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    Section buy cheap generic cialis va prescription for cialis 1. Purpose. My Administration is committed to preventing the tragedy of suicide, ending the opioid crisis, and improving mental and behavioral health.

    Before the COVID-19 pandemic, these urgent issues were prioritized through significant initiatives, including the President's Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS), expanded access to medication-assisted treatment and life-saving naloxone, and budget requests for significant buy cheap generic cialis investments in the funding of evidence-based treatment for mental- and behavioral-health needs. During the COVID-19 pandemic, the Federal Government has dedicated billions of dollars and thousands of hours in resources to help Americans, including approximately $425 million in emergency funds to address mental and substance use disorders through the Substance Abuse and Mental Health Services Administration. The pandemic has also exacerbated mental- and behavioral-health conditions as a result of stress from prolonged lockdown orders, lost employment, and social isolation.

    Survey data from the Centers for Disease Control and buy cheap generic cialis Prevention show that during the last week of June, 40.9 percent of Americans struggled with mental-health or substance-abuse issues and 10.7 percent reported seriously considering suicide. We must enhance the ability of the Federal Government, as well as its State, local, and Tribal partners, to appropriately address these ongoing mental- and behavioral-health concerns. Sec.

    2. Policy. It is the policy of the United States to prevent suicides, drug-related deaths, and poor behavioral-health outcomes, particularly those that are induced or made worse by prolonged State and local COVID-19 shutdown orders.

    I am therefore issuing a national call to action to. (a) Engage the resources of the Federal Government to address the mental- and behavioral-health needs of vulnerable Americans, including by. (i) providing crisis-intervention services to treat those in immediate life-threatening situations.

    And (ii) increasing the availability of and access to quality continuing care following initial crisis resolution to improve behavioral-health outcomes. (b) Permit and encourage safe in-person mentorship programs. Support-group participation.

    And attendance at communal facilities, including schools, civic centers, and houses of worship. (c) Increase the availability of telehealth and online mental-health and substance-use tools and services. And (d) Marshal public and private resources to address deteriorating mental health, such as factors that contribute to prolonged unemployment and social isolation.

    Sec. 3. Establishment of a Coronavirus Mental Health Working Group.

    The Coronavirus Mental Health Working Group (Working Group) is hereby established to facilitate an “all-of-government” response to the mental-health conditions induced or exacerbated by the pandemic, including issues related to suicide prevention. The Working Group will be co-chaired by the Secretary of Health and Human Services, or his designee, and the Assistant to the Start Printed Page 63978President for Domestic Policy, or her designee. The Working Group shall be composed of representatives from the Department of Defense, the Department of Justice, the Department of Agriculture, the Department of Labor, the Department of Housing and Urban Development, the Department of Education, the Department of Veterans Affairs, the Small Business Administration, the Office of National Drug Control Policy, the Office of Management and Budget (OMB), and such representatives of other executive departments, agencies, and offices as the Co-Chairs may, from time to time, designate with the concurrence of the head of the department, agency, or office concerned.

    All members of the Working Group shall be full-time, or permanent part-time, officers or employees of the Federal Government. Sec. 4.

    Responsibilities of the Coronavirus Mental Health Working Group. (a) As part of the Working Group's efforts, it shall consider the mental- and behavioral-health conditions of those vulnerable populations affected by the pandemic, including. Minorities, seniors, veterans, small business owners, children, and individuals potentially affected by domestic violence or physical abuse.

    Those living with disabilities. And those with a substance use disorder. The Working Group shall examine existing protocols and evidence-based programs that may serve as models to better support these at-risk groups, including implementation and broader application of the PREVENTS, and the Department of Labor's Employer Assistance and Resource Network on Disability Inclusion's Mental Health Toolkit and Centralized Accommodation Programs.

    (b) Within 45 days of the date of this order, the Working Group shall develop and submit to the President a report that outlines a plan for improved service coordination between all relevant public and private stakeholders and executive departments and agencies (agencies) to assist individuals in crisis so that they receive effective treatment and recovery services. Sec. 5.

    Grant Funding for States and Organizations that Permit In-Person Treatment and Recovery Support Activities for Mental and Behavioral Health. The heads of agencies, in consultation with the Director of OMB, shall.

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    A 33-year old man was found to have a second SARS-CoV-2 infection some four-and-a-half how long does cialis take to kick in months after he was diagnosed with his first, published here from which he recovered. The man, who showed no symptoms, was diagnosed when he returned to Hong Kong after a trip to Spain.I am a virologist with expertise in coronaviruses and enteroviruses, and I’ve been curious about reinfections since the beginning of the pandemic. Because people infected with SARS-CoV-2 can often test positive for the virus for weeks to months, likely due to the sensitivity of the test and leftover RNA fragments, the only way to really answer the question of reinfection is by sequencing the viral genome at the time of each infection and looking for differences in how long does cialis take to kick in the genetic code.There is no published peer-review report on this man – only a press release from the University of Hong Kong – although reports say the work will be published in the journal Clinical Infectious Diseases. Here I address some questions raised by the current news reports.Why wasn’t the man immune to reinfection?.

    Immunity to endemic coronaviruses – how long does cialis take to kick in those that cause symptoms of the common cold – is relatively short-lived, with reinfections occurring even within the same season. So it isn’t completely surprising that reinfection with SARS-CoV-2, the virus that causes COVID-19, might be possible.Immunity is complex and involves multiple mechanisms in the body. That includes the generation of antibodies – through what’s known as the adaptive how long does cialis take to kick in immune response – and through the actions of T-cells, which can help to educate the immune system and to specifically eliminate virus-infected cells. However, researchers around the world are still learning about immunity to this virus and so can’t say for sure, based on this one case, whether reinfection will be a cause for broad concern.[Get the best of The Conversation, every weekend.

    Sign up for our weekly newsletter.]How different is the second strain how long does cialis take to kick in that infected the Hong Kong man?. “Strain” has a particular definition when referring to viruses. Often a different how long does cialis take to kick in “strain” is a virus that behaves differently in some way. The coronavirus that infected this man in Europe is likely not a new strain.A STAT News article reports that the genetic make up of the sequenced virus from the patient’s second infection had 24 nucleotides – building blocks of the virus’s RNA genome – that differed from the SARS-CoV-2 isolate that infected him the first time.SARS-CoV-2 has a genome that is made up of about 30,000 nucleotides, so the virus from the man’s second infection was roughly 0.08% different than the original in genome sequence.

    That shows that the virus that caused the second infection resource was new. Not a how long does cialis take to kick in recurrence of the first virus.The man was asymptomatic – what does that mean?. The man wasn’t suffering any of the hallmark COVID-19 symptoms which might mean he had some degree of protective immunity to the second infection because he didn’t seem sick. But this is difficult to how long does cialis take to kick in prove.I see three possible explanations.

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    A 33-year old man was found to have buy cheap generic cialis a second SARS-CoV-2 infection some four-and-a-half months after he was diagnosed with his first, from which he recovered. The man, who showed no symptoms, was diagnosed when he returned to Hong Kong after a trip to Spain.I am a virologist with expertise in coronaviruses and enteroviruses, and I’ve been curious about reinfections since the beginning of the pandemic. Because people infected with SARS-CoV-2 can often test positive for the virus for weeks to months, likely due to the sensitivity of the test and leftover RNA fragments, the only way to really answer the question of reinfection is by sequencing the viral genome at the time of each buy cheap generic cialis infection and looking for differences in the genetic code.There is no published peer-review report on this man – only a press release from the University of Hong Kong – although reports say the work will be published in the journal Clinical Infectious Diseases. Here I address some questions raised by the current news reports.Why wasn’t the man immune to reinfection?.

    Immunity to endemic coronaviruses – those that cause symptoms of the common cold – is relatively short-lived, with reinfections occurring even buy cheap generic cialis within the same season. So it isn’t completely surprising that reinfection with SARS-CoV-2, the virus that causes COVID-19, might be possible.Immunity is complex and involves multiple mechanisms in the body. That includes the generation of antibodies – through what’s known as the adaptive immune buy cheap generic cialis response – and through the actions of T-cells, which can help to educate the immune system and to specifically eliminate virus-infected cells. However, researchers around the world are still learning about immunity to this virus and so can’t say for sure, based on this one case, whether reinfection will be a cause for broad concern.[Get the best of The Conversation, every weekend.

    Sign up for our weekly newsletter.]How different is the second strain that infected the Hong Kong man? buy cheap generic cialis. “Strain” has a particular definition when referring to viruses. Often a different “strain” is a buy cheap generic cialis virus that behaves differently in some way. The coronavirus that infected this man in Europe is likely not a new strain.A STAT News article reports that the genetic make up of the sequenced virus from the patient’s second infection had 24 nucleotides – building blocks of the virus’s RNA genome – that differed from the SARS-CoV-2 isolate that infected him the first time.SARS-CoV-2 has a genome that is made up of about 30,000 nucleotides, so the virus from the man’s second infection was roughly 0.08% different than the original in genome sequence.

    That shows that the virus that caused the second infection was new. Not a recurrence of the first virus.The man was asymptomatic – buy cheap generic cialis what does that mean?. The man wasn’t suffering any of the hallmark COVID-19 symptoms which might mean he had some degree of protective immunity to the second infection because he didn’t seem sick. But this is difficult to prove.I see three possible explanations buy cheap generic cialis.

    The first is that the immunity he gained from the first infection protected him and allowed for a mild second infection. Another possibility buy cheap generic cialis is that the infection was mild because he was presymptomatic, and went on to develop symptoms in the coming days. Finally, sometimes infections with SARS-CoV-2 are asymptomatic – at the moment it is difficult to determine whether this was due to the differences in the virus or in the host.What can we say about reinfection based on this one case?. Only that it seems to be possible after enough time buy cheap generic cialis has elapsed.

    We do not know how likely or often it is to occur.Should people who have recovered from COVID-19 still wear a mask?. As we are still learning about how humans develop immunity to SARS-CoV-2 after infection, my recommendation is for continued masking, hand hygiene and buy cheap generic cialis distancing practices, even after recovery from COVID-19, to protect against the potential for reinfection.Megan Culler Freeman is a Pediatric Infectious Diseases Fellow at the University of Pittsburgh. This article originally appeared on The Conversation and is republished under a Creative Commons license. Read the original here..

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    Headlines popped up spreading the news, sparking conversations far and wide and forcing http://www.amisdepasteur.fr/cialis-20mg-price-walmart/ many to reconsider their preferred cialis online usa style of face mask. A Washington Post story said “some cotton cloth masks are about as effective as surgical masks, while thin polyester spandex gaiters may be worse than going maskless.” A Forbes article, referring to neck gaiters, said the study “found that one type of face covering might actually be doing more harm than good.” But the study didn’t show that, nor was it designed to. It was actually a test on how to test masks inexpensively, not to determine which one was most effective.

    The researchers set up cialis online usa a green laser beam in a dark room. A masked subject was then asked to speak so that the droplets from the speaker’s mouth showed up in the green beam. The whole process was video recorded on a cell phone, after which researchers calculated the number of droplets that showed up.

    The process cialis online usa was repeated 10 times for each mask (14 in total, one of which was a neck gaiter) and the setup cost less than $200. What was meant as a study on the pricing and efficacy of a test turned into, at least in some journalistic circles, a definitive nail-in-the-coffin for gaiters. Days after the initial reports that neck gaiters might not only be useless but maybe even harmful, a new round of new reports came out saying that those initial reports were overblown and misleading.

    The authors of the study even held a press conference where they emphasized that their study was never meant to test cialis online usa the effectiveness of masks. They only tested one gaiter-style mask, which says nothing about that style of mask in general. The combination of reporting on the actual findings of the study and the direct comments from the authors seems to have abated the anti-neck gaiter fervor.

    But all of this this—or most cialis online usa of it, anyway—likely could have been prevented. You could make the argument that it’s not a scientist’s job to worrying about how their science might be interpreted. It’s their job to do the research and publish it in a scientific manuscript.

    Leave the communicating for someone cialis online usa else. But that’s not how the spread of information works. Fewer and fewer newsrooms have staffers with scientific backgrounds, or who are dedicated to scientific reporting.

    To be cialis online usa clear, journalists don’t need to be scientists to understand science, but reporting on science does require a certain amount of expertise. When newsrooms ask reporters to cover more and more topic areas and this specialization decreases, an attention to detail is sometimes lost. So, the onus to help journalists (and frankly, all nonscientists) get the facts straight falls to the scientists doing the science.

