drove the toll among health workers to more than 2,900. And before Ennis could get the shot, she learned she would have to wait at least a few more days, until she could get a erectile dysfunction treatment test. She found out she’d been exposed to the kamagra by a colleague.

Shoshana Dubnow and Anna Sirianni contributed to this report. Video by Hannah Norman. Web production by Lydia Zuraw.

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. Who die from erectile dysfunction treatment, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Christina Jewett. ChristinaJ@kff.org, @by_cjewett Related Topics Contact Us Submit a Story TipJournalists from KHN and The Guardian have identified 2,921 workers who reportedly died of complications from erectile dysfunction treatment after they contracted it on the job. Reporters are working to confirm the cause of death and workplace conditions in each case.

They are also writing about the people behind the statistics — their personalities, passions and quirks — and telling the story of every life lost.Explore the new interactive tool tracking those health worker deaths.(Note. The previous total announced by The Guardian and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments.

These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure fatalities did not appear in the database twice.) More From This Series. Related Topics Health Industry erectile dysfunction treatment Doctors Investigation Lost On The Frontline Nursing HomesCan’t see the audio player?.

Click here to listen on SoundCloud. erectile dysfunction treatment was the dominant — but not the only — health policy story of 2020. In this special year-in-review episode of KHN’s “What the Health?.

€ podcast, panelists look back at some of the biggest non-erectile dysfunction stories. Those included Supreme Court cases on the Affordable Care Act, Medicaid work requirements and abortion, as well as a year-end surprise ending to the “surprise bill” saga. This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Sarah Karlin-Smith of Pink Sheet.

Among the takeaways from this week’s podcast. The erectile dysfunction kamagra strengthened the hand of ACA supporters, even as the Trump administration sought to get the Supreme Court to overturn the federal health law. Many people felt it was an inopportune time to get rid of that safety valve while so many Americans were losing their jobs — and their health insurance — due to the economic chaos from the kamagra.Preliminary enrollment numbers released by federal officials last week suggest that more people were taking advantage of the option to buy coverage for 2021 through the ACA marketplaces than for 2020, even in the absence of enrollment encouragement from the federal government.The ACA’s Medicaid expansion had a bit of a roller-coaster ride this year.

Voters in two more states — Oklahoma and Missouri — approved the expansion in ballot measures, but the Trump administration continued its support of state plans that require many adults to prove they are working in order to continue their coverage. The Supreme Court has agreed to hear a challenge to that policy. Although lower courts have ruled that the Medicaid law does not allow such restrictions, it’s not clear how the new conservative majority on the court will view this issue.Concerns are beginning to grow in Washington about the near-term prospect of the Medicare trust fund going insolvent.

That can likely be fixed only with a remedy adopted by Congress, and that may not happen unless lawmakers feel a crisis is very near.The Trump administration has sought to bring down drug out-of-pocket expenses for Medicare beneficiaries. Among those initiatives is a demonstration project to lower the cost of insulin. About a third of Medicare beneficiaries will be enrolled in plans that offer reduced prices in 2021.

But the effort could have a hidden consequence. Higher insurance premiums.Many members of Congress began this session two years ago with grand promises of working to lower drug prices — but they never reached an agreement on how to do it.President Donald Trump, however, was strongly motivated by the issue and late this year issued an order to set many Medicare drug prices based on what is paid in other industrialized nations. Drugmakers detest the idea and have vowed to fight it in court.

Although some Democrats endorse the concept, it seems unlikely that President-elect Joe Biden would want to spend much capital in a legal battle for a plan that hasn’t been carefully vetted.The gigantic spending and erectile dysfunction treatment relief bill that Congress finally approved Monday includes a provision to protect consumers from surprise medical bills when they are unknowingly treated by doctors or hospitals outside their insurance network. The law sets up a mediation process to resolve the charges, but the process favors the doctors. Insurers are likely to pass along any extra costs to consumers through higher premiums.

To hear all our podcasts, click here. And subscribe to What the Health?. on iTunes, Stitcher, Google Play, Spotify, or Pocket Casts.

Related Topics Contact Us Submit a Story Tip.

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Take Kamagra by mouth with a glass of water. The dose is usually taken 1 hour before sexual activity. You should not take the dose more than once per day. Do not take your medicine more often than directed. Overdosage: If you think you have taken too much of Kamagra contact a poison control center or emergency room at once. NOTE: Kamagra is only for you. Do not share Kamagra with others.

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18 or cheap kamagra supplier uk <. 19 in school) 138% FPL*** Children <. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN* For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care.

See info here 1 2 1 2 3 1 2 Income $884 (up from $875 in 2020) $1300 (up from $1,284 in 2020) $1,482 $2,004 $2,526 $2,146 $2,903 Resources $15,900 (up from $15,750 in 2020) $23,400 (up from $23,100 in 2020) NO LIMIT** NO cheap kamagra supplier uk LIMIT 2020 levels are in GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates and attachments here * MAGI and ESSENTIAL plan levels are based on Federal Poverty Levels, which are not released until later in 2021. 2020 levels are used until then. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?.

WHAT IS THE HOUSEHOLD cheap kamagra supplier uk SIZE?. See rules here. HOW TO READ THE HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels.

Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the cheap kamagra supplier uk rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers. People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &.

Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME cheap kamagra supplier uk LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 C.F.R. § 435.4.

Certain populations have an even higher income limit - 224% FPL for pregnant women and babies cheap kamagra supplier uk <. Age 1, 154% FPL for children age 1 - 19. CAUTION.

What is counted as income may not be what you cheap kamagra supplier uk think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI).

There are good changes and bad changes cheap kamagra supplier uk. GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income.

BAD cheap kamagra supplier uk. There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see.

ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules HOW cheap kamagra supplier uk TO DETERMINE SIZE OF HOUSEHOLD TO IDENTIFY WHICH INCOME LIMIT APPLIES The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid.

Here are the 2 basic categories cheap kamagra supplier uk and the rules for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article.

Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet cheap kamagra supplier uk on Medicare -- this is the new "MAGI" population. Their household size will be determined using federal income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp.

8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including cheap kamagra supplier uk how to determine the Household Size. See slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient.

Spouses or cheap kamagra supplier uk legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category. Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p.

573, NYS GIS 2000 MA-007 cheap kamagra supplier uk CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI.

The cheap kamagra supplier uk following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid. Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household.

It was cheap kamagra supplier uk sometimes known as "S/CC" category for Singles and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income.

This category has cheap kamagra supplier uk now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL.

For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health cheap kamagra supplier uk Plans on the Exchange. PAST INCOME &. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order.

These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs cheap kamagra supplier uk and other public health programs in NYS. This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care.

The special income standard for housing expenses helps pay for housing expenses to help certain nursing home or adult home cheap kamagra supplier uk residents to safely transition back to the community with MLTC. Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult homes. GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust.

KNOW YOUR RIGHTS - cheap kamagra supplier uk FACT SHEET on THREE ways to Reduce Spend-down, including this Special Income Standard. September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below. "How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify.

"Nursing home administrators, nursing home discharge planning staff, adult home cheap kamagra supplier uk operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC plan. Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community.

Questions regarding the special income standard may be directed to DOH cheap kamagra supplier uk at 518-474-8887. Who is eligible for this special income standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC.

How much is the allowance? cheap kamagra supplier uk. The rates vary by region and change yearly. Region Counties Deduction (2021) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St.

Lawrence, Tioga, Tompkins $450 Long Island Nassau, Suffolk $1,393 NYC Bronx, Kings, cheap kamagra supplier uk Manhattan, Queens, Richmond $1,535 (up from 1,451 in 2020) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $524 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $1,075 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $469 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $413 Past rates published as follows, available on DOH website 2021 rates published in Attachment I to GIS 20 MA/13 -- 2021 Medicaid Levels and Other Updates 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates. The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS.

2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N. Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?. Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo.

Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!. HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard.

See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it. The procedures in NYC are explained in this Troubleshooting guide. In NYC, submit the application with the MAP-751W (check off "Budgeting Changes" and "Special Housing Standard").

(The MAP-751W is also posted in languages other than English in this link. (Updated 3-15-2021.)) NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest).

NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III – OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02. MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy. References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard.

GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept. 28, 2018 - this finally implements the most recent Special Terms &. Conditions of the CMS 1115 Waiver that governs the MLTC program, dated Jan.

19 in Low cost viagra school) 138% FPL*** Children < kamagra tablets online. 5 and pregnant women have HIGHER LIMITS than shown ESSENTIAL PLAN* For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $884 (up from $875 in 2020) $1300 (up from $1,284 in 2020) $1,482 $2,004 $2,526 $2,146 $2,903 Resources $15,900 (up from $15,750 in 2020) $23,400 (up from $23,100 in 2020) NO LIMIT** NO LIMIT 2020 levels are in GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates and attachments here * MAGI and ESSENTIAL plan levels are based on Federal Poverty Levels, which are not released until later in 2021.

2020 levels kamagra tablets online are used until then. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?. WHAT IS THE HOUSEHOLD SIZE?.

See rules kamagra tablets online here. HOW TO READ THE HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers.

People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or kamagra tablets online may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school.

42 kamagra tablets online C.F.R. § 435.4. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <.

Age 1, 154% FPL for children age kamagra tablets online 1 - 19. CAUTION. What is counted as income may not be what you think.

