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IntroductionThe lymphatic system is a network of vessels important for whole body fluid homeostasis, lipid absorption and immune cell trafficking.1 2 Lymphoedema is caused by lymphatic dysfunction, can i buy ventolin over the counter uk which discover this leads to a build-up of interstitial fluid within the tissues. This manifests with swelling of the extremities, usually of the legs but may involve other regions or segments of the body such as the upper limbs, face, trunk or genital area. There is an increased risk of due to disturbances in immune cell trafficking within the segment of compromised lymph drainage.3 Lymphatic dysfunction within the thorax and abdomen, here referred to as systemic/internal involvement (but can be referred to as visceral or central involvement), may present with pleural or pericardial effusions or ascites, any of which may be chylous, as well as intestinal or pulmonary lymphangiectasia, protein losing enteropathy or chylous reflux.The International Society for the Study of Vascular Anomalies (ISSVA) updated their classification for vascular anomalies in 2018.4 The vascular malformations are subgrouped into âcombinedâ, which include more than one type of vessel, can i buy ventolin over the counter uk âsimpleâ (only involving one vessel type), and those âassociated with other anomaliesâ.Lymphoedema due to a presumed genetic developmental fault in the structure or function of lymph conducting pathways is called primary lymphoedema.5 Some developmental faults can lead to overt structural defects of the lymph conducting pathways and are called lymphatic malformations. Such malformations if interfering with lymph drainage cause lymphoedema (truncal malformations) but some lymphatic malformations remain as isolated anomalies with no connection to main lymph drainage pathways and do not cause lymphoedema (non-truncal malformations).6 A primary lymphatic anomaly is an umbrella term referring to all lymphatic abnormalities arising from a developmental fault.For a long time, the diagnosis of primary lymphoedema was based largely on the age of presentation of the swelling, congenital, pubertal and late onset, with limited differentiation between the phenotypes.

The discovery of the first causal gene, vascular endothelial growth factor receptor 3 for Milroy disease, indicated that a molecular diagnosis was possible.7 The first St Georgeâs classification algorithm of primary lymphoedema and other primary lymphatic disorders was an attempt to guide a clearer categorisation of phenotypes and enable the discovery of further causal genes.8 Age of can i buy ventolin over the counter uk onset remained a key criterion, but the sites affected and associated features, for example, dysmorphology, distichiasis (aberrant eyelashes), varicose veins, vascular malformations and limb overgrowth were also considered, as was internal or systemic involvement, for example, fetal hydrops, intestinal lymphangiectasia, pleural and pericardial effusions and chylous reflux. A family history of lymphoedema with determination of the mode of inheritance was considered useful.More rigorous phenotyping facilitated the identification of subgroups of patients with the same broad category of primary lymphatic anomaly. These cohorts were then used for molecular studies to can i buy ventolin over the counter uk identify more causal genes. Once the genotype was known then crosschecking of the clinical characteristics, natural history and inheritance patterns was possible and an accurate phenotype defined.

Investigations such as lymphoscintigraphy helped to refine the phenotype further and give insight into the mechanisms for the development of the lymphatic can i buy ventolin over the counter uk disorder. A first update of the classification was published in 2013.9The St Georgeâs classification algorithm is intended to help clinicians categorise their patients and guide testing towards, where possible, a molecular diagnosis. This algorithm can i buy ventolin over the counter uk is criteria matching, that is, using certain key findings for classification through a multistep process of history taking, examination findings, mutation testing, etc. The next step using the information gathered is to advise on natural history, prognosis and risk (including genetic counselling) and to guide management.

While a molecular diagnosis should provide the most specific and accurate diagnosis, it can be seen particularly with the postzygotic mosaic disorders that one genotype can be clinically can i buy ventolin over the counter uk very heterogenous so there will probably always be a place for good clinical phenotyping supported by investigation to guide management.Here, we present a second update of the St Georgeâs classification algorithm to include newly discovered genes and to bring it in-line with the 2018 ISSVA classification for vascular anomalies.4 The results of an audit, the purpose of which was to determine how well the algorithm was performing as a diagnostic aid to classify patients with primary lymphatic anomalies and guide molecular testing are also presented.MethodsSt Georgeâs classification algorithm of primary lymphatic anomaliesThe St Georgeâs classification algorithm was updated (figure 1) and then applied, retrospectively, to all patients presenting to the national multidisciplinary âPrimary and Paediatric Lymphoedemaâ Clinic held at St Georgeâs Hospital over a 1-year period. Careful phenotyping was undertaken both on clinical grounds and after selective investigations, for example, lymphoscintigraphy. Where possible and appropriate, targeted genetic testing was performed (this was prior to the introduction of a lymphoedema gene panel in our unit) for some can i buy ventolin over the counter uk of the genes listed in table 1.St Georgeâs classification algorithm for primary lymphatic anomalies. The five main groupings (colour coded) with their various clinical subtypes of disease.

Primary lymphoedema is the major clinical feature in can i buy ventolin over the counter uk the green, pink and purple sections. Text in red indicates the suggested genetic test and/or differential diagnosis for the subgroup, however, the indicated genes do not explain the cause of disease in all patients in each grouping. For example, only 70% of patients with Milroy disease are explained by mutations in FLT4/VEGFR3.33 can i buy ventolin over the counter uk FH, family history. +ve, positive.

Âve, negative. (Image shared by St Georgeâs Lymphovascular Research Group under the CC BY-SA 4.0 International can i buy ventolin over the counter uk licence on Wikimedia Commons)." data-icon-position data-hide-link-title="0">Figure 1 St Georgeâs classification algorithm for primary lymphatic anomalies. The five main groupings (colour coded) with their various clinical subtypes of disease. Primary lymphoedema is the major clinical can i buy ventolin over the counter uk feature in the green, pink and purple sections.

Text in red indicates the suggested genetic test and/or differential diagnosis for the subgroup, however, the indicated genes do not explain the cause of disease in all patients in each grouping. For example, only 70% of patients with can i buy ventolin over the counter uk Milroy disease are explained by mutations in FLT4/VEGFR3.33 FH, family history. +ve, positive. Âve, negative can i buy ventolin over the counter uk.

(Image shared by St Georgeâs Lymphovascular Research Group under the CC BY-SA 4.0 International licence on Wikimedia Commons).View this table:Table 1 An overview of genetic disorders with primary lymphoedema as a frequent and dominant feature, categorised by inheritance and age of onsetWithin the St Georgeâs classification algorithm (figure 1), there are five main categories of primary lymphatic anomalies. These are presented can i buy ventolin over the counter uk in the form of colour-coded sections with the individual subtypes (including genotypes) within the categories. For definitions of some of the terms used, see Glossary of Terms (see online supplementary section).Supplemental materialFirst, the yellow section includes the âvascular malformations associated with other anomaliesâ and the âlymphatic malformationsâ (as defined in the âIntroductionâ section).Second, the patient is assessed for syndromes that have lymphoedema as a non-dominant feature (blue section), for example, the patient is dysmorphic with learning difficulties and possibly has other abnormalities.Then if not obviously syndromic, and the lymphatic problems are the dominant feature, further assessment and investigations for systemic/internal lymphatic dysfunction or central conducting anomalies (eg, chylothoraces, chylopericardial effusions, ascites or protein losing enteropathy) are undertaken (pink section). These include a careful medical history asking specifically about prenatal history (eg, hydrothoraces, fetal hydrops), chronic diarrhoea, abdominal bloating or discomfort with fatty foods, weight can i buy ventolin over the counter uk loss or faltering growth (in a child) or shortness of breath on exertion.

Blood investigations (including serum albumin, immunoglobulins, lymphocyte subsets, faecal levels of calprotectin or alpha-1-antitrysin), echocardiograms and chest radiographs are helpful if central lymphatic dysfunction is suspected.Where none of the above features is present, then the age of onset is used to determine the grouping. The green section deals with congenital-onset primary lymphoedema (includes syndromes where lymphoedema can i buy ventolin over the counter uk is the dominant clinical problem, and which is present at birth or develops within the first year of life but is not associated with systemic/internal lymphatic dysfunction). The purple section addresses late-onset primary lymphoedema (ie, lymphoedema that is the dominant clinical problem, and which develops after the first year of life but is not associated with systemic/internal lymphatic dysfunction). It was decided not to differentiate between pubertal onset (praecox) and can i buy ventolin over the counter uk later onset in life (tarda) when it was discovered that one genotype such as FOXC2 can cause both.It is important to note that the specific diagnosis may be difficult in a neonate presenting with isolated congenital primary lymphoedema.

A baby born with lymphoedema may later present with developmental delay, systemic involvement, progressive segmental overgrowth or a vascular malformation, which could suggest a diagnosis in one of the other categories. It should also be emphasised can i buy ventolin over the counter uk that each colour-coded section is not exclusive. Some somatic overgrowth anomalies may possess significant internal involvement. Also, lymphoedema distichiasis syndrome is allocated to the purple late-onset lymphoedema section because the dominant can i buy ventolin over the counter uk feature is the late-onset lymphoedema not the associated features, which make it a syndrome.