    That’s where science communication training cialis online usa comes in. Science communication, or scicomm as it’s known colloquially, is not a core part of coursework in a majority of degree-granting science programs at the undergraduate and graduate levels. This trend is slowly changing as more institutions incorporate scicomm into their curriculums.

    Outside of academia, nonprofits and scientific societies are taking cialis online usa up the mantle. I work for the American Geophysical Union (AGU), a society for Earth and space scientists, in the Sharing Science program, where we teach scientists to communicate with nonscientists through courses, workshops, webinars and other trainings. Aside from the AGU, there is the American Association for the Advancement of Science (AAAS), the Stony Brook–affiliated Alan Alda Center for Communicating Science and the science storytelling organization The Story Collider, to name just to name a few.

    We teach cialis online usa the so-called “soft skills” that the ivory tower of science has shunned for so long but that are so necessary in effectively communicating. One thing we stress is “know your audience.” Scientists must think about how their science will be perceived, no matter how relevant or not it might be to the broader public. Science does not exist in a vacuum.

    It never cialis online usa has. But especially now, and especially with anything related to COVID-19, scientists much be hypervigilant when communicating results and try, to the best of their abilities, to account for as many interpretations as possible. Yes, it is onerous, especially on top of the multitude of other responsibilities that come with being a scientist, but it is necessary.

    The traditional cialis online usa ways in which scientists communicate their results (i.e., scientific manuscripts) are not going away anytime soon. However, and while it may be an unfair ask, scientists must not only be able to communicate their science to their peers. They must always think about nonscience audiences as the lines between science and “the public” continue to blur.

    Training scientists to effectively communicate to, or at least think about, diverse audiences is a necessary part of science.In 1835 French philosopher Auguste Comte asserted that cialis online usa nobody would ever know what the stars were made of. €œWe understand the possibility of determining their shapes, their distances, their sizes and their movements,” he wrote, “whereas we would never know how to study by any means their chemical composition, or their mineralogical structure, and, even more so, the nature of any organized beings that might live on their surface.” Comte would be stunned by the discoveries made since then. Today we know that the universe is far bigger and stranger than anyone suspected.

    Not only does it extend beyond the Milky Way to untold numbers of other galaxies—this would come as a surprise to astronomers cialis online usa of the 19th and early 20th century to whom our galaxy was “the universe”—but it is expanding faster every day. Now we can confidently trace cosmic history back 13.8 billion years to a moment only a billionth of a second after the big bang. Astronomers have pinned down our universe's expansion rate, the mean density of its main constituents, and other key numbers to a precision of 1 or 2 percent.

    They have also worked out new laws of physics governing space—general relativity and quantum mechanics—that turn cialis online usa out to be much more outlandish than the classical laws people understood before. These laws in turn predicted cosmic oddities such as black holes, neutron stars and gravitational waves. The story of how we gained this knowledge is full of accidental discoveries, stunning surprises and dogged scientists pursuing goals others thought unreachable.

    Our first hint of the true nature of stars came in 1860, when Gustav Kirchhoff recognized that the dark lines in cialis online usa the spectrum of light coming from the sun were caused by different elements absorbing specific wavelengths. Astronomers analyzed similar features in the light of other bright stars and discovered that they were made of the same materials found on Earth—not of some mysterious “fifth essence” as the ancients had believed. But it took longer to understand what fuel made the stars shine.

    Lord Kelvin (William Thomson) calculated that if stars derived their power just from gravity, slowly deflating as their radiation leaked out, then the sun's age was 20 million to cialis online usa 40 million years—far less time than Charles Darwin or the geologists of the time inferred had elapsed on Earth. In his last paper on the subject, in 1908, Kelvin inserted an escape clause stating that he would stick by his estimate “unless there were some other energy source laid up in the storehouse of creation.” That source, it turned out, is nuclear fusion—the process by which atomic nuclei join to create a larger nucleus and release energy. In 1925 astrophysicist Cecilia Payne-Gaposchkin used the light spectra of stars to calculate their chemical abundances and found that, unlike Earth, they were made mainly of hydrogen and helium.

    She revealed her conclusions in what astronomer Otto Struve described as “the most brilliant Ph.D cialis online usa. Thesis ever written in astronomy.” A decade later physicist Hans Bethe showed that the fusion of hydrogen nuclei into helium was the main power source in ordinary stars. What is the source of the sun's power?.

    The answer—fusion—came in cialis online usa 1938. Credit. SOHO (ESA and NASA) At the same time stars were becoming less mysterious, so, too, was the nature of fuzzy “nebulae” becoming clearer.

    In a “great debate” held before the National Academy of Sciences in Washington, D.C., on April 26, 1920, Harlow Shapley maintained that our Milky Way was preeminent and cialis online usa that all the nebulae were part of it. In contrast, Heber Curtis argued that some of the fuzzy objects in the sky were separate galaxies—“island universes”—fully the equal of our Milky Way. The conflict was settled not that night but just a few years later, in 1924, when Edwin Hubble measured the distances to many nebulae and proved they were beyond the reaches of the Milky Way.

    His evidence came from Cepheids, cialis online usa variable stars in the nebulae that reveal their true brightness, and thus their distance, by their pulsation period—a relation discovered by Henrietta Swan Leavitt. Soon after Hubble realized that the universe was bigger than many had thought, he found that it was still growing. In 1929 he discovered that spectral features in the starlight from distant galaxies appeared redder—that is, they had longer wavelengths—than the same features in nearby stars.

    If this effect was interpreted as a Doppler shift—the natural spreading of waves as cialis online usa they recede—it would imply that other galaxies were moving away from one another and from us. Indeed, the farther away they were, the faster their recession seemed to be. This was the first clue that our cosmos was not static but was expanding all the time.

    The universe also appeared to contain cialis online usa much that we could not see. In 1933 Fritz Zwicky estimated the mass of all the stars in the Coma cluster of galaxies and found that they make up only about 1 percent of the mass necessary to keep the cluster from flying apart. The discrepancy was dubbed “the missing mass problem,” but many scientists at the time doubted Zwicky's suggestion that hidden matter might be to blame.

    The question remained divisive until the 1970s, when cialis online usa work by Vera Rubin and W. Kent Ford (observing stars) and by Morton Roberts and Robert Whitehurst (making radio observations) showed that the outer parts of galactic disks would also fly apart unless they were subject to a stronger gravitational pull than stars and gas alone could provide. Finally, most astronomers were compelled to accept that some kind of “dark matter” must be present.

    €œWe have peered into a new world,” Rubin wrote, “and have seen that it is more mysterious and more complex than we had imagined.” Scientists now believe that dark matter outnumbers visible matter by about a factor cialis online usa of five, yet we are hardly closer than we were in the 1930s to figuring out what it is. Gravity, the force that revealed all that dark matter, has proved to be nearly as baffling. A pivotal moment came in 1915 when Albert Einstein published his general theory of relativity, which transcended Isaac Newton's mechanics and revealed that gravity is actually the deformation of the fabric of space and time.

    This new theory was slow to take hold cialis online usa. Even after it was shown to be correct by observations of a 1919 solar eclipse, many dismissed the theory as an interesting quirk—after all, Newton's laws were still good enough for calculating most things. €œThe discoveries, while very important, did not, however, affect anything on this earth,” astronomer W.J.S.

    Lockyer told the New York Times after the cialis online usa eclipse. For almost half a century after it was proposed, general relativity was sidelined from the mainstream of physics. Then, beginning in the 1960s, astronomers started discovering new and extreme phenomena that only Einstein's ideas could explain.

    One example lurks in the Crab Nebula, one of the best-known cialis online usa objects in the sky, which is composed of the expanding debris from a supernova witnessed by Chinese astronomers in a.d. 1054. Since it appeared, the nebula has kept on shining blue and bright—but how?.

    Its light source was a cialis online usa longtime puzzle, but the answer came in 1968, when the dim star at its center was revealed to be anything but normal. It was actually an ultracompact neutron star, heavier than the sun but only a few miles in radius and spinning at 30 revolutions per second. €œThis was a totally unexpected, totally new kind of object behaving in a way that astronomers had never expected, never dreamt of,” said Jocelyn Bell Burnell, one of the discoverers of the phenomenon.

    The star's excessive spin sends out cialis online usa a wind of fast electrons that generate the blue light. The gravitational force at the surface of such an incredibly dense object falls way outside of Newton's purview—a rocket would need to be fired at half the speed of light to escape its pull. Here the relativistic effects predicted by Einstein must be taken into account.

    Thousands of such spinning neutron stars—called pulsars—have been cialis online usa discovered. All are believed to be remnants of the cores of stars that exploded as supernovae, offering an ideal laboratory for studying the laws of nature under extreme conditions. The most exotic result of Einstein's theory was the concept of black holes—objects that have collapsed so far that not even light can escape their gravitational pull.

    For decades these were only conjecture, and Einstein wrote in 1939 that they “do not exist in physical reality.” cialis online usa But in 1963 astronomers discovered quasars. Mysterious, hyperluminous beacons in the centers of some galaxies. More than a decade passed before a consensus emerged that this intense brightness was generated by gas swirling into huge black holes lurking in the galaxies' cores.

    It was the strongest evidence yet cialis online usa that these bizarre predictions of general relativity actually exist. When did the universe begin?. Did it even have a beginning?.

    Astronomers had long debated these questions when, in the middle of the 20th century, two competing theories proposed very different cialis online usa answers. The “hot big bang” model said the cosmos began extremely small, hot and dense and then cooled and spread out over time. The “steady state” hypothesis held that the universe had essentially existed in the same form forever.

    The contest was cialis online usa settled by a serendipitous discovery. In 1965 radio astronomers Arno Penzias and Robert Wilson were trying to calibrate a new antenna at Bell Labs in New Jersey. They had a problem.

    No matter what they did to reduce background interference, they measured a consistent level of noise in every direction cialis online usa. They even evicted a family of pigeons that had been nesting in the antenna in the hope that they were the source of the problem. But the signal persisted.

    They had discovered that intergalactic space is not cialis online usa completely cold. Instead it is warmed to nearly three kelvins (just above absolute zero) by weak microwaves. Penzias and Wilson had accidentally uncovered the “afterglow of creation”—the cooled and diluted relic of an era when everything in the universe was squeezed until it was hot and dense.

    The finding tipped the balance firmly in favor of the big cialis online usa bang picture of cosmology. According to the model, during the earliest, hottest epochs of time, the universe was opaque, rather like the inside of a star, and light was repeatedly scattered by electrons. When the temperature fell to 3,000 kelvins, however, the electrons slowed down enough to be captured by protons and created neutral atoms.

    Thereafter light could travel freely cialis online usa. The Bell Labs signal was this ancient light, first released about 300,000 years after the birth of the universe and still pervading the cosmos—what we call the cosmic microwave background. It took a while for the magnitude of the discovery to sink in for the scientists who made it.

    €œWe were very pleased to have a possible explanation [for the antenna noise], but I don't think either of us cialis online usa really took the cosmology very seriously at first,” Wilson says. €œWalter Sullivan wrote a first-page article in the New York Times about it, and I began to think at that point that, you know, maybe I better start taking this cosmology seriously.” Measurements of this radiation have since enabled scientists to understand how galaxies emerged. Precise observations of the microwaves reveal that they are not completely uniform over the sky.

    Some patches are slightly hotter, cialis online usa others slightly cooler. The amplitude of these fluctuations is only one part in 100,000, but they are the seeds of today's cosmic structure. Any region of the expanding universe that started off slightly denser than average expanded less because it was subjected to extra gravity.

    Its growth lagged further and further, the contrast between its density and that of cialis online usa its surroundings becoming greater and greater. Eventually these clumps were dense enough that gas was pulled in and compressed into stars, forming galaxies. The crucial point is this.

    Computer models that simulate cialis online usa this process are fed the initial fluctuations measured in the cosmic microwave background, which represent the universe when it was 300,000 years old. The output after 13.8 billion years of virtual time have elapsed is a cosmos where galaxies resemble those we see, clustered as they are in the actual universe. This is a real triumph.

    We understand, at least in outline, 99.998 percent of cosmic history cialis online usa. It is not only the big cosmic picture that we have come to understand. A series of discoveries has also revealed the history of the elemental building blocks that make up stars, planets and even our own bodies.

    Starting in the 1950s, progress in atomic physics cialis online usa led to accurate modeling of stars' surface layers. Simultaneously, detailed knowledge of the nuclei not just of hydrogen and helium atoms but also of the rest of the elements allowed scientists to calculate which nuclear reactions dominate at different stages in a star's life. Astronomers came to understand how nuclear fusion creates an onion-skin structure in massive stars as atoms successively fuse to build heavier and heavier elements, ending with iron in the innermost, hottest layer.