For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as kamagra tablets online before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes and bad changes.

GOOD kamagra tablets online. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD.

There is no more "spousal" or parental refusal for this population kamagra tablets online (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules HOW TO DETERMINE SIZE OF HOUSEHOLD TO IDENTIFY WHICH INCOME LIMIT APPLIES The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person.

HOWEVER, Medicaid rules about how to calculate the kamagra tablets online household size are not intuitive or even logical. There are different rules depending on the "category" of the person seeking Medicaid. Here are the 2 basic categories and the rules for calculating their household size.

People who are Disabled, Aged 65+ or Blind - "DAB" or kamagra tablets online "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population.

Their household size will be determined using federal kamagra tablets online income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size.

See slides kamagra tablets online 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category.

Under this rule, a child may be excluded from the household if that child's income causes other family kamagra tablets online members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p. 573, NYS GIS 2000 MA-007 CAUTION.

Different people in the same household may be in different "categories" and hence have different household sizes kamagra tablets online AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI. The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid.

Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and kamagra tablets online infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples.

This category kamagra tablets online had lower income limits than DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income. This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL.

Family Health Plus - this was an expansion of Medicaid to families kamagra tablets online with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL. For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange.

PAST INCOME & kamagra tablets online. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order. These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs in NYS.

This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier kamagra tablets online to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care. The special income standard for housing expenses helps pay for housing expenses to help certain nursing home or adult home residents to safely transition back to the community with MLTC.

Originally it was just for former nursing home residents but in kamagra tablets online 2014 it was expanded to include people who lived in adult homes. GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust. KNOW YOUR RIGHTS - FACT SHEET on THREE ways to Reduce Spend-down, including this Special Income Standard.

September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or kamagra tablets online adult home may obtain this budgeting upon discharge, if they meet the other criteria below. "How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify. "Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC plan.

Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual kamagra tablets online may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community. Questions regarding the special income standard may be directed to DOH at 518-474-8887.

Who is eligible kamagra tablets online for this special income standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC. How much is the allowance?.

The rates vary by kamagra tablets online region and change yearly. Region Counties Deduction (2021) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence, Tioga, Tompkins $450 Long Island Nassau, Suffolk $1,393 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,535 (up from 1,451 in 2020) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $524 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $1,075 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $469 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $413 Past rates published as follows, available on DOH website 2021 rates published in Attachment I to GIS 20 MA/13 -- 2021 Medicaid Levels and Other Updates 2020 rates published in Attachment I to GIS 19 MA/12 – 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates.

The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH kamagra tablets online 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS. 2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N.

Metropolitan $791 Rochester kamagra tablets online $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?. Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo. Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYC—2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!.

HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard. See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it.

The procedures in NYC are explained in this Troubleshooting guide. In NYC, submit the application with the MAP-751W (check off "Budgeting Changes" and "Special Housing Standard"). (The MAP-751W is also posted in languages other than English in this link.

(Updated 3-15-2021.)) NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest). NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III – OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02.

MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy. References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept.

28, 2018 - this finally implements the most recent Special Terms &. Conditions of the CMS 1115 Waiver that governs the MLTC program, dated Jan. 19, 2017.

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By combining injectable naltrexone and oral bupropion, researchers waar kamagra bestellen within the National Institute on Drug Abuse Clinical Trials Network, part of the National Institutes of Health, have seen success in treating patients with moderate to severe methamphetamine use disorder in addition to other approaches to treatment, such as cognitive behavioral therapy and contingency management interventions. €œThe opioid crisis and resulting overdose deaths in the United States are now well known, but what is less recognized is that there is a growing crisis of overdose deaths involving methamphetamine and other stimulants. However, unlike for waar kamagra bestellen opioids, there are currently no approved medications for treating methamphetamine use disorder,” said NIDA Director Nora D. Volkow. €œThis advance demonstrates that medical treatment waar kamagra bestellen for methamphetamine use disorder can help improve patient outcomes.”The study, “Accelerated Development of Additive Pharmacotherapy Treatment for Methamphetamine Use Disorder,” was conducted between 2017 and 2019 at clinics across the country.

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Madhukar H. Trivedi of the University of Texas waar kamagra bestellen Southwestern Medical Center, Dallas, who led the trial. €œThe good news is that some of the structural and neurochemical brain changes are reversed in people who recover, underscoring the importance of identifying new and more effective treatment strategies.”Shutterstock Between 2010 and 2017, the rates of pregnant women diagnosed with opioid use disorder spiked 131 percent, and babies born with neonatal abstinence syndrome (NAS) grew 82 percent, according to a U.S. Department of Health and Human Services waar kamagra bestellen (HHS) study.Although some states had rates as high as one in 20 deliveries affected by opioids, the increases were seen nationwide. Twenty-five states doubled their rates between 2010 and 2017 while rates plateaued in New England.“We found that rural, white, and Medicaid populations continue to have the highest rates of maternal waar kamagra bestellen opioid-related diagnoses and neonatal abstinence syndrome,” Dr.

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By combining injectable naltrexone and oral bupropion, researchers within the National Institute on Drug Abuse Clinical Trials Network, part of the National Institutes of Health, have seen success in treating patients with moderate to severe methamphetamine use disorder in addition to other approaches to kamagra tablets online treatment, such as cognitive behavioral therapy and contingency management interventions. €œThe opioid crisis and resulting overdose deaths in the United States are now well known, but what is less recognized is that there is a growing crisis of overdose deaths involving methamphetamine and other stimulants. However, unlike for opioids, there are currently kamagra tablets online no approved medications for treating methamphetamine use disorder,” said NIDA Director Nora D. Volkow. €œThis advance demonstrates that medical treatment for methamphetamine use disorder can help improve patient outcomes.”The study, “Accelerated Development of Additive Pharmacotherapy Treatment for Methamphetamine Use Disorder,” was conducted between kamagra tablets online 2017 and 2019 at clinics across the country.

Using 403 adult volunteers between 18 and 65 with moderate to severe kamagra tablets online methamphetamine use disorder, the study provided some volunteers with the naltrexone, bupropion combination while giving the other placebos. Urine samples were collected throughout the study, and a volunteer was considered successfully treated if three of four urine samples came back without traces of methamphetamine. The study found that participants taking the drug combination were more likely to report that they had fewer cravings for the drug kamagra tablets online and greater improvements in their lives. Additionally, there were no significant adverse effects associated with the drug combination. €œLong-term methamphetamine misuse has been shown kamagra tablets online to cause diffuse changes to the brain, which can contribute to severe health consequences beyond addiction itself,” said Dr.

Madhukar H. Trivedi of kamagra tablets online the University of Texas Southwestern Medical Center, Dallas, who led the trial. €œThe good news is that some of the structural and neurochemical brain changes are reversed in people who recover, underscoring the importance of identifying new and more effective treatment strategies.”Shutterstock Between 2010 and 2017, the rates of pregnant women diagnosed with opioid use disorder spiked 131 percent, and babies born with neonatal abstinence syndrome (NAS) grew 82 percent, according to a U.S. Department of Health and kamagra tablets online Human Services (HHS) study.Although some states had rates as high as one in 20 deliveries affected by opioids, the increases were seen nationwide. Twenty-five states doubled their rates between 2010 and 2017 while rates plateaued in New England.“We found that rural, white, and Medicaid populations continue to have the highest kamagra tablets online rates of maternal opioid-related diagnoses and neonatal abstinence syndrome,” Dr.

Jean Ko, Maternal Health and Chronic Disease Team lead in the Centers for Disease Control and Prevention’s (CDC) Division of Reproductive Health said. €œHowever, large variation by state highlight the importance of state-level kamagra tablets online strategies and initiatives to address the opioid crisis for pregnant and postpartum women and their infants.”HHS’ Health Resources and Services Administration, the CDC, Vanderbilt University Medical Center, and the Agency for Healthcare Research and Quality conducted the study.Researchers examined 11.8 million hospital records for trends in maternal opioid diagnoses and NAS. The records were from community, non-rehabilitation hospitals in 47 states and the District of Columbia.Shutterstock A team of scientists, led by Duke University, have developed a bio-compatible surgical patch that releases nonopioid painkillers directly to the site of a wound.The polymer patch, made of poly(ester urea) homopolymers and co-polymers, lasts for several days and then dissolves. It uses kamagra tablets online a controlled release of a drug that blocks the enzyme COX-2. The polymer’s surface area and thicknesses control the release of the painkiller.Traditional polymers swell and the medicine is released at once.“If you can get four or five days of pain control out of the patch and not have to take those other pain drugs, not only do you avoid some of the side effects and risks of addiction, you’re concentrating therapy where you need it,” Matthew Becker, Duke’s Pratt School of Engineering professor of mechanical engineering and materials science, said.Becker received a $2 million grant from the state of Ohio at his previous institution to investigate nonopioid pain management as a means of controlling the opioid epidemic.

Becker began working at Duke in 2019, and he and kamagra tablets online his research team partnered with Dr. Ru-Rong Ji, a pain control expert, and his team.Researchers originally planned to devise hernia meshes and antimicrobial films..

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For as long as he http://ywsf.org/events/graphics/124/ could remember, Razel Colón cheap kamagra online had known pain. It ripped down his neck and back, shot through his legs and traveled on to his feet, often leaving him writhing and incapacitated. He suffered occasional attacks of cheap kamagra online “acute chest,” in which breathing suddenly becomes difficult.

€œIt felt like an elephant was sitting on my chest, with tight, tight pain,” Colón tells me. Trips to the emergency department and the hospital were commonplace. €œIf I was lucky,” he says, “I could cheap kamagra online stay away for a month.” Colón, from Hoboken, N.J., is just 19, but the sickle cell disease that produced these effects had been a constant, if unwelcome, companion.

But he tells his story now from the perspective of one who has gone a year and a half without that pain. He can do things that previously were out of the question. Play basketball, lift weights, cheap kamagra online swim in cold water.

His treatment, says his long-time physician Stacey Rifkin-Zenenberg, a pediatric hematologist-oncologist at Hackensack University Medical Center, “changed him from having the disease to being a carrier.” Colón’s case represents a point on the curve of an emerging technology that may forever alter our approach to treating diseases like sickle cell. That world, the cutting-edge world cheap kamagra online of innovative genomic therapies, is once again in the midst of explosive change—and designer DNA lies at the heart of the conversation. This is daring new territory.

Some strategies, such as gene therapy, have been available for some time, including the ability to genetically modify cells in order to produce a therapeutic effect—that is, to add a corrected gene into the genome in order to try to treat disease. Traditionally, kamagraes have been used to deliver healthy genes into cells, but cheap kamagra online the past decade has been witness to profound change. Multiple gene therapies have been approved to treat a variety of conditions.

Squamous cell skin cancer, a rare form of inherited blindness, melanoma, blood disorders and so on. It was this type of treatment, as part of the largest lentikamagra ongoing gene therapy trial led by Bluebird Bio, that cheap kamagra online effectively arrested Colón’s sickle cell condition. Unpublished interim data from 19 participants in the trial followed for at least six months, with a history of severe vaso-occlusive events (VOEs), or sickle cell crises similar to Colón’s, demonstrated complete resolution of severe VOEs in all patients, according to a company spokesperson.

The trial is ongoing, and data are not yet complete, so caution is prudent, but “the promise is tremendous,” the spokesperson said. The next-generation technology, gene editing, is another level altogether cheap kamagra online. Gene editing enables scientists to precisely target abnormal genes of many organisms (bacteria, plants, animals), snip the DNA, then remove, replace or add new DNA at the incision site.

€œImagine you have a car with a flat tire,” says Fyodor cheap kamagra online Urnov, a gene editing expert at the University of California, Berkeley, and the Innovative Genomics Institute. €œGene therapy is taking a fifth wheel and putting it somewhere on the car and hoping it runs. Gene editing is repairing the flat.” The technology received a huge boost with the arrival in 2012 of a gene-editing tool called CRISPR, an acronym for Clustered Regularly Interspaced Short Palindromic Repeats.

The CRISPR technology is easier to use, cheaper and more efficient cheap kamagra online than older genome editing methods, enabling scientists to quickly alter DNA sequences to modify gene function. That could positively affect the health of the organism, or even reverse disease symptoms. €œIt is often described as ‘molecular scissors,’” says Jennifer Doudna, its co-inventor and Nobel laureate in chemistry.

€œScientists can harness CRISPR to cheap kamagra online not just cut specific locations in DNA of any organism, but also to provide a template to repair the DNA.” In sickle cell disease, or SCD, a single mutation in the beta-hemoglobin gene leads to red blood cells that become crescent-shaped, or sickled. These sickled cells are sticky, and they clog arteries, preventing adequate oxygen delivery to tissues in the body. This can cheap kamagra online cause acute debilitating pain episodes, such as the kinds that Colón experienced, and may result in any number of complications.

Anemia, strokes and organ damage involving the lungs, heart, kidney, spleen, etc. Patients often have a poor quality of life because of repeated hospitalizations and transfusions, and face the prospect of early deaths. In regions like Africa and the Middle East where health care resources are much more limited, many children die of cheap kamagra online SCD before their fifth year of life.

CRISPR is accelerating the pace at which treating such disease via genetic engineering is moving. Matthew Porteus, a gene-editing pioneer, founder of CRISPR Therapeutics and professor of pediatrics at Stanford School of Medicine, says researchers currently employ two primary gene-editing strategies in their attempt to cure sickle cell patients. One type uses CRISPR to essentially flip a genomic switch, cheap kamagra online turning on healthy fetal hemoglobin production again, which was shut down early in life.

The advantage?. The fetal hemoglobin doesn’t sickle. A second gene editing strategy, gene correction, directly fixes the mutation in a faulty gene that cheap kamagra online has caused disease.

In the case of sickle cell, the correction allows the body simply to produce normal hemoglobin. Researchers have cheap kamagra online logged a staggering amount of work trying to get to this point. While progress has been made with the approval of several new drugs to help alleviate the symptoms of SCD, they are not curative.

Bone marrow (stem cell) transplants are the only option for cure, but finding healthy donor matches can be challenging. Enter the genomic therapies, which Theodore Friedmann of the University of California, cheap kamagra online San Diego, first proposed for genetic disease in 1972, and which took a step toward reality the same year with the production of recombinant DNA by Paul Berg at Stanford University. In the 1980s, scientists showed how DNA could be delivered into cells, and by 2003 the entire human genome had been deciphered.

There were setbacks, and even when gene editing systems came to be as the new century opened, using them remained challenging and time-consuming. Then, came CRISPR, slicing and dicing its way into the clinical cheap kamagra online arena, poised to potentially change not only treatment but prevention of disease. The technology is already being employed by scientists researching cancer, lymphoma, AIDS, cystic fibrosis and more, for diagnostics including erectile dysfunction detection, and even in agricultural efforts to engineer larger tomatoes, non-browning apples, and longer-lasting mushrooms.

In real time, the hope is that genetic editing will provide a cure for a very common and debilitating inherited disease, sickle cell. Several experts cheap kamagra online with whom I spoke suggested, for the first time, that a cure for SCD may be in the offing. That is an astounding thought.

In practice, the ability to excise nonworking genes and replace them with normally functioning ones may help blunt the worst effects cheap kamagra online of a wide variety of diseases. When the 2020 Nobel Prize in Chemistry was awarded to Jennifer Doudna and Emmanuelle Charpentier for their invention of this technology, the secretary-general of the Royal Swedish Academy of Sciences, Goran K. Hansson, put it plainly.

€œThis year’s prize is about rewriting the code of life.” And cheap kamagra online scientists are already working on next-gen CRISPR technology that’s more precise. €œBase editors," which correct single-letter DNA mutations without cutting the DNA double helix, have been shown recently to treat sickle cell disease in mice. And then there are “prime editors” which can replace even larger DNA snafus.

It’s all pretty remarkable—and it’s still early cheap kamagra online. €œThe field of genomic therapies for the hemoglobinopathies is not a zero-sum game,” says Urnov. €œI am convinced cheap kamagra online ultimately that there will be multiple approved medicines.

There will be multiple gene therapy approvals, and there will be multiple gene-editing approvals.” There remain many questions to consider, including the moral implications of how far a concept like gene editing might be taken, as well as cost, safety and accessibility (experts say current treatments can run to $2 million). Says Doudna, “A true cure means a treatment for everyone who needs it, which is why we’re hard at work on the next generation of therapies to bring down the cost and make it more accessible.” And, as gene editing is not perfect, “The long-term safety of all the genetic modification therapies will have to be studied carefully,” says Porteus. In the coming months, a University of California Consortium cheap kamagra online (U.C.

San Francisco, U.C. Berkeley and U.C.L.A.), will conduct the first human open label phaseI–II trial using nonvirally delivered CRISPR technology developed at the Innovative Genomics Institute. Scientists hope to alleviate the suffering of sickle cell trial participants by substituting their faulty beta-globin gene—the one that causes the disease—with a corrected one, directly fixing the mutation in their blood stem cheap kamagra online cells.

“The more of the mutations that are corrected and propagated in healthy red blood cells, the more likely a cure is to follow,” says Mark Walters, the trial’s principal investigator and a professor of pediatrics at U.C. San Francisco. €œSickle cell disease will cheap kamagra online be cured using genomic therapies.” That is the highest use of the technology, after all—and it may become a reality even as we continue to learn about the field.

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Swim between starsin this little galaxy, the oneyou built wholly from yourself.Thawing permafrost threatens to undermine the supports holding up an elevated section of the Trans-Alaska Pipeline, jeopardizing the structural integrity of one of the world’s largest oil pipelines and raising the potential of an oil spill in a delicate and remote landscape where it would be extremely difficult to clean up. The slope of permafrost where an 810-foot section of pipeline is secured has started to shift as it thaws, causing several of the braces holding up the pipeline to tilt and bend, according to an analysis by the Alaska Department of Natural Resources. The department has permitted construction of a cooling system designed to keep the permafrost surrounding the vulnerable section of pipeline just north of Fairbanks frozen, as well as to replace the damaged portions of the support structure.

This appears to be the first instance that the pipeline supports have been damaged by “slope creep” caused by thawing permafrost, records and interviews with officials involved with managing the pipeline show. In response, the Alaska Department of Natural Resources has approved the use of about 100 thermosyphons—tubes that suck heat out of permafrost—to keep the frozen slope in place and prevent further damage to the pipeline’s support structure. €œThe proposed project is integral to the protection of the pipeline,” according to the department’s November 2020 analysis.

Alaska officials who oversee the pipeline have been unable to find any records of previous damage to the pipeline caused by slumping permafrost, or of the use of thermosyphons as a defensive safeguard once a slope has begun to slide, and could cite no incidents in which either of those things had occurred. The installation of the heat pipes builds on an obvious irony. The state is heating up twice as fast as the global average, which is driving the thawing of permafrost that the oil industry must keep frozen to maintain the infrastructure that allows it to extract more of the fossil fuels that cause the warming.

Any spill from the 48-inch diameter pipeline that flows with an average of 20 million gallons of oil a day, and the resulting clean-up activity, could accelerate the thawing of the permafrost even more, environmental experts said. The extent of the ecological damage would depend on the amount of oil spilled, how deep it saturated the soil and whether the plume reached water sources. But any harm from an oil spill would likely be greater than in most other landscapes because of the fragile nature of the Alaskan land and water.

€œThis is a wake-up call,” said Carl Weimer, a special projects advisor for Pipeline Safety Trust, a nonprofit watchdog organization based in Bellingham, Washington. €œThe implications of this speak to the pipeline’s integrity and the effect climate change is having on pipeline safety in general.” Weimer said this incident should trigger discussions between regulators and the industry about how to safeguard pipelines from the effects of thawing permafrost and other climate dangers. €œScience points to climate change getting worse.

Now is the time to ask what’s being done about it,” Weimer said, referring to the effect of global warming on pipeline safety. To safeguard the pipeline from possible collapse, the pipeline operator, Alyeska Pipeline Service Company, was granted permission earlier this year by the natural resources department to construct the passive cooling system to arrest the thaw of permafrost that is essential to locking the supports in the ground and keeping the slope from slumping or sliding. Alyeska is installing approximately 100 free-standing thermosyphons 40 to 60 feet into the ground.

Construction is expected to take 120 days and will also include a three-foot layer of insulating wood chips atop the permafrost. Industry Silence About an Increasing Threat Michelle Egan, a spokeswoman for Alyeska, an association of oil companies that includes a subsidiary of Hilcorp Energy Co., as well as ConocoPhillips and ExxonMobil, declined to talk about the condition of the weakened section of pipe or the extent of permafrost thawing. Conoco deferred to Alyeska for comment.

Hilcorp and Exxon did not respond to questions about the pipeline. In its application to the state, Alyeska confirmed thawing permafrost posed a threat. “The purpose of this project is to protect the integrity of the Trans-Alaska Pipeline (mainline) from permafrost degradation,” the company’s application said.

Generally, Egan said, planning for and responding to changing permafrost conditions has been important to Alyeska since before construction of the pipeline in the mid-1970s. €œPermafrost changes were anticipated during the original design,” she said. €œThe construction mode and method of pipe support are designed to maintain the integrity of the pipeline and minimize impacts to the environment.” To avoid problems with the permafrost, 420 miles of the Trans-Alaska Pipeline were built on an elevated support system that keeps the pipe about six feet above the ground.

The frames that hold the pipeline, called vertical support members, look like a capital H with the pipeline resting on the cross stroke. Many of them have thermosyphons incorporated into the structure to keep the permafrost frozen. There are about 124,000 thermosyphons arrayed along the path of the pipeline—a nod from its engineers to the importance of keeping the ground below it frozen.

The tubes are bored from 15 to 70 feet into the permafrost in areas where warming might cause it to thaw. But those chillers only cool the permafrost directly below the pipeline, which holds the supports. As the wider slope of permafrost surrounding the pipeline has warmed, the new thermosyphon project was required to keep it from collapsing or sliding and damaging the supports.

Tony Strupulis, the pipeline coordinator for the Alaska Department of Natural Resources, said there is no reason for panic—the support structures are not in immediate danger of collapse and the thawing of permafrost is a gradual process that allows time to address problems the defrosting might cause. Yet, he said, the agency is “very mindful” of the state of permafrost in relation to the stability of the pipeline and other infrastructure under its purview. “The design philosophy is, ‘If it’s frozen, keep it frozen,’” he said.

Temperatures that can thaw permafrost are more common in the region where the stabilization work is being done than in the Arctic, hundreds of miles to the north, he said. So the state depends on Alyeska’s maintenance crews to be especially watchful in those warmer areas, he said. €œIf the support structures begin to sink or lean.

That’s the big concern,” Strupulis said. The section of shifting Trans-Alaska Pipeline is 57 miles northwest of Fairbanks near the Dalton Highway in the central part of the state, where mean annual winter temperature has warmed more than eight degrees Fahrenheit since 1949, according to data kept by the Alaska how to get kamagra without a doctor Climate Research Center. About three quarters of the 800-mile pipeline, which opened in 1977 and runs from Prudhoe Bay in the north to Valdez on Prince William Sound in the south, passes through terrain with permafrost.

Since opening, more than 18 billion barrels of oil have moved through the pipeline, a milestone that underscores its importance to the state’s economy and its role in meeting the energy demands of the country, as well as its part in driving the global warming that is thawing the ground that supports it. Pipeline Plans Considered Permafrost Thaw, But Not Climate Change Permafrost is ground that has remained completely frozen for at least two years straight and is found beneath nearly 85 percent of Alaska. Some permafrost, which is composed of a combination of soil, rocks and sand that are held together by ice, has been frozen for thousands of years.

But, in the last few decades, permafrost temperatures in Alaska have warmed as much as 3.5 degrees Fahrenheit, and the state’s average temperature is projected to increase by 2 to 4 degrees more by the middle of the century. A study published in the journal Nature Climate Change projects that with every 2 degree increase in temperature, 1.5 million square miles of permafrost could be lost to thawing. The pipeline was built to flex and absorb some movement, especially from seismic activity, without failing.

Engineers and pipeline consultants praise it for its “robust” safety design. In the event of a rupture in the pipe, Alyeska said it can initiate an emergency shutdown to stop the flow of oil and isolate the damaged section of pipeline within 15 minutes. There have been 18 breaches of the Trans-Alaska Pipeline in the last 20 years, according to data from the Pipeline Hazardous Material Safety Administration (PHMSA).

Spills have ranged from less than one barrel to 6,800 barrels. In all, the pipeline has spilled 9,784 barrels of oil, which resulted in $52.7 million in damages and costs, according to the PHMSA records. Causes of the spills range from breaks in corroded pipe to equipment failure and operator error.

None of the spills recorded by PHMSA were attributed to permafrost thaw. Clean-up of a spill along the pipeline would also threaten to accelerate more permafrost thawing, Alyeska said in its emergency response plans filed with federal and state regulators. “Thermal erosion can occur at any time during a discharge, containment, recovery, and final cleanup period,” according to the company’s plan.

€œThis geological condition should not impact response actions but may affect efficiencies and the methods used to perform containment and recovery actions in order to protect permafrost areas from long term damage.” Alyeska recognizes permafrost can act as a barrier to the spread of spilled oil just as it has acted for decades to prevent the release of toxic substances from Alaskan landfills, former military installations and a Superfund site. €œPermafrost can be a containment asset as it prevents downward migration of spilled oil,” the company said in its response plan. Many of the pipelines in Alaska were designed decades ago, accounting for the permafrost projections that are now far short of the reality in which annual temperatures are soaring and thousands of square miles of permafrost are thawing.

Richard Kuprewicz, president of Accufacts Inc., a pipeline consulting firm, said it wouldn’t be wise for pipeline operators to count on permafrost remaining solid in the same way as in the past. Assessing pipelines to determine if years-old structural designs can withstand the changing conditions and accelerated rate of permafrost thaw is prudent, he said. €œOperators need to understand this new world being brought about by climate change,” he said.

“What was true in the past may not be true today.” So it’s the responsibility of the operator to be ahead of the threats, Kuprewicz said. €œIt’s not yet to the level of panic, but it is an issue that has to be considered,” he said. Tom DeRuyter, a former on-scene spill coordinator for the Alaska Department of Environmental Conservation, has observed the effects of thawing permafrost for decades.

He’s seen the vertical support structures of pipelines sinking, he said, and noticed that such movement has accelerated as temperatures have warmed. €œThe fact is there is a problem with subsidence,” said DeRuyter, who retired last year after 24 years with the state agency. €œYou have pipelines that were built level and are now starting to wobble.” DeRuyter, who emphasizes he is not an engineer and cannot comment on the potential threat to the structural integrity of the sagging pipelines, said his assessment is based on his observations.

€œYou see it pretty much on all of the pipelines,” he said. €œYou drive down the road and it looks like the pipelines are undulating.” While the thawing and subsidence are usually too gradual and incremental to draw attention, the result is increasingly obvious, he said. “You can’t see it day-by-day, but year-by-year you notice these pipelines aren’t straight anymore,” he said.

Although there have been no documented instances of thawing permafrost causing a pipeline failure, in June 2020, it was blamed for the collapse of a fuel tank in northern Siberia that dumped 21,000 tons of diesel, which spread over seven miles and seeped into the Ambarnaya River. The second worst oil spill in modern Russian history, Norilsk Nickel, the owner of the plant, reported in a statement that permafrost thawing during a historic Siberian heat wave led one of the tank’s support pillars to buckle. Russian environmental authorities estimated it will take 10 years to clean up the spill.

This story originally appeared in Inside Climate News and is republished here as part of Covering Climate Now, a global journalism collaboration strengthening coverage of the climate story.A California power plant likely will shut down for the first time ever because of low water during a prolonged drought, squeezing the state’s very tight electricity supplies, state officials said yesterday. The Edward Hyatt power plant, an underground facility next to Oroville Dam in Butte County, is expected to close in August or September, said John Yarbrough, California Department of Water Resources assistant deputy director of the State Water Project. The plant has run continuously since opening in 1967.

It receives water from Lake Oroville, and that reservoir has dropped because of the drought, as CNN previously reported. Lake Oroville is among several California reservoirs hit by drought. In addition, “high heat events in California and the rest of the West have begun earlier than usual and have exceeded historic temperature levels,” the California Energy Commission and California Public Utilities Commission leaders said in a July 1 letter to the California Independent System Operator (CAISO), the grid manager.

The state’s power system expects to lose about 1,000 megawatts of power generation as a result. While that’s a fraction of a system with daily peak demand of 44,000 MW, supplies already are tight, said Lindsay Buckley, a California Energy Commission spokesperson. €œBased on our May projections, we really didn’t have 1,000 megawatts to lose,” Buckley said in an interview.

€œSo it’s something that we’re now grappling with” related to the state’s hydropower resources. The Golden State’s drought is connected to warming and is one of the many ways climate change is hitting the state and its power supplies, according to climate scientists. California also is struggling with the impacts of wildfires and extreme heat.

State officials anticipate that to keep the lights on this summer, they will rely in part on residents cutting back their power use during peak demand hours, roughly from 4 to 9 p.m. Local time. €œThe climate impacts are coming at us hard and fast,” Buckley said.

€œWe need all hands on deck, and that includes everyday Californians and just helping to conserve during these times.” Last weekend, California narrowly avoided rolling blackouts of electricity when smoke from the Bootleg Fire in Oregon, acting as an electrical conductor, shorted out power lines that feed the Bonneville Power Administration’s California-Oregon Intertie transmission network (Energywire, July 15). The grid lost an estimated 5,500 MW of power flows, the equivalent of about 10 large power plants. California Gov.

Gavin Newsom (D) issued an executive order Saturday temporarily lifting some environmental restrictions on natural gas-fired power plants, one of several moves to free up power supplies. Newsom yesterday announced he was sending more firefighting resources to Oregon to help combat the Bootleg Fire and new fires. The state’s grid operator said it was seeking to buy additional power capacity that would be available this summer.

It “did not commit to seeking a specific number of MWs because we will be considering evolving conditions as we move through the summer, ” CAISO spokeswoman Anne Gonzales said in an email. The grid manager solicits bids in an open market and then will “designate the resources to have available to the system for a significant event, while taking into account the most current information, including up-to-date load forecasts, the potential West-wide extreme heat events, and low hydro conditions. € CAISO’s Summer Assessment report identified late summer as the period of greatest risk for having enough electricity supplies coming from hydropower.

Conditions studied assumed significant drought, Gonzales said. €œTo address forecasted low hydro conditions and possible extreme heat events this summer, we recently exercised our Capacity Procurement Mechanism to get more energy into our market in the late afternoon/evening when the grid is at greatest risk for having tight supplies,” she said. €œWe are monitoring hydro conditions and reservoir levels very closely and coordinating with the state and plant operators.” Meanwhile, drought is affecting Lake Powell, a human-made reservoir on the Colorado River in Utah and Arizona.

The Bureau of Reclamation plans to release water into Lake Powell to keep it from dropping below levels needed for hydro-fueled power generation, NPR reporter Luke Runyon tweeted yesterday. The release will happen if the reservoir level drops below 3,525 feet. Water would come from the Blue Mesa, Flaming Gorge and Navajo reservoirs, as stipulated under a “Drought Response Operations Agreement” for protecting Lake Powell, Becki Bryant, Reclamation spokeswoman, said in an email.

Reclamation said it plans to release today its July 2021 Operation Plan for Colorado River System Reservoirs, which will include a 24-month study and more information on planned water releases. Droughts in Western states affect one another, Buckley said. €œOther states are seeing reductions in their [electricity generation] capacity,” Buckley said.

€œWe rely on each other” in the electricity import-export market. The loss of generation at the Hyatt plant would occur if the lake levels fall to around 630-640 feet of elevation, due to lack of water to turn the plant’s hydropower turbines, said Yarbrough with the California DWR. Lake Oroville is currently at 666 feet of elevation with 1.015 million acre-feet of water storage, which is 29% of its total capacity and 37% of its historical average.

Over the last week, the reservoir has decreased from 673 to 666 feet, he said. Hyatt is designed to produce up to 750 MW of power but typically produces between 100 and 400 MW, depending on lake levels, Buckley said. The state DWR expects the plant this year to generate about 20% of what it generated last year.

The Thermalito power plant downstream of the Oroville Dam will continue to operate at minimum levels, Yarbrough, said. Environmental laws restrict how much water can be released from the system into reservoirs. Water releases to the Feather River are required for water supply, environmental and fishery needs.

For health and safety. And to prevent salinity intrusion, Yarbrough said. Reprinted from E&E News with permission from POLITICO, LLC.

Copyright 2021. E&E News provides essential news for energy and environment professionals.In 2014, I was in ballet class when I got a call from the hospital that my dad had experienced a stroke. I rushed to the hospital to join him, and found him buried in a nest of cables, surrounded by a variety of monochromatic, rapidly beeping assistive machines.

They seemed to form a single, massive enclosure around him. Every few moments he would peer up at one of the machines with wide, confused eyes. It became clear that many of the technologies that were meant to be helping and supporting him were scary and inaccessible.

During the most stressful moments of his life, the machines multiplied his fear. I wondered how I could make him feel reassured, safe, and dignified around these devices. At the time, I was a professional dancer and choreographer.

Dancers, performers and theater artists are all masters at evoking emotions, so I began to contemplate how I might improve machines to help him feel empowered and hopeful rather than afraid. My dad is now in his early 70s and fully recovered. But his story, and my personal questioning of technology’s effect on society, led me to start combining my passions for dance and technology.

I’ve danced with different robots all around the world, in installations and live performances. I’m now a Ph.D. Candidate in mechanical engineering at Stanford University, where I work on models and interfaces that allow robots to learn new tasks from humans, and I work on ways to reduce alienation and increase empowerment for humans when interacting with machines.

It’s fascinating how much dance and robotics theory overlap—the notion of kinesphere (dance) or workspace (robotics), for example. And my work thus far in graduate school has solidified my notion from 2014. Dance and robotics share intriguing similarities under the themes of human perception and interaction.

[embedded content] One of the first things humans notice about robots is how they move. We see evidence of this in studies where humans draw patterns and emotional meaning from random collections of dots and minimal representations of bodies. €œHumans have been moving and feeling much longer than they have been thinking, talking and writing,” said psychologist Barbara Tversky, at a talk she gave at the Stanford Human-Computer Interaction (HCI) Seminar last year.

As the general public encounters and forms impressions of robots up close for the first time, the robots’ movement is paramount. Traditional methods of programming robot movement do not always account for the broader personality that the robot conveys. Areas of robotics research like social navigation, where robots update their paths to account for nearby humans’ movements, implicitly build upon dance improvisation.

Dancers are given a set of rules or guidelines to follow, responding to the space, timing, and orientation of others around them. One important problem in social navigation is accurate human motion comprehension and prediction. This is because the movements a human makes, whether waving a hand or skipping, can be meaningfully different depending on other humans, robots, and environmental circumstances nearby.

Choreographers not only sequence motions together but place different agents’ motions in a relative context, to weigh importance and direct audiences’ attention. They use tools like repetition, foregrounding, mirroring, and translation to do this. This choreographic thinking could inspire new ways of modeling human motion and generating robot actions in complex environments where humans will interact with robots.

As the number of robots in society continues to increase, more people need to be capable of using them. I think of other ubiquitous technologies like laptops and phones, and reflect that I have minimized the breadth of my movement to adapt to the binary demands of a series of buttons. Since robots are embodied and often mobile, the whole robot can be an interface, and new ways to interact become possible.

Some such interaction modes include gesturing at a robot, teleoperating it with a controller, or puppeting the robot through physical contact. These sorts of interaction modes let a user like my dad actively direct the robot with natural human motions, and thus necessitate a diverse selection of meaningful, purposeful human gestures and physical touch points. Generating and then parsing these motions into discrete inputs for robots strikes me as a choreographic challenge.

I am entrenched in one such challenge at the moment - determining how a robot will respond to a series of complicated gestures from more than one human interactant. I believe the intersection between robotics and dance will continue to expand as robots move out of the factory and into the general public. As a result of the use of robots in performances and the increasing number of interdisciplinary research practitioners, this interlinking is formalizing into a field called choreorobotics or choreobotics.

There will be a course offered on choreorobotics at Brown University next spring, academic conferences like the International Conference on Movement and Computing (MOCO) bring together practicing movement artists and academics from computer science and engineering, and increasingly, roboticists are using the term “choreography” to build movement sequences for robots. Just as the personal computing revolution instigated intersections between computing and other fields like graphic design and psychology, personal robotics will do the same. I am not sure how soon my dad will have a robot in his house, but I believe that when it arrives, it will be imbued with dance knowledge.

This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American..

For as buy cheap kamagra uk long as he could remember, Razel Colón kamagra tablets online had known pain. It ripped down his neck and back, shot through his legs and traveled on to his feet, often leaving him writhing and incapacitated. He suffered occasional attacks of “acute chest,” in which kamagra tablets online breathing suddenly becomes difficult.

€œIt felt like an elephant was sitting on my chest, with tight, tight pain,” Colón tells me. Trips to the emergency department and the hospital were commonplace. €œIf I was lucky,” kamagra tablets online he says, “I could stay away for a month.” Colón, from Hoboken, N.J., is just 19, but the sickle cell disease that produced these effects had been a constant, if unwelcome, companion.

But he tells his story now from the perspective of one who has gone a year and a half without that pain. He can do things that previously were out of the question. Play basketball, kamagra tablets online lift weights, swim in cold water.

His treatment, says his long-time physician Stacey Rifkin-Zenenberg, a pediatric hematologist-oncologist at Hackensack University Medical Center, “changed him from having the disease to being a carrier.” Colón’s case represents a point on the curve of an emerging technology that may forever alter our approach to treating diseases like sickle cell. That world, the cutting-edge world of innovative genomic therapies, is once again in the midst of explosive change—and designer DNA lies at the heart kamagra tablets online of the conversation. This is daring new territory.

Some strategies, such as gene therapy, have been available for some time, including the ability to genetically modify cells in order to produce a therapeutic effect—that is, to add a corrected gene into the genome in order to try to treat disease. Traditionally, kamagraes have been used to deliver healthy genes into cells, but the past decade has been witness to profound kamagra tablets online change. Multiple gene therapies have been approved to treat a variety of conditions.

Squamous cell skin cancer, a rare form of inherited blindness, melanoma, blood disorders and so on. It was this type of treatment, as part of the largest lentikamagra ongoing gene kamagra tablets online therapy trial led by Bluebird Bio, that effectively arrested Colón’s sickle cell condition. Unpublished interim data from 19 participants in the trial followed for at least six months, with a history of severe vaso-occlusive events (VOEs), or sickle cell crises similar to Colón’s, demonstrated complete resolution of severe VOEs in all patients, according to a company spokesperson.

The trial is ongoing, and data are not yet complete, so caution is prudent, but “the promise is tremendous,” the spokesperson said. The next-generation kamagra tablets online technology, gene editing, is another level altogether. Gene editing enables scientists to precisely target abnormal genes of many organisms (bacteria, plants, animals), snip the DNA, then remove, replace or add new DNA at the incision site.

€œImagine you have a car with a flat tire,” says Fyodor Urnov, a gene editing expert at the University kamagra tablets online of California, Berkeley, and the Innovative Genomics Institute. €œGene therapy is taking a fifth wheel and putting it somewhere on the car and hoping it runs. Gene editing is repairing the flat.” The technology received a huge boost with the arrival in 2012 of a gene-editing tool called CRISPR, an acronym for Clustered Regularly Interspaced Short Palindromic Repeats.

The CRISPR technology is easier to use, cheaper and kamagra tablets online more efficient than older genome editing methods, enabling scientists to quickly alter DNA sequences to modify gene function. That could positively affect the health of the organism, or even reverse disease symptoms. €œIt is often described as ‘molecular scissors,’” says Jennifer Doudna, its co-inventor and Nobel laureate in chemistry.

€œScientists can harness CRISPR to not just cut specific locations in DNA of any organism, but also to provide a template to kamagra tablets online repair the DNA.” In sickle cell disease, or SCD, a single mutation in the beta-hemoglobin gene leads to red blood cells that become crescent-shaped, or sickled. These sickled cells are sticky, and they clog arteries, preventing adequate oxygen delivery to tissues in the body. This can kamagra tablets online cause acute debilitating pain episodes, such as the kinds that Colón experienced, and may result in any number of complications.

Anemia, strokes and organ damage involving the lungs, heart, kidney, spleen, etc. Patients often have a poor quality of life because of repeated hospitalizations and transfusions, and face the prospect of early deaths. In regions like Africa and the Middle East where health care resources are much more limited, many children die of SCD before their fifth year kamagra tablets online of life.

CRISPR is accelerating the pace at which treating such disease via genetic engineering is moving. Matthew Porteus, a gene-editing pioneer, founder of CRISPR Therapeutics and professor of pediatrics at Stanford School of Medicine, says researchers currently employ two primary gene-editing strategies in their attempt to cure sickle cell patients. One type uses CRISPR to essentially flip a genomic switch, turning on healthy fetal hemoglobin production kamagra tablets online again, which was shut down early in life.

The advantage?. The fetal hemoglobin doesn’t sickle. A second gene editing strategy, gene correction, kamagra tablets online directly fixes the mutation in a faulty gene that has caused disease.

In the case of sickle cell, the correction allows the body simply to produce normal hemoglobin. Researchers have logged a staggering amount kamagra tablets online of work trying to get to this point. While progress has been made with the approval of several new drugs to help alleviate the symptoms of SCD, they are not curative.

Bone marrow (stem cell) transplants are the only option for cure, but finding healthy donor matches can be challenging. Enter the genomic therapies, which Theodore Friedmann of the University of California, San Diego, first proposed for genetic disease in 1972, and kamagra tablets online which took a step toward reality the same year with the production of recombinant DNA by Paul Berg at Stanford University. In the 1980s, scientists showed how DNA could be delivered into cells, and by 2003 the entire human genome had been deciphered.

There were setbacks, and even when gene editing systems came to be as the new century opened, using them remained challenging and time-consuming. Then, came CRISPR, slicing and dicing its way into the clinical arena, poised to potentially change not kamagra tablets online only treatment but prevention of disease. The technology is already being employed by scientists researching cancer, lymphoma, AIDS, cystic fibrosis and more, for diagnostics including erectile dysfunction detection, and even in agricultural efforts to engineer larger tomatoes, non-browning apples, and longer-lasting mushrooms.

In real time, the hope is that genetic editing will provide a cure for a very common and debilitating inherited disease, sickle cell. Several experts with kamagra tablets online whom I spoke suggested, for the first time, that a cure for SCD may be in the offing. That is an astounding thought.

In practice, the ability to excise nonworking genes and replace them with normally functioning ones may help blunt the worst effects of a kamagra tablets online wide variety of diseases. When the 2020 Nobel Prize in Chemistry was awarded to Jennifer Doudna and Emmanuelle Charpentier for their invention of this technology, the secretary-general of the Royal Swedish Academy of Sciences, Goran K. Hansson, put it plainly.

€œThis year’s prize kamagra tablets online is about rewriting the code of life.” And scientists are already working on next-gen CRISPR technology that’s more precise. €œBase editors," which correct single-letter DNA mutations without cutting the DNA double helix, have been shown recently to treat sickle cell disease in mice. And then there are “prime editors” which can replace even larger DNA snafus.

It’s all pretty remarkable—and kamagra tablets online it’s still early. €œThe field of genomic therapies for the hemoglobinopathies is not a zero-sum game,” says Urnov. €œI am convinced ultimately that there will be multiple approved kamagra tablets online medicines.

There will be multiple gene therapy approvals, and there will be multiple gene-editing approvals.” There remain many questions to consider, including the moral implications of how far a concept like gene editing might be taken, as well as cost, safety and accessibility (experts say current treatments can run to $2 million). Says Doudna, “A true cure means a treatment for everyone who needs it, which is why we’re hard at work on the next generation of therapies to bring down the cost and make it more accessible.” And, as gene editing is not perfect, “The long-term safety of all the genetic modification therapies will have to be studied carefully,” says Porteus. In the coming months, a University of kamagra tablets online California Consortium (U.C.

San Francisco, U.C. Berkeley and U.C.L.A.), will conduct the first human open label phaseI–II trial using nonvirally delivered CRISPR technology developed at the Innovative Genomics Institute. Scientists hope to alleviate the suffering of sickle cell trial participants by substituting their faulty beta-globin gene—the one that causes the disease—with a corrected kamagra tablets online one, directly fixing the mutation in their blood stem cells.

“The more of the mutations that are corrected and propagated in healthy red blood cells, the more likely a cure is to follow,” says Mark Walters, the trial’s principal investigator and a professor of pediatrics at U.C. San Francisco. €œSickle cell disease will be cured using genomic therapies.” That is the highest use of the technology, after all—and it may become a reality even kamagra tablets online as we continue to learn about the field.

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Swim between starsin this little galaxy, the oneyou built wholly from yourself.Thawing permafrost threatens to undermine the supports holding up an elevated section of the Trans-Alaska Pipeline, jeopardizing the structural integrity of one of the world’s largest oil pipelines and raising the potential of an oil spill in a delicate and remote landscape where it would be extremely difficult to clean up. The slope of permafrost where an 810-foot section of pipeline is secured has started to shift as it thaws, causing several of the braces holding up the pipeline to tilt and bend, according to an analysis by the Alaska Department of Natural Resources. The department has permitted construction of a cooling system designed to keep the permafrost surrounding the vulnerable section of pipeline just north of Fairbanks frozen, as well as to replace the damaged portions of the support structure.

This appears to be the first instance that the pipeline supports have been damaged by “slope creep” caused by thawing permafrost, records and interviews with officials involved with managing the pipeline show. In response, the Alaska Department of Natural Resources has approved the use of about 100 thermosyphons—tubes that suck heat out of permafrost—to keep the frozen slope in place and prevent further damage to the pipeline’s support structure. €œThe proposed project is integral to the protection of the pipeline,” according to the department’s November 2020 analysis.

Alaska officials who oversee the pipeline have been unable to find any records of previous damage to the pipeline caused by slumping permafrost, or of the use of thermosyphons as a defensive safeguard once a slope has begun to slide, and could cite no incidents in which either of those things had occurred. The installation of the heat pipes builds on an obvious irony. The state is heating up twice as fast as the global average, which is driving the thawing of permafrost that the oil industry must keep frozen to maintain the infrastructure that allows it to extract more of the fossil fuels that cause the warming.

Any spill from the 48-inch diameter pipeline that flows with an average of 20 million gallons of oil a day, and the resulting clean-up activity, could accelerate the thawing of the permafrost even more, environmental experts said. The extent of the ecological damage would depend on the amount of oil spilled, how deep it saturated the soil and whether the plume reached water sources. But any harm from an oil spill would likely be greater than in most other landscapes because of the fragile nature of the Alaskan land and water.

€œThis is a wake-up call,” said Carl Weimer, a special projects advisor for Pipeline Safety Trust, a nonprofit watchdog organization based in Bellingham, Washington. €œThe implications of this speak to the pipeline’s integrity and the effect climate change is having on pipeline safety in general.” Weimer said this incident should trigger discussions between regulators and the industry about how to safeguard pipelines from the effects of thawing permafrost and other climate dangers. €œScience points to climate change getting worse.

Now is the time to ask what’s being done about it,” Weimer said, referring to the effect of global warming on pipeline safety. To safeguard the pipeline from possible collapse, the pipeline operator, Alyeska Pipeline Service Company, was granted permission earlier this year by the natural resources department to construct the passive cooling system to arrest the thaw of permafrost that is essential to locking the supports in the ground and keeping the slope from slumping or sliding. Alyeska is installing approximately 100 free-standing thermosyphons 40 to 60 feet into the ground.

Construction is expected to take 120 days and will also include a three-foot layer of insulating wood chips atop the permafrost. Industry Silence About an Increasing Threat Michelle Egan, a spokeswoman for Alyeska, an association of oil companies that includes a subsidiary of Hilcorp Energy Co., as well as ConocoPhillips and ExxonMobil, declined to talk about the condition of the weakened section of pipe or the extent of permafrost thawing. Conoco deferred to Alyeska for comment.

Hilcorp and Exxon did not respond to questions about the pipeline. In its application to the state, Alyeska confirmed thawing permafrost posed a threat. “The purpose of this project is to protect the integrity of the Trans-Alaska Pipeline (mainline) from permafrost degradation,” the company’s application said.

Generally, Egan said, planning for and responding to changing permafrost conditions has been important to Alyeska since before construction of the pipeline in the mid-1970s. €œPermafrost changes were anticipated during the original design,” she said. €œThe construction mode and method of pipe support are designed to maintain the integrity of the pipeline and minimize impacts to the environment.” To avoid problems with the permafrost, 420 miles of the Trans-Alaska Pipeline were built on an elevated support system that keeps the pipe about six feet above the ground.

The frames that hold the pipeline, called vertical support members, look like a capital H with the pipeline resting on the cross stroke. Many of them have thermosyphons incorporated into the structure to keep the permafrost frozen. There are about 124,000 thermosyphons arrayed along the path of the pipeline—a nod from its engineers to the importance of keeping the ground below it frozen.

The tubes are bored from 15 to 70 feet into the permafrost in areas where warming might cause it to thaw. But those chillers only cool the permafrost directly below the pipeline, which holds the supports. As the wider slope of permafrost surrounding the pipeline has warmed, the new thermosyphon project was required to keep it from collapsing or sliding and damaging the supports.

Tony Strupulis, the pipeline coordinator for the Alaska Department of Natural Resources, said there is no reason for panic—the support structures are not in immediate danger of collapse and the thawing of permafrost is a gradual process that allows time to address problems the defrosting might cause. Yet, he said, the agency is “very mindful” of the state of permafrost in relation to the stability of the pipeline and other infrastructure under its purview. “The design philosophy is, ‘If it’s frozen, keep it frozen,’” he said.

Temperatures that can thaw permafrost are more common in the region where the stabilization work is being done than in the Arctic, hundreds of miles to the north, he said. So the state depends on Alyeska’s maintenance crews to be especially watchful in those warmer areas, he said. €œIf the support structures begin to sink or lean.

That’s the big concern,” Strupulis said. The section of shifting Trans-Alaska Pipeline is 57 miles northwest of Fairbanks near the Dalton Highway in the central part of the state, where mean annual winter temperature has warmed more than eight degrees Fahrenheit since 1949, according to data kept by the Alaska Climate Research Center. About three quarters of the 800-mile pipeline, which opened in 1977 and runs from Prudhoe Bay in the north to Valdez on Prince William Sound in the south, passes through terrain with permafrost.

Since opening, more than 18 billion barrels of oil have moved through the pipeline, a milestone that underscores its importance to the state’s economy and its role in meeting the energy demands of the country, as well as its part in driving the global warming that is thawing the ground that supports it. Pipeline Plans Considered Permafrost Thaw, But Not Climate Change Permafrost is ground that has remained completely frozen for at least two years straight and is found beneath nearly 85 percent of Alaska. Some permafrost, which is composed of a combination of soil, rocks and sand that are held together by ice, has been frozen for thousands of years.

But, in the last few decades, permafrost temperatures in Alaska have warmed as much as 3.5 degrees Fahrenheit, and the state’s average temperature is projected to increase by 2 to 4 degrees more by the middle of the century. A study published in the journal Nature Climate Change projects that with every 2 degree increase in temperature, 1.5 million square miles of permafrost could be lost to thawing. The pipeline was built to flex and absorb some movement, especially from seismic activity, without failing.

Engineers and pipeline consultants praise it for its “robust” safety design. In the event of a rupture in the pipe, Alyeska said it can initiate an emergency shutdown to stop the flow of oil and isolate the damaged section of pipeline within 15 minutes. There have been 18 breaches of the Trans-Alaska Pipeline in the last 20 years, according to data from the Pipeline Hazardous Material Safety Administration (PHMSA).

Spills have ranged from less than one barrel to 6,800 barrels. In all, the pipeline has spilled 9,784 barrels of oil, which resulted in $52.7 million in damages and costs, according to the PHMSA records. Causes of the spills range from breaks in corroded pipe to equipment failure and operator error.

None of the spills recorded by PHMSA were attributed to permafrost thaw. Clean-up of a spill along the pipeline would also threaten to accelerate more permafrost thawing, Alyeska said in its emergency response plans filed with federal and state regulators. “Thermal erosion can occur at any time during a discharge, containment, recovery, and final cleanup period,” according to the company’s plan.

€œThis geological condition should not impact response actions but may affect efficiencies and the methods used to perform containment and recovery actions in order to protect permafrost areas from long term damage.” Alyeska recognizes permafrost can act as a barrier to the spread of spilled oil just as it has acted for decades to prevent the release of toxic substances from Alaskan landfills, former military installations and a Superfund site. €œPermafrost can be a containment asset as it prevents downward migration of spilled oil,” the company said in its response plan. Many of the pipelines in Alaska were designed decades ago, accounting for the permafrost projections that are now far short of the reality in which annual temperatures are soaring and thousands of square miles of permafrost are thawing.

Richard Kuprewicz, president of Accufacts Inc., a pipeline consulting firm, said it wouldn’t be wise for pipeline operators to count on permafrost remaining solid in the same way as in the past. Assessing pipelines to determine if years-old structural designs can withstand the changing conditions and accelerated rate of permafrost thaw is prudent, he said. €œOperators need to understand this new world being brought about by climate change,” he said.

“What was true in the past may not be true today.” So it’s the responsibility of the operator to be ahead of the threats, Kuprewicz said. €œIt’s not yet to the level of panic, but it is an issue that has to be considered,” he said. Tom DeRuyter, a former on-scene spill coordinator for the Alaska Department of Environmental Conservation, has observed the effects of thawing permafrost for decades.

He’s seen the vertical support structures of pipelines sinking, he said, and noticed that such movement has accelerated as temperatures have warmed. €œThe fact is there is a problem with subsidence,” said DeRuyter, who retired last year after 24 years with the state agency. €œYou have pipelines that were built level and are now starting to wobble.” DeRuyter, who emphasizes he is not an engineer and cannot comment on the potential threat to the structural integrity of the sagging pipelines, said his assessment is based on his observations.

€œYou see it pretty much on all of the pipelines,” he said. €œYou drive down the road and it looks like the pipelines are undulating.” While the thawing and subsidence are usually too gradual and incremental to draw attention, the result is increasingly obvious, he said. “You can’t see it day-by-day, but year-by-year you notice these pipelines aren’t straight anymore,” he said.

Although there have been no documented instances of thawing permafrost causing a pipeline failure, in June 2020, it was blamed for the collapse of a fuel tank in northern Siberia that dumped 21,000 tons of diesel, which spread over seven miles and seeped into the Ambarnaya River. The second worst oil spill in modern Russian history, Norilsk Nickel, the owner of the plant, reported in a statement that permafrost thawing during a historic Siberian heat wave led one of the tank’s support pillars to buckle. Russian environmental authorities estimated it will take 10 years to clean up the spill.

This story originally appeared in Inside Climate News and is republished here as part of Covering Climate Now, a global journalism collaboration strengthening coverage of the climate story.A California power plant likely will shut down for the first time ever because of low water during a prolonged drought, squeezing the state’s very tight electricity supplies, state officials said yesterday. The Edward Hyatt power plant, an underground facility next to Oroville Dam in Butte County, is expected to close in August or September, said John Yarbrough, California Department of Water Resources assistant deputy director of the State Water Project. The plant has run continuously since opening in 1967.

It receives water from Lake Oroville, and that reservoir has dropped because of the drought, as CNN previously reported. Lake Oroville is among several California reservoirs hit by drought. In addition, “high heat events in California and the rest of the West have begun earlier than usual and have exceeded historic temperature levels,” the California Energy Commission and California Public Utilities Commission leaders said in a July 1 letter to the California Independent System Operator (CAISO), the grid manager.

The state’s power system expects to lose about 1,000 megawatts of power generation as a result. While that’s a fraction of a system with daily peak demand of 44,000 MW, supplies already are tight, said Lindsay Buckley, a California Energy Commission spokesperson. €œBased on our May projections, we really didn’t have 1,000 megawatts to lose,” Buckley said in an interview.

€œSo it’s something that we’re now grappling with” related to the state’s hydropower resources. The Golden State’s drought is connected to warming and is one of the many ways climate change is hitting the state and its power supplies, according to climate scientists. California also is struggling with the impacts of wildfires and extreme heat.

State officials anticipate that to keep the lights on this summer, they will rely in part on residents cutting back their power use during peak demand hours, roughly from 4 to 9 p.m. Local time. €œThe climate impacts are coming at us hard and fast,” Buckley said.

€œWe need all hands on deck, and that includes everyday Californians and just helping to conserve during these times.” Last weekend, California narrowly avoided rolling blackouts of electricity when smoke from the Bootleg Fire in Oregon, acting as an electrical conductor, shorted out power lines that feed the Bonneville Power Administration’s California-Oregon Intertie transmission network (Energywire, July 15). The grid lost an estimated 5,500 MW of power flows, the equivalent of about 10 large power plants. California Gov.

Gavin Newsom (D) issued an executive order Saturday temporarily lifting some environmental restrictions on natural gas-fired power plants, one of several moves to free up power supplies. Newsom yesterday announced he was sending more firefighting resources to Oregon to help combat the Bootleg Fire and new fires. The state’s grid operator said it was seeking to buy additional power capacity that would be available this summer.

It “did not commit to seeking a specific number of MWs because we will be considering evolving conditions as we move through the summer, ” CAISO spokeswoman Anne Gonzales said in an email. The grid manager solicits bids in an open market and then will “designate the resources to have available to the system for a significant event, while taking into account the most current information, including up-to-date load forecasts, the potential West-wide extreme heat events, and low hydro conditions. € CAISO’s Summer Assessment report identified late summer as the period of greatest risk for having enough electricity supplies coming from hydropower.

Conditions studied assumed significant drought, Gonzales said. €œTo address forecasted low hydro conditions and possible extreme heat events this summer, we recently exercised our Capacity Procurement Mechanism to get more energy into our market in the late afternoon/evening when the grid is at greatest risk for having tight supplies,” she said. €œWe are monitoring hydro conditions and reservoir levels very closely and coordinating with the state and plant operators.” Meanwhile, drought is affecting Lake Powell, a human-made reservoir on the Colorado River in Utah and Arizona.

The Bureau of Reclamation plans to release water into Lake Powell to keep it from dropping below levels needed for hydro-fueled power generation, NPR reporter Luke Runyon tweeted yesterday. The release will happen if the reservoir level drops below 3,525 feet. Water would come from the Blue Mesa, Flaming Gorge and Navajo reservoirs, as stipulated under a “Drought Response Operations Agreement” for protecting Lake Powell, Becki Bryant, Reclamation spokeswoman, said in an email.

Reclamation said it plans to release today its July 2021 Operation Plan for Colorado River System Reservoirs, which will include a 24-month study and more information on planned water releases. Droughts in Western states affect one another, Buckley said. €œOther states are seeing reductions in their [electricity generation] capacity,” Buckley said.

€œWe rely on each other” in the electricity import-export market. The loss of generation at the Hyatt plant would occur if the lake levels fall to around 630-640 feet of elevation, due to lack of water to turn the plant’s hydropower turbines, said Yarbrough with the California DWR. Lake Oroville is currently at 666 feet of elevation with 1.015 million acre-feet of water storage, which is 29% of its total capacity and 37% of its historical average.

Over the last week, the reservoir has decreased from 673 to 666 feet, he said. Hyatt is designed to produce up to 750 MW of power but typically produces between 100 and 400 MW, depending on lake levels, Buckley said. The state DWR expects the plant this year to generate about 20% of what it generated last year.

The Thermalito power plant downstream of the Oroville Dam will continue to operate at minimum levels, Yarbrough, said. Environmental laws restrict how much water can be released from the system into reservoirs. Water releases to the Feather River are required for water supply, environmental and fishery needs.

For health and safety. And to prevent salinity intrusion, Yarbrough said. Reprinted from E&E News with permission from POLITICO, LLC.

Copyright 2021. E&E News provides essential news for energy and environment professionals.In 2014, I was in ballet class when I got a call from the hospital that my dad had experienced a stroke. I rushed to the hospital to join him, and found him buried in a nest of cables, surrounded by a variety of monochromatic, rapidly beeping assistive machines.

They seemed to form a single, massive enclosure around him. Every few moments he would peer up at one of the machines with wide, confused eyes. It became clear that many of the technologies that were meant to be helping and supporting him were scary and inaccessible.

During the most stressful moments of his life, the machines multiplied his fear. I wondered how I could make him feel reassured, safe, and dignified around these devices. At the time, I was a professional dancer and choreographer.

Dancers, performers and theater artists are all masters at evoking emotions, so I began to contemplate how I might improve machines to help him feel empowered and hopeful rather than afraid. My dad is now in his early 70s and fully recovered. But his story, and my personal questioning of technology’s effect on society, led me to start combining my passions for dance and technology.

I’ve danced with different robots all around the world, in installations and live performances. I’m now a Ph.D. Candidate in mechanical engineering at Stanford University, where I work on models and interfaces that allow robots to learn new tasks from humans, and I work on ways to reduce alienation and increase empowerment for humans when interacting with machines.

It’s fascinating how much dance and robotics theory overlap—the notion of kinesphere (dance) or workspace (robotics), for example. And my work thus far in graduate school has solidified my notion from 2014. Dance and robotics share intriguing similarities under the themes of human perception and interaction.

[embedded content] One of the first things humans notice about robots is how they move. We see evidence of this in studies where humans draw patterns and emotional meaning from random collections of dots and minimal representations of bodies. €œHumans have been moving and feeling much longer than they have been thinking, talking and writing,” said psychologist Barbara Tversky, at a talk she gave at the Stanford Human-Computer Interaction (HCI) Seminar last year.

As the general public encounters and forms impressions of robots up close for the first time, the robots’ movement is paramount. Traditional methods of programming robot movement do not always account for the broader personality that the robot conveys. Areas of robotics research like social navigation, where robots update their paths to account for nearby humans’ movements, implicitly build upon dance improvisation.

Dancers are given a set of rules or guidelines to follow, responding to the space, timing, and orientation of others around them. One important problem in social navigation is accurate human motion comprehension and prediction. This is because the movements a human makes, whether waving a hand or skipping, can be meaningfully different depending on other humans, robots, and environmental circumstances nearby.

Choreographers not only sequence motions together but place different agents’ motions in a relative context, to weigh importance and direct audiences’ attention. They use tools like repetition, foregrounding, mirroring, and translation to do this. This choreographic thinking could inspire new ways of modeling human motion and generating robot actions in complex environments where humans will interact with robots.

As the number of robots in society continues to increase, more people need to be capable of using them. I think of other ubiquitous technologies like laptops and phones, and reflect that I have minimized the breadth of my movement to adapt to the binary demands of a series of buttons. Since robots are embodied and often mobile, the whole robot can be an interface, and new ways to interact become possible.

Some such interaction modes include gesturing at a robot, teleoperating it with a controller, or puppeting the robot through physical contact. These sorts of interaction modes let a user like my dad actively direct the robot with natural human motions, and thus necessitate a diverse selection of meaningful, purposeful human gestures and physical touch points. Generating and then parsing these motions into discrete inputs for robots strikes me as a choreographic challenge.

I am entrenched in one such challenge at the moment - determining how a robot will respond to a series of complicated gestures from more than one human interactant. I believe the intersection between robotics and dance will continue to expand as robots move out of the factory and into the general public. As a result of the use of robots in performances and the increasing number of interdisciplinary research practitioners, this interlinking is formalizing into a field called choreorobotics or choreobotics.

There will be a course offered on choreorobotics at Brown University next spring, academic conferences like the International Conference on Movement and Computing (MOCO) bring together practicing movement artists and academics from computer science and engineering, and increasingly, roboticists are using the term “choreography” to build movement sequences for robots. Just as the personal computing revolution instigated intersections between computing and other fields like graphic design and psychology, personal robotics will do the same. I am not sure how soon my dad will have a robot in his house, but I believe that when it arrives, it will be imbued with dance knowledge.

This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American..