The blue âsyndromicâ section refers to conditions with a collection of features where lymphoedema is not the main characteristic. The algorithm is intended to guide a clinical diagnosis and target gene testing.Genetic methodologyFor the purposes of the audit, targeted genetic testing of FOXC2, VEGFR3, CCBE1, SOX18, RASopathy genes and PIK3CA was performed by Sanger sequencing of DNA extracted from lymphocytes or skin fibroblasts in patients in whom a specific genetic diagnosis was suspected. This was before the can i buy ventolin over the counter uk introduction of a lymphoedema gene panel. Some patients, who were either negative for the targeted genes or did not fit the relevant phenotypes of those genes, were included in Whole Exome Sequencing (WES) cohorts after classification, which then led to the identification of new disease genes such as EPHB4, GATA2, PIEZO1, GJC2 and FAT4.Retrospective audit of the St Georgeâs Clinic for 2016A 12-month retrospective audit for the year 2016 (1 January 2016â31 December 2016) was performed.

The aim of the audit was to look at the proportion of patients in each category of the classification algorithm and to look at the success of making a can i buy ventolin over the counter uk molecular diagnosis through use of the algorithm. The audit criteria required the patients to be seen in our specialist clinic, at any age, with a diagnosis of a primary lymphatic anomaly with data collected from medical records and laboratory results.ResultsResults of the retrospective auditOver a 12-month period in 2016, 227 patients were seen (age range 2 weeks to 70 years), 25.6% (n=58/227) of which were new patients. Over one-third (38%) of patients seen in the clinic had a can i buy ventolin over the counter uk family history of primary lymphoedema.Few patients had received genetic testing prior to referral to the clinic. Targeted genetic testing was completed in 63% (n=143) of the patients seen.

At that time, a lymphoedema gene panel was not available, patients were only tested if the clinician felt there was a reasonable chance of finding a molecular cause, that is, testing was can i buy ventolin over the counter uk targeted.Of those tested, the underlying genetic cause was identified in 41% (n=59/143). Overall, a molecular diagnosis was made in 26% (59/227) of all the patients seen in 2016.Vascular malformations with associated anomalies and lymphatic malformations (yellow)This group presents with malformations in the structure and organisation of blood and lymphatic vessels with a patchy, segmental distribution. Lymphoedema may develop in combination with vascular malformations and segmental overgrowth (or occasionally, undergrowth) of tissues can i buy ventolin over the counter uk within the swollen limb, for example, muscle, skeletal or adipose tissues (figure 2A). The combination of lymphatic and vascular malformations in this group reflects the mutual embryological origins of the two vascular systems.A graphic representation of the 227 audited patients seen in clinic in 2016 and their distribution across the five categories from figure 1 (pie chart).

(AâG) Images show features can i buy ventolin over the counter uk of each category. (A) Patients with postzygotic mutations often present with asymmetrical swelling and segmental overgrowth as this patient, who is mosaic for a mutation in KRAS. (B) Webbed neck in Noonan can i buy ventolin over the counter uk syndrome. (C) In rare cases, swellings can be widespread affecting all segments of the body such as in this child with biallelic CCBE1 mutations.

(D) In milder forms, often just the dorsum of the foot is affected as can i buy ventolin over the counter uk in this baby with a VEGFR3 mutation. (E, F) Lower limb swelling and distichiasis (arrowheads in F) in a patient with a FOXC2 mutation. (G) Lymphoedema is a major cause of skin disease and affected patients suffer can i buy ventolin over the counter uk from severe and recurrent episodes of cutaneous , especially HPV-associated warts as seen in patients with GATA2 mutations. GLD, generalised lymphatic dysplasia." data-icon-position data-hide-link-title="0">Figure 2 A graphic representation of the 227 audited patients seen in clinic in 2016 and their distribution across the five categories from figure 1 (pie chart).

(AâG) Images show features can i buy ventolin over the counter uk of each category. (A) Patients with postzygotic mutations often present with asymmetrical swelling and segmental overgrowth as this patient, who is mosaic for a mutation in KRAS. (B) Webbed neck in Noonan syndrome. (C) In rare cases, swellings can be can i buy ventolin over the counter uk widespread affecting all segments of the body such as in this child with biallelic CCBE1 mutations.

(D) In milder forms, often just the dorsum of the foot is affected as in this baby with a VEGFR3 mutation. (E, F) can i buy ventolin over the counter uk Lower limb swelling and distichiasis (arrowheads in F) in a patient with a FOXC2 mutation. (G) Lymphoedema is a major cause of skin disease and affected patients suffer from severe and recurrent episodes of cutaneous , especially HPV-associated warts as seen in patients with GATA2 mutations. GLD, generalised lymphatic dysplasia.These conditions are usually due can i buy ventolin over the counter uk to postzygotic mutations, for example, PIK3CA-related overgrowth spectrum (PROS)).

Exceptions to this are capillary malformation-arteriovenous malformation (MIM 608354) such as Parkes-Weber syndrome, which may be caused by heterozygous, germline mutations in RASA1.10Of the 227 patients seen in 2016, 17% (n=39) had lymphoedema associated with vascular malformations and/or segmental overgrowth (or undergrowth) (figure 2, pie chart) in comparison with 15% in 2010.8 It has been shown that postzygotic, gain of function mutations in PIK3CA may be responsible for many of the mosaic segmental overgrowth spectrum disorders.11 Postzygotic mutations are rarely identified in blood samples and therefore require a skin biopsy of the affected region. In the 2016 cohort, only 10 patients (26%) provided skin biopsies for can i buy ventolin over the counter uk genetic analysis, producing just one molecular diagnosis. More research in this field is required to identify the genetic basis for some of the conditions in this category. However, since the last revision, we have gained a much better understanding of the classification of some of these postzygotic mosaic conditions, therefore a brief review of the latest developments in this area is given in the online supplementary section.Syndromic lymphoedema (blue)Syndromes associated with primary lymphatic anomalies are listed can i buy ventolin over the counter uk in table 2 and include chromosomal abnormalities, single gene disorders and imprinting disorders.

Patients attending the clinic with syndromic primary lymphoedema made up 13% (n=29) (figure 2, pie chart), similar to the 15% reported by Connell et al.8 Nearly three-quarters (72%, n=21) of this cohort had a molecular or chromosomal diagnosis. The most frequently seen syndromes were Noonan syndrome (n=8) (figure 2B), Turner syndrome (n=4) and Phelan McDermid syndrome (n=3).View this table:Table 2 An overview of âKnown Syndromesâ with primary lymphoedema as a non-dominant association as referred to in the St Georgeâs classification algorithm (figure 1, blue section)Lymphoedema with prenatal or postnatal systemic involvement (pink)In some conditions, lymphoedema may be associated with internal (systemic or visceral) disturbances of the lymphatic system within thorax or abdomen, for example, fetal hydrops, intestinal lymphangiectasia (presenting as can i buy ventolin over the counter uk protein-losing enteropathy), pulmonary lymphangiectasia or with pericardial and/or pleural effusions (often chylous), or chylous reflux (often into the genitalia). Broadly, there are two types of lymphoedema with systemic involvement. (A) âwidespreadâ swelling affecting all segments of the body (figure 2C), such as that seen in generalised can i buy ventolin over the counter uk lymphatic dysplasia (GLD).

Due to faulty development, the structural or functional abnormality of the lymphatic system is affecting the whole body. One type is can i buy ventolin over the counter uk Hennekam-lymphangiectasia-lymphoedema syndrome12. (B) âpatchyâ areas of swelling, for example, left arm and right leg, which have been named âmultisegmental lymphatic dysplasiaâ (MLD) (figure 1).Prenatally, these conditions may present with pleural effusions (hydrothoraces), or as non-immune fetal hydrops (the accumulation of fluid in at least two compartments of a fetus such as the abdominal cavity, pleura or subcutaneous oedema). Fifteen per cent of non-immune cases of hydrops are the result of lymphatic disorders, and approximately 20% are idiopathic, some of can i buy ventolin over the counter uk which may be due to, as yet, unidentified lymphatic abnormalities.13In our audit, this cohort accounted for 12% (n=27) of patients (figure 2, pie chart), slightly higher than the 8% reported in 2010.8 Molecular testing was carried out in 17 patients.

Nine of those tested had GLD, and pathogenic variants were identified in seven (78%). Five had biallelic variants can i buy ventolin over the counter uk in the PIEZO1 gene and one each with biallelic variants in FAT4 and SOX18. Interestingly, two of the families described by Connell et al, cases 3 and 4, have subsequently been found to be caused by biallelic variants in the PIEZO1 gene.8 14None of the eight patients, who presented with âpatchyâ distribution of lymphoedema (MLD), had an identifiable molecular diagnosis. It is suspected that these patients could have a postzygotic mosaic mutation or WILD syndrome.15Since the last revision of the St Georgeâs classification algorithm was published,9 five new causal genes associated with GLD and/or non-immune fetal hydrops have been identified.