    Inside the Crab cialis online usa Nebula is a neutron star. Classical physics fails, and relativity applies. Credit.

    NASA, ESA and Hubble Heritage Team (STSCI and AURA) Astronomers also learned how stars die when they exhaust their hydrogen fuel and blow off their cialis online usa outer gaseous layers. Lighter stars then settle down to a quiet demise as dense, dim objects called white dwarfs, but heavier stars shed more of their mass, either in winds during their lives or in an explosive death via supernova. This expelled mass turns out to be crucial to our own existence.

    It mixes into the interstellar medium and recondenses into new stars orbited by planets such cialis online usa as Earth. The concept was conceived by Fred Hoyle, who developed it during the 1950s along with two other British astronomers, Margaret Burbidge and Geoffrey Burbidge, and American nuclear physicist William Fowler. In their classic 1957 paper in Reviews of Modern Physics (known by the initials of its authors as BBFH), they analyzed the networks of the nuclear reactions involved and discovered how most atoms in the periodic table came to exist.

    They calculated why oxygen and carbon, for instance, are common, whereas gold cialis online usa and uranium are rare. Our galaxy, it turns out, is a huge ecological system where gas is being recycled through successive generations of stars. Each of us contains atoms forged in dozens of different stars spread across the Milky Way that lived and died more than 4.5 billion years ago.

    Scientists long assumed this process was cialis online usa seeding planets—and possibly even life—around stars other than our own sun. But we did not know for sure whether planets existed outside our solar system until the 1990s, when astronomers developed clever methods for identifying worlds that are too dim for us to see directly. One technique looks for tiny periodic changes in a star's movement caused by the gravitational pull of a planet orbiting it.

    In 1995 Michel Mayor and Didier Queloz used this strategy to detect 51 Pegasi b, the first known exoplanet orbiting a sunlike cialis online usa star. The technique can reveal a planet's mass, the length of its “year” and the shape of its orbit. So far more than 800 exoplanets have been found this way.

    A second cialis online usa technique works better for smaller planets. A star dims slightly when a planet transits in front of it. An Earth-like planet passing a sunlike star can cause a dimming of about one part in 10,000 once per orbit.

    The Kepler spacecraft launched in 2009 found more than 2,000 planets this way, many no bigger cialis online usa than Earth. A big surprise to come from astronomers' success in planet hunting was the variety of different planets out there—many much larger and closer to their stars than the bodies in our solar system—suggesting that our cosmic neighborhood may be somewhat special. By this point scientists understood where almost all the elements that form planets, stars and galaxies originated.

    The final cialis online usa piece in this puzzle, however, arrived very recently and from a seemingly unrelated inquiry. General relativity had predicted a phenomenon called gravitational waves—ripples in spacetime produced by the movement of massive objects. Despite decades of searching for them, however, no waves were seen—until September 2015.

    That was when the Laser Interferometer cialis online usa Gravitational-wave Observatory (LIGO) detected the first evidence of gravitational waves in the form of a “chirp”—a minute shaking of spacetime that speeds up and then dies away. In this case, it was caused by two black holes in a binary system that had started out orbiting each other but gradually spiraled together and eventually converged into a single massive hole. The crash occurred more than a billion light-years away.

    LIGO's detectors consist of mirrors four kilometers apart whose separation is measured by cialis online usa laser beams that reflect light back and forth between them. A passing gravitational wave causes the space between the two mirrors to jitter by an amount millions of times as small as the diameter of a single atom—LIGO is indeed an amazing feat of precision engineering and perseverance. Since that first find, more than a dozen similar events have been detected, opening up a new field that probes the dynamics of space itself.

    One event was of special astrophysical interest because it signaled the merger of two pulsars cialis online usa. Unlike black hole mergers, this kind of collision, a splat between two ultradense stars, yields a pulse of optical light, x-rays and gamma rays. The discovery filled a gap in the classic work of BBFH.

    The authors cialis online usa had explained the genesis of many of the elements in space but were flummoxed by the forging of gold. In the 1970s David N. Schramm and his colleagues had speculated that the exotic nuclear processes involved in hypothetical mergers of pulsar stars might do the job—a theory that has since been validated.

    Despite the incredible progress in astronomy over the past 175 years, we have perhaps more questions now than we did cialis online usa back then. Take dark matter. I am on record as having said more than 20 years ago that we would know dark matter's nature long before today.

    Although that cialis online usa prediction has proved wrong, I have not given up hope. Dark energy, however, is a different story. Dark energy entered the picture in 1998, when researchers measuring the distances and speeds of supernovae found that the expansion of the universe was actually accelerating.

    Gravitational attraction pulling galaxies toward one another seemed to be overwhelmed cialis online usa by a mysterious new force latent in empty space that pushes galaxies apart—a force that came to be known as dark energy. The mystery of dark energy has lingered—we still do not know what causes it or why it has the particular strength it does—and we probably will not understand it until we have a model for the graininess of space on a scale a billion billion times smaller than an atomic nucleus. Theorists working on string theory or loop quantum gravity are tackling this challenge, but the phenomenon seems so far from being accessible by any experiment that I am not expecting answers anytime soon.

    The upside, however, is that a theory that could account for the energy in the vacuum of space might also yield insights into the very beginning of our universe, when everything was so cialis online usa compressed and dense that quantum fluctuations could shake the entire cosmos. Which brings us to another major question facing us now. How did it all begin?.

    What exactly set off the big bang that started our cialis online usa universe?. Did space undergo a period of extremely rapid early expansion called inflation, as many theorists believe?. And there is something else.

    Some models, such as eternal inflation, suggest that “our” big bang could be just one island of spacetime in cialis online usa a vast archipelago—one big bang among many. If this hypothesis is true, different big bangs may cool down differently, leading to unique laws of physics in each case—a “multiverse” rather than a universe. Some physicists hate the multiverse concept because it means that we will never have neat explanations for the fundamental numbers that govern our physical laws, which may in this grander perspective be just environmental accidents.

    But our preferences are irrelevant cialis online usa to nature. About 10 years ago I was on a panel at Stanford University where we were asked by someone in the audience how much we would bet on the multiverse concept. I said that on a scale of betting my goldfish, my dog or my life, I was nearly at the dog level.

    Andrei Linde, who cialis online usa had spent 25 years promoting eternal inflation, said he would almost bet his life. Later, on being told this, physicist Steven Weinberg said he would happily bet my dog and Linde's life. Linde, my dog and I will all be dead before the question is settled.

    But none of this should be cialis online usa dismissed as metaphysics. It is speculative science—exciting science. And it may be true.

    And what will happen cialis online usa to this universe—or multiverse—of ours?. Long-range forecasts are seldom reliable, but the best and most conservative bet is that we have almost an eternity ahead with an ever colder and ever emptier cosmos. Galaxies will accelerate away and disappear.

    All that will be left from our vantage point will be the remnants of the Milky Way, Andromeda cialis online usa and smaller neighbors. Protons may decay, dark matter particles may be annihilated, there may be occasional flashes when black holes evaporate—and then silence. This possible future is based on the assumption that the dark energy stays constant.

    If it decays, however, there could be a “big crunch” cialis online usa with the universe contracting in on itself. Or if dark energy strengthens, there would be a “big rip” when galaxies, stars and even atoms are torn apart. Other questions closer to home tantalize us.

    Could there cialis online usa be life on any of these new planets we are discovering?. Here we are still in the realm of speculation. But unless the origin of life on Earth involved a rare fluke, I expect evidence of a biosphere on an exoplanet within 20 years.

    I will not hold my breath for the cialis online usa discovery of aliens, but I think the search for extraterrestrial intelligence is a worthwhile gamble. Success in the search would carry the momentous message that concepts of logic and physics are not limited to the hardware in human skulls. Until now, progress in cosmology and astrophysics has owed 95 percent to advancing instruments and technology and less than 5 percent to armchair theory.

    I expect cialis online usa that balance to persist. What Hubble wrote in the 1930s remains a good maxim today. €œNot until the empirical resources are exhausted, need we pass on to the dreamy realms of speculation.” There have been many particularly exhilarating eras in the past 175 years—the 1920s and 1930s, when we realized the universe was not limited to the Milky Way, and the 1960s and 1970s, when we discovered objects that defy classical physics, such as neutron stars and quasars, and clues about the beginning of time from the cosmic microwave background.

    Since then, cialis online usa the pace of advancement has crescendoed rather than slackened. When the history of science gets written, this amazing progress will be acclaimed as one of its greatest triumphs—up there with plate tectonics, the genome and the Standard Model of particle physics. And some major fields in astronomy are just getting going.

    Exoplanet research is only 25 years cialis online usa old, and serious work in astrobiology is really only starting. Some exoplanets may have life—they may even harbor aliens who know all the answers already. I find that encouraging.

    Credit cialis online usa. Moritz Stefaner and Christian LässerFor more context, see “Visualizing 175 Years of Words in Scientific American”Fully functional quantum computers and a new quantum industry may appear much sooner than many have anticipated—thanks to five new National Quantum Information Science Research centers just announced by the U.S. Department of Energy.

    This latest development in the recently launched National Quantum Initiative Act, signed into cialis online usa law in December 2018, comes with $625 million in funding over five years. It’s a huge deal. For the first time, researchers from academia, U.S.

    National labs and industry cialis online usa will be working side by side aiming to speed up the fundamental quantum information science research. And more research should bring us closer to advanced quantum technologies and the grandest goal of quantum information science, creating a fault-tolerant quantum computer that can indefinitely compute without errors. Why do we need quantum computers?.

    We need them to speed up the process of scientific discovery so that we can address some our greatest global cialis online usa challenges, from designing new materials for more efficient carbon capture plants and batteries to better drugs and vaccines. Traditionally, material design has depended a lot on either happy accidents or a long and tedious iterative process of experimentation. Over the past half a century, classical computers have greatly accelerated this process by performing molecular simulations.

    Still, classical computers can’t simulate cialis online usa complex molecules with enough accuracy, and that’s where quantum computing will be able to help. Quantum computers rely on the same physical rules as atoms to manipulate information. Just like traditional, classical, computers execute logical circuits to run software programs, quantum computers use the physics phenomena of superposition, entanglement and interference to execute quantum circuits.

    One day soon, they should be able to perform mathematical calculations out of cialis online usa the reach of the most advanced current and future classical supercomputers. But to get there, we will need to build quantum machines that compute without errors. Quantum computers rely on fragile qubits, short for quantum bits, which are only of use when they are in a delicate quantum state.

    Any external disturbances or “noise,” such as heat, light or vibrations, inevitably yanks cialis online usa these qubits out of their quantum state and turns them into regular bits. Overcoming this hurdle is beyond the limits of a single team, and we need scores of scientists from academia, the national labs and industry to get us there. This is where the new centers come in.

    At last, they will get the talent from cialis online usa all our R&D sectors to work together on quantum-related issues. Take the problem of building a quantum system that would compute without errors. Our best theories estimate that to get there, we should build machines with tens of millions of qubits on a single cooled-down chip.

    But we don’t want to cool cialis online usa down quantum chips the size of football fields. To avoid it, we need many breakthroughs—meaning we have to invest in research at scale. Luckily, some of the latest results show that it’s possible to reduce the number of qubits we need to implement error-correcting codes.

    But even if we achieve this, we cialis online usa will have to overcome another hurdle. Linking quantum processors, just like we connect today’s computer chips inside data centers using intranets. This requires quantum interconnects that transfer the fragile quantum information stored in the processor’s qubits into a different quantum format (say, photons) that “communicate” the data to another processor.

    Advances in this space must unite disparate technologies like superconducting qubits and fiber optics, while cialis online usa solving outstanding challenges in materials science and quantum communications. Research teams could probably solve these problems, and many other challenges the quantum information science community is tackling, individually. But it would take decades, and we can’t afford to wait this long.

    Partnerships and collaboration, through the new centers, will offer us the chance of making the quantum leap we cialis online usa need. With a long-term vision of establishing a robust national quantum ecosystem, academia, national labs and industry partners at last have a quantum roadmap. Now it’s up to all the partners in this joint effort to create a quantum ecosystem and industry.

    A Washington Post story said “some buy cheap generic cialis cotton cloth masks are about as effective as surgical masks, while thin polyester spandex gaiters may be worse than going maskless.” A Forbes article, referring to neck gaiters, said the study “found that one type of face covering might actually be doing more harm than good.” But the study didn’t show that, check here nor was it designed to. It was actually a test on how to test masks inexpensively, not to determine which one was most effective. The researchers set up a green laser beam in a dark room. A masked buy cheap generic cialis subject was then asked to speak so that the droplets from the speaker’s mouth showed up in the green beam.

    The whole process was video recorded on a cell phone, after which researchers calculated the number of droplets that showed up. The process was repeated 10 times for each mask (14 in total, one of which was a neck gaiter) and the setup cost less than $200. What was meant as a study on the pricing and efficacy buy cheap generic cialis of a test turned into, at least in some journalistic circles, a definitive nail-in-the-coffin for gaiters. Days after the initial reports that neck gaiters might not only be useless but maybe even harmful, a new round of new reports came out saying that those initial reports were overblown and misleading.

    The authors of the study even held a press conference where they emphasized that their study was never meant to test the effectiveness of masks. They only tested one gaiter-style mask, which says nothing about that buy cheap generic cialis style of mask in general. The combination of reporting on the actual findings of the study and the direct comments from the authors seems to have abated the anti-neck gaiter fervor. But all of this this—or most of it, anyway—likely could have been prevented.

    You could make the argument that it’s not a scientist’s job to worrying about how their science might buy cheap generic cialis be interpreted. It’s their job to do the research and publish it in a scientific manuscript. Leave the communicating for someone else. But that’s not how the spread of information buy cheap generic cialis works.

    Fewer and fewer newsrooms have staffers with scientific backgrounds, or who are dedicated to scientific reporting. To be clear, journalists don’t need to be scientists to understand science, but reporting on science does require a certain amount of expertise. When newsrooms ask reporters to cover buy cheap generic cialis more and more topic areas and this specialization decreases, an attention to detail is sometimes lost. So, the onus to help journalists (and frankly, all nonscientists) get the facts straight falls to the scientists doing the science.

    That’s where science communication training comes in. Science communication, or scicomm as it’s known colloquially, is not a core part of coursework in a majority of buy cheap generic cialis degree-granting science programs at the undergraduate and graduate levels. This trend is slowly changing as more institutions incorporate scicomm into their curriculums. Outside of academia, nonprofits and scientific societies are taking up the mantle.

    I work for buy cheap generic cialis the American Geophysical Union (AGU), a society for Earth and space scientists, in the Sharing Science program, where we teach scientists to communicate with nonscientists through courses, workshops, webinars and other trainings. Aside from the AGU, there is the American Association for the Advancement of Science (AAAS), the Stony Brook–affiliated Alan Alda Center for Communicating Science and the science storytelling organization The Story Collider, to name just to name a few. We teach the so-called “soft skills” that the ivory tower of science has shunned for so long but that are so necessary in effectively communicating. One thing we stress is “know your audience.” Scientists must think buy cheap generic cialis about how their science will be perceived, no matter how relevant or not it might be to the broader public.

    Science does not exist in a vacuum. It never has. But especially now, and especially with anything related to buy cheap generic cialis COVID-19, scientists much be hypervigilant when communicating results and try, to the best of their abilities, to account for as many interpretations as possible. Yes, it is onerous, especially on top of the multitude of other responsibilities that come with being a scientist, but it is necessary.

    The traditional ways in which scientists communicate their results (i.e., scientific manuscripts) are not going away anytime soon. However, and while it may be an buy cheap generic cialis unfair ask, scientists must not only be able to communicate their science to their peers. They must always think about nonscience audiences as the lines between science and “the public” continue to blur. Training scientists to effectively communicate to, or at least think about, diverse audiences is a necessary part of science.In 1835 French philosopher Auguste Comte asserted that nobody would ever know what the stars were made of.

    €œWe understand the possibility of determining their shapes, their distances, their sizes and their movements,” he wrote, “whereas we would never know how to study by any means their chemical composition, or their mineralogical structure, and, even more so, the nature of any organized buy cheap generic cialis beings that might live on their surface.” Comte would be stunned by the discoveries made since then. Today we know that the universe is far bigger and stranger than anyone suspected. Not only does it extend beyond the Milky Way to untold numbers of other galaxies—this would come as a surprise to astronomers of the 19th and early 20th century to whom our galaxy was “the universe”—but it is expanding faster every day. Now we can confidently trace cosmic history back 13.8 billion years to a moment only a billionth of a second after the big buy cheap generic cialis bang.

    Astronomers have pinned down our universe's expansion rate, the mean density of its main constituents, and other key numbers to a precision of 1 or 2 percent. They have also worked out new laws of physics governing space—general relativity and quantum mechanics—that turn out to be much more outlandish than the classical laws people understood before. These laws in turn predicted cosmic oddities such buy cheap generic cialis as black holes, neutron stars and gravitational waves. The story of how we gained this knowledge is full of accidental discoveries, stunning surprises and dogged scientists pursuing goals others thought unreachable.

    Our first hint of the true nature of stars came in 1860, when Gustav Kirchhoff recognized that the dark lines in the spectrum of light coming from the sun were caused by different elements absorbing specific wavelengths. Astronomers analyzed similar features in the light of other bright stars and discovered that they were made of the same buy cheap generic cialis materials found on Earth—not of some mysterious “fifth essence” as the ancients had believed. But it took longer to understand what fuel made the stars shine. Lord Kelvin (William Thomson) calculated that if stars derived their power just from gravity, slowly deflating as their radiation leaked out, then the sun's age was 20 million to 40 million years—far less time than Charles Darwin or the geologists of the time inferred had elapsed on Earth.

    In his last paper on the subject, in 1908, Kelvin inserted an escape clause stating that he would stick by his estimate “unless there were some other energy buy cheap generic cialis source laid up in the storehouse of creation.” That source, it turned out, is nuclear fusion—the process by which atomic nuclei join to create a larger nucleus and release energy. In 1925 astrophysicist Cecilia Payne-Gaposchkin used the light spectra of stars to calculate their chemical abundances and found that, unlike Earth, they were made mainly of hydrogen and helium. She revealed her conclusions in what astronomer Otto Struve described as “the most brilliant Ph.D. Thesis ever written in astronomy.” A decade later physicist Hans Bethe showed that the fusion of hydrogen buy cheap generic cialis nuclei into helium was the main power source in ordinary stars.

    What is the source of the sun's power?. The answer—fusion—came in 1938. Credit. SOHO (ESA and NASA) At the same time stars were becoming less mysterious, so, too, was the nature of fuzzy “nebulae” becoming clearer.

    In a “great debate” held before the National Academy of Sciences in Washington, D.C., on April 26, 1920, Harlow Shapley maintained that our Milky Way was preeminent and that all the nebulae were part of it. In contrast, Heber Curtis argued that some of the fuzzy objects in the sky were separate galaxies—“island universes”—fully the equal of our Milky Way. The conflict was settled not that night but just a few years later, in 1924, when Edwin Hubble measured the distances to many nebulae and proved they were beyond the reaches of the Milky Way. His evidence came from Cepheids, variable stars in the nebulae that reveal their true brightness, and thus their distance, by their pulsation period—a relation discovered by Henrietta Swan Leavitt.

    Soon after Hubble realized that the universe was bigger than many had thought, he found that it was still growing. In 1929 he discovered that spectral features in the starlight from distant galaxies appeared redder—that is, they had longer wavelengths—than the same features in nearby stars. If this effect was interpreted as a Doppler shift—the natural spreading of waves as they recede—it would imply that other galaxies were moving away from one another and from us. Indeed, the farther away they were, the faster their recession seemed to be.

    This was the first clue that our cosmos was not static but was expanding all the time. The universe also appeared to contain much that we could not see. In 1933 Fritz Zwicky estimated the mass of all the stars in the Coma cluster of galaxies and found that they make up only about 1 percent of the mass necessary to keep the cluster from flying apart. The discrepancy was dubbed “the missing mass problem,” but many scientists at the time doubted Zwicky's suggestion that hidden matter might be to blame.

    The question remained divisive until the 1970s, when work by Vera Rubin and W. Kent Ford (observing stars) and by Morton Roberts and Robert Whitehurst (making radio observations) showed that the outer parts of galactic disks would also fly apart unless they were subject to a stronger gravitational pull than stars and gas alone could provide. Finally, most astronomers were compelled to accept that some kind of “dark matter” must be present. €œWe have peered into a new world,” Rubin wrote, “and have seen that it is more mysterious and more complex than we had imagined.” Scientists now believe that dark matter outnumbers visible matter by about a factor of five, yet we are hardly closer than we were in the 1930s to figuring out what it is.

    Gravity, the force that revealed all that dark matter, has proved to be nearly as baffling. A pivotal moment came in 1915 when Albert Einstein published his general theory of relativity, which transcended Isaac Newton's mechanics and revealed that gravity is actually the deformation of the fabric of space and time. This new theory was slow to take hold. Even after it was shown to be correct by observations of a 1919 solar eclipse, many dismissed the theory as an interesting quirk—after all, Newton's laws were still good enough for calculating most things.

    €œThe discoveries, while very important, did not, however, affect anything on this earth,” astronomer W.J.S. Lockyer told the New York Times after the eclipse. For almost half a century after it was proposed, general relativity was sidelined from the mainstream of physics. Then, beginning in the 1960s, astronomers started discovering new and extreme phenomena that only Einstein's ideas could explain.

    One example lurks in the Crab Nebula, one of the best-known objects in the sky, which is composed of the expanding debris from a supernova witnessed by Chinese astronomers in a.d. 1054. Since it appeared, the nebula has kept on shining blue and bright—but how?. Its light source was a longtime puzzle, but the answer came in 1968, when the dim star at its center was revealed to be anything but normal.

    It was actually an ultracompact neutron star, heavier than the sun but only a few miles in radius and spinning at 30 revolutions per second. €œThis was a totally unexpected, totally new kind of object behaving in a way that astronomers had never expected, never dreamt of,” said Jocelyn Bell Burnell, one of the discoverers of the phenomenon. The star's excessive spin sends out a wind of fast electrons that generate the blue light. The gravitational force at the surface of such an incredibly dense object falls way outside of Newton's purview—a rocket would need to be fired at half the speed of light to escape its pull.

    Here the relativistic effects predicted by Einstein must be taken into account. Thousands of such spinning neutron stars—called pulsars—have been discovered. All are believed to be remnants of the cores of stars that exploded as supernovae, offering an ideal laboratory for studying the laws of nature under extreme conditions. The most exotic result of Einstein's theory was the concept of black holes—objects that have collapsed so far that not even light can escape their gravitational pull.

    For decades these were only conjecture, and Einstein wrote in 1939 that they “do not exist in physical reality.” But in 1963 astronomers discovered quasars. Mysterious, hyperluminous beacons in the centers of some galaxies. More than a decade passed before a consensus emerged that this intense brightness was generated by gas swirling into huge black holes lurking in the galaxies' cores. It was the strongest evidence yet that these bizarre predictions of general relativity actually exist.

    When did the universe begin?. Did it even have a beginning?. Astronomers had long debated these questions when, in the middle of the 20th century, two competing theories proposed very different answers. The “hot big bang” model said the cosmos began extremely small, hot and dense and then cooled and spread out over time.

    The “steady state” hypothesis held that the universe had essentially existed in the same form forever. The contest was settled by a serendipitous discovery. In 1965 radio astronomers Arno Penzias and Robert Wilson were trying to calibrate a new antenna at Bell Labs in New Jersey. They had a problem.

    No matter what they did to reduce background interference, they measured a consistent level of noise in every direction. They even evicted a family of pigeons that had been nesting in the antenna in the hope that they were the source of the problem. But the signal persisted. They had discovered that intergalactic space is not completely cold.

    Instead it is warmed to nearly three kelvins (just above absolute zero) by weak microwaves. Penzias and Wilson had accidentally uncovered the “afterglow of creation”—the cooled and diluted relic of an era when everything in the universe was squeezed until it was hot and dense. The finding tipped the balance firmly in favor of the big bang picture of cosmology. According to the model, during the earliest, hottest epochs of time, the universe was opaque, rather like the inside of a star, and light was repeatedly scattered by electrons.

    When the temperature fell to 3,000 kelvins, however, the electrons slowed down enough to be captured by protons and created neutral atoms. Thereafter light could travel freely. The Bell Labs signal was this ancient light, first released about 300,000 years after the birth of the universe and still pervading the cosmos—what we call the cosmic microwave background. It took a while for the magnitude of the discovery to sink in for the scientists who made it.

    €œWe were very pleased to have a possible explanation [for the antenna noise], but I don't think either of us really took the cosmology very seriously at first,” Wilson says. €œWalter Sullivan wrote a first-page article in the New York Times about it, and I began to think at that point that, you know, maybe I better start taking this cosmology seriously.” Measurements of this radiation have since enabled scientists to understand how galaxies emerged. Precise observations of the microwaves reveal that they are not completely uniform over the sky. Some patches are slightly hotter, others slightly cooler.

    The amplitude of these fluctuations is only one part in 100,000, but they are the seeds of today's cosmic structure. Any region of the expanding universe that started off slightly denser than average expanded less because it was subjected to extra gravity. Its growth lagged further and further, the contrast between its density and that of its surroundings becoming greater and greater. Eventually these clumps were dense enough that gas was pulled in and compressed into stars, forming galaxies.

    The crucial point is this. Computer models that simulate this process are fed the initial fluctuations measured in the cosmic microwave background, which represent the universe when it was 300,000 years old. The output after 13.8 billion years of virtual time have elapsed is a cosmos where galaxies resemble those we see, clustered as they are in the actual universe. This is a real triumph.

    We understand, at least in outline, 99.998 percent of cosmic history. It is not only the big cosmic picture that we have come to understand. A series of discoveries has also revealed the history of the elemental building blocks that make up stars, planets and even our own bodies. Starting in the 1950s, progress in atomic physics led to accurate modeling of stars' surface layers.

    Simultaneously, detailed knowledge of the nuclei not just of hydrogen and helium atoms but also of the rest of the elements allowed scientists to calculate which nuclear reactions dominate at different stages in a star's life. Astronomers came to understand how nuclear fusion creates an onion-skin structure in massive stars as atoms successively fuse to build heavier and heavier elements, ending with iron in the innermost, hottest layer. Inside the Crab Nebula is a neutron star. Classical physics fails, and relativity applies.

    Credit. NASA, ESA and Hubble Heritage Team (STSCI and AURA) Astronomers also learned how stars die when they exhaust their hydrogen fuel and blow off their outer gaseous layers. Lighter stars then settle down to a quiet demise as dense, dim objects called white dwarfs, but heavier stars shed more of their mass, either in winds during their lives or in an explosive death via supernova. This expelled mass turns out to be crucial to our own existence.

    It mixes into the interstellar medium and recondenses into new stars orbited by planets such as Earth. The concept was conceived by Fred Hoyle, who developed it during the 1950s along with two other British astronomers, Margaret Burbidge and Geoffrey Burbidge, and American nuclear physicist William Fowler. In their classic 1957 paper in Reviews of Modern Physics (known by the initials of its authors as BBFH), they analyzed the networks of the nuclear reactions involved and discovered how most atoms in the periodic table came to exist. They calculated why oxygen and carbon, for instance, are common, whereas gold and uranium are rare.

    Our galaxy, it turns out, is a huge ecological system where gas is being recycled through successive generations of stars. Each of us contains atoms forged in dozens of different stars spread across the Milky Way that lived and died more than 4.5 billion years ago. Scientists long assumed this process was seeding planets—and possibly even life—around stars other than our own sun. But we did not know for sure whether planets existed outside our solar system until the 1990s, when astronomers developed clever methods for identifying worlds that are too dim for us to see directly.

    One technique looks for tiny periodic changes in a star's movement caused by the gravitational pull of a planet orbiting it. In 1995 Michel Mayor and Didier Queloz used this strategy to detect 51 Pegasi b, the first known exoplanet orbiting a sunlike star. The technique can reveal a planet's mass, the length of its “year” and the shape of its orbit. So far more than 800 exoplanets have been found this way.

    A second technique works better for smaller planets. A star dims slightly when a planet transits in front of it. An Earth-like planet passing a sunlike star can cause a dimming of about one part in 10,000 once per orbit. The Kepler spacecraft launched in 2009 found more than 2,000 planets this way, many no bigger than Earth.

    A big surprise to come from astronomers' success in planet hunting was the variety of different planets out there—many much larger and closer to their stars than the bodies in our solar system—suggesting that our cosmic neighborhood may be somewhat special. By this point scientists understood where almost all the elements that form planets, stars and galaxies originated. The final piece in this puzzle, however, arrived very recently and from a seemingly unrelated inquiry. General relativity had predicted a phenomenon called gravitational waves—ripples in spacetime produced by the movement of massive objects.

    Despite decades of searching for them, however, no waves were seen—until September 2015. That was when the Laser Interferometer Gravitational-wave Observatory (LIGO) detected the first evidence of gravitational waves in the form of a “chirp”—a minute shaking of spacetime that speeds up and then dies away. In this case, it was caused by two black holes in a binary system that had started out orbiting each other but gradually spiraled together and eventually converged into a single massive hole. The crash occurred more than a billion light-years away.

    LIGO's detectors consist of mirrors four kilometers apart whose separation is measured by laser beams that reflect light back and forth between them. A passing gravitational wave causes the space between the two mirrors to jitter by an amount millions of times as small as the diameter of a single atom—LIGO is indeed an amazing feat of precision engineering and perseverance. Since that first find, more than a dozen similar events have been detected, opening up a new field that probes the dynamics of space itself. One event was of special astrophysical interest because it signaled the merger of two pulsars.

    Unlike black hole mergers, this kind of collision, a splat between two ultradense stars, yields a pulse of optical light, x-rays and gamma rays. The discovery filled a gap in the classic work of BBFH. The authors had explained the genesis of many of the elements in space but were flummoxed by the forging of gold. In the 1970s David N.

    Schramm and his colleagues had speculated that the exotic nuclear processes involved in hypothetical mergers of pulsar stars might do the job—a theory that has since been validated. Despite the incredible progress in astronomy over the past 175 years, we have perhaps more questions now than we did back then. Take dark matter. I am on record as having said more than 20 years ago that we would know dark matter's nature long before today.

    Although that prediction has proved wrong, I have not given up hope. Dark energy, however, is a different story. Dark energy entered the picture in 1998, when researchers measuring the distances and speeds of supernovae found that the expansion of the universe was actually accelerating. Gravitational attraction pulling galaxies toward one another seemed to be overwhelmed by a mysterious new force latent in empty space that pushes galaxies apart—a force that came to be known as dark energy.

    The mystery of dark energy has lingered—we still do not know what causes it or why it has the particular strength it does—and we probably will not understand it until we have a model for the graininess of space on a scale a billion billion times smaller than an atomic nucleus. Theorists working on string theory or loop quantum gravity are tackling this challenge, but the phenomenon seems so far from being accessible by any experiment that I am not expecting answers anytime soon. The upside, however, is that a theory that could account for the energy in the vacuum of space might also yield insights into the very beginning of our universe, when everything was so compressed and dense that quantum fluctuations could shake the entire cosmos. Which brings us to another major question facing us now.

    How did it all begin?. What exactly set off the big bang that started our universe?. Did space undergo a period of extremely rapid early expansion called inflation, as many theorists believe?. And there is something else.

    Some models, such as eternal inflation, suggest that “our” big bang could be just one island of spacetime in a vast archipelago—one big bang among many. If this hypothesis is true, different big bangs may cool down differently, leading to unique laws of physics in each case—a “multiverse” rather than a universe. Some physicists hate the multiverse concept because it means that we will never have neat explanations for the fundamental numbers that govern our physical laws, which may in this grander perspective be just environmental accidents. But our preferences are irrelevant to nature.

    About 10 years ago I was on a panel at Stanford University where we were asked by someone in the audience how much we would bet on the multiverse concept. I said that on a scale of betting my goldfish, my dog or my life, I was nearly at the dog level. Andrei Linde, who had spent 25 years promoting eternal inflation, said he would almost bet his life. Later, on being told this, physicist Steven Weinberg said he would happily bet my dog and Linde's life.

    Linde, my dog and I will all be dead before the question is settled. But none of this should be dismissed as metaphysics. It is speculative science—exciting science. And it may be true.

    And what will happen to this universe—or multiverse—of ours?. Long-range forecasts are seldom reliable, but the best and most conservative bet is that we have almost an eternity ahead with an ever colder and ever emptier cosmos. Galaxies will accelerate away and disappear. All that will be left from our vantage point will be the remnants of the Milky Way, Andromeda and smaller neighbors.

    Protons may decay, dark matter particles may be annihilated, there may be occasional flashes when black holes evaporate—and then silence. This possible future is based on the assumption that the dark energy stays constant. If it decays, however, there could be a “big crunch” with the universe contracting in on itself. Or if dark energy strengthens, there would be a “big rip” when galaxies, stars and even atoms are torn apart.

    Other questions closer to home tantalize us. Could there be life on any of these new planets we are discovering?. Here we are still in the realm of speculation. But unless the origin of life on Earth involved a rare fluke, I expect evidence of a biosphere on an exoplanet within 20 years.

    I will not hold my breath for the discovery of aliens, but I think the search for extraterrestrial intelligence is a worthwhile gamble. Success in the search would carry the momentous message that concepts of logic and physics are not limited to the hardware in human skulls. Until now, progress in cosmology and astrophysics has owed 95 percent to advancing instruments and technology and less than 5 percent to armchair theory. I expect that balance to persist.

    What Hubble wrote in the 1930s remains a good maxim today. €œNot until the empirical resources are exhausted, need we pass on to the dreamy realms of speculation.” There have been many particularly exhilarating eras in the past 175 years—the 1920s and 1930s, when we realized the universe was not limited to the Milky Way, and the 1960s and 1970s, when we discovered objects that defy classical physics, such as neutron stars and quasars, and clues about the beginning of time from the cosmic microwave background. Since then, the pace of advancement has crescendoed rather than slackened. When the history of science gets written, this amazing progress will be acclaimed as one of its greatest triumphs—up there with plate tectonics, the genome and the Standard Model of particle physics.

    And some major fields in astronomy are just getting going. Exoplanet research is only 25 years old, and serious work in astrobiology is really only starting. Some exoplanets may have life—they may even harbor aliens who know all the answers already. I find that encouraging.

    Credit. Moritz Stefaner and Christian LässerFor more context, see “Visualizing 175 Years of Words in Scientific American”Fully functional quantum computers and a new quantum industry may appear much sooner than many have anticipated—thanks to five new National Quantum Information Science Research centers just announced by the U.S. Department of Energy. This latest development in the recently launched National Quantum Initiative Act, signed into law in December 2018, comes with $625 million in funding over five years.

    It’s a huge deal. For the first time, researchers from academia, U.S. National labs and industry will be working side by side aiming to speed up the fundamental quantum information science research. And more research should bring us closer to advanced quantum technologies and the grandest goal of quantum information science, creating a fault-tolerant quantum computer that can indefinitely compute without errors.

    Why do we need quantum computers?. We need them to speed up the process of scientific discovery so that we can address some our greatest global challenges, from designing new materials for more efficient carbon capture plants and batteries to better drugs and vaccines. Traditionally, material design has depended a lot on either happy accidents or a long and tedious iterative process of experimentation. Over the past half a century, classical computers have greatly accelerated this process by performing molecular simulations.

    Still, classical computers can’t simulate complex molecules with enough accuracy, and that’s where quantum computing will be able to help. Quantum computers rely on the same physical rules as atoms to manipulate information. Just like traditional, classical, computers execute logical circuits to run software programs, quantum computers use the physics phenomena of superposition, entanglement and interference to execute quantum circuits. One day soon, they should be able to perform mathematical calculations out of the reach of the most advanced current and future classical supercomputers.

    But to get there, we will need to build quantum machines that compute without errors. Quantum computers rely on fragile qubits, short for quantum bits, which are only of use when they are in a delicate quantum state. Any external disturbances or “noise,” such as heat, light or vibrations, inevitably yanks these qubits out of their quantum state and turns them into regular bits. Overcoming this hurdle is beyond the limits of a single team, and we need scores of scientists from academia, the national labs and industry to get us there.

    This is where the new centers come in. At last, they will get the talent from all our R&D sectors to work together on quantum-related issues. Take the problem of building a quantum system that would compute without errors. Our best theories estimate that to get there, we should build machines with tens of millions of qubits on a single cooled-down chip.

    But we don’t want to cool down quantum chips the size of football fields. To avoid it, we need many breakthroughs—meaning we have to invest in research at scale. Luckily, some of the latest results show that it’s possible to reduce the number of qubits we need to implement error-correcting codes. But even if we achieve this, we will have to overcome another hurdle.

    Linking quantum processors, just like we connect today’s computer chips inside data centers using intranets. This requires quantum interconnects that transfer the fragile quantum information stored in the processor’s qubits into a different quantum format (say, photons) that “communicate” the data to another processor. Advances in this space must unite disparate technologies like superconducting qubits and fiber optics, while solving outstanding challenges in materials science and quantum communications. Research teams could probably solve these problems, and many other challenges the quantum information science community is tackling, individually.

    But it would take decades, and we can’t afford to wait this long. Partnerships and collaboration, through the new centers, will offer us the chance of making the quantum leap we need. With a long-term vision of establishing a robust national quantum ecosystem, academia, national labs and industry partners at last have a quantum roadmap. Now it’s up to all the partners in this joint effort to create a quantum ecosystem and industry.

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

    The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over.

    The prevalence of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids.

    The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the two conditions remains unclear,” she says.

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

    The other authors on this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit.

    The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors. - Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows.

    The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

    As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an infection. These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma.

    The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear.

    To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation.

    The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer. €œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

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

    However, he explains, this cancer type is often caused by a virus, which seems to encourage a strong immune response despite the cancer’s lower mutational burden. In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried.

    Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. €œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says.

    Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

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

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

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

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

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

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

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

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

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

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

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

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

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    Many athletes have cialis duration of action had their baseball season http://www.amisdepasteur.fr/cost-of-cialis-20mg-in-canada/ shortened or cancelled due to COVID-19. This extra rest can be helpful in decreasing stress on the shoulder and elbow joints, but it can also lead to decreased strength and ROM. Overhead athletes need to keep their bodies strong, and a great way to achieve that is by performing a regular strengthening program. With many gyms remaining closed or cialis duration of action limiting access during social distancing, that can be even more challenging.

    However, there are many exercises that can be done at home with minimal equipment needs. A great program to focus on during the off season is the Thrower’s Ten program that was developed with the overhead athlete in mind. These exercises focus on cialis duration of action the muscle groups that matter most for the overhead athlete. We use our entire body to throw a ball and the stress on the shoulder to decelerate the arm is about twice our body weight.

    Most of this stress gets placed on the rotator cuff and scapular muscles that slow the arm down as we follow through with our throw. Weakness in these muscles can lead cialis duration of action to problems with the shoulder and elbow joints. Common injuries can be Little League shoulder and elbow or strains to the ulnar collateral ligaments (Tommy John). If you have dealt with pain or injuries in the past, a comprehensive evaluation by a physical therapist (PT) who focuses on treating the overhead athlete can be extremely helpful in identifying areas of concern.

    Your PT will evaluate your strength with a dynamometer to look at cialis duration of action any significant abnormalities between shoulders. They can also perform a video throwing analysis to look at ways to potentially reduce injury risk and improve performance. This can almost always be achieved with only a couple of visits, and the off season is a great time to start addressing areas of concern to be ready for next season or throwing during the winter. Your PT can help cialis duration of action you develop a customized home exercise program based on your needs.

    Physical Therapist Kyle Stevenson, D.P.T., sees patients at MidMichigan’s Rehabilitation Services location in Greater Midland North-End Fitness Center. He has a special interest in sports medicine, and enjoys working with athletes of all ages. He has completed specialized coursework and cialis duration of action training for the throwing athletes. New patients are welcome with a physician referral by calling (989) 832-5913.

    Those who would like more information about MidMichigan’s Rehabilitation Services may visit www.midmichigan.org/rehabilitation.Have you ever woken up with a sore throat and used your phone to get a virtual visit?. The odds are it’s cialis duration of action not available to you, and there is a reason for that. You may be hearing about how virtual care, often described as telehealth or telemedicine, is beneficial during COVID-19 and how health systems are offering virtual access like never before. There’s a reason for that, too.

    For the past few weeks I’ve seen Facebook posts daily from former nursing colleagues in metro cialis duration of action Detroit, one of the hardest hit areas in the country, as they provide front-line care to patients with COVID-19. It makes me very proud to call these nurses my friends. As a former emergency department nurse, I recall the feeling of satisfaction knowing that I’ve helped someone on the worst day of their life. One of the best cialis duration of action parts of being a nurse is knowing you matter to the only person in health care that truly matters.

    The patient. Several years ago I made the difficult decision to no longer perform bedside nursing and become a nurse administrator. The biggest loss from my transition is the feeling that cialis duration of action what I do matters to the patient. COVID-19 has forced a lot of us to rethink the role we play in health care and what the real priority should be.

    Things that were top priorities three months ago have been rightfully cast aside to either care for patients in a pandemic or prepare for the unknown future of, “When is our turn?. € For me, COVID-19 has reignited the feeling that what I do matters as virtual care has become a powerful tool on the forefront cialis duration of action of care during this crisis. It has also shown that many of the powerful rules and regulations that limit virtual care are not needed and should be discarded permanently. When I became the director of virtual care at our organization in 2015 I knew nothing about telehealth.

    Sure, I had seen a stroke robot in some Emergency Departments, and I had some friends that told me their insurance company cialis duration of action lets them FaceTime a doctor for free (spoiler alert. It’s not FaceTime). I was tech-savvy from a consumer perspective and a tech novice from an IT perspective. Nevertheless, my team and I spent the next few years learning as we cialis duration of action built one of the higher volume virtual care networks in the state of Michigan.

    We discovered a lot of barriers that keep virtual care from actually making the lives of patients and providers better and we also became experts in working around those barriers. But, there were two obstacles that we could not overcome. Government regulation and insurance provider cialis duration of action willingness to cover virtual visits. These two barriers effectively cripple most legitimate attempts to provide value-added direct-to-consumer virtual care, which I define as using virtual care technologies to provide care outside of our brick-and-mortar facilities, most commonly in the patient home.

    The need to social distance, cancel appointments, close provider offices, keep from overloading emergency departments and urgent cares and shelter in place created instant demand for direct-to-consumer virtual care. In all honesty, I’ve always considered direct-to-consumer virtual care to be the flashy, must-have holiday gift of the year cialis duration of action that organizations are convinced will be the way of the future. If a health system wants to provide on-demand access to patients for low-complexity acute conditions, they will easily find plenty of vendors that will sell them their app and their doctors and put the health system’s logo on it. What a health system will struggle with is to find is enough patient demand to cover the high cost.

    Remember my friends from earlier that told me about the cialis duration of action app their insurance gave them?. Nearly all of them followed that up by telling me they’ve never actually used it. I am fortunate that I work for an organization that understands this and instead focuses on how can we provide care that our patients actually want and need from the doctors they want to see. Ironically, this fiscal year we had a corporate top priority around cialis duration of action direct-to-consumer virtual care.

    We wanted to expand what we thought were some successful pilots and perform 500 direct-to-consumer visits. This year has been one of the hardest of my leadership career because, frankly, up until a month ago I was about to fail on this top priority. With only four months left, we were only about halfway there. The biggest problem we ran into was that every great idea a physician brought to me was instantly dead in the water because practically no insurance company would pay for cialis duration of action it.

    There are (prior to COVID-19) a plethora of rules around virtual care billing but the simplest way to summarize it is that most virtual care will only be paid if it happens in a rural location and inside of a health care facility. It is extremely limited what will be paid for in the patient home and most of it is so specific that the average patient isn’t eligible to get any in-home virtual care. Therefore, most good medical uses for direct-to-consumer care would be asking the patient to pay cash or the physician to forgo reimbursement for a visit that would be covered if cialis duration of action it happened in office. Add to that the massive capital and operating expenses it takes to build a virtual care network and you can see why these programs don’t exist.

    A month ago I was skeptical we’d have a robust direct-to-consumer program any time soon and then COVID-19 hit. When COVID-19 started to spread rapidly in the United States, regulations and cialis duration of action reimbursement rules were being stripped daily. The first change that had major impact is when the Centers for Medicare and Medicaid Services (CMS) announced that they would temporarily begin reimbursing for virtual visits conducted in the patient’s home for COVID-19 and non-COVID related visits. We were already frantically designing a virtual program to handle the wave of COVID-19 screening visits that were overloading our emergency departments and urgent cares.

    We were having plenty of discussions around reimbursement cialis duration of action for this clinic. Do we attempt to bill insurances knowing they will likely deny, do we do a cash clinic model or do we do this as a community benefit and eat the cost?. The CMS waiver gave us hope that we would be compensated for diverting patients away from reimbursed visits to a virtual visit that is more convenient for the patient and aligns with the concept of social distancing. Realistically we don’t know cialis duration of action if we will be paid for any of this.

    We are holding all of the bills for at least 90 days while the industry sorts out the rules. I was excited by the reimbursement announcement because I knew we had eliminated one of the biggest direct-to-consumer virtual care barriers. However, I was quickly brought back to reality when I was reminded that HIPAA (Health Insurance Portability and Accountability Act) still cialis duration of action existed. I had this crazy idea that during a pandemic we should make it as easy as possible for people to receive virtual care and that the best way to do that was to meet the patient on the device they are most comfortable with and the application (FaceTime, Facebook, Skype, etc.) that they use every day.

    The problem is nearly every app the consumer uses on a daily basis is banned by HIPAA because “it’s not secure.” I’m not quite sure what a hacker stands to gain by listening into to my doctor and me talk about how my kids yet again gave me strep throat but apparently the concern is great enough to stifle the entire industry. Sure, not every cialis duration of action health care discussion is as low-key as strep throat and a patient may want to protect certain topics from being discussed over a “non-secure” app but why not let the patient decide through informed consent?. Regulators could also abandon this all-or-nothing approach and lighten regulations surrounding specific health conditions. The idea that regulations change based on medical situation is not new.

    For example, in my home state of Michigan, adolescents are essentially considered emancipated if it involves sexual health, mental health or substance cialis duration of action abuse. Never mind that this same information is freely given over the phone by every office around the country daily without issue, but I digress. While my job is to innovate new pathways for care, our lawyer’s job is to protect the organization and he, along with IT security, rightfully shot down my consumer applications idea. A few days later I legitimately screamed out cialis duration of action loud in joy when the Department of Health and Human Services announced that it would use discretion on enforcing HIPAA compliance rules and specifically allowed for use of consumer applications.

    The elimination of billing restrictions and HIPAA regulations changed what is possible for health care organizations to offer virtually. Unfortunately both changes are listed as temporary and will likely be removed when the pandemic ends. Six days after the HIPAA changes were announced, we launched a centralized virtual clinic for any patient that wanted a direct-to-consumer video visit to be screened by cialis duration of action a provider for COVID-19. It allows patients to call in without a referral and most patients are on-screen within five minutes of clicking the link we text them.

    They don’t have to download an app, create an account or even be an established patient of our health system. It saw over 900 patients in the first cialis duration of action 12 days it was open. That is 900 real patients that received care from a physician or advanced practice provider without risking personal exposure and without going to an already overwhelmed ED or urgent care. To date, 70 percent of the patients seen by the virtual clinic did not meet CDC testing criteria for COVID-19.

    I don’t believe we could have reached even half of these patients had the cialis duration of action consumer application restrictions been kept. A program like this almost certainly wouldn’t exist if not for the regulations being lifted and even if it did, it would have taken six to 12 months to navigate barriers and implement in normal times. Sure, the urgency of a pandemic helps but the impact of provider, patients, regulators and payors being on the same page is what fueled this fire. During the virtual clinic’s first two weeks, my team turned its attention to getting over 300 providers across 60+ offices virtual so they could see their patients at cialis duration of action home.

    Imagine being an immunocompromised cancer patient right now and being asked to leave your home and be exposed to other people in order to see your oncologist. Direct-to-consumer virtual care is the best way to safely care for these patients and without these temporary waivers it wouldn’t be covered by insurance even if you did navigate the clunky apps that are HIPAA compliant. Do we really think the cialis duration of action immunocompromised cancer patient feels any more comfortable every normal flu season?. Is it any more appropriate to ask them to risk exposure to the flu than it is to COVID-19?.

    And yet we deny them this access in normal times and it quite possibly will be stripped away from them when this crisis is over. Now 300 cialis duration of action to 400 patients per day in our health system are seen virtually by their own primary care doctor or specialist for non-COVID related visits. Not a single one of these would have been reimbursed one month ago and I am highly skeptical I would have gotten approval to use the software that connects us to the patient. Lastly, recall that prior to COVID-19, our system had only found 250 total patients that direct-to-consumer care was value-added and wasn’t restricted by regulation or reimbursement.

    COVID-19 has been a wake-up call to cialis duration of action the whole country and health care is no exception. It has put priorities in perspective and shined a light on what is truly value-added. For direct-to-consumer virtual care it has shown us what is possible when we get out of our own way. If a regulation has to be removed to allow cialis duration of action for care during a crisis then we must question why it exists in the first place.

    HIPAA regulation cannot go back to its antiquated practices if we are truly going to shift the focus to patient wellness. CMS and private payors must embrace value-added direct-to-consumer virtual care and allow patients the access they deserve. COVID-19 has forced this industry forward, we cannot allow it to regress and be forgotten when this is over.

    Overhead athletes buy cheap generic cialis need to keep their bodies when will cialis be over the counter strong, and a great way to achieve that is by performing a regular strengthening program. With many gyms remaining closed or limiting access during social distancing, that can be even more challenging. However, there are many exercises that can be done at home with minimal equipment needs. A great program to focus on during the off season is the Thrower’s buy cheap generic cialis Ten program that was developed with the overhead athlete in mind.

    These exercises focus on the muscle groups that matter most for the overhead athlete. We use our entire body to throw a ball and the stress on the shoulder to decelerate the arm is about twice our body weight. Most of this stress gets placed on the rotator cuff and scapular muscles that slow the arm down as we follow through with our buy cheap generic cialis throw. Weakness in these muscles can lead to problems with the shoulder and elbow joints.

    Common injuries can be Little League shoulder and elbow or strains to the ulnar collateral ligaments (Tommy John). If you have dealt with pain or injuries in the past, a comprehensive evaluation by a physical therapist buy cheap generic cialis (PT) who focuses on treating the overhead athlete can be extremely helpful in identifying areas of concern. Your PT will evaluate your strength with a dynamometer to look at any significant abnormalities between shoulders. They can also perform a video throwing analysis to look at ways to potentially reduce injury risk and improve performance.

    This can almost always be achieved with only a couple of visits, and the off season is a great time to start addressing areas of concern to be ready for next buy cheap generic cialis season or throwing during the winter. Your PT can help you develop a customized home exercise program based on your needs. Physical Therapist Kyle Stevenson, D.P.T., sees patients at MidMichigan’s Rehabilitation Services location in Greater Midland North-End Fitness Center. He has a special interest in sports medicine, and enjoys working with buy cheap generic cialis athletes of all ages.

    He has completed specialized coursework and training for the throwing athletes. New patients are welcome with a physician referral by calling (989) 832-5913. Those who would like more information about MidMichigan’s buy cheap generic cialis Rehabilitation Services may visit www.midmichigan.org/rehabilitation.Have you ever woken up with a sore throat and used your phone to get a virtual visit?. The odds are it’s not available to you, and there is a reason for that.

    You may be hearing about how virtual care, often described as telehealth or telemedicine, is beneficial during COVID-19 and how health systems are offering virtual access like never before. There’s a buy cheap generic cialis reason for that, too. For the past few weeks I’ve seen Facebook posts daily from former nursing colleagues in metro Detroit, one of the hardest hit areas in the country, as they provide front-line care to patients with COVID-19. It makes me very proud to call these nurses my friends.

    As a former emergency department nurse, I recall the feeling buy cheap generic cialis of satisfaction knowing that I’ve helped someone on the worst day of their life. One of the best parts of being a nurse is knowing you matter to the only person in health care that truly matters. The patient. Several years ago I made the difficult decision to no buy cheap generic cialis longer perform bedside nursing and become a nurse administrator.

    The biggest loss from my transition is the feeling that what I do matters to the patient. COVID-19 has forced a lot of us to rethink the role we play in health care and what the real priority should be. Things that were top priorities three months ago have been rightfully cast aside to either care for patients in a pandemic or prepare for the unknown future of, buy cheap generic cialis “When is our turn?. € For me, COVID-19 has reignited the feeling that what I do matters as virtual care has become a powerful tool on the forefront of care during this crisis.

    It has also shown that many of the powerful rules and regulations that limit virtual care are not needed and should be discarded permanently. When I became the director of virtual care at our organization buy cheap generic cialis in 2015 I knew nothing about telehealth. Sure, I had seen a stroke robot in some Emergency Departments, and I had some friends that told me their insurance company lets them FaceTime a doctor for free (spoiler alert. It’s not FaceTime).

    I was tech-savvy from a consumer perspective buy cheap generic cialis and a tech novice from an IT perspective. Nevertheless, my team and I spent the next few years learning as we built one of the higher volume virtual care networks in the state of Michigan. We discovered a lot of barriers that keep virtual care from actually making the lives of patients and providers better and we also became experts in working around those barriers. But, there were two obstacles that we could not buy cheap generic cialis overcome.

    Government regulation and insurance provider willingness to cover virtual visits. These two barriers effectively cripple most legitimate attempts to provide value-added direct-to-consumer virtual care, which I define as using virtual care technologies to provide care outside of our brick-and-mortar facilities, most commonly in the patient home. The need to social distance, cancel appointments, close provider offices, keep from overloading emergency departments and urgent cares and shelter in place buy cheap generic cialis created instant demand for direct-to-consumer virtual care. In all honesty, I’ve always considered direct-to-consumer virtual care to be the flashy, must-have holiday gift of the year that organizations are convinced will be the way of the future.

    If a health system wants to provide on-demand access to patients for low-complexity acute conditions, they will easily find plenty of vendors that will sell them their app and their doctors and put the health system’s logo on it. What a health system will struggle with buy cheap generic cialis is to find is enough patient demand to cover the high cost. Remember my friends from earlier that told me about the app their insurance gave them?. Nearly all of them followed that up by telling me they’ve never actually used it.

    I am fortunate that I work for an organization that understands this and instead focuses on how can we provide care that our buy cheap generic cialis patients actually want and need from the doctors they want to see. Ironically, this fiscal year we had a corporate top priority around direct-to-consumer virtual care. We wanted to expand what we thought were some successful pilots and perform 500 direct-to-consumer visits. This year has been one buy cheap generic cialis of the hardest of my leadership career because, frankly, up until a month ago I was about to fail on this top priority.

    With only four months left, we were only about halfway there. The biggest problem we ran into was that every great idea a physician brought to me was instantly dead in the water because practically no insurance company would pay for it. There are (prior to COVID-19) a plethora of rules around virtual care billing but the simplest way to summarize it is that most virtual care will only be paid if it happens in a rural location and inside of a health care facility. It is extremely limited what will be paid for buy cheap generic cialis in the patient home and most of it is so specific that the average patient isn’t eligible to get any in-home virtual care.

    Therefore, most good medical uses for direct-to-consumer care would be asking the patient to pay cash or the physician to forgo reimbursement for a visit that would be covered if it happened in office. Add to that the massive capital and operating expenses it takes to build a virtual care network and you can see why these programs don’t exist. A month ago I was skeptical we’d have a robust direct-to-consumer program any buy cheap generic cialis time soon and then COVID-19 hit. When COVID-19 started to spread rapidly in the United States, regulations and reimbursement rules were being stripped daily.

    The first change that had major impact is when the Centers for Medicare and Medicaid Services (CMS) announced that they would temporarily begin reimbursing for virtual visits conducted in the patient’s home for COVID-19 and non-COVID related visits. We were already frantically designing a virtual program to handle the wave of COVID-19 screening visits that were buy cheap generic cialis overloading our emergency departments and urgent cares. We were having plenty of discussions around reimbursement for this clinic. Do we attempt to bill insurances knowing they will likely deny, do we do a cash clinic model or do we do this as a community benefit and eat the cost?.

    The CMS waiver gave us hope that we would be compensated for diverting patients away from reimbursed visits to a virtual visit that is more convenient for the patient and aligns with the concept of social distancing buy cheap generic cialis. Realistically we don’t know if we will be paid for any of this. We are holding all of the bills for at least 90 days while the industry sorts out the rules. I was excited by the reimbursement announcement because I knew we had eliminated one buy cheap generic cialis of the biggest direct-to-consumer virtual care barriers.

    However, I was quickly brought back to reality when I was reminded that HIPAA (Health Insurance Portability and Accountability Act) still existed. I had this crazy idea that during a pandemic we should make it as easy as possible for people to receive virtual care and that the best way to do that was to meet the patient on the device they are most comfortable with and the application (FaceTime, Facebook, Skype, etc.) that they use every day. The problem is nearly every app the consumer uses on a daily basis is banned by HIPAA because “it’s not secure.” I’m not quite sure what a hacker stands to gain by listening into to my doctor and me talk buy cheap generic cialis about how my kids yet again gave me strep throat but apparently the concern is great enough to stifle the entire industry. Sure, not every health care discussion is as low-key as strep throat and a patient may want to protect certain topics from being discussed over a “non-secure” app but why not let the patient decide through informed consent?.

    Regulators could also abandon this all-or-nothing approach and lighten regulations surrounding specific health conditions. The idea buy cheap generic cialis that regulations change based on medical situation is not new. For example, in my home state of Michigan, adolescents are essentially considered emancipated if it involves sexual health, mental health or substance abuse. Never mind that this same information is freely given over the phone by every office around the country daily without issue, but I digress.

    While my job is to innovate new pathways for care, our lawyer’s job is to protect the organization and he, along with IT security, rightfully shot down buy cheap generic cialis my consumer applications idea. A few days later I legitimately screamed out loud in joy when the Department of Health and Human Services announced that it would use discretion on enforcing HIPAA compliance rules and specifically allowed for use of consumer applications. The elimination of billing restrictions and HIPAA regulations changed what is possible for health care organizations to offer virtually. Unfortunately both changes buy cheap generic cialis are listed as temporary and will likely be removed when the pandemic ends.

    Six days after the HIPAA changes were announced, we launched a centralized virtual clinic for any patient that wanted a direct-to-consumer video visit to be screened by a provider for COVID-19. It allows patients to call in without a referral and most patients are on-screen within five minutes of clicking the link we text them. They don’t have to download an app, create an account or even be an established patient of buy cheap generic cialis our health system. It saw over 900 patients in the first 12 days it was open.

    That is 900 real patients that received care from a physician or advanced practice provider without risking personal exposure and without going to an already overwhelmed ED or urgent care. To date, 70 percent of the patients seen by buy cheap generic cialis the virtual clinic did not meet CDC testing criteria for COVID-19. I don’t believe we could have reached even half of these patients had the consumer application restrictions been kept. A program like this almost certainly wouldn’t exist if not for the regulations being lifted and even if it did, it would have taken six to 12 months to navigate barriers and implement in normal times.

    Sure, the urgency of a pandemic helps but the impact of provider, patients, regulators and payors being on the same buy cheap generic cialis page is what fueled this fire. During the virtual clinic’s first two weeks, my team turned its attention to getting over 300 providers across 60+ offices virtual so they could see their patients at home. Imagine being an immunocompromised cancer patient right now and being asked to leave your home and be exposed to other people in order to see your oncologist. Direct-to-consumer virtual care is the best way to safely care for these patients and without these temporary waivers it wouldn’t be buy cheap generic cialis covered by insurance even if you did navigate the clunky apps that are HIPAA compliant.

    Do we really think the immunocompromised cancer patient feels any more comfortable every normal flu season?. Is it any more appropriate to ask them to risk exposure to the flu than it is to COVID-19?. And yet we deny them this access in normal times and it quite possibly will be stripped buy cheap generic cialis away from them when this crisis is over. Now 300 to 400 patients per day in our health system are seen virtually by their own primary care doctor or specialist for non-COVID related visits.

    Not a single one of these would have been reimbursed one month ago and I am highly skeptical I would have gotten approval to use the software that connects us to the patient. Lastly, recall that prior to COVID-19, our system had only buy cheap generic cialis found 250 total patients that direct-to-consumer care was value-added and wasn’t restricted by regulation or reimbursement. COVID-19 has been a wake-up call to the whole country and health care is no exception. It has put priorities in perspective and shined a light on what is truly value-added.

    For direct-to-consumer virtual care it has shown us what is possible when we get out of buy cheap generic cialis our own way. If a regulation has to be removed to allow for care during a crisis then we must question why it exists in the first place. HIPAA regulation cannot go back to its antiquated practices if we are truly going to shift the focus to patient wellness. CMS and private payors must embrace value-added direct-to-consumer virtual care and allow patients the access they deserve buy cheap generic cialis.

    COVID-19 has forced this industry forward, we cannot allow it to regress and be forgotten when this is over. Tom Wood is the director of trauma and virtual care for MidMichigan Health, a non-profit health system headquartered in Midland, Michigan, affiliated with Michigan Medicine, the health care division of the University of Michigan. The views and opinions expressed in this commentary are his own..

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    Community care? cialis failure cialis at walgreens price. Our Editor’s Choice this month explores a novel approach to care delivery, the Physician Response Unit (PRU), which aims to reduce ED attendances by finding a community solution to the emergency complaint. Joy and colleagues’ retrospective analysis of 12 months of data from this service, which is based in London, demonstrated that of nearly 2000 patients attended to, 67% remained in the cialis failure community. The authors conclude that this model of care is a successful demonstration of integration and collaboration that also reduced ambulance conveyances and ED attendances.

    These results are promising, however, as the excellent commentary by Professor Sue Mason identifies, some unanswered questions remain. Whether these results can be generalised across the wider NHS, beyond the unique confines of the capital, and in light of starkly heterogenous healthcare systems and workforces remains unknown.Moving closer to the front doorPhysician in Triage (PIT) remains a cialis failure controversial topic in EM. In an interesting analysis of PIT from Israel, Schwarzfuchs and colleagues present an uncontrolled before-after analysis of the impacts of this triage strategy on a single time-critical condition, STEMI. At the cialis failure EMJ, we usually discourage this type of study.

    However, here, the authors demonstrate how, with the inclusion of an appropriate logistic regression to consider confounders, this methodology may be an appropriate way to evaluate such interventions which may be difficult to do within a randomised controlled trial. €œMinutes mean myocardium” and as such the reduction in door-to-balloon time of 9 min when a senior physician was present, demonstrated here, may lend further support to the implementation of PIT. This is certainly a rich area for quality improvement work evaluating such targeted interventions for our patients.All about the Bayes’We welcome an observational analysis from Hautz and colleagues that seeks to explain the patient, physician and contextual cialis failure factors associated with diagnostic test ordering. Baye’s theorem describes the probability of an event based on the prior knowledge conditions that may relate to that event.

    A key concept we should all adopt in test ordering. However, this manuscript goes further in exploring that prior knowledge by cialis failure evaluating physician experience, patient and situational context. Rather surprisingly, in this single centre analysis of 473 patients and 38 physicians, these factors seem to have a limited impact on test ordering. Rather, it cialis failure seems that, uncertainty around the patient’s condition (high acuity) and case difficulty seem to influence test ordering more.

    So, uncertain pre-test probability equates to higher degrees of diagnostic test ordering. The Reverend Bayes would be turning in his grave.WellnessNow, unlike ever before, it is important to establish the need for physical and psychological recuperation among our staff. The first manuscript within our Wellness section, from Graham and colleagues (this months Reader’s Choice) evaluates the Need For Recovery (NFR) Score in 168 emergency workers at a single cialis failure site. The high NFR in this population provides a quantifiable insight into our high work intensity but further validation is required beyond a single site.

    Over to you TERN….While knowing the extent of the problem is of great importance, what we do about it is perhaps a greater challenge. We would therefore encourage our readers to take home some of the top tips included in our expert practice review cialis failure this month, Top Ten Evidence-Based Countermeasures for Night Shift Workers by Wallace and Haber.There’s a bug going around…We have had a record number of submissions during the COVID-19 pandemic and the extent to which the EM community has pulled together to inform clinical practice at this time has been breath taking. We are sorry we cannot accept all your excellent work. It is a pleasure to publish a number of Reports from the cialis failure Front on this topic ranging from patient level interventions such as proning, to invaluable lessons from systems wide responses to the pandemic.

    However, the importance of evidence-based medicine has never been higher and this is discussed in our excellent Concepts paper by some very eminent EM Professors.Introducing SONO case seriesLastly, this month sees the first in a series of SONO cases published in the EMJ. This will be a regular feature and is a case-based approach to demonstrate how ED Ultrasound can influence and improve patient care.As demand for healthcare in the UK rises, the challenges become those of trying to meet this demand in a patient-centred way whilst managing changes in the delivery of healthcare to enhance the effectiveness and efficiency of services. This requires an increased level of understanding and cialis failure cooperation between different healthcare professionals, provider organisations and patients. The changes mean reconsidering traditional roles and where appropriate, redefining professional roles, areas of responsibility and team structures, and renegotiating the boundaries between acute and community care.

    Government policy has emphasised the need for the NHS to provide increased patient choice, ease of access and delivery of a high-quality service. This is relevant to providers of emergency care services which need to develop new ways of meeting patient needs closer to home and work cialis failure environments. In emergency care, ambulance services have had to consider new types of responses to those usually provided. Policy initiatives have meant local NHS organisations assuming responsibility for managing and monitoring how cialis failure local services respond to urgent and non-urgent 999 ambulance calls.

    Alongside this, the NHS Long Term Plan emphasises the importance of integrating care through a more joined-up multidisciplinary approach that spans boundaries between primary and secondary care but aims to keep patients out of hospital.At the same time, we are facing workforce crisis across the NHS. This is especially the case in emergency medicine. Failure to seek new opportunities to develop the workforce will only lead cialis failure to further attrition. The challenge is how to do this in a sustainable, cost-effective and generalisable manner that leads to clear benefits for the workforce, services and patients.

    Currently, the emphasis is on the deployment of non-medical practitioner roles in EDs and ambulance services, such as ….

    Community care? buy cheap generic cialis. Our Editor’s Choice this month explores a novel approach to care delivery, the Physician Response Unit (PRU), which aims to reduce ED attendances by finding a community solution to the emergency complaint. Joy and colleagues’ retrospective analysis of 12 months of data from this service, which is based in buy cheap generic cialis London, demonstrated that of nearly 2000 patients attended to, 67% remained in the community. The authors conclude that this model of care is a successful demonstration of integration and collaboration that also reduced ambulance conveyances and ED attendances. These results are promising, however, as the excellent commentary by Professor Sue Mason identifies, some unanswered questions remain.

    Whether these results can buy cheap generic cialis be generalised across the wider NHS, beyond the unique confines of the capital, and in light of starkly heterogenous healthcare systems and workforces remains unknown.Moving closer to the front doorPhysician in Triage (PIT) remains a controversial topic in EM. In an interesting analysis of PIT from Israel, Schwarzfuchs and colleagues present an uncontrolled before-after analysis of the impacts of this triage strategy on a single time-critical condition, STEMI. At the EMJ, we usually buy cheap generic cialis discourage this type of study. However, here, the authors demonstrate how, with the inclusion of an appropriate logistic regression to consider confounders, this methodology may be an appropriate way to evaluate such interventions which may be difficult to do within a randomised controlled trial. €œMinutes mean myocardium” and as such the reduction in door-to-balloon time of 9 min when a senior physician was present, demonstrated here, may lend further support to the implementation of PIT.

    This is certainly a rich area for quality improvement work evaluating such targeted interventions for our patients.All about the Bayes’We welcome an observational analysis from Hautz and colleagues that seeks to explain the patient, physician and contextual factors associated with diagnostic test buy cheap generic cialis ordering. Baye’s theorem describes the probability of an event based on the prior knowledge conditions that may relate to that event. A key concept we should all adopt in test ordering. However, this manuscript goes further in exploring buy cheap generic cialis that prior knowledge by evaluating physician experience, patient and situational context. Rather surprisingly, in this single centre analysis of 473 patients and 38 physicians, these factors seem to have a limited impact on test ordering.

    Rather, it seems that, uncertainty around the patient’s condition (high acuity) and case difficulty seem to influence test ordering buy cheap generic cialis more. So, uncertain pre-test probability equates to higher degrees of diagnostic test ordering. The Reverend Bayes would be turning in his grave.WellnessNow, unlike ever before, it is important to establish the need for physical and psychological recuperation among our staff. The first manuscript within our Wellness section, from buy cheap generic cialis Graham and colleagues (this months Reader’s Choice) evaluates the Need For Recovery (NFR) Score in 168 emergency workers at a single site. The high NFR in this population provides a quantifiable insight into our high work intensity but further validation is required beyond a single site.

    Over to you TERN….While knowing the extent of the problem is of great importance, what we do about it is perhaps a greater challenge. We would therefore encourage our readers to take home some of the top tips included in our expert practice review this month, Top Ten Evidence-Based Countermeasures for Night Shift Workers by Wallace and Haber.There’s a bug going around…We have had a record number of submissions during the COVID-19 buy cheap generic cialis pandemic and the extent to which the EM community has pulled together to inform clinical practice at this time has been breath taking. We are sorry we cannot accept all your excellent work. It is a pleasure to publish a number of Reports from the Front on this topic ranging from patient level interventions such as proning, to invaluable buy cheap generic cialis lessons from systems wide responses to the pandemic. However, the importance of evidence-based medicine has never been higher and this is discussed in our excellent Concepts paper by some very eminent EM Professors.Introducing SONO case seriesLastly, this month sees the first in a series of SONO cases published in the EMJ.

    This will be a regular feature and is a case-based approach to demonstrate how ED Ultrasound can influence and improve patient care.As demand for healthcare in the UK rises, the challenges become those of trying to meet this demand in a patient-centred way whilst managing changes in the delivery of healthcare to enhance the effectiveness and efficiency of services. This requires an buy cheap generic cialis increased level of understanding and cooperation between different healthcare professionals, provider organisations and patients. The changes mean reconsidering traditional roles and where appropriate, redefining professional roles, areas of responsibility and team structures, and renegotiating the boundaries between acute and community care. Government policy has emphasised the need for the NHS to provide increased patient choice, ease of access and delivery of a high-quality service. This is relevant to providers of emergency care services which need to buy cheap generic cialis develop new ways of meeting patient needs closer to home and work environments.

    In emergency care, ambulance services have had to consider new types of responses to those usually provided. Policy initiatives have meant local NHS organisations assuming responsibility for managing and monitoring how local services respond to urgent buy cheap generic cialis and non-urgent 999 ambulance calls. Alongside this, the NHS Long Term Plan emphasises the importance of integrating care through a more joined-up multidisciplinary approach that spans boundaries between primary and secondary care but aims to keep patients out of hospital.At the same time, we are facing workforce crisis across the NHS. This is especially the case in emergency medicine. Failure to buy cheap generic cialis seek new opportunities to develop the workforce will only lead to further attrition.

    The challenge is how to do this in a sustainable, cost-effective and generalisable manner that leads to clear benefits for the workforce, services and patients. Currently, the emphasis is on the deployment of non-medical practitioner roles in EDs and ambulance services, such as ….

  • How long does cialis take to kick in

    Où rencontrer Pasteur dans Dole

    A la façon du Circuit du Chat Perché qui permet de découvrir les sites les plus attractifs de Dole, Alain Marchal nous propose de déambuler dans certains lieux publics dolois...pour admirer statues, fresques trompe-l’œil, mosaïques ou bustes à l'effigie...

    > LIRE LA SUITE

  • How long does cialis take to kick in

    Où rencontrer Pasteur dans Dole

    A la façon du Circuit du Chat Perché qui permet de découvrir les sites les plus attractifs de Dole, Alain Marchal nous propose de déambuler dans certains lieux publics dolois...pour admirer statues, fresques trompe-l’œil, mosaïques ou bustes à l'effigie...

    > LIRE LA SUITE

  • How long does cialis take to kick in

    Visite passion

    Pendant les vacances , venez faire la connaissance de Louis PASTEUR, visitez sa maison natale à Dole et la salle scientifique exposant les découvertes de notre grand savant Jurassien.
    Les bénévoles des Amis de PASTEUR vous proposent une "visite passion...

    > LIRE LA SUITE

  • How long does cialis take to kick in

    Visite passion

    Pendant les vacances , venez faire la connaissance de Louis PASTEUR, visitez sa maison natale à Dole et la salle scientifique exposant les découvertes de notre grand savant Jurassien.
    Les bénévoles des Amis de PASTEUR vous proposent une "visite passion...

    > LIRE LA SUITE

  • How long does cialis take to kick in

    Louis Pasteur et le ver à soie :


    Une exposition présentera à la Maison natale des aspects actuels de l'utilisation de la soie, dans les domaines industriels et techniques, dans la création artistique, avec un clin d'oeil aux travaux de Pasteur sur les maladies des vers à soie en...

    > LIRE LA SUITE

  • How long does cialis take to kick in

    Visite passion

    Pendant les vacances , venez faire la connaissance de Louis PASTEUR, visitez sa maison natale à Dole et la salle scientifique exposant les découvertes de notre grand savant Jurassien.
    Les bénévoles des Amis de PASTEUR vous proposent une "visite passion...

    > LIRE LA SUITE