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IntroductionApproximately 2%–4% of pregnancies present with major fetal anomalies, which can be isolated or occur with other anomalies and can range in severity from mild to severe.1 Fetal uasound is the standard-of-care for identification of structural congenital anomalies and, in Canada, is typically conducted at 18–22 weeks gestation, although some centres may offer earlier scans.2 The characterisation of anomalies, and providing the option of appropriate diagnostic investigations, is a mainstay of prenatal genetics, with the purpose of understanding the aetiology and guiding ventolin evohaler uses pregnancy and neonatal management.For over 30 years, the buy ventolin over the counter uk standard diagnostic investigations for fetal anomalies have included conventional prenatal cytogenetic analysis via karyotyping. Rapid aneuploidy detection for the identification of specific common fetal aneuploidies (trisomy 13, 18 and 21, sex chromosome aneuploidy and triploidy) has replaced karyotyping in many centres in Canada and, when normal, is followed by chromosomal microarray analysis to improve resolution and detect both microscopic and submicroscopic pathogenic CNVs.3 Chromosomal microarray analysis accounts for an increased diagnostic yield dependent on the anomalies, and ranges from approximately 3%–6% in fetuses with an isolated anomaly to greater buy ventolin over the counter uk than 10% when multiple anomalies or other fetal findings are present (eg, intrauterine growth restriction, oligohydramnios/anhydramnios).4 5These diagnostic investigations can identify a number of genetic variations including aneuploidy, CNV (with specific size guidelines for reporting) and areas of loss of heterozygosity, but are unable to detect pathogenic single nucleotide variants and small insertions/deletions, which are major causes of monogenic diseases. Historically, testing for these has been done via single-gene testing. However, as the understanding of genetic heterogeneity for different disorders has increased and technical methods have improved, prenatal testing has expanded to include next-generation sequencing (NGS) methodologies such as multigene panels buy ventolin over the counter uk.

Access to and use of multigene panels prenatally vary by province. These panels may have limitations buy ventolin over the counter uk. For example, they can be difficult to update and therefore slow to incorporate newly discovered genes or genes associated with ua-rare conditions, or may not be well targeted to emerging fetal phenotypes. Moreover, fetal findings may warrant testing using more than one panel, buy ventolin over the counter uk which can be prohibitively expensive and time-consuming if pursued sequentially.

Given these limitations, there is interest in pursuing less targeted genome-wide sequencing (GWS) approaches in the prenatal context.Postnatally, GWS is widely applied for the diagnostic assessment of suspected monogenic diseases. Over 9000 patients have now been buy ventolin over the counter uk reported in the scientific literature. A recent meta-analysis found a pooled diagnostic yield of 41% for whole genome sequencing and 36% for exome sequencing (ES),6 and hundreds of thousands of additional patients have now been sequenced in clinical diagnostic laboratories. Given its success buy ventolin over the counter uk in the postnatal context, it is reasonable to presume this test would result in an increased diagnostic yield in the prenatal context.

Studies are emerging showing diagnostic utility for fetal ES in the context of highly select prenatal indications, and, as a result, clinical ES for fetal anomalies is buy ventolin over the counter uk increasingly being sought. Determining the optimal diagnostic testing options for a fetus with anomalies and the scenarios under which the testing should be considered has therefore become important.At the time of writing, fetal GWS is not widely available in Canada nor funded by all provinces, currently limiting its use. This document addresses the buy ventolin over the counter uk clinical use of GWS for fetuses during pregnancy in Canada and aims to provide anticipatory guidance for the implementation of fetal GWS as it becomes available in each province. While the document was developed to guide practice in Canada, the applicability of this statement is not confined to Canadian borders and may be of interest to clinicians and health authorities internationally.The Canadian College of Medical Geneticists (CCMG) is a national professional organisation that ensures adherence to high standards in the delivery of medical genetics services in Canada, including standards for the training, competence and behaviour of those delivering these services.

This position statement buy ventolin over the counter uk provides recommendations for fetal GWS during pregnancy for those providing prenatal genetic services in Canada. The statement was developed by a multidisciplinary working group representing the CCMG clinical and laboratory disciplines as well as the practices of maternal fetal medicine, genetic counselling and bioethics. The group met buy ventolin over the counter uk by teleconference on several occasions to draft this position statement. It was circulated to the CCMG membership on 7 December 2020 for comment by the membership and approved by the CCMG Board of Directors on 19 February 2021.ConsiderationsDiagnostic yield of fetal GWS during pregnancyIn comparison with the postnatal literature, there is a relative paucity of scientific literature regarding the application of GWS technologies in pregnancy.

A recent scoping review found that the diagnostic buy ventolin over the counter uk yield varied dramatically between studies.8 This was attributed to significant differences in study design, particularly criteria for inclusion (eg, specific fetal findings or anomalies), timing of testing and methods for analysis.8 Most studies are retrospective case series of highly selected and small numbers (typically <50) of fetuses with diverse indications for testing (eg, stillbirths, fetuses from terminated pregnancies and other highly selected cases based on anomalies present), which make them difficult to compare and generalise with regard to the diagnostic utility of this testing.Two large prospective studies using a trio ES approach have been published that recruited singleton pregnancies with structural anomalies, including increased nuchal translucency, identified on prenatal uasound.9 10 In Lord et al,9 genetic diagnoses were identified in 8.5% (52 of 610) of fetuses, and in Petrovski et al10 genetic diagnoses were identified in 10% (24 of 234). Both studies showed that ES for isolated anomalies has a lower yield compared with those with multisystem anomalies, with approximately 6% yield for isolated anomalies and 15% and 19% yields for multisystem anomalies.When considering specific isolated anomalies, ascertaining detailed information on diagnostic yields is challenging. When reported, the results are based on a small number of fetuses in each single anomaly category and it is not possible to combine the buy ventolin over the counter uk data across different studies given differences in study design. The two large prospective studies mentioned above9 10 reported higher diagnostic yields for some anomalies.

However, there was variation even between buy ventolin over the counter uk these two studies. Evidence focused on buy ventolin over the counter uk specific indications is continuing to emerge. In a recent relatively large study, Sparks et al11 identified a genetic aetiology in 29% of fetuses with non-immune fetal hydrops (NIFH), revealing a high diagnostic rate for this particular presentation. Ultimately these papers provide buy ventolin over the counter uk initial work that alludes to the potential utility of ES for certain isolated anomalies.

Thus, despite there being limited evidence at the time of this statement to support the use of GWS for any specific isolated fetal anomaly (beyond NIFH), we have delineated a set of guiding principles for the use of fetal GWS that can be applied when additional evidence becomes available.Balancing diagnostic yield with personal and clinical utilityIn addition to assessing the likelihood of finding a diagnosis using GWS (eg, the diagnostic yield for a given indication), clinicians must also consider the test in the context of its potential personal and clinical utility for their patient. Personal utility in genetics has been used to refer to the utility beyond health management, such as allowing the patient to prepare psychologically for the future buy ventolin over the counter uk and facilitating reproductive planning.12 In contrast, clinical utility is defined as ‘leading to an improved health outcome, including diagnosis, treatment, management, or disease prevention, that will benefit a patient or his/her family members’.13 In the prenatal context, this includes options for ongoing fetal and maternal surveillance, implications for the delivery, and postnatal management of the neonate. The application of usual definitions of utility is complicated in the prenatal context by limited treatment options during pregnancy. However, providing buy ventolin over the counter uk a diagnosis helps patients make informed decisions regarding the option of pregnancy interruption.

Utility in each case is also influenced by the gestational age and timing of results.Thus far, there is very little evidence regarding personal and clinical utility following prenatal GWS. Regardless, the Working Group strongly believes that both buy ventolin over the counter uk of these concepts should be considered while making national recommendations. We are of the opinion that it will be a balance between the diagnostic yield and personal and clinical utility (ie, the usefulness of a diagnosis in informing prognosis and guiding management for the specific patient and care team) that will be the most useful approach for determining appropriate application of GWS as a diagnostic test during pregnancy. Consider the scenario in which fetal imaging reveals multiple severe buy ventolin over the counter uk fetal anomalies—in such a scenario, despite a higher expected diagnostic yield, GWS may actually have less additional prognostic value, because in cases of severe anomalies the fetal outcome can often be predicted to be poor without additional information.

Patients may thus be able to make decisions buy ventolin over the counter uk (eg, interruption of pregnancy or plans for postnatal management) independent of a genetic diagnosis. In such cases, there may be harm related to the anxiety from postponing decision-making until the GWS results are available, as well as the uncertainty based on unclear results, the risk of false reassurance with a negative result and the possibility of identifying incidental findings. In contrast, identification of a genetic diagnosis in a fetus with an apparently isolated fetal anomaly, although with a lower diagnostic yield, has the potential to significantly inform the prognosis and thus could significantly buy ventolin over the counter uk impact the management of that pregnancy.Pretest counselling using a patient-centred approach can help patients understand what to expect and decide if testing, when clinically appropriate, would have utility for them. In any deferred testing scenario, postnatal GWS should remain available after interruption of pregnancy or at birth when more phenotypic information is available.Challenges in the application of clinical GWS during pregnancyThere are a number of challenges associated with the use of GWS in the prenatal context that should be considered, including complexities associated with clinical phenotyping, technical considerations, timing considerations and interpretation of the results.Perhaps the most significant challenge is that of adequate and accurate phenotyping.

Deep phenotyping is limited to prenatal structural findings, which can be limited due buy ventolin over the counter uk to gestational age, general imaging limitations and the fact that key diagnostic features may not be a structural finding. In addition, some phenotypic features of a disorder may not yet have developed, and what has developed may appear different from our common, postnatally biased, understanding of the condition. The full prenatal phenotypic spectrum of many diseases is not yet known.Technical aspects and issues with timeline introduce further complexities, as with buy ventolin over the counter uk all prenatal genetic testing. Invasive prenatal procedures (eg, chorionic villus sampling or amniocentesis) are needed to obtain fetal DNA samples for testing.

Cell culture may be required, which adds buy ventolin over the counter uk to the turnaround time (TAT) of the test. Precautions must be taken to ensure the DNA tested reflects the affected fetal DNA, including maternal cell contamination studies and testing in multifetal pregnancies. Furthermore, in many cases, single-gene tests or multigene buy ventolin over the counter uk panels may still be more appropriate than GWS. Advantages to more targeted testing include factors such as depth of coverage, decreased need for a trio approach, gene-specific reporting expertise, decreased chance of incidental findings and potentially faster TAT, among others.Timing considerations such as its integration with other genetic tests and the TAT of these tests need to be considered.

Once the decision is made to pursue fetal GWS, ‘rapid’ or ‘expedited’ results are often sought buy ventolin over the counter uk to guide pregnancy management and prolonged TATs for GWS may limit available options.14 At the current time, clinical GWS testing is available in some laboratories with a rapid TAT, but is usually more costly both in terms of financial and laboratory resources than standard TATs. This is an important consideration in the context of a single payer system like Canada’s, particularly given the limited evidence regarding the personal and clinical utility of the test.GWS introduces buy ventolin over the counter uk the potential to report a complex variety of results including pathogenic, likely pathogenic and variants of uncertain significance (VUS) possibly related to the primary indication for testing, as well as secondary and incidental findings. Some of these findings may be difficult to interpret in the context of an ongoing pregnancy and may further exacerbate an already stressful, pressured and time-sensitive situation. For example, VUS are harder to investigate in a prenatal context than postnatally, as buy ventolin over the counter uk secondary sources of information may not be available.

In addition, VUS do not provide sufficient information on which to base clinical decisions and may add anxiety and confusion, with little benefit to the patient. At the time of writing this position statement, there is little, if any, evidence regarding the benefits and harms of identifying secondary and incidental findings in a fetus.The Canadian contextCanada’s publicly buy ventolin over the counter uk funded healthcare system is guided by the Canada Health Act and provides universal coverage for medically necessary healthcare services, although each provincial and territorial healthcare system decides how best to define specific funding parameters for their jurisdiction. In addition, physicians practising within each province must balance their obligations to the individual patient with the utilisation of finite resources when considering diagnostic testing options. Interruption of pregnancy is included in these services with no legal definition regarding gestational age limitations, although there buy ventolin over the counter uk are significant and variable non-legal barriers to access between provinces.14 The recommendations herein provide a basis for standard practice for the use of clinical GWS during pregnancy in Canada.IntroductionMutations of the transforming growth factor-beta (TGF-β) signalling pathway have been shown to play a critical role in the aetiology of several connective tissue disorders including Loeys-Dietz syndrome (LDS) and Sphrintzen-Goldberg syndrome (SGS).

LDS (types 1–5, MIM# 609192, 610168, 613795, 614816, 615582) is a rare autosomal dominant connective tissue disorder with multisystemic involvement, resulting from heterozygous mutations in the TGF-β signalling pathway.1 Originally, LDS was misdiagnosed as Marfan syndrome (FBN1) due to similar vascular features, including aortic root aneurysms. However, patients with LDS have more severe cardiac symptoms, with dissections occurring at younger ages and at smaller diameters throughout the arterial tree, as well as craniofacial abnormalities that have not been thoroughly described.Five LDS-causing mutations have been identified along the TGF-β pathway including the genes encoding TGF-β receptor 1 (TGFBR1) and TGF-β receptor 2 (TGFBR2), mothers against decapentaplegic homologue 3 (SMAD3), TGF-β ligand 2 (TGFB2) and TGF-β ligand 3 (TGFB3), considered LDS types 1–5, respectively.2 Mutations in the gene encoding the SKI proto-oncogene (SKI), also involved in TGF-β signalling through the inhibition of SMADs, have been associated with SGS, a condition with less severe buy ventolin over the counter uk cardiac defects than LDS but more pronounced craniofacial abnormalities.3–5Phenotypically, LDS was originally characterised by a triad of features. Arterial tortuosity and aneurysms, hypertelorism, and bifid uvula or cleft palate.6 In the decade since its discovery, intense research has been performed on patients and mouse models to better understand the striking variable phenotype of LDS, particularly visible in the craniofacial region. However, not all patients with LDS possess the craniofacial features of the original triad.7 8 Additional craniofacial features reported include craniosynostosis, facial asymmetry, blepharoptosis, retrognathia, malar hypoplasia, dolichocephaly, blue sclerae and strabismus.9–12 Previous papers reported that patients with LDS type 2 have mild craniofacial involvement, while patients with LDS type 1 have more significant craniofacial involvement.6 13 However, buy ventolin over the counter uk the assignment of disease type at the time was based on clinical findings, not molecular diagnosis.Despite the prevalence of craniofacial features in patients with LDS and the high phenotypic variability, no study has focused on the disparate craniofacial anomalies and the correlation of genotype to the craniofacial phenotype of the different LDS types, and none has done so quantitatively.

The goal of buy ventolin over the counter uk this study is to provide a comprehensive phenotypic characterisation of the craniofacial anomalies of LDS and SGS and explore the variability within and across the different subtypes. This is achieved through deep clinical phenotyping, three-dimensional (3D) facial surface analysis, cephalometric and multivariate geometric morphometric analyses of one of the largest LDS cohorts. Through this comprehensive and quantitative approach, we elucidate the impact of TGF-β pathway mutations on craniofacial development in these two rare disorders.ResultsClinical phenotyping, N=44A total of 44 patients, buy ventolin over the counter uk 40 with LDS and 4 with SGS, were enrolled. Among the 40 patients with LDS, 15 had mutations in TGFBR1 (LDS1), 14 had mutations in TGFBR2 (LDS2), 3 had mutations in SMAD3 (LDS3), 7 had mutations in TGFB2 (LDS4) and 1 had a mutation in TGFB3 (LDS5).

Mean age buy ventolin over the counter uk was 17.2 years (2.4–57.4 years). 22 were female, 22 were male (table 2). Additional information regarding the genetic mutations of the subjects included in buy ventolin over the counter uk this cohort can be found in online supplemental table 2. We also explored the possibility of specific genotype–phenotype correlations using the known genetic variants, with negative results.View this table:Table 2 DemographicsFacial shape was highly variable.

Craniosynostosis was reported in 10 cases (22.7%), with the sagittal and buy ventolin over the counter uk metopic sutures affected evenly. Eight patients had clinically significant overall facial asymmetry (18.2%). However, there were specific regions with buy ventolin over the counter uk asymmetry. 43.2% with vertical eye dystopia, 20.5% with deviation of nasal tip, 18.2% with lip asymmetry.

Mandibular hypoplasia or retrognathism (84.1%) and midface and/or infraorbital flatness (84.1%) were the buy ventolin over the counter uk most prevalent characteristics. A tall and broad forehead (54.5%) was common (table 1, figure buy ventolin over the counter uk 1).Clinical views of patients with LDS (subtypes 1–5) and SGS. This photo gallery illustrates the highly variable clinical craniofacial phenotype in TGF-β-opathies. LDS, Loeys-Dietz syndrome buy ventolin over the counter uk.

SGS, Shprintzen-Goldberg syndrome. TGF-β, transforming buy ventolin over the counter uk growth factor-beta." data-icon-position data-hide-link-title="0">Figure 1 Clinical views of patients with LDS (subtypes 1–5) and SGS. This photo gallery illustrates the highly variable clinical craniofacial phenotype in TGF-β-opathies. LDS, Loeys-Dietz buy ventolin over the counter uk syndrome.

SGS, Shprintzen-Goldberg syndrome. TGF-β, transforming buy ventolin over the counter uk growth factor-beta.The eye shape and position demonstrated downslanting palpebral fissures or other abnormal eye shape (72.7%), blepharoptosis (65.9%), increased scleral show (61.4%), hypertelorism (40.9%) and telecanthus (27.3%). Nasal anomalies included bulbous nasal tip and/or slit-nares shape (65.9%). Lip anomalies included thin buy ventolin over the counter uk upper lip vermillion or indistinct phium (63.6%).

Ear shape was not affected, but the position of the ears buy ventolin over the counter uk was low set (72.7%). The presence of a submucous cleft palate was confirmed in only two cases, while bifid uvula was more common (38.6%). There was buy ventolin over the counter uk no cleft lip or palate. A nasal dorsal vein was characteristic in 38.6%, as well as velvet, translucent skin texture (59.1%).LDS subtype distinctionsSGS and LDS2 had the highest percentage of craniofacial anomalies.

Mandibular retrognathism buy ventolin over the counter uk was the most prevalent among the different subtypes. SGS (100.0%), LDS1 (93.3%), LDS2 (92.9%), LDS3 (66.7%) and LDS4 (57.1%). Midface flatness buy ventolin over the counter uk was also common. LDS2 (85.7%), SGS (75.0%) and LDS1 (73.3%).

LDS2 (71.4%) and LDS1 (40.0%) had palatal deformities buy ventolin over the counter uk (submucosal cleft palate or bifid uvula), while other LDS types did not have submucous cleft or bifid uvula. More patients with LDS2 presented with telecanthus (42.9%) and hypertelorism (50%) compared with the other LDS types. SGS had a very high occurrence (>75%) of almost every craniofacial anomaly, including craniosynostosis (100%), with the exception of submucous cleft palate/bifid uvula (25%) buy ventolin over the counter uk (table 1).Functional abnormalitiesThe total prevalence of TMD was 38.6%, which is relatively high considering the young average age of the cohort. The disorders included arthralgia or pain reported by questionnaire (22.7%), joint sounds (31.8%), deviation of the mandible with opening (6.8%) and limited range of motion (2.3%).

Conductive hearing loss was noted in five patients (11.4%), and subclinical buy ventolin over the counter uk hearing loss in three patients. Importantly, 22.7% were diagnosed with OSA and buy ventolin over the counter uk 38.6% reported snoring. Functional eye abnormalities such as nystagmus and strabismus affected 43.2% and were most notable in LDS2 (table 1).CAI scores (N=44)Based on the average index scores, SGS had the most craniofacial anomalies among the cohort, with a mean score of 18.0 (range 17.0–19.0) followed by LDS2=12.4 (range 4.0–18.0), LDS1=11.3 (range 3.0–20.0), LDS4=8.1 (range 4.0–11.0), LDS3=7 (range 5–8), while the single proband with LDS5 had a score of 5 (table 1).Surgeries of the craniofacial regionFifty-nine per cent of patients had a history of one or more surgeries of the craniofacial region. Among the 10 patients with a buy ventolin over the counter uk diagnosis of craniosynostosis, 6 had a history of surgical repair (SGS=3.

LDS2=2. LDS1=1). Other reported surgical procedures included adenoidectomy (n=9), tonsillectomy (n=7), tympanostomy tube placement (n=8), strabismus correction (n=6), and soft palate or bifid uvula repair (n=5). One patient with SGS required mandibular distraction osteogenesis for congenital micrognathia.

Other isolated procedures include blepharoptosis correction, lingual frenectomy, tympanografts and removal of lip haemangioma. Individuals with LDS1 and LDS2 required the most surgical interventions (online supplemental table 3).3D photo facial surface analysis, N=39The mean age was 17.9 years (range 2.4–57.4 years). 20 female and 20 male subjects. The 3D photos of five young patients (n=4 LDS, n=1 SGS) had to be excluded due to poor quality and lack of cooperation.

The average of right and left measurements was used, since no significant soft tissue asymmetry was detected (figure 2, online supplemental table 4).(A) Heatmap of Z-scores depicting the deviation of the soft tissue measurements in the different LDS subtypes and SGS, based on the normal values provided by FaceBase. The orange shades represent positive values, blue represents negative values. SGS, LDS2 and LDS1 are the subtypes with extreme Z-score values. LDS2, followed by LDS1, have the greatest variability.

Facial depth, eyes and nose projection measurements were uniformly affected across the cohort. The facial depth and nasal projection were the most negatively affected features, while the eye measurements were increased. (B) The 3D mesh view of the face of an individual with LDS2 with the annotated landmarks used for the photo surface analysis. (C) PCA plot of the 3D photo surface landmark coordinate data depicting the variability of the soft tissue morphology among the different LDS subtypes, with the greatest variability in LDS2.

3D, three-dimensional. LDS, Loeys-Dietz syndrome. PCA, principal component analysis. SGS, Sphrintzen-Goldberg syndrome." data-icon-position data-hide-link-title="0">Figure 2 (A) Heatmap of Z-scores depicting the deviation of the soft tissue measurements in the different LDS subtypes and SGS, based on the normal values provided by FaceBase.

The orange shades represent positive values, blue represents negative values. SGS, LDS2 and LDS1 are the subtypes with extreme Z-score values. LDS2, followed by LDS1, have the greatest variability. Facial depth, eyes and nose projection measurements were uniformly affected across the cohort.

The facial depth and nasal projection were the most negatively affected features, while the eye measurements were increased. (B) The 3D mesh view of the face of an individual with LDS2 with the annotated landmarks used for the photo surface analysis. (C) PCA plot of the 3D photo surface landmark coordinate data depicting the variability of the soft tissue morphology among the different LDS subtypes, with the greatest variability in LDS2. 3D, three-dimensional.

LDS, Loeys-Dietz syndrome. PCA, principal component analysis. SGS, Sphrintzen-Goldberg syndrome.The cranial base width (Z=−1.14), midface depth (Z=−1.35) and lower face depth (Z=−1.50) were reduced subclinically in all subgroups except for LDS5. These results indicate a tendency for midface and mandibular hypoplasia.

Moreover, the cohort exhibited subclinical alterations in the vertical plane, including morphological face height (Z=−1.54) and upper face height (Z=−1.09), with the exception of LDS5. Intercanthal distance was subclinically increased (Z=1.16). Nasal dimensions showed an increased subnasal width (Z=1.20), while nasal projection (Z=−1.01) and alar length (Z=−1.38) were subclinically decreased. The dimensions of the lips were not significantly affected.LDS subtype distinctionsSGS subtype demonstrated a more uniform but severe phenotype with a greater percentage of affected craniofacial measurements beyond ±2.0 Z-score compared with the LDS subtypes.

Lower facial projection (Z=−2.79), total facial height (Z=−3.14) and upper facial height (Z=−4.30) were profoundly deficient in SGS, whereas intercanthal distance was significantly increased (Z=3.13). In LDS1 and especially LDS2, there was a characteristic heterogeneity, including patients who had normal Z-scores and others with Z-scores beyond ±2. Therefore, the computed average Z-scores per LDS type were not representative for these two subtypes. In LDS3 and LDS4, there was less variability and no extreme Z-scores.Cephalometric analysis, N=20, LDS onlyCBCT scans were obtained for 20 patients with LDS (10 female.

10 male). Mean age was 26.9 years (9–57 years). No patients with SGS had CBCTs.The mean cranial base angle (nasion–sella–articulare) was 3.00 SD above the norm, indicating a flattened cranial base angle, with the most significant alterations in LDS2 (Z=4.20). Platybasia (defined as a cranial base angle >143°) was detected in four cases among the LDS2 subtype (figure 3A).

There was also significant shortening of the anterior cranial base (sella–nasion, Z=−2.35), with greatest deviation in the LDS1, LDS2 and LDS4. The posterior cranial base (sella–articulare, Z=−1.56) was subclinically affected (figure 3, online supplemental table 5).(A) Average Z-scores for each LDS subtype for each of the 2D cephalometric measurements, compared with normal values for the general population. The growth and position of the cranial base, maxilla and mandible are significantly affected in LDS, especially in LDS1 and LDS2. (B) The 3D craniofacial landmarks used for the cephalometric and geometric morphometric analysis annotated on a 3D view of a skull (C).

PCA plot depicting the variation in the craniofacial shape in LDS. The variability in LDS2 and LDS1 can be appreciated, while all other subtypes are closer to the means of the axes. 2D, two-dimensional. 3D, three-dimensional.

LDS, Loeys-Dietz syndrome. PCA, principal component analysis. SNA, sella–nasion–A point. SNB, sella–nasion–B point." data-icon-position data-hide-link-title="0">Figure 3 (A) Average Z-scores for each LDS subtype for each of the 2D cephalometric measurements, compared with normal values for the general population.

The growth and position of the cranial base, maxilla and mandible are significantly affected in LDS, especially in LDS1 and LDS2. (B) The 3D craniofacial landmarks used for the cephalometric and geometric morphometric analysis annotated on a 3D view of a skull (C). PCA plot depicting the variation in the craniofacial shape in LDS. The variability in LDS2 and LDS1 can be appreciated, while all other subtypes are closer to the means of the axes.

2D, two-dimensional. 3D, three-dimensional. LDS, Loeys-Dietz syndrome. PCA, principal component analysis.

SNA, sella–nasion–A point. SNB, sella–nasion–B point.In the vertical plane, there was reduced anterior facial height (nasion–menton, Z=−2.45) and posterior facial height (sella–gonion, Z=−1.95). The lower face height, ramus height and gonial angle were within normal range.In the sagittal plane, the midface length (condylion–A point, Z=−3.02) was significantly reduced. The overall cohort mean Z-scores for SNA (sella–nasion–A point) and SNB (sella–nasion–B point) were −1.84 and −2.31, respectively, with the most significant deviations in the patients with LDS2 (SNA, Z=−3.31.

SNB, Z=−3.28). Moreover, the mandibular body length was reduced in all LDS subtypes (gonion–pogonion, Z=−2.83), except for LDS5, where it was significantly increased (Z=2.78).Overall, the craniofacial alterations from most severe to least severe were identified in LDS2, LDS1, LDS5, LDS3 and LDS4. The single patient with LDS5 had a broadly different craniofacial pattern than the other types, with normal cranial base and increased growth of the mandible (mandibular body length=2.78. Lower facial height=4.23).We tested for significant differences via ANOVA for each of the cephalometric measures across the three groups.

LDS1, LDS2 and other LDS types. No statistically significant craniofacial cephalometric measures were found among the various LDS subtypes except for SNA, which was significantly smaller in LDS2 (p<0.05 for all comparisons), indicating significant maxillary hypoplasia.Pharyngeal airway assessment and hyoid bone position, N=20, LDS onlyIn 55.0% of the patients, there was reduced PAS. This included all six patients with LDS1, four LDS2, one LDS3 and one patient with LDS4 (online supplemental figure 1). The same patients had significantly reduced minimum CSA.

The vertical position of the hyoid bone, based on the H-MP measurements, was low in 47.6% of the patients, many of whom also had reduced PAS.Multivariate analysis of 3D craniofacial shape. 3D photos and CBCTThe PCA plot of the 3D photo data supported the findings of the cephalometric and 3D photo Z-score analyses and demonstrated the variability in LDS2. On the plot for the soft tissue landmark data (figure 2C), PC1 explained 25.9% of the shape variance while PC2 explained an additional 16.2%, for a total of 42.1% of the facial shape variance across the entire LDS cohort. LDS2 expanded across PC1 and PC2 axes in both directions, whereas the other LDS subtypes cluster closer to the centre of the plot.

In contrast, SGS cluster separately and on the negative aspect of PC1 axis, indicating a clear morphological difference in these patients.According to the PCA on the CBCT data, PC1 explained 25.5% of craniofacial shape variance and PC2 explained an additional 18.6%, for a total of 44.1% of craniofacial shape variance (figure 3C). LDS1 and LDS2 cohorts spanned both the PC1 and PC2 axes, however, LDS2 had more extreme variability. LDS3 and LDS5 were closer to the centre of the plot on the negative PC1 axis, while LDS4 was on the positive PC1 axis.DiscussionThis study is the first to quantitatively examine the craniofacial anomalies associated with two TGF-β-opathies, LDS and SGS, and to correlate the craniofacial phenotype to genotype using a multimodality approach. While the more severe craniofacial abnormalities in LDS have been previously reported, including craniosynostosis, hypertelorism, strabismus and cleft palate, these features were not common in this cohort compared with significant hypoplasia of the maxilla and mandible, abnormal eye shape with increased sclera show and blepharoptosis, abnormal lip shape, low-set ears and skin translucency, with more than 50% of the participants exhibiting these characteristics.

Several of these features also indicate abnormalities of the cranial base.The results of the quantitative cephalometric analysis conducted on CBCT images further revealed the underlying skeletal abnormalities and sources of dysmorphologies not readily identified with the clinical or surface analysis. Multiple angular measurements associated with the cranial base were significantly altered. The mean cranial base angle was over 3 SDs above the norm and four cases of platybasia were detected in LDS2. The length of the anterior cranial base was reduced.

A more inferior location of the sella turcica contributed to an alteration in the inclination of the anterior cranial base, which resulted in an increased cranial base angle, increased SN-FH (Frankfort Horizontal plane) angle, and the extremely low SNA and SNB angles. The changes of the cranial base clearly impacted the development of the maxilla and mandible.According to the clinical, cephalometric and 3D surface morphometric assessment, significant retrognathia of the mandible and maxilla was observed throughout the cohort. The cephalometric analysis confirmed that the retrognathia is not only due to positional changes of the cranial base but to the absolute underdevelopment of the maxilla and mandible. Vertically, there was a reduction in both anterior and posterior facial heights, but the cephalometric data suggest the cranial base and upper facial skeleton are the source of underdevelopment, as the ramus height and gonial angle were within the normal range.Less clear are the underlying skeletal and developmental abnormalities contributing to the clefting of the uvula, although our data suggest a wider maxilla in the transverse plane in patients with LDS2 compared with the other types.

Given the small sample size, we could not apply multiple testing corrections.Using geometric morphometric analysis of overall facial shape, PCA analysis of both the CBCTs and 3D photos shows increased variability in LDS2, followed by variability in LDS4, with SGS clustering at the negative extreme of PC2. LDS1, LDS3 and LDS5 tend to cluster closer to the intersection of PC1 and PC2, suggesting these patients represent more of a mean LDS phenotype in terms of skeletal and facial shape. Although the sample size is small for the dimensionality of this multivariate geometric morphometric analysis, we are confident about the validity of these results given the consistent pattern of affected traits through clinical phenotyping and cephalometric analysis. In addition to LDS2 displaying the greatest phenotypic variability, the more severe abnormalities were identified in LDS2 and SGS, as confirmed by the craniofacial anomalies’ indices.

This suggests unique craniofacial developmental perturbations that are specific to TGFBR2 and SKI mutation variants.The value of the 3D photos and surface analysis is rapid capture of information and the ability to digitally acquire anthropometric measurements. This is particularly valuable for assessing young and less cooperative patients while gathering quantifiable data. Additionally, we were able to detect subtle clinical feature variations, such as a relatively increased intercanthal distance, an increased nasal width, and decreased nasal projection and height, throughout the cohort. One of the limitations of this analysis is the limited normative values from FaceBase.

Some normative data are based on very small groups with as little as six subjects, and some of the SD values are as low as 1.0, which can lead to relatively increased Z-scores. In addition, there are no published 3D facial norms for individuals of non-European descent. These factors could potentially influence the validity of the generated Z-scores.An important finding was the prevalence of TMD. This may be attributed to structural craniofacial abnormalities, such as the high percentage and severity of mandibular retrognathism, the underlying connective tissue disorder or a combination of the two factors.

Some morphological changes were detected through qualitative CBCT assessment, but a more specialised analysis is required for further assessment that exceeds the scope of this paper. Interestingly, TMD has also been linked to a lower oral health-related quality of life in patients with LDS.15 An animal model may assist in understanding the TMD aetiology and development in LDS.Our analysis revealed a tendency for the development of sleep-related breathing disorders. OSA in LDS, to our knowledge, has only been described in one case report of a patient with LDS2.24 Apart from the 10 subjects who had a diagnosis of OSA, a larger number reported snoring (n=17) and history of adenoidectomy (n=9). Moreover, the quantitative analysis of CBCTs demonstrated a reduction in posterior airway space, low position of the hyoid, and a retrognathic mandible and maxilla, all of which are known contributors or risks for OSA.25–31 Considering the effect of OSA on cardiovascular events and hypertension,32 it is extremely important to consider sleep apnoea studies and assessment of craniofacial abnormalities in these patients.One of the limits of this study and all studies of rare diseases is the small cohort and sample size.

Additionally, we could not safely obtain CBCT images for all individuals due to the young age and radiation risks. Despite this, we have optimised the research potential by the deep clinical phenotyping and use of multimodality imaging analysis. Previous studies on craniofacial dysmorphology have relied on ‘gestalt’ and limited clinical assessment. And while ‘gestalt’ is helpful for obvious features and diseases with homogeneous characteristics, it is less useful when there is significant phenotypic variation within a cohort.

Unfortunately, such assessments do not provide methods to link the craniofacial developmental aberrations to the underlying mutations, even when the genotype is established. The strength of this study is the multimodality morphometrics, particularly the skeletal imaging, which provides an objective, quantitative phenotypic characterisation and demonstrates the segregation of craniofacial development to the mutations along the TGF-β pathway. Clearly, the mutations associated with the TGFBR2 and SKI genes have a profound effect on craniofacial development with perturbations associated with the cranium and cranial base with severe downstream effects on the orbit, maxilla and mandible. Additionally, the highest variability noted in LDS2 suggests epigenetic, non-canonical or distant enhancers of the TGFBR2 gene mutation that may induce the variable phenotypic spectrum.

We continue to examine these variations in the mouse models of TGF-β pathway mutations, however, the opportunity to deeply phenotype and understand the variation in human subjects is invaluable.In summary, as precision medicine becomes more possible, the detailed data provided by the present study will be added to the growing literature and will assist clinicians in the future in predicting the clinical anomalies per genetic variant. In addition, we address for the first time the higher prevalence of TMD and relatively increased risk of OSA in the case of LDS, particularly in the LDS1 and LDS2 subtypes, and encourage clinicians to include more detailed assessments regarding these conditions as part of the physical evaluation of these patients..

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The Surgical websites Center at Columbia Orthopaedic Group in Missouri, like so many ambulatory surgery centers across the country, do procedures today that are far more complex than ventolin tablet those it did five years ago.THE PROBLEM"In the past, we haven't worried as much about coordinating care across the patient journey, from preoperative education to surgical aftercare," said Andrew Lovewell, administrator. "But as the sheer complexity of our procedures increased, we wanted our patients to have remote access to instructional videos and better connectivity with their care teams."We didn't want to complete surgeries in a transactional way, without any intimacy or continued communication with the patient to ensure they were experiencing excellent results," he added.As one of the top surgery centers in the nation per Newsweek for both 2021 and 2022, The Surgical Center at Columbia Orthopaedic Group felt it was representative of its quality and reputation to create a ventolin tablet system that improved the care it offered patients."During the early stages of the ventolin, we had many patients that were afraid of going to physical therapy, and several facilities were shut down for extended periods," Lovewell recalled. "We knew we needed to create an environment of safety while still retaining control over our patients' recovery journey."We wanted to gain insights into how patients were recovering at home, see feedback on their progress and outcomes, and enrich the patient experience from start to finish," he said.PROPOSALTo help meet this goal, the ambulatory surgery center contracted with health IT vendor Force Therapeutics, which offers a digital care management platform that leverages clinical data and custom protocols to educate patients and monitor their progress throughout an episode of care."The platform uses clinical care paths, adaptive education, personalized goal setting and virtual physical therapy to drive a smooth and efficient recuperation," Lovewell explained. "The platform also captures patient input and makes real-time adjustments to care paths as necessary, such as changing the type of exercise video presented based on patient feedback regarding ventolin tablet the difficulty level of the last video."The platform was designed to supplement our standard pain-scale reporting with questions about recent levels of activity, or how well the patient is following their medication regimen," he continued.

"Depending on the answers, a patient might then be advised on how to rest following activity, or how to alternate anti-inflammatory medications for better pain relief."The platform alerts the patient's care team when needed, prompting clinicians to check in with the patient about mobility issues, pain management or other concerns."Despite a common misconception that remote care management platforms replace direct care from providers, the platform is intended to complement the treatment course and reflect providers' messaging," ventolin tablet Lovewell said. "It helps to strengthen the patient/physician relationship, as all content and care protocols are prescribed and shaped by the patient's physicians."Instead of randomly searching online for medical information about their surgery, patients can trust the Force platform, as they know this information is clinically validated and approved by their surgeon," he continued. "Patients also can message their care teams through the platform to confirm ventolin tablet information or clarify a postoperative symptom they're experiencing."MARKETPLACEThere are many vendors of telemedicine technology and services on the health IT market today. Healthcare IT News published a ventolin tablet special report highlighting many of these vendors with detailed descriptions of their products.

To read the special report, click here.MEETING THE CHALLENGEAbout two years ago, The Surgical Center at Columbia Orthopaedic Group launched the Force Therapeutics care management platform to connect patients to their care teams throughout their recovery process. Today, 22 of 27 of the center's surgeons are on the platform, including all sports medicine, spine and total joint surgeons."As soon as the patient is scheduled for surgery, they receive a notification via text or email to sign up for the platform, which is integrated with our homegrown scheduling system," Lovewell ventolin tablet said. "Before their surgery, patients log into the platform to learn how they can prepare themselves and their homes for a good recovery."The platform helps patients really remember and internalize instructions, because it offers short, digestible videos at the best time in the process, which is right before the patient needs to know that particular piece of information," he continued.The platform also is integrated with the center's documentation software, Emme, ventolin tablet which it uses in the postoperative stay suite at its lodge."After patients are discharged, they typically become a guest at our lodge for one night before they return home," Lovewell explained. "Demographic data is imported from Emme into the Force platform to inform care path personalization."Once they're home, patients log into the platform throughout their recovery to complete their physical therapy videos and get individualized tips for dealing with mobility issues and any pain they might have," he added."Now, our surgeons will respond to all their patient messages while they're on call, as opposed to the patients needing to come to the ER or urgent care to be seen by an entirely different care team."Andrew Lovewell, The Surgical Center at Columbia Orthopaedic GroupForce Therapeutics developed all of the content the center uses in the patient care paths, but the center spent some time refining its own custom protocols so it could track the data it wanted and get the specific alerts it needed to improve outcomes."We started with just five total joint surgeons on the platform, which helped us figure out the cadence of how the videos should be rolled out to patients," Lovewell said.

"We incorporated patient feedback to adjust and tweak our protocols, and then we ventolin tablet arrived at a product that is delivering really great results."Our surgeons use the platform's data on a daily basis," he added. "We produce monthly internal reports that compare each surgeon's key performance indicators to their colleagues' KPIs, and Force data is included in ventolin tablet that report. For example, surgeons might notice their care team takes longer to respond to patient messages than their partner's care team does. Can they change their habits to address ventolin tablet that lag time?.

"Most important, according to Lovewell, the ventolin tablet platform has given the center a way to assess quantitative results in terms of patient outcomes. Rather than just relying on their expertise to evaluate patient outcomes at a postoperative visit, surgeons can track how their patients are doing on several scales and compare that progress to other patients."This also leads to protocol improvements, because as we analyze the data, trends become clear. This particular patient cohort does better with outpatient physical therapy rather than outpatient home health, while this medication prevents more postoperative ventolin tablet swelling than alternative medications, especially when given at a specific interval," he explained. "We've developed a great cycle of continuous improvement because of the data ventolin tablet analytics this tool enables."RESULTSIn the areas of productivity and volume, The Surgical Center at Columbia Orthopaedic Group has increased productivity because it's getting more patients to flow through the clinic more efficiently."When we started with Force, we were probably doing about 60 total joint procedures a month, and 20 spine cases," Lovewell recalled.

"Now we're up to 120 joint procedures a month and 40 spine cases. Of course, this can't be attributed entirely to digital care management, but it's a big component."Previously, our ventolin tablet doctors saw patients in the clinic for their preoperative education visit, and explained what the procedure does and what the recovery process would be," he continued. "We also had hired a nurse navigator to gather the patient's pre-operative information and make patient calls ahead of time."Now, with the ventolin for sale online platform, the center can scale business much faster because it has reduced so many manual ventolin tablet intervention points."Instead of our doctors spending hours upon hours in the clinic doing patient counseling, we are much more strategic with their time," he reported. "Our doctors are talking to patients about much more meaningful topics, not simply repeating the same preoperative speech over again.

We've hired more nurse navigators to enable the greater volume."The platform takes on the brunt of ventolin tablet the work for care coordination, and we fill in the gaps," he continued. "If a patient isn't engaging with the platform or watching their physical therapy ventolin tablet videos, we step in to help. As we're addressing such a big percentage of patient concerns through the combo of the Force platform and our nurse navigation program, our doctor offices are not getting bogged down in the back-and-forth of phone tag just to answer a simple patient question."Then there are lower readmission and rates. As an ambulatory surgery center, it has to be very intentional about collecting readmission data ventolin tablet from the regional hospital.

It asks its doctors to self-report on control tracking and readmission tracking, and all patients fill out a survey about 30 days after surgery, which asks about their recovery."The Force platform helps us serve as a first line of ventolin tablet defense when questions arise, so we can divert patients away from urgent care or the ER," he said. "We know from past experience that most of our patients' postoperative concerns are superficial issues – their wound looks red, or there is drainage from the incision site."If a patient messages us through the platform with a concern, we answer the question, point them to the right digital education resource, and follow up with them to ensure they don't have any further concerns," he added.Prior to using the platform, the center's rate for total joint surgeries was already quite low – four s out of 800 surgeries. Since it implemented ventolin tablet the platform, that rate has dropped to one out of 1,800 surgeries."There's been a very stark difference, although it's hard to say with utter certainty the primary cause," Lovewell noted.On another front, there is patient-reported outcomes data. As a high-touch ambulatory surgery center, it already had ventolin tablet very high patient satisfaction scores before it implemented the platform because it concentrated on making the patient experience as seamless as possible, Lovewell said."But we have found that patients love the added sense of connection that the Force platform brings, and we hear these comments in our surveys," he noted.

"They love being able to message their doctors, and they really appreciate saving money on their co-pays and not needing to go to so many outpatient therapy appointments."This enthusiasm for the platform is reflected in our patient-reported outcomes data and collection rates," he continued. "When I first saw these quarterly reports, I didn't believe the numbers could be right, but it's true ventolin tablet. 96% of our patients take the time to complete ventolin tablet a one-year postoperative outcome assessment via the platform. That compliance rate is just off the charts."Having those granular insights and outcome assessments from 96% of patients lets the center understand quantitatively how it is doing."It gives our physicians reassurance and real-time feedback to make changes to their protocols if necessary," Lovewell said.

"Collecting the data also is very important to us from an accreditation standpoint, ventolin tablet and gives us a way to benchmark ourselves with similar groups. Without this key insight, we would be flying blind and assuming that we ventolin tablet are already operating at our highest ability."ADVICE FOR OTHERSWhen The Surgical Center at Columbia Orthopaedic Group first launched the digital care management platform, several doctors were hesitant, especially about the patient messaging functionality. They felt that patients already had the access they needed, and they didn't want a barrage of messages."And now, the messaging function is one of the features that our surgeons like the best," Lovewell reported. "They can message patients directly, and if a patient's message is escalated ventolin tablet to them, they can log in and investigate the patient's outcomes before responding."We've created a direct conduit for our providers to get instant feedback on how the patients are doing via a quantitative method, not just a qualitative one," he said.

"Now, our surgeons will respond to all their patient messages while they're on call, as opposed to the patients needing to come to the ER or urgent care to be seen by an entirely different care team."When a patient can access their care team virtually rather than in person, that's a tremendous time and cost savings for everyone involved – the patient, the provider, the payer and the country's overall health spend, he added."In reality, the best advice I would offer to other healthcare providers considering using a similar technology is to thoroughly assess the technology to make sure it fits ventolin tablet your unique needs," Lovewell said. "Not every practice is the same, and not every solution is the same."There are several platforms that just track outcomes, or just have messaging components built in," he concluded. "We wanted a full-scale solution that ventolin tablet gave us everything in one platform. Being able to message patients, track their progress, and offer a virtual care solution that saves patients time and money is a huge value-add for the patients we serve.".

The Surgical Center at Columbia Orthopaedic Group in Missouri, like so many ambulatory surgery centers across the country, do procedures today that are buy ventolin over the counter uk far more complex than those it did five years ago.THE PROBLEM"In the past, we haven't http://www.raabs-raps.at/impressum-datenschutz/ worried as much about coordinating care across the patient journey, from preoperative education to surgical aftercare," said Andrew Lovewell, administrator. "But as the sheer complexity of our procedures increased, we wanted our patients to have remote access to instructional videos and better connectivity with their care teams."We didn't want to complete surgeries in a transactional way, without any intimacy or continued communication with the patient to ensure they were experiencing excellent results," he added.As one of the top surgery centers in the nation per Newsweek for both 2021 and 2022, The Surgical Center at Columbia Orthopaedic Group felt it was representative of its quality and reputation to create a buy ventolin over the counter uk system that improved the care it offered patients."During the early stages of the ventolin, we had many patients that were afraid of going to physical therapy, and several facilities were shut down for extended periods," Lovewell recalled. "We knew we needed to create an environment of safety while still retaining control over our patients' recovery journey."We wanted to gain insights into how patients were recovering at home, see feedback on their progress and outcomes, and enrich the patient experience from start to finish," he said.PROPOSALTo help meet this goal, the ambulatory surgery center contracted with health IT vendor Force Therapeutics, which offers a digital care management platform that leverages clinical data and custom protocols to educate patients and monitor their progress throughout an episode of care."The platform uses clinical care paths, adaptive education, personalized goal setting and virtual physical therapy to drive a smooth and efficient recuperation," Lovewell explained. "The platform also captures patient input and makes real-time adjustments to care paths as necessary, such as changing the type of exercise video presented based on patient feedback regarding the difficulty level of the last video."The platform was designed to supplement our standard pain-scale reporting with questions about recent levels of activity, or buy ventolin over the counter uk how well the patient is following their medication regimen," he continued. "Depending on the answers, a patient might then be advised on how to rest following activity, or how to alternate anti-inflammatory medications for better pain relief."The platform alerts the patient's care team when needed, prompting clinicians to check in with the patient about mobility issues, pain management or other concerns."Despite a common misconception that remote care management platforms replace direct care from providers, the platform is intended to buy ventolin over the counter uk complement the treatment course and reflect providers' messaging," Lovewell said.

"It helps to strengthen the patient/physician relationship, as all content and care protocols are prescribed and shaped by the patient's physicians."Instead of randomly searching online for medical information about their surgery, patients can trust the Force platform, as they know this information is clinically validated and approved by their surgeon," he continued. "Patients also can message their care buy ventolin over the counter uk teams through the platform to confirm information or clarify a postoperative symptom they're experiencing."MARKETPLACEThere are many vendors of telemedicine technology and services on the health IT market today. Healthcare IT News published a special report highlighting many of these vendors with detailed descriptions of buy ventolin over the counter uk their products. To read the special report, click here.MEETING THE CHALLENGEAbout two years ago, The Surgical Center at Columbia Orthopaedic Group launched the Force Therapeutics care management platform to connect patients to their care teams throughout their recovery process. Today, 22 of 27 of the center's surgeons are on the platform, including all sports medicine, spine and total joint surgeons."As soon as the patient is scheduled for buy ventolin over the counter uk surgery, they receive a notification via text or email to sign up for the platform, which is integrated with our homegrown scheduling system," Lovewell said.

"Before their surgery, patients log into the platform to learn how they can prepare themselves and their homes for a good recovery."The platform helps patients really remember and internalize instructions, because it offers short, digestible videos at buy ventolin over the counter uk the best time in the process, which is right before the patient needs to know that particular piece of information," he continued.The platform also is integrated with the center's documentation software, Emme, which it uses in the postoperative stay suite at its lodge."After patients are discharged, they typically become a guest at our lodge for one night before they return home," Lovewell explained. "Demographic data is imported from Emme into the Force platform to inform care path personalization."Once they're home, patients log into the platform throughout their recovery to complete their physical therapy videos and get individualized tips for dealing with mobility issues and any pain they might have," he added."Now, our surgeons will respond to all their patient messages while they're on call, as opposed to the patients needing to come to the ER or urgent care to be seen by an entirely different care team."Andrew Lovewell, The Surgical Center at Columbia Orthopaedic GroupForce Therapeutics developed all of the content the center uses in the patient care paths, but the center spent some time refining its own custom protocols so it could track the data it wanted and get the specific alerts it needed to improve outcomes."We started with just five total joint surgeons on the platform, which helped us figure out the cadence of how the videos should be rolled out to patients," Lovewell said. "We incorporated patient feedback to adjust and tweak our protocols, and then we arrived at a product that is delivering really great results."Our surgeons use the platform's data on a daily basis," buy ventolin over the counter uk he added. "We produce buy ventolin over the counter uk monthly internal reports that compare each surgeon's key performance indicators to their colleagues' KPIs, and Force data is included in that report. For example, surgeons might notice their care team takes longer to respond to patient messages than their partner's care team does.

Can they buy ventolin over the counter uk change their habits to address that lag time?. "Most important, according to Lovewell, the platform has given the center a way to assess quantitative results in terms buy ventolin over the counter uk of patient outcomes. Rather than just relying on their expertise to evaluate patient outcomes at a postoperative visit, surgeons can track how their patients are doing on several scales and compare that progress to other patients."This also leads to protocol improvements, because as we analyze the data, trends become clear. This particular patient cohort does better with outpatient physical therapy rather than outpatient home buy ventolin over the counter uk health, while this medication prevents more postoperative swelling than alternative medications, especially when given at a specific interval," he explained. "We've developed a great cycle of continuous improvement because of the data analytics this tool enables."RESULTSIn the areas of productivity and volume, The Surgical Center at Columbia Orthopaedic Group has increased productivity because it's getting more patients to flow through the clinic more efficiently."When we started with Force, we were buy ventolin over the counter uk probably doing about 60 total joint procedures a month, and 20 spine cases," Lovewell recalled.

"Now we're up to 120 joint procedures a month and 40 spine cases. Of course, this can't be attributed entirely to digital care management, but it's a big component."Previously, our doctors saw patients in the clinic buy ventolin over the counter uk for their preoperative education visit, and explained what the procedure does and what the recovery process would be," he continued. "We also had hired a nurse navigator to gather the patient's pre-operative information and make patient calls ahead of time."Now, with the platform, the center can scale http://www.ec-cigognes-oberschaeffolsheim.ac-strasbourg.fr/archives/continuite-pedagogique/ce2/semaines-precedentes/semaine-du-18-au-22-mai/ business much faster because it has reduced so many manual intervention points."Instead of our doctors spending hours upon hours in the clinic doing patient counseling, we buy ventolin over the counter uk are much more strategic with their time," he reported. "Our doctors are talking to patients about much more meaningful topics, not simply repeating the same preoperative speech over again. We've hired more nurse navigators to enable the greater buy ventolin over the counter uk volume."The platform takes on the brunt of the work for care coordination, and we fill in the gaps," he continued.

"If a patient isn't buy ventolin over the counter uk engaging with the platform or watching their physical therapy videos, we step in to help. As we're addressing such a big percentage of patient concerns through the combo of the Force platform and our nurse navigation program, our doctor offices are not getting bogged down in the back-and-forth of phone tag just to answer a simple patient question."Then there are lower readmission and rates. As an ambulatory surgery center, it buy ventolin over the counter uk has to be very intentional about collecting readmission data from the regional hospital. It asks its doctors to self-report on control tracking and readmission tracking, and all patients fill out a survey about 30 buy ventolin over the counter uk days after surgery, which asks about their recovery."The Force platform helps us serve as a first line of defense when questions arise, so we can divert patients away from urgent care or the ER," he said. "We know from past experience that most of our patients' postoperative concerns are superficial issues – their wound looks red, or there is drainage from the incision site."If a patient messages us through the platform with a concern, we answer the question, point them to the right digital education resource, and follow up with them to ensure they don't have any further concerns," he added.Prior to using the platform, the center's rate for total joint surgeries was already quite low – four s out of 800 surgeries.

Since it implemented the platform, that rate has dropped to buy ventolin over the counter uk one out of 1,800 surgeries."There's been a very stark difference, although it's hard to say with utter certainty the primary cause," Lovewell noted.On another front, there is patient-reported outcomes data. As a high-touch ambulatory surgery center, it already had very high patient satisfaction scores before it implemented the platform because it concentrated on making the patient experience as seamless as possible, Lovewell said."But buy ventolin over the counter uk we have found that patients love the added sense of connection that the Force platform brings, and we hear these comments in our surveys," he noted. "They love being able to message their doctors, and they really appreciate saving money on their co-pays and not needing to go to so many outpatient therapy appointments."This enthusiasm for the platform is reflected in our patient-reported outcomes data and collection rates," he continued. "When I first saw these quarterly reports, I didn't believe the numbers could be right, but buy ventolin over the counter uk it's true. 96% of our buy ventolin over the counter uk patients take the time to complete a one-year postoperative outcome assessment via the platform.

That compliance rate is just off the charts."Having those granular insights and outcome assessments from 96% of patients lets the center understand quantitatively how it is doing."It gives our physicians reassurance and real-time feedback to make changes to their protocols if necessary," Lovewell said. "Collecting the buy ventolin over the counter uk data also is very important to us from an accreditation standpoint, and gives us a way to benchmark ourselves with similar groups. Without this key insight, we would be flying blind and assuming buy ventolin over the counter uk that we are already operating at our highest ability."ADVICE FOR OTHERSWhen The Surgical Center at Columbia Orthopaedic Group first launched the digital care management platform, several doctors were hesitant, especially about the patient messaging functionality. They felt that patients already had the access they needed, and they didn't want a barrage of messages."And now, the messaging function is one of the features that our surgeons like the best," Lovewell reported. "They can message patients directly, and if a patient's message is escalated to them, they can log in and investigate the patient's outcomes before responding."We've created a direct conduit for our providers to get instant feedback on how the buy ventolin over the counter uk patients are doing via a quantitative method, not just a qualitative one," he said.

"Now, our surgeons will respond to all buy ventolin over the counter uk their patient messages while they're on call, as opposed to the patients needing to come to the ER or urgent care to be seen by an entirely different care team."When a patient can access their care team virtually rather than in person, that's a tremendous time and cost savings for everyone involved – the patient, the provider, the payer and the country's overall health spend, he added."In reality, the best advice I would offer to other healthcare providers considering using a similar technology is to thoroughly assess the technology to make sure it fits your unique needs," Lovewell said. "Not every practice is the same, and not every solution is the same."There are several platforms that just track outcomes, or just have messaging components built in," he concluded. "We wanted a full-scale solution that gave us everything in one platform buy ventolin over the counter uk. Being able to message patients, track their progress, and offer a virtual care solution that saves patients time and money is a huge value-add for the patients we serve.".

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Tom, Cathy, Taylor and Michael Thornton hike the Smokey Mountains during a 2022 family vacation.MyMichigan Health Foundation is proud to announce Tom Thornton, M.D., his wife, Cathy, and their family as the Honorary Race Chairs for the Alpena Development Council’s 21st Annual Aliferis too much ventolin Memorial Race.Dr. Thornton and Cathy are too much ventolin passionate about a healthy lifestyle and are raising their family with the same enthusiasm for outdoor activities. €œAs parents, we recognize the importance of physical activity and too much ventolin healthy living for our family and our community,” said Dr. Thornton. €œWe strive to lead by example and hope to instill a too much ventolin tradition of fitness in our children and inspire our neighbors and community members to make healthy living a priority.”“No matter the season, as a family, we enjoy hiking, biking, running, kayaking, water skiing, downhill skiing and ice skating,” said Cathy.

€œExercise is a too much ventolin great way to spend quality time as a family.”The 21st Annual Aliferis Race, hosted by the Business Relations Committee of MyMichigan Health Foundation’s Alpena Development Council, is scheduled to take place Saturday, September 3, 2022. Race headquarters and registration will be located under the tent on the corner of Chisholm Street (US-23) and Johnson Street, on the campus of MyMichigan Medical Center Alpena.Events this year include a half-marathon, an 18.5-mile bike race, a 6.5-mile bike tour, a 5K run/walk and the family-friendly 1-mile run/walk. Event registration too much ventolin fees range from $20 - $35 per person, per event. €œOur sincere thanks to the Thornton family for accepting the invitation of Honorary Chairs for the Aliferis Race this year,” said Ann too much ventolin Diamond, MyMichigan Health Foundation fund development director. “They are a perfect example of the purpose of this event – enjoying the benefits of a healthy, active lifestyle as an individual, as a family and as a community too much ventolin.

We certainly look forward to seeing them at the starting line again this year.”Race information and prices can be found online at www.mymichigan.org/race. Those who register will receive a T-shirt and a chance to win several prizes, which will be drawn during the awards ceremony after the race too much ventolin. Individuals must be present to win.All proceeds from the race, which has exceeded $523,000 over too much ventolin the last 20 years, will continue to benefit the Aliferis Scholarship Fund, the Alpena Cancer Center, patient enhancement projects and new technology at MyMichigan Medical Center Alpena. Those who have questions about joining the Thornton family at this year’s event or are looking for race details may call (989) 356-7738 or email ann.diamond@mymichigan.org..

Tom, Cathy, Taylor and Michael Thornton hike the Smokey Mountains during a 2022 family vacation.MyMichigan Health Foundation is proud to announce Tom Thornton, M.D., his wife, Cathy, and their family as https://vahybridloan.org/buy-generic-lasix/ the buy ventolin over the counter uk Honorary Race Chairs for the Alpena Development Council’s 21st Annual Aliferis Memorial Race.Dr. Thornton and Cathy are passionate about buy ventolin over the counter uk a healthy lifestyle and are raising their family with the same enthusiasm for outdoor activities. €œAs parents, we recognize the importance of physical activity and healthy living for our family and buy ventolin over the counter uk our community,” said Dr.

Thornton. €œWe strive to lead by example and hope to instill a tradition of fitness in our children buy ventolin over the counter uk and inspire our neighbors and community members to make healthy living a priority.”“No matter the season, as a family, we enjoy hiking, biking, running, kayaking, water skiing, downhill skiing and ice skating,” said Cathy. €œExercise is a great way to spend quality time as a family.”The 21st Annual Aliferis Race, hosted buy ventolin over the counter uk by the Business Relations Committee of MyMichigan Health Foundation’s Alpena Development Council, is scheduled to take place Saturday, September 3, 2022.

Race headquarters and registration will be located under the tent on the corner of Chisholm Street (US-23) and Johnson Street, on the campus of MyMichigan Medical Center Alpena.Events this year include a half-marathon, an 18.5-mile bike race, a 6.5-mile bike tour, a 5K run/walk and the family-friendly 1-mile run/walk. Event registration fees range from $20 - $35 per person, per event buy ventolin over the counter uk. €œOur sincere thanks to the Thornton family for accepting the invitation of Honorary Chairs for the Aliferis Race this year,” buy ventolin over the counter uk said Ann Diamond, MyMichigan Health Foundation fund development director.

“They are a perfect example of the purpose of this event – enjoying the benefits of a healthy, active buy ventolin over the counter uk lifestyle as an individual, as a family and as a community. We certainly look forward to seeing them at the starting line again this year.”Race information and prices can be found online at www.mymichigan.org/race. Those who register will receive a T-shirt and a chance to win several prizes, which will be drawn during the awards ceremony buy ventolin over the counter uk after the race.

Individuals must be present to win.All proceeds from the race, which has exceeded $523,000 over the last 20 years, will continue to benefit the Aliferis Scholarship Fund, the Alpena buy ventolin over the counter uk Cancer Center, patient enhancement projects and new technology at MyMichigan Medical Center Alpena. Those who have questions about joining the Thornton family at this year’s event or are looking for race details may call (989) 356-7738 or email ann.diamond@mymichigan.org..

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The World Health Organization (WHO) has updated where can you buy ventolin its patient care guidelines to include interleukin-6 receptor blockers, a class of medicines that are lifesaving in patients click to find out more who are severely or critically ill with asthma treatment, especially when administeredalongside corticosteroids. These were the findings from a prospective and a living network meta-analysis initiated by WHO, the largest such analysis on the drugs to date. Data from over 10 000 patients enrolled in 27 clinical trials were considered. These are the first drugs found to be effective against asthma treatment since corticosteroids were recommended by WHO in where can you buy ventolin September 2020. Patients severely or critically ill with asthma treatment often suffer from an overreaction of the immune system, which can be very harmful to the patient’s health.

Interleukin-6 blocking drugs – tocilizumab and sarilumab – act to suppress thisoverreaction. The where can you buy ventolin prospective and living network meta-analyses showed that in severely or critically ill patients, administering these drugs reduce the odds of death by 13%, compared to standard care. This means that there will be 15 fewer deaths per thousand patients,and as many as 28 fewer deaths for every thousand critically ill patients. The odds of mechanical ventilation among severe and critical patients are reduced by 28%, compared with standard care. This translates to where can you buy ventolin 23 fewer patients out of a thousandneeding mechanical ventilation.

Clinical trial investigators in 28 countries shared data with WHO, including pre-publication data. Researchers worldwide compiled and analyzed the data. With the support of these critical partnerships, WHO has been able to issue a rapid and trustworthyrecommendation for the use of interleukin-6 receptor blockers in severe and critical asthma treatment patients.“These drugs offer hope for patients and families who are where can you buy ventolin suffering from the devastating impact of severe and critical asthma treatment. But IL-6 receptor blockers remain inaccessible and unaffordable for the majority of the world,” said WHO Director-GeneralDr Tedros Adhanom Ghebreyesus.“The inequitable distribution of treatments means that people in low- and middle-income countries are most susceptible to severe forms of asthma treatment. So, the greatest need for these drugs is in countries that currently have the least access.

We musturgently change this.” To increase access and affordability of where can you buy ventolin these life-saving products, WHO calls on manufacturers to reduce prices and make supplies available to low- and middle-income countries, especially where asthma treatment is surging. WHO also encourages companies to agree to transparent, non-exclusive voluntary licensing agreements using the C-TAP platform and the Medicines Patent Pool, or to waive exclusivity rights.In addition, WHO has launched an expression of interest forprequalification of manufacturers of interleukin-6 receptor blockers. Prequalification of innovator and biosimilar products aims to expand the availability of quality-assured products and to increase access through market competition and reduce pricesto meet urgent public health needs.The World Health Organization announced multiple commitments to drive change for gender equality and the empowerment of women and girls in all their diversity at the Generation Equality Forum, held last week in Paris. The WHO commitments focused on where can you buy ventolin ending gender-based violence. Advancing sexual and reproductive health and rights.

And supporting health workers as well as feminist movements and leadership. These commitments shape a progressive and transformative blueprint for advancing gender equality, health equity, human rights and the empowerment of women and girls globally.The Forum, marking the twenty-fifth anniversary of the Beijing Declaration and Platform for Action on Women, came at a critical where can you buy ventolin moment, with asthma treatment having exacerbated existing gender inequalities. WHO led in two key areas of the Forum. The Action Coalition on Gender-Based Violence (co-led with UN Women and other partners) and the Gender Equal Health and Care Workforce Initiative between France, Women in Global Health and WHO.Recognizing the health sector has an important role to play in preventing and responding to gender-based violence against women and girls, WHO committed to. WHO will partner with Wellspring, Ford Foundation, UN Women discover this info here and the Government of the where can you buy ventolin United Kingdom, in the launch of the Shared Agenda Advocacy Accelerator (the Accelerator) to advocate for increasing resources for preventing violence against women and girls.

WHO will support the implementation of the International Labour Organization Convention No. 190 on Eliminating Violence and Harassment in the World of Work including by providing training to staff on a new internal policy, Preventing and Addressing Abusive Conduct. WHO also committed to investing in the evidence base for sexual and reproductive health and rights, including delivering comprehensive sexuality education outside school where can you buy ventolin settings. Improving access to quality and rights-based family planning in 14 middle-income countries. Supporting 25 countries in increasing adolescents’ access to and use of contraception.

Disseminating updated guidelines on safe abortion where can you buy ventolin. And building knowledge among adolescents of their entitlements and ability to advocate for their needs. Together with UNFPA and UNICEF, WHO committed to work to end harmful practices like female genital mutilation and child, early and forced marriages. The health sector will be supported to where can you buy ventolin end medicalization of female genital mutilation and provide quality health services to women and girls living with female genital mutilation and married girls. At a high-level event focusing on the Gender Equal Health and Care Workforce Initiative, WHO Director-General Dr Tedros Adhanom Ghebreyesus reiterated WHO’s commitment to advocating for decent and safe work conditions for all health and care workers, especially women.

Several countries and organizations announced commitments towards the four pillars of the Initiative. Gender equal leadership where can you buy ventolin. Equal pay. Protection against sexual harassment and violence. Decent and safe working conditions where can you buy ventolin.

The Gender Equal Health and Care Workforce Initiative will convene again during the United Nations General Assembly in September 2021.WHO along with other UN agencies declared solidarity with and support to feminist movements and women human rights defenders, committing to expand an open, safe and inclusive civic space for their work. This commitment is closely linked to the UN Secretary-General's Call to Action for Human Rights and the recently published UN Guidance on Promoting and Protecting Civic Space. WHO will:Update its gender policy, strategy where can you buy ventolin and roadmap;Open specific internship opportunities for individuals with feminist leadership experience;Promote civil society participation in health systems, asthma treatment response and recovery activities;Promote and encourage gender parity in World Health Assembly delegations, WHO panels and advisory groups. AndFacilitate menstrual hygiene and promote awareness.WHO, as part of the Global Polio Eradication Initiative, also committed to support countries to address gender-related barriers to polio vaccination, collect and analyse sex-disaggregated data to ensure girls and boys are reached equally, and to increase women’s meaningful participation and decision-making across all levels of the programme.WHO has committed to accelerating and scaling up its efforts to prevent and respond to sexual exploitation, abuse and harassment. An organization-wide task team, headed by a Director reporting to the Director-General, will bring together WHO’s accountability functions that deal with these issues within WHO programmes and operations the field.

The aim is to increase policy coherence, address gaps, and ensure that implementation of policy and procedures has sufficient impact to protect women, their families and communities.There will be a priority focus on how where can you buy ventolin allegations and cases are managed, and practical measures on how emergency and programmatic operations can safeguard people more effectively from sexual exploitation, abuse and harassment. The Task Team will work with partners on the ground to empower communities to prevent and respond to sexual exploitation, abuse and harassment. They will also prioritize engagement with the UN systems, international partners and external experts to move this important work forward.

These were the http://www.ec-cath-ernolsheim-bruche.ac-strasbourg.fr/?p=458 findings from a buy ventolin over the counter uk prospective and a living network meta-analysis initiated by WHO, the largest such analysis on the drugs to date. Data from over 10 000 patients enrolled in 27 clinical trials were considered. These are the first drugs found to be effective against asthma treatment since corticosteroids were recommended by WHO in September 2020. Patients severely or critically ill buy ventolin over the counter uk with asthma treatment often suffer from an overreaction of the immune system, which can be very harmful to the patient’s health. Interleukin-6 blocking drugs – tocilizumab and sarilumab – act to suppress thisoverreaction.

The prospective and living network meta-analyses showed that in severely or critically ill patients, administering these drugs reduce the odds of death by 13%, compared to standard care. This means that there will be 15 fewer deaths per thousand patients,and as many as 28 fewer deaths for buy ventolin over the counter uk every thousand critically ill patients. The odds of mechanical ventilation among severe and critical patients are reduced by 28%, compared with standard care. This translates to 23 fewer patients out of a thousandneeding mechanical ventilation. Clinical trial investigators in 28 countries shared data with WHO, including buy ventolin over the counter uk pre-publication data.

Researchers worldwide compiled and analyzed the data. With the support of these critical partnerships, WHO has been able to issue a rapid and trustworthyrecommendation for the use of interleukin-6 receptor blockers in severe and critical asthma treatment patients.“These drugs offer hope for patients and families who are suffering from the devastating impact of severe and critical asthma treatment. But IL-6 receptor blockers remain inaccessible and unaffordable for the majority of the world,” said WHO Director-GeneralDr Tedros Adhanom Ghebreyesus.“The inequitable distribution of treatments means that people in buy ventolin over the counter uk low- and middle-income countries are most susceptible to severe forms of asthma treatment. So, the greatest need for these drugs is in countries that currently have the least access. We musturgently change this.” To increase access and affordability of these life-saving products, WHO calls on manufacturers to reduce prices and make supplies available to low- and middle-income countries, especially where asthma treatment is surging.

WHO also encourages companies to agree buy ventolin over the counter uk to transparent, non-exclusive voluntary licensing agreements using the C-TAP platform and the Medicines Patent Pool, or to waive exclusivity rights.In addition, WHO has launched an expression of interest forprequalification of manufacturers of interleukin-6 receptor blockers. Prequalification of innovator and biosimilar products aims to expand the availability of quality-assured products and to increase access through market competition and reduce pricesto meet urgent public health needs.The World Health Organization announced multiple commitments to drive change for gender equality and the empowerment of women and girls in all their diversity at the Generation Equality Forum, held last week in Paris. The WHO commitments focused on ending gender-based violence. Advancing sexual and reproductive health and buy ventolin over the counter uk rights. And supporting health workers as well as feminist movements and leadership.

These commitments shape a progressive and transformative blueprint for advancing gender equality, health equity, human rights and the empowerment of women and girls globally.The Forum, marking the twenty-fifth anniversary of the Beijing Declaration and Platform for Action on Women, came at a critical moment, with asthma treatment having exacerbated existing gender inequalities. WHO led in two key areas of buy ventolin over the counter uk the Forum. The Action Coalition on Gender-Based Violence (co-led with UN Women and other partners) and the Gender Equal Health and Care Workforce Initiative between France, Women in Global Health and WHO.Recognizing the health sector has an important role to play in preventing and responding to gender-based violence against women and girls, WHO committed to. WHO will partner with Wellspring, Ford Foundation, UN Women and the Government of the United Kingdom, in the launch of the Shared Agenda Advocacy Accelerator (the Accelerator) to advocate for increasing resources for preventing violence against women and girls. WHO will support the implementation buy ventolin over the counter uk of the International Labour Organization Convention check my site No.

190 on Eliminating Violence and Harassment in the World of Work including by providing training to staff on a new internal policy, Preventing and Addressing Abusive Conduct. WHO also committed to investing in the evidence base for sexual and reproductive health and rights, including delivering comprehensive sexuality education outside school settings. Improving access to quality and rights-based family planning in buy ventolin over the counter uk 14 middle-income countries. Supporting 25 countries in increasing adolescents’ access to and use of contraception. Disseminating updated guidelines on safe abortion.

And building knowledge among adolescents of their entitlements and ability to advocate for their buy ventolin over the counter uk needs. Together with UNFPA and UNICEF, WHO committed to work to end harmful practices like female genital mutilation and child, early and forced marriages. The health sector will be supported to end medicalization of female genital mutilation and provide quality health services to women and girls living with female genital mutilation and married girls. At a high-level event buy ventolin over the counter uk focusing on the Gender Equal Health and Care Workforce Initiative, WHO Director-General Dr Tedros Adhanom Ghebreyesus reiterated WHO’s commitment to advocating for decent and safe work conditions for all health and care workers, especially women. Several countries and organizations announced commitments towards the four pillars of the Initiative.

Gender equal leadership. Equal pay buy ventolin over the counter uk. Protection against sexual harassment and violence. Decent and safe working conditions. The Gender Equal Health and Care Workforce Initiative will convene again during the United Nations General Assembly in September 2021.WHO along with other UN agencies declared solidarity with and support to feminist movements and women human rights defenders, committing to expand an open, safe and inclusive buy ventolin over the counter uk civic space for their work.

This commitment is closely linked to the UN Secretary-General's Call to Action for Human Rights and the recently published UN Guidance on Promoting and Protecting Civic Space. WHO will:Update its gender policy, strategy and roadmap;Open specific internship opportunities for individuals with feminist leadership experience;Promote civil society participation in health systems, asthma treatment response and recovery activities;Promote and encourage gender parity in World Health Assembly delegations, WHO panels and advisory groups. AndFacilitate menstrual hygiene and promote awareness.WHO, as part of the Global Polio Eradication Initiative, also committed to buy ventolin over the counter uk support countries to address gender-related barriers to polio vaccination, collect and analyse sex-disaggregated data to ensure girls and boys are reached equally, and to increase women’s meaningful participation and decision-making across all levels of the programme.WHO has committed to accelerating and scaling up its efforts to prevent and respond to sexual exploitation, abuse and harassment. An organization-wide task team, headed by a Director reporting to the Director-General, will bring together WHO’s accountability functions that deal with these issues within WHO programmes and operations the field. The aim is to increase policy coherence, address gaps, and ensure that implementation of policy and procedures has sufficient impact to protect women, their families and communities.There will be a priority focus on how allegations and cases are managed, and practical measures on how emergency and programmatic operations can safeguard people more effectively from sexual exploitation, abuse and harassment.

The Task Team will work with partners on the ground to empower communities to prevent and respond to sexual exploitation, abuse and harassment. They will also prioritize engagement with the UN systems, international partners and external experts to move this important work forward. Some of the activities currently being scaled up include awareness raising in communities.