ADAMTS3,16 EPHB4,17 FAT4,18 FBXL719 and PIEZO114 20 and are reviewed in the online supplementary section.Congenital onset lymphoedema (green)In this can i buy ventolin over the counter uk category, congenital onset is defined as lymphoedema that is present at birth or develops within the first year of life. Bilateral lower limb swelling is the most frequent presentation (figure 2D), but the swelling may be unilateral and/or involve the arms, genitalia and/or face, depending on the underlying cause. There are a number of different genetic can i buy ventolin over the counter uk disorders presenting with congenital lymphoedema (table 1). Milroy disease (ORPHA79452.

OMIM 153100) is the most common form, occurring as a result of pathogenic variants in FLT4/VEGFR3.21 22 The mutation may occur de novo, can i buy ventolin over the counter uk so a family history is not essential for this diagnosis. The lymphoedema is always confined to the lower limbs but may be unilateral, and may (rarely) involve the genitalia. Approximately 10% can i buy ventolin over the counter uk of mutation carriers do not have lymphoedema. Fetuses with Milroy disease may present antenatally with pedal oedema in the third trimester, and, in a few cases, with bilateral hydrothoraces, which resolve before birth.Pathogenic variants in VEGFC, the ligand for VEGFR3, have also been identified in association with congenital primary lymphoedema of Gordon (OMIM 615907), also affecting the lower limbs.23â26The congenital category represents 21% (n=47) of the patients seen in 2016 (figure 2, pie chart) compared with 24% in 2010.8 A pathogenic variant was identified in 19 of the 47 (40%) patients genetically tested in this category.

The majority (n=18) had pathogenic can i buy ventolin over the counter uk variants identified in FLT4/VEGFR3 and, in one patient, a pathogenic variant in the GJC2 gene. A GJC2 mutation in a patient presenting with lymphoedema at birth is unusual but shows the variability of the phenotype.Many of the conditions listed under the other categories in the classification algorithm may initially present with congenital lymphoedema but systemic involvement, progressive overgrowth or vascular malformation may present later and are so reclassified. Likewise, some syndromic forms may present with congenital lymphoedema before any other manifestations, making diagnosis difficult at times can i buy ventolin over the counter uk. Thus, the diagnosis of âisolatedâ congenital primary lymphoedema may be difficult in a neonate presenting with pedal oedema.

Therefore, a can i buy ventolin over the counter uk molecular diagnosis in the neonatal period is clinically very useful in the management of these patients.Late-onset lymphoedema (purple)âLate-onsetâ lymphoedema is defined as presenting after the first year of life. Swelling can range from being unilateral, bilateral or can involve all four limbs and can present from early childhood up to adulthood (figures 1 and 2E). Some may present with unilateral swelling, but the contralateral limb may become involved later or show abnormalities on can i buy ventolin over the counter uk lymphoscintigram even when clinically uninvolved. The phenotypes also range from mild to severe.

There are currently five genes known to be associated with can i buy ventolin over the counter uk late-onset lymphoedema. FOXC2 (figure 2F),27 GJC2,28 29 GATA2 (figure 2G),30 HGF31 and CELSR132 (table 1). For many patients the molecular cause remains elusive, particularly in those patients with Meige disease and late-onset (usually pubertal) unilateral can i buy ventolin over the counter uk lower limb lymphoedema.Late-onset primary lymphoedema accounted for 37% (n=85) in 2016 (figure 2, pie chart) comparable to the 36% reported in 2010.8 This category has a low number of molecular diagnoses (n=12. 14%) as there are currently no causative genes for Meige disease, which made up 36% (n=31) of patients in this category.DiscussionThis review presents an updated St Georgeâs classification algorithm of primary lymphatic anomalies and brings it in-line with the ISSVA classification for vascular anomalies.

It cites eight new causative genes since the last publication and highlights the areas where the genetic basis is still not known. This rapidly evolving field demonstrates that primary lymphoedema and vascular malformations are highly heterogenous.The audit reports an overall successful molecular diagnosis in 26% of patients seen in the clinic, but 41% of those patients selected can i buy ventolin over the counter uk for molecular testing. This is a considerable improvement on the rate of a molecular diagnosis since the algorithm was first published in 2010. Only two can i buy ventolin over the counter uk causal genes were known at that time.

We can conclude from the audit that the algorithm works well in targeting mutation testing. Furthermore, use can i buy ventolin over the counter uk of the algorithm has led to the discovery of a number of causal genes. While it could be argued that the introduction of the lymphoedema gene panel obviates any need for targeted gene tests, we believe that matching a phenotype to a likely gene reduces wasteful testing and helps enormously in the interpretation of variants of unknown significance, which are becoming an increasing problem in the era of next-generation sequencing.Although providing a molecular diagnosis in one-quarter of all the patients with primary lymphoedema represents a considerable improvement from when the algorithm was last reviewed, the molecular diagnosis is still not identified in the majority of patients seen in the St Georgeâs Clinic. In the diagnostic setting, the introduction of next-generation sequencing with a targeted (virtual) âlymphoedema gene panelâ may improve the diagnostic can i buy ventolin over the counter uk rate and broaden the phenotypic spectrum of many of the known genetic disorders.

Understanding of the natural history of the disorder will enable appropriate surveillance of, for example, leukaemia in Emberger syndrome (GATA2), and allow investigations for known associated problems, for example, congenital heart disease in patients with lymphoedema distichiasis syndrome (FOXC2). Prenatal diagnosis for the more serious conditions also becomes possible can i buy ventolin over the counter uk. Knowledge of causal genes, and mechanisms of pathophysiology, provide an opportunity for new, improved treatments (personalised medicine) (eg, mammalian target of rapamycin inhibitors for progressive overgrowth disorders).In conclusion, the St Georgeâs classification algorithm for primary lymphatic anomalies has been further refined. With this review, we have provided insight into the most recently discovered genotypes and how this algorithm can be used in the clinic to guide management of patients with primary lymphoedema.The General Medical Councilâs (GMC) motto of âWorking with doctors, working for patientsâ is at can i buy ventolin over the counter uk the heart of the work we carry out to ensure medical schools and postgraduate medical training is of the high standard that patients demand, and rightly deserve.

However, we know delivering world-class healthcare is taking its toll on doctors and carrying out research into how we can ease the burden and find how burnout can be prevented is becoming a key focus of our work.While still delivering our important statutory functions of controlling access to the register and investigating when things go wrong, we are actively supporting professionals to maintain and improve standards of good medical practice. Additionally, there is a vast amount of work can i buy ventolin over the counter uk taking place behind the scenes at the GMC to adapt to the ever-evolving environment we are training doctors to work in.SHAPING TRAINING TO MEET THE NEEDS OF WORKFORCE AND PATIENTSThe UK population is continuously changing. We have an ageing and consequently increasingly frail population with more people with complex and comorbid diseases. We have more patients with disabilities related to mental and physical health problemsâwhich we expect will continue to can i buy ventolin over the counter uk rise due to the asthma treatment ventolin.

In addition, more young people tend to live in urban areas, whereas there are more older people generally residing in more rural areas.This in turn places a demand on services meaning we need to train more doctors with more generalist, flexible skills and have doctors located in the right geographical areas to treat patients. The ongoing asthma treatment ventolin has can i buy ventolin over the counter uk highlighted the importance of doctors working flexibly.The medical workforce is also ever-varying. Our most recent âThe state of medical education and practice in the UKâ1 report showed we are seeing more female doctors on the register. Increasingly, female doctors make up a higher proportion of the workforce as male â¦.

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When experiencing the ups and downs of a virtual roller where can i get ventolin coaster ride, people who get migraine headaches reported more dizziness and motion sickness than people who do not get migraines, according to a new study published in the July 7, 2021, online issue of Neurology, the medical journal of the American http://www.storybones.net/bookstore/world-building/gazetteer-writers-manual/ Academy of Neurology.Researchers also found that people who get migraines also had more nerve cell activity in certain areas of the brain during the virtual roller coaster ride and less activity in other areas. Researchers said this abnormal processing of the visual motion stimuli in the brain was linked to migraine disability and more susceptibility to motion sickness."Millions of people regularly experience painful and debilitating migraine headaches that can reduce their quality of life," said study author Arne May, MD, PhD, of the University of Hamburg in Germany. "People with migraine often complain of dizziness, where can i get ventolin balance problems and misperception of their body's place in space during migraine.

By simulating a virtual roller coaster ride, our study found that some of these problems are not only magnified in people who experience migraine, but they are also associated with changes in various areas of the brain. By identifying where can i get ventolin and pinpointing these changes, our research could lead to a better understanding of migraine which could in turn lead to the development of better treatments."The study involved 20 people with migraine who were compared to 20 people without migraine. Participants had an average age of 30 and more than 80% were women.

People with migraine where can i get ventolin had an average of four migraines per month.Researchers used functional magnetic resonance imaging (fMRI) to take brain scans of each participant as they watched videos to experience the virtual roller coaster rides. No participants experienced a migraine during the virtual rides. After the virtual rides, participants were surveyed about their perceived levels of dizziness, motion sickness and other symptoms.Researchers found that 65% where can i get ventolin of people with migraine experienced dizziness compared to 30% of people without migraine.

On a questionnaire about motion sickness, which scored symptom intensity on a scale of 1-180, those with migraine had an average score of 47 compared to an average score of 24 for people without migraine. People with migraine also experienced symptoms where can i get ventolin longer, an average of 1 minute and 19 seconds compared to an average of 27 seconds. Their symptoms were also more intense.From the brain scans, researchers were able to identify changes in nerve cell activity based on blood flow to certain areas of the brain.

People with migraine had increased activity in five areas of the brain, including two areas in the occipital gyrus, the visual processing area of the brain, and decreased activity where can i get ventolin in two other areas including the middle frontal gyrus. These brain changes correlated with migraine disability and motion sickness scores."One other area of the brain where we found pronounced nerve cell activity in people with migraine was within the pontine nuclei, which helps regulate movement and other motor activity," said May. "This increased where can i get ventolin activity could relate to abnormal transmission of visual, auditory and sensory information within the brain.

Note. Content may be edited for style and length.There are many reasons that an intranasal treatment against the asthma ventolin would be helpful in the fight against asthma treatment s, University of Alabama at Birmingham immunologists Fran Lund, Ph.D., and Troy Randall, Ph.D., write in a viewpoint article in the journal Science.That route of vaccination gives two additional layers of protection over intramuscular shots because it produces. 1) immunoglobulin A and resident memory B and T cells in the respiratory mucosa that are an effective barrier to at those sites, and 2) cross-reactive resident memory B and T cells that can respond earlier than other immune cells if a viral variant does start an ."Given the respiratory tropism of the ventolin, it seems surprising that only seven of the nearly 100 asthma treatments currently in clinical trials are delivered intranasally," Lund and Randall said.

"Advantages of intranasal treatments include needle-free administration, delivery of antigen to the site of , and the elicitation of mucosal immunity in the respiratory tract."Their viewpoint article goes on to detail the individual advantages and challenges of each of the seven intranasal treatment candidates. Six are viral vectors, including three different adenoventolin vectors, and one candidate each for live-attenuated influenza ventolin, live-attenuated respiratory syncytial ventolin and live-attenuated asthma. The seventh treatment candidate is an inert protein subunit.Among the drawbacks of using ventolines that people may have encountered before is negative interference from anti-vector antibodies that impair treatment delivery.

And because of the minimal risk of reversion for the live-attenuated asthma ventolin, it would likely be contraindicated for infants, people over 49 and immunocompromised persons."Notably absent from the list of intranasal treatments are those formulated as lipid-encapsulated mRNA," Lund and Randall said, listing some of the challenges and adverse side effects that accompany that approach."Ultimately, the goal of vaccination is to elicit long-lived protective immunity," the UAB researchers concluded. Comparing the benefits and disadvantages of intranasal vaccination against intramuscular vaccinations, they suggest that perhaps effective vaccination need not be restricted to a single route."The ideal vaccination strategy," the immunologists concluded, "may use an intramuscular treatment to elicit a long-lived systemic immunoglobulin G response and a broad repertoire of central memory B and T cells, followed by an intranasal booster that recruits memory B and T cells to the nasal passages and further guides their differentiation toward mucosal protection, including immunoglobulin A secretion and tissue-resident memory cells in the respiratory tract."At UAB, Lund is a professor of microbiology and holds the Charles H. McCauley Chair of Microbiology.

Randall is a professor of medicine in the Division of Clinical Immunology and Rheumatology, and he holds the Meyer Foundation William J. Koopman, M.D., Endowed Chair in Immunology and Rheumatology. Story Source.

Materials provided by University of Alabama at Birmingham. Original written by Jeff Hansen. Note.

Content may be edited for style and length.Small and seemingly specialized, the brain's locus coeruleus (LC) region has been stereotyped for its outsized export of the arousal-stimulating neuromodulator norepinephrine. In a new paper and with a new grant from the National Institutes of Health, an MIT neuroscience lab is making the case that the LC is not just an alarm button but has a more nuanced and multifaceted impact on learning, behavior and mental health than it has been given credit for.With inputs from more than 100 other brain regions and sophisticated control of where and when it sends out norepinephrine (NE), the LC's tiny population of surprisingly diverse cells may represent an important regulator of learning from reward and punishment, and then applying that experience to optimize behavior, said Mriganka Sur, Newton Professor of Neuroscience in The Picower Institute for Learning and Memory and the Department of Brain and Cognitive Sciences at MIT."What was formerly considered a homogenous nucleus exerting global, uniform influence over its many diverse target regions, is now suggested to be a heterogeneous population of NE-releasing cells, potentially exhibiting both spatial and temporal modularity that govern its functions," wrote Sur, postdoc Vincent Breton-Provencher and graduate student Gabrielle Drummond in a review article published last month in Frontiers in Neural Circuits.The article presents copious emerging evidence from Sur's group and many others, suggesting that that the LC may integrate sensory inputs and internal cognitive states from across the brain to precisely exert its NE-mediated influence to affect actions -- by throttling NE to the motor cortex -- and the processing of resulting feedback of reward or punishment -- by throttling NE to the prefrontal cortex.To investigate that hypothesis, the team has begun working with a $2.1 million, 5-year NIH grant awarded in April. In this study they are engaging mice in learning tasks where they are cued by tones of varying pitches and volumes.

Over the course of training the mice will learn that when a tone is high pitched, pressing a lever will yield a reward and when the tone is low pitched, the correct response would be to not push lest it experience an unpleasant air puff. By varying the tone volume, the experimenters will vary the certainty the mice can feel that they heard the cue correctly.The hypothesis (borne out by preliminary data) predicts that the NE will matter in multiple crucial ways, Sur said. When the mouse hears the cue tone, if the pitch is low the LC would send less NE via a cadre of neurons to the motor cortex, reflecting the animal's belief that the lever should not be pushed because no reward will be forthcoming.

Meanwhile the lower the volume, the less certainty the animal has in its decision. Conversely, a high tone of high volume would send more NE, reflecting the animal's certainty that pushing the lever would produce a reward.After the mouse has acted, the more surprising the feedback, the more NE it will produce and send via a distinct group to the prefrontal cortex, stimulating greater learning. So for instance, if the mouse hears a faint, high tone and gingerly presses the lever, the surprise of a resulting reward will stimulate a strong output of NE to instruct the prefrontal cortex because its expectations weren't very high.

Whenever a mouse guesses wrong and feels an air puff, that will stimulate the strongest NE release to the prefrontal cortex. After such dynamics, Sur's team has observed consistent performance changes on the subsequent trial."This is a way by which norepinephrine can be thought of as an arousal signal, but it's also, importantly, in the context of ongoing function a learning signal," Sur said. "It is both an execution signal and a learning signal, for both of which we can describe the actual quantitative relationships."Not only will the team be measuring the activity of LC-NE neurons, they'll also take them over using optogenetics (in which neurons can be controlled with light), so that they can silence or amplify LC-NE output to show how doing each affects action and learning.Understanding the true nature of how the LC works could be useful for improving treatments for certain disorders, Sur said.

Addressing that loss in the right way could help sustain forms of learning and cognition.One of the keys to a long life may lie in your net worth.In the first wealth and longevity study to incorporate siblings and twin pair data, researchers from Northwestern University analyzed the midlife net worth of adults (mean age 46.7 years) and their mortality rates 24 years later. They discovered those with greater wealth at midlife tended to live longer.The researchers used data from the Midlife in the United States (MIDUS) project, a longitudinal study on aging. Using data from the first collection wave in 1994-1996 through a censor date of 2018, the researchers used survival models to analyze the association between net worth and longevity.To tease apart factors of genetics and wealth, the full sample was segmented into subsets of siblings and twins.In the full sample of 5,400 adults, higher net worth was associated with lower mortality risk.

Within the data set of siblings and twin pairs (n=2,490), they discovered a similar association with a tendency for the sibling or twin with more wealth to live longer than their co-sibling/twin with less. This finding suggests the wealth-longevity connection may be causal, and isn't simply a reflection of heritable traits or early experiences that cluster in families."The within-family association provides strong evidence that an association between wealth accumulation and life expectancy exists, because comparing siblings within the same family to each other controls for all of the life experience and biology that they share," said corresponding author Eric Finegood, a postdoctoral fellow in the Institute for Policy Research at Northwestern.The researchers also considered the possibility that previous health conditions, such as heart disease or cancer, could impact an individual's ability to accrue wealth due to activity limitations or healthcare costs -- possibly confounding any association between wealth and longevity. To address this, they re-analyzed the data using only individuals without cancer or heart disease.

However, even within this sub-group of healthy individuals, the within-family association between wealth and longevity remained.The study's senior author is Greg Miller, the Louis W. Menk Professor of Psychology and faculty fellow at the Institute for Policy Research at Northwestern. Co-authors of the study include other Northwestern faculty and trainees (Edith Chen, Daniel Mroczek, Alexa Freedman) as well as researchers from the University of Illinois, Urbana-Champaign.

West Virginia University. Purdue University. And the University of Minnesota."Far too many American families are living paycheck to paycheck with little to no financial savings to draw on in times of need, said Miller.

"At the same time, wealth inequality has skyrocketed. Our results suggest that building wealth is important for health at the individual level, even after accounting for where one starts out in life. So, from a public health perspective, policies that support and protect individuals' ability to achieve financial security are needed." Story Source.

Materials provided by Northwestern University. Original written by Stephanie Kulke. Note.

Content may be edited for style and length.Elderly patients with neurological conditions are significantly more likely to develop delirium shortly after they are hospitalised.A new study has discovered that a delayed transfer to a hospital floor is associated with greater short-term risk of delirium among patients aged 65 and over, and for those who arrive to the Emergency Department (ED) on days with higher risk of prolonged lengths of stay -- found to be Sunday and Tuesday.Delirium is an acute cognitive disorder characterised by altered awareness, attentional deficits, confusion, and disorientation. Current estimates of new-onset delirium highlight the fact that delirium overwhelmingly develops in medical settings (as high as 82 per cent in intensive care settings) compared to the community at large (between one per cent and two per cent). Research has shown that between 30 per cent and 40 per cent of all delirium cases are preventable.Authored by Valdery Moura Junior, an Executive PhD Research student at the Business School (formerly Cass), the study explores whether a combination of the care experienced at the ED and the delayed implementation of delirium prevention measures contribute to an increased risk of the disorder.

For example, it is possible that the bright lights and high ambient noise level of the ED for 24 hours a day will contribute to increased short-term risk.The findings showed that of the 858 patients who presented to the ED with a neurological emergency, delirium was documented in 234 (30 per cent) patients within the first 72 hours from ED arrival.This study also found that there was a connection between the onset of delirium and the day in which the patient arrived in the ED. Those arriving on Sundays and Tuesdays were more likely to demonstrate symptoms in a shorter time. Casual factors suggested include fewer hospital beds, delayed floor admission -- a waiting time greater than 13 hours -- and a greater proportion of elective pre-surgical admissions.Mr.

Moura has outlined several measures which can be taken to help prevent the likelihood of the onset of delirium in these settings, as well as reduce spending. These include an earlier initiation of delirium prevention measures. A quicker transfer from the ED to the hospital bed.

And improving communication across healthcare managers in primary care, emergency rooms, operating rooms, and post-acute services.Valdery Moura Junior, who is also computer scientist and technical leader at the Mass General Brigham, a Boston-based non-profit hospital and physicians network that includes Brigham and Women's Hospital (BWH) and Massachusetts General Hospital (MGH), two of the Harvard Medical School's most prestigious teaching hospitals, said:"New-onset delirium in older patients alone will mean a high price for the health care system and poses a global challenge for healthcare managers, providers, and payors. Managing hospital capacity has been an enormous challenge throughout the ventolin, with many admission processes reviewed as a result with the goal of improving patient outcomes. Our study may help to identify feasible targets to improve processes between ED and the rest of the hospital."Professor Feng Li, Chair of Information Management at the Business School, said.

"This is an excellent example where routine operational data in a hospital can be used to identify anomaly and improve patient outcomes. Valdery's research demonstrated that more systematic use of such data can lead to significant improvement in the management of hospital capacity and operational processes, and most of all, quality of patient care." Story Source. Materials provided by City University London.

Original written by Luke Lambert. Note. Content may be edited for style and length..

When experiencing the ups and downs of a virtual roller coaster ride, people who get migraine headaches reported more dizziness and motion sickness than people who do not get migraines, according to a new study published in the July 7, 2021, online issue of Neurology, the medical journal of the American Academy of Neurology.Researchers also found that people who get migraines also had more nerve cell activity in certain areas of the brain http://crossfitvtg.com/uncategorized/monday-210823/ during the virtual roller coaster ride and less activity can i buy ventolin over the counter uk in other areas. Researchers said this abnormal processing of the visual motion stimuli in the brain was linked to migraine disability and more susceptibility to motion sickness."Millions of people regularly experience painful and debilitating migraine headaches that can reduce their quality of life," said study author Arne May, MD, PhD, of the University of Hamburg in Germany. "People with migraine often can i buy ventolin over the counter uk complain of dizziness, balance problems and misperception of their body's place in space during migraine. By simulating a virtual roller coaster ride, our study found that some of these problems are not only magnified in people who experience migraine, but they are also associated with changes in various areas of the brain. By identifying and pinpointing these changes, our research could lead to a better understanding of migraine which could in turn lead to the development of better treatments."The study involved 20 people can i buy ventolin over the counter uk with migraine who were compared to 20 people without migraine.

Participants had an average age of 30 and more than 80% were women. People with migraine had an average of four migraines per month.Researchers used functional magnetic resonance imaging (fMRI) to take brain scans of each participant as they watched videos can i buy ventolin over the counter uk to experience the virtual roller coaster rides. No participants experienced a migraine during the virtual rides. After the virtual rides, participants were surveyed about their perceived levels of dizziness, motion sickness and other symptoms.Researchers found that 65% of people with migraine experienced dizziness compared can i buy ventolin over the counter uk to 30% of people without migraine. On a questionnaire about motion sickness, which scored symptom intensity on a scale of 1-180, those with migraine had an average score of 47 compared to an average score of 24 for people without migraine.

People with migraine also experienced symptoms longer, an average of 1 minute and 19 can i buy ventolin over the counter uk seconds compared to an average of 27 seconds. Their symptoms were also more intense.From the brain scans, researchers were able to identify changes in nerve cell activity based on blood flow to certain areas of the brain. People with migraine had increased activity in five areas of the can i buy ventolin over the counter uk brain, including two areas in the occipital gyrus, the visual processing area of the brain, and decreased activity in two other areas including the middle frontal gyrus. These brain changes correlated with migraine disability and motion sickness scores."One other area of the brain where we found pronounced nerve cell activity in people with migraine was within the pontine nuclei, which helps regulate movement and other motor activity," said May. "This increased activity could relate to abnormal transmission of visual, auditory and sensory can i buy ventolin over the counter uk information within the brain.

Future research should now look at larger groups of people with migraine to see if our findings can be confirmed."The study was supported by the German Research Foundation. Story Source can i buy ventolin over the counter uk. Materials provided by American Academy of Neurology. Note. Content may be edited for style and length.There are many reasons that an intranasal treatment against the asthma ventolin would be helpful in the fight against asthma treatment s, University of Alabama at Birmingham immunologists Fran Lund, Ph.D., and Troy Randall, Ph.D., write in a viewpoint article in the journal Science.That route of vaccination gives two additional layers of protection over intramuscular shots because it produces.

1) immunoglobulin A and resident memory B and T cells in the respiratory mucosa that are an effective barrier to at those sites, and 2) cross-reactive resident memory B and T cells that can respond earlier than other immune cells if a viral variant does start an ."Given the respiratory tropism of the ventolin, it seems surprising that only seven of the nearly 100 asthma treatments currently in clinical trials are delivered intranasally," Lund and Randall said. "Advantages of intranasal treatments include needle-free administration, delivery of antigen to the site of , and the elicitation of mucosal immunity in the respiratory tract."Their viewpoint article goes on to detail the individual advantages and challenges of each of the seven intranasal treatment candidates. Six are viral vectors, including three different adenoventolin vectors, and one candidate each for live-attenuated influenza ventolin, live-attenuated respiratory syncytial ventolin and live-attenuated asthma. The seventh treatment candidate is an inert protein subunit.Among the drawbacks of using ventolines that people may have encountered before is negative interference from anti-vector antibodies that impair treatment delivery. And because of the minimal risk of reversion for the live-attenuated asthma ventolin, it would likely be contraindicated for infants, people over 49 and immunocompromised persons."Notably absent from the list of intranasal treatments are those formulated as lipid-encapsulated mRNA," Lund and Randall said, listing some of the challenges and adverse side effects that accompany that approach."Ultimately, the goal of vaccination is to elicit long-lived protective immunity," the UAB researchers concluded.

Comparing the benefits and disadvantages of intranasal vaccination against intramuscular vaccinations, they suggest that perhaps effective vaccination need not be restricted to a single route."The ideal vaccination strategy," the immunologists concluded, "may use an intramuscular treatment to elicit a long-lived systemic immunoglobulin G response and a broad repertoire of central memory B and T cells, followed by an intranasal booster that recruits memory B and T cells to the nasal passages and further guides their differentiation toward mucosal protection, including immunoglobulin A secretion and tissue-resident memory cells in the respiratory tract."At UAB, Lund is a professor of microbiology and holds the Charles H. McCauley Chair of Microbiology. Randall is a professor of medicine in the Division of Clinical Immunology and Rheumatology, and he holds the Meyer Foundation William J. Koopman, M.D., Endowed Chair in Immunology and Rheumatology. Story Source.

Materials provided by University of Alabama at Birmingham. Original written by Jeff Hansen. Note. Content may be edited for style and length.Small and seemingly specialized, the brain's locus coeruleus (LC) region has been stereotyped for its outsized export of the arousal-stimulating neuromodulator norepinephrine. In a new paper and with a new grant from the National Institutes of Health, an MIT neuroscience lab is making the case that the LC is not just an alarm button but has a more nuanced and multifaceted impact on learning, behavior and mental health than it has been given credit for.With inputs from more than 100 other brain regions and sophisticated control of where and when it sends out norepinephrine (NE), the LC's tiny population of surprisingly diverse cells may represent an important regulator of learning from reward and punishment, and then applying that experience to optimize behavior, said Mriganka Sur, Newton Professor of Neuroscience in The Picower Institute for Learning and Memory and the Department of Brain and Cognitive Sciences at MIT."What was formerly considered a homogenous nucleus exerting global, uniform influence over its many diverse target regions, is now suggested to be a heterogeneous population of NE-releasing cells, potentially exhibiting both spatial and temporal modularity that govern its functions," wrote Sur, postdoc Vincent Breton-Provencher and graduate student Gabrielle Drummond in a review article published last month in Frontiers in Neural Circuits.The article presents copious emerging evidence from Sur's group and many others, suggesting that that the LC may integrate sensory inputs and internal cognitive states from across the brain to precisely exert its NE-mediated influence to affect actions -- by throttling NE to the motor cortex -- and the processing of resulting feedback of reward or punishment -- by throttling NE to the prefrontal cortex.To investigate that hypothesis, the team has begun working with a $2.1 million, 5-year NIH grant awarded in April.

In this study they are engaging mice in learning tasks where they are cued by tones of varying pitches and volumes. Over the course of training the mice will learn that when a tone is high pitched, pressing a lever will yield a reward and when the tone is low pitched, the correct response would be to not push lest it experience an unpleasant air puff. By varying the tone volume, the experimenters will vary the certainty the mice can feel that they heard the cue correctly.The hypothesis (borne out by preliminary data) predicts that the NE will matter in multiple crucial ways, Sur said. When the mouse hears the cue tone, if the pitch is low the LC would send less NE via a cadre of neurons to the motor cortex, reflecting the animal's belief that the lever should not be pushed because no reward will be forthcoming. Meanwhile the lower the volume, the less certainty the animal has in its decision.

Conversely, a high tone of high volume would send more NE, reflecting the animal's certainty that pushing the lever would produce a reward.After the mouse has acted, the more surprising the feedback, the more NE it will produce and send via a distinct group to the prefrontal cortex, stimulating greater learning. So for instance, if the mouse hears a faint, high tone and gingerly presses the lever, the surprise of a resulting reward will stimulate a strong output of NE to instruct the prefrontal cortex because its expectations weren't very high. Whenever a mouse guesses wrong and look what i found feels an air puff, that will stimulate the strongest NE release to the prefrontal cortex. After such dynamics, Sur's team has observed consistent performance changes on the subsequent trial."This is a way by which norepinephrine can be thought of as an arousal signal, but it's also, importantly, in the context of ongoing function a learning signal," Sur said. "It is both an execution signal and a learning signal, for both of which we can describe the actual quantitative relationships."Not only will the team be measuring the activity of LC-NE neurons, they'll also take them over using optogenetics (in which neurons can be controlled with light), so that they can silence or amplify LC-NE output to show how doing each affects action and learning.Understanding the true nature of how the LC works could be useful for improving treatments for certain disorders, Sur said.

A potential treatment for PTSD, for instance, involves damping receptiveness to NE, but that also promotes drowsiness. A more principled and precise treatment could improve efficacy and reduce those side effects, he said."The hope is to affect the anxiety but not make you sleepy, if we understand the targets and theory behind it," Sur said. "That is the hope of basic science for treating disorders -- to make things more and more specific, to define the circuits and the specificity of functions that a system is involved in."Moreover the LC is an early region affected in Alzheimer's disease, he said. Addressing that loss in the right way could help sustain forms of learning and cognition.One of the keys to a long life may lie in your net worth.In the first wealth and longevity study to incorporate siblings and twin pair data, researchers from Northwestern University analyzed the midlife net worth of adults (mean age 46.7 years) and their mortality rates 24 years later. They discovered those with greater wealth at midlife tended to live longer.The researchers used data from the Midlife in the United States (MIDUS) project, a longitudinal study on aging.

Using data from the first collection wave in 1994-1996 through a censor date of 2018, the researchers used survival models to analyze the association between net worth and longevity.To tease apart factors of genetics and wealth, the full sample was segmented into subsets of siblings and twins.In the full sample of 5,400 adults, higher net worth was associated with lower mortality risk. Within the data set of siblings and twin pairs (n=2,490), they discovered a similar association with a tendency for the sibling or twin with more wealth to live longer than their co-sibling/twin with less. This finding suggests the wealth-longevity connection may be causal, and isn't simply a reflection of heritable traits or early experiences that cluster in families."The within-family association provides strong evidence that an association between wealth accumulation and life expectancy exists, because comparing siblings within the same family to each other controls for all of the life experience and biology that they share," said corresponding author Eric Finegood, a postdoctoral fellow in the Institute for Policy Research at Northwestern.The researchers also considered the possibility that previous health conditions, such as heart disease or cancer, could impact an individual's ability to accrue wealth due to activity limitations or healthcare costs -- possibly confounding any association between wealth and longevity. To address this, they re-analyzed the data using only individuals without cancer or heart disease. However, even within this sub-group of healthy individuals, the within-family association between wealth and longevity remained.The study's senior author is Greg Miller, the Louis W.

Menk Professor of Psychology and faculty fellow at the Institute for Policy Research at Northwestern. Co-authors of the study include other Northwestern faculty and trainees (Edith Chen, Daniel Mroczek, Alexa Freedman) as well as researchers from the University of Illinois, Urbana-Champaign. West Virginia University. Purdue University. And the University of Minnesota."Far too many American families are living paycheck to paycheck with little to no financial savings to draw on in times of need, said Miller.

Note. Content may be edited for style and length.Elderly patients with neurological conditions are significantly more likely to develop delirium shortly after they are hospitalised.A new study has discovered that a delayed transfer to a hospital floor is associated with greater short-term risk of delirium among patients aged 65 and over, and for those who arrive to the Emergency Department (ED) on days with higher risk of prolonged lengths of stay -- found to be Sunday and Tuesday.Delirium is an acute cognitive disorder characterised by altered awareness, attentional deficits, confusion, and disorientation. Current estimates of new-onset delirium highlight the fact that delirium overwhelmingly develops in medical settings (as high as 82 per cent in intensive care settings) compared to the community at large (between one per cent and two per cent). Research has shown that between 30 per cent and 40 per cent of all delirium cases are preventable.Authored by Valdery Moura Junior, an Executive PhD Research student at the Business School (formerly Cass), the study explores whether a combination of the care experienced at the ED and the delayed implementation of delirium prevention measures contribute to an increased risk of the disorder. For example, it is possible that the bright lights and high ambient noise level of the ED for 24 hours a day will contribute to increased short-term risk.The findings showed that of the 858 patients who presented to the ED with a neurological emergency, delirium was documented in 234 (30 per cent) patients within the first 72 hours from ED arrival.This study also found that there was a connection between the onset of delirium and the day in which the patient arrived in the ED.

Those arriving on Sundays and Tuesdays were more likely to demonstrate symptoms in a shorter time. Casual factors suggested include fewer hospital beds, delayed floor admission -- a waiting time greater than 13 hours -- and a greater proportion of elective pre-surgical admissions.Mr. Moura has outlined several measures which can be taken to help prevent the likelihood of the onset of delirium in these settings, as well as reduce spending. These include an earlier initiation of delirium prevention measures. A quicker transfer from the ED to the hospital bed.

Materials provided by City University London. Original written by Luke Lambert. Note. Content may be edited for style and length..

Where should I keep Ventolin?

Keep out of the reach of children. Store albuterol tablets in the refrigerator (36 to 46 degrees F). Other tablets may be stored at room temperature (59 to 86 degrees F), check the packaging or ask your pharmacist. Keep container closed tightly. Throw away any unused medicine after the expiration date.

Is proventil and ventolin the same thing

This article is proventil and ventolin the same thing contains affiliate links to products. We may receive a commission for purchases made through these links.CBD and THC are definitely two of the most well-known cannabinoids. CBD is known for is proventil and ventolin the same thing its calming, therapeutic effects while THC is famous for its psychoactive effects that cause feelings of euphoria and sometimes confusion. While CBD and THC have both had plenty of time in the spotlight, lesser-known cannabinoids, such as CBG, are capturing interest from consumers and scientists alike.Initial studies show that CBG may have similar characteristics of CBD.

Both of these cannabinoids have is proventil and ventolin the same thing no psychoactive properties. Instead, they offer antioxidant, anti-inflammatory, neuroprotective, and analgesic properties.Hereâs what you need to know about the similarities and differences between CBG and CBD. We'll also take a look at some of the top CBD products on the market.What is CBG?. CBG, which stands for cannabigerol, is is proventil and ventolin the same thing one of more than 100 cannabinoids found in hemp and cannabis plants.

Young hemp plants produce cannabigerolic acid (CBGA). As the plant matures, CBGA is proventil and ventolin the same thing breaks down into cannabidiolic acid (CBDA) and tetrahydrocannabinolic acid (THCA). These two compounds are then converted into CBD and THC. Any leftover CBGA is converted into CBG.Even though CBG was first isolated back in 1964, the cannabinoid didnât get a lot of attention, so there are very few studies about the compound.

Modern research is in preclinical stages, but from what we know so far, CBG is proventil and ventolin the same thing may have various therapeutic side effects.Itâs possible that CBG has strong pain-relieving properties that may be more effective than THC. CBG may interact with the CB1 and CB2 receptors of the endocannabinoid system, which influence inflammation, pain, and even heat sensitivity. The cannabinoid is proventil and ventolin the same thing may also have antidepressant, anticancer, and antibacterial qualities.What is CBD?. CBD, which stands for cannabidiol, naturally occurs in high concentrations in hemp and cannabis plants.

CBD was first isolated all the way back in the 1930s but was mostly put aside until the 1970s when scientists determined it may be an effective anti-convulsant.Over the years, research has confirmed many of the therapeutic benefits that CBD offers, including anti-anxiety, pain-relieving, anti-nausea, and sedative qualities. CBD has also shown to be an effective treatment for severe forms of childhood epilepsy and is used in an FDA approved drug, Epidiolex is proventil and ventolin the same thing. Over the last few years, CBD has become the cannabinoid of choice, not only for the many therapeutic benefits it offers, but also because it has no psychoactive properties. Unlike THC, CBD offers pain relief and other benefits without the risk is proventil and ventolin the same thing of paranoia, anxiety, or impaired cognitive function.

Like CBG, CBD interacts with the CB1 and CB2 receptors.Differences Between CBG &. CBDThough they offer very similar therapeutic properties, CBG and CBD is proventil and ventolin the same thing do have some differences. For example, the two cannabinoids have different molecular structures. This means that the arrangement of carbon, hydrogen, and oxygen is different.

Molecular structure impacts how the cannabinoid binds with receptors and also impacts bioavailability.CBG is proventil and ventolin the same thing and CBD are also unique in how they activate receptors. One study looked at how CBG and CBD interact with the 5-HT1A serotonin receptor. CBG behaves as an antagonist at that receptor, where CBD has strong anti-nausea effects, which means it acts like an agonist.So even though the two cannabinoids are similar, when bound to the same place, they have opposing effects on is proventil and ventolin the same thing this specific receptor.CBG and CBD differ in how they stimulate the appetite. A study conducted on rats found that CBG encouraged the animals to eat two times their normal food intake.

But, a study conducted on CBD found that the cannabinoid significantly reduces total food intake.Therapeutic Benefits of CBG vs CBDThere isnât a lot of research that has delved into the therapeutic effects of CBG. However, preclinical studies offer a little bit of insight as to how the cannabinoid may interact is proventil and ventolin the same thing with the body. Like CBD, CBG doesnât have any psychoactive properties. Instead, it offers other therapeutic benefits, including:â Appetite stimulationâ Anti-cancer propertiesâ Antibiotic propertiesâ Potential treatment for MRSA bacterial sAs interest in CBG continues to grow, we can expect to learn more about the cannabinoid over the next few years is proventil and ventolin the same thing.

The hope is that more clinical studies and research will be conducted so that we can get a better understanding of the benefits that CBG offers.CBD is in a similar situation, but there are far more studies that have been conducted. Research has found that CBD offers a host of therapeutic benefits, including:â Pain reliefâ Improved sleepâ Lowered stress and anxietyâ Neuroprotective propertiesBut as with any cannabinoid, there is always more to learn. Most studies have been conducted on animals, so human trials are crucial to fully understand how CBG and CBD interact in the is proventil and ventolin the same thing body.Are you interested in trying CBD, CBG, or maybe a product that contains both?. Here are some of the best hemp-derived products available on the market today.Top 4 CBD ProductsVerma Farms is one of the highest-quality CBD brands that weâve found.

All of their products are is proventil and ventolin the same thing made with top notch ingredients that are organic and all natural. They offer an extensive collection of items to choose from, including gummies, oils, capsules, topicals, and even tropical dried fruit!. Verma Farms uses broad spectrum extract, which contains is proventil and ventolin the same thing all of the wellness-boosting plant compounds, with the exception of THC. This means you can enjoy the benefits of minor cannabinoids, terpenes, flavonoids, and fatty acids!.

This is a brand that takes a Hawaiian approach to making CBD. All of their products are influenced is proventil and ventolin the same thing by the islands, so you can drift off to your own tropical paradise.Penguin is another top brand that we highly recommend. They offer some of the purest and most potent CBD products on the markets. With a well-rounded selection of products, youâre sure to find the CBD is proventil and ventolin the same thing that best meets your lifestyle needs.

Choose from gummies, oils, topicals, and capsules.Penguin only uses the best ingredients, including broad-spectrum CBD oil that is extracted from Oregon grown hemp. Because these products contain no THC, you can enjoy peak mental performance while also enjoying the many therapeutic benefits that CBD has to offer.Whatâs even better is that the brand offers some delicious flavors. Penguinâs CBD gummy worms are coated is proventil and ventolin the same thing in a tangy sugar that will make your taste buds go wild. Thereâs also deliciously flavored CBD oil, including options such as Cookies &.

Cream, Citrus, Strawberry, and is proventil and ventolin the same thing Mint.Feel more balanced and in sync with Evn CBD. This is the go-to brand for anyone who wants a natural sense of calm and relaxation. These products are formulated to boost focus, restore balance, aid in recovery, and even improve endurance.Evn CBD products are all made with broad spectrum extract, which is rich in cannabinoids, terpenes, phytonutrients, and other health-boosting compounds. Whether you enjoy the brandâs CBD gummy bears or mint-flavored tincture, youâre sure to feel better than ever.Aside from oils and gummies, Evn CBD is proventil and ventolin the same thing also offers topical products as well as capsules so that you can enjoy CBD on the go.Medterra uses the highest-quality CBD in all of its product formulations.

In fact, the brand is one of the few that are U.S. Hemp Authorityâ¢ Certified, which shows that Medterra is dedicated to is proventil and ventolin the same thing creating safe, effective, and legal CBD products.Medterra offers one of the biggest collections of products, including:â CBD gummiesâ CBD oilâ CBD supplementsThe brand also offers three distinct collections. The CBD Full Spectrum collection is a line of products that are made with high quality full spectrum, whole plant CBD extract. The Ua Broad Spectrum + CBG collection offers the added benefits of CBG.

Last is the CBD Wellness collection, which combines CBD with superfoods, botanicals, adaptogens, and medicinal mushrooms.Final ThoughtsCBD and is proventil and ventolin the same thing CBG are two similar yet unique cannabinoids. While hemp plants contain a much higher dose of CBD, CBG can also be extracted and used in all sorts of products. These two cannabinoids offer a variety of therapeutic benefits, and when combined, can provide highly effective relief that keeps you is proventil and ventolin the same thing feeling your best.Synthetic cannabinoids, commonly known as âspiceâ and âK2,â are substances that mimic the psychoactive chemical compounds present in cannabis. They're commonly used by vulnerable populations, including people experiencing homelessness, and have triggered mass overdoses.

Though traditionally advertised as a harmless alternative is proventil and ventolin the same thing to marijuana, they can do far more serious damage than their naturally occurring predecessors. Studies suggest that synthetic cannabinoids can cause acute anxiety, panic and psychosis. These compounds also have high abuse and addiction potential, according to research published in Psychopharmacology this September. Based on data gathered between 2015 and 2016, this study represents the most comprehensive analysis so far of spice withdrawal is proventil and ventolin the same thing symptoms and the first to compare their severity with cannabis withdrawals.

The crucial finding. Continued spice consumption is proventil and ventolin the same thing produces worse cravings than cannabis. The survey data included 284 people who said they had consumed synthetic cannabinoids 10 times or more and made attempts to stop within the previous year. Most respondents noted that their attempts triggered three or more withdrawal symptoms, including insomnia, irritability, despondency and craving â and that these symptoms were serious.âAlthough originally produced as a legal alternative to cannabis, our findings show that spice is a far more harmful drug,â lead study author and psychology Ph.D.

Student Sam is proventil and ventolin the same thing Craft said in a statement last month. ÂItâs therefore important that greater effort is made to ensure that spice is not used as a substitute for cannabis, or any other drug, and that people experiencing problems with spice should be supported with treatment.â What Are Synthetic Cannabinoids?. These lab-made alternatives weren't developed is proventil and ventolin the same thing with recreational use in mind. In the 1990s, John W.

Huffman and a team of fellow chemists at Clemson University created some of the first formulas for synthetic cannabinoid receptor agonists (SCRAs), a family of substances that imitate the physiological and psychological impacts of cannabis on our systems. Huffman created hundreds of these is proventil and ventolin the same thing substances to study naturally occurring cannabinoids, the chemical compounds found in marijuana. âThese are all drugs that he synthesized for scientific pursuits,â says Deepak Cyril DâSouza, a practicing psychiatrist and professor at Yale University School of Medicine. ÂWhen he synthesized these compounds, he published scientific papers where he is proventil and ventolin the same thing described in exquisite detail how these compounds were synthesized.â In almost no time at all, chemists abused these instructions.

Starting in the 2000s, chemical companies (that some specialists believe to be based in China) produced massive quantities of powdered synthetic cannabinoids, which they then submerged in acetone solutions and sprayed over shreds of plant matter. These businesses then packaged the product and sold it, says DâSouza, sometimes as incense and potpourri and sometimes as âspice,â a recreational smoking mixture which would supposedly produce psychoactive responses similar to marijuana is proventil and ventolin the same thing â without the health and legal risks. "There are these unscrupulous chemists out there in the world working in unsanctioned, illegal labs, who have used their creativity and ingenuity to come up with new molecules every morning,â says Ruben Baler, who serves as the health scientist administrator at the National Institute on Drug Abuse. ÂThere is an infinite array of possibilities for these chemists to come up with.âWhy Spice Is So StrongUltimately, thousands of synthetic cannabinoid users appeared at medical centers in the U.S.

Throughout the is proventil and ventolin the same thing 2000s and 2010s. They complained of chest pains, palpitations, arrhythmia, nausea, vomiting, twitches, tremors and seizures. Some patients lost their coordination and consciousness is proventil and ventolin the same thing. Others faced changes in mood and memory and felt anxious, aggressive, paranoid and suicidal.

Those who consumed spice repeatedly saw the worst symptoms, including prolonged psychotic bouts. Initially, doctors didn't fully understand what was going on, says DâSouza, because these were such new compounds.In 2008, chemists determined that the active ingredient in several spice mixtures was a compound called JWH-018, one of Huffmanâs first synthetic cannabinoids â an essential finding is proventil and ventolin the same thing in explaining the patientsâ mysterious, extreme reactions. Several factors contribute to synthetic cannabinoidsâ intensity, says DâSouza, who co-authored a comprehensive overview of these substances in 2013. First and foremost, though synthetic cannabinoids imitate marijuanaâs principal psychoactive cannabinoid, tetrahydrocannabinol is proventil and ventolin the same thing (THC), DâSouza says they are 10 to 200 times more potent than the original.

This fact accounts for their significant side effects. Synthetic cannabinoids are also absorbed differently within the brain and throughout the body. When someone consumes cannabis, the THC travels through their system and activates cannabinoid is proventil and ventolin the same thing receptors. This drives the psychoactive effects, DâSouza explains.

THC acts as a âpartial agonist,â meaning that is proventil and ventolin the same thing the compound stimulates the cannabinoid receptors only partially. But synthetic cannabinoids attach and respond to these receptors much more thoroughly as âfull agonists.â âLet's say you have a tap,â DâSouza says. ÂIf you open the tap only halfway, is proventil and ventolin the same thing you're only going to get about half the amount of water flowing through the tap â¦ a partial agonist would be the tap that's half opened.â Meanwhile, full agonists such as synthetic cannabinoids would supply a flood of water and, thus, a surge of stronger symptoms. The chemical structure of synthetic cannabinoids may deliver feelings of relaxation and calm similar to those that accompany marijuana.

But they could also confer heightened danger and unpredictability. While the high will be much is proventil and ventolin the same thing higher, so will the anxiety, paranoia and psychosis. Purity issues only make matters worse. Synthetic cannabinoids is proventil and ventolin the same thing can also cause severe health outcomes due to their unregulated production process, says Peter H.

Addy, a professional counselor in Oregon and a co-author on DâSouzaâs 2013 paper. ÂTheir creation process and testing process are unregulated,â he says. ÂSo, thereâs all sorts of reasons why synthetic cannabinoids are is proventil and ventolin the same thing bad for you.â It isnât clear how pure or potent these substances are, nor can users know what synthetic cannabinoids have been mixed with.Regulating Synthetic CannabinoidsSince 2008, several countries have passed restrictions against JWH-018 and similar synthetic substances. In the U.S., for instance, the Synthetic Drug Abuse Prevention Act of 2012 placed several synthetic cannabinoids, including JWH-018, into the strictest classification of illicit drugs.

Yet, these regulations have their limits â synthetic cannabinoid manufacturers can is proventil and ventolin the same thing make minor adjustments to their productsâ chemical structure to circumvent these laws. Because the first generation of synthetic cannabinoids were made illegal in the U.S., Addy says, manufacturers came up with a second generation. Cannabinoid molecules can be altered with the tiniest tweak (like moving a specific moleculeâs position) and become an entirely different chemical, he explains. This scenario is proventil and ventolin the same thing prompts chemical companies to constantly produce newer, non-regulated compounds.

ÂItâs this ridiculous cat-and-mouse game where state or federal governments will outlaw certain compounds, but there's many more to choose from,â he says. In 2012, five percent of adults in the is proventil and ventolin the same thing U.S. Aged 19 to 30 said that they had consumed synthetic cannabinoids at some point in the previous year, according to a 2021 survey by the National Institute on Drug Abuse. That said, these substances are not as prevalent today as around a decade ago.

Last year, only 1.2 percent of people in the same age range reported consuming is proventil and ventolin the same thing them in 2020. This decline may relate to recent shifts in cannabis regulation. Most people would is proventil and ventolin the same thing likely pick natural cannabis over synthetic cannabinoids whenever legally accessible, says Addy, meaning that the movement to decriminalize marijuana may diminish many peopleâs demand for synthetic cannabinoids as an alternative. ÂThe main point is that this phenomenon is a direct result of the criminalization of cannabis,â he says.

ÂCriminalizing cannabis is proventil and ventolin the same thing is just making things worse for everyone. K2 is an obvious and extreme example of that.â While it emerged in the increasingly foregone era of criminalized cannabis, DâSouza says synthetic cannabinoid use (and the resulting health risks) may never disappear completely. Fully decriminalized cannabis may discourage potential users from trying synthetic cannabinoids for the first time, yet the drugâs potency could encourage prior users to stick with synthetics. When people who use cannabis try spice, they subsequently don't feel any effects if they return is proventil and ventolin the same thing to the relatively weaker cannabis, says DâSouza.The crux of the issue.

Synthetic cannabinoids have higher risks than those forged in nature. In fact, is proventil and ventolin the same thing the threat posed by these substances is so immense itâs built into their identity and marketed to thrill seekers. ÂThey were initially sold as âK2,ââ says DâSouza. ÂK2 is one of the most treacherous mountains â¦ The name speaks for itself.

It can is proventil and ventolin the same thing get you really high but can also be really dangerous.âThis article contains affiliate links to products. We may receive a commission for purchases made through these links.CBD is here to stay. In fact, over the last few years, the popularity of is proventil and ventolin the same thing CBD products has only continued to grow. CBD is an effective alternative treatment for some of the most common ailments, including pain, poor sleep, stress, anxiety, and even depression.

Whatâs great about CBD is that it can be infused into all different types of products. Today, youâll find CBD-infused gummies, capsules, and edible options such as gummies is proventil and ventolin the same thing. Oils and tinctures are also popular, offering the power of CBD in just a few drops.Interested in trying CBD but donât know where to start?. Weâve got you covered! is proventil and ventolin the same thing.

Keep reading to learn the ins and outs of what CBD is and what the cannabinoid can be used for. Weâll also discuss some is proventil and ventolin the same thing of the top CBD products on the market.What is CBD?. CBD, also known as cannabidiol, is a cannabinoid that is extracted from hemp. CBD has no psychoactive properties, which means it wonât get you high or cause you to feel mentally altered in any way.

Instead, the cannabinoid is best known for its therapeutic benefits, including the ability to calm the mind and body.When ingested, CBD reacts is proventil and ventolin the same thing with the CB1 and CB2 receptors of the endocannabinoid system (ECS). This system spans throughout the body and helps to regulate key bodily functions. Research has found that ECS plays a role in many physiological functions, including:â Chronic painâ Appetite stimulationâ is proventil and ventolin the same thing Metabolismâ Inflammationâ Immune system responseBy interacting with the ECS, CBD is able to promote healthy responses to stress, reduce inflammation, and offer a host of other benefits.What Are the Benefits of Taking CBD Oil?. One of the quickest and most convenient ways to use CBD is in oil form.

All you have to do is place a few drops under your tongue. This method offers quick results that is proventil and ventolin the same thing can last for up to a few hours. CBD oil can also be mixed into food or your favorite drink, such as a smoothie.Here are some of the top benefits that CBD oil offers.Natural Pain ReliefOne of the most widely sought therapeutic benefits that CBD offers is relief from aches and pains, including chronic pain caused by underlying health conditions. For those who suffer from arthritis, fibromyalgia, and even neuropathic pain, CBD may is proventil and ventolin the same thing be an effective all-natural alternative for living a pain-free life.More often than not, people use over-the-counter options, such as NSAIDs to treat their pain.

Others require stronger treatments, such as prescription painkillers in order to get through the day.The problem with these conventional options is that they pose all sorts of health risks and negative side effects, including the risk of substance abuse and addiction. Thereâs a reason why the U.S. Continues to struggle with its opioid epidemic.CBD is proventil and ventolin the same thing on the other hand, has a very low risk of minor side effects, such as dry mouth or appetite changes. CBD also has no addictive properties, so the risk of a negative experience is all but zero.Reduced Anxiety &.

DepressionDid you know that over 300 million people suffer from depression and/or is proventil and ventolin the same thing anxiety?. While most mental health conditions are treated using prescription medications, such as SSRIs, CBD may be a promising alternative option.Research has found that CBD may reduce the symptoms of anxiety and depression. A 2014 study found that CBD has positive interactions with serotonin receptors in the brain. This is is proventil and ventolin the same thing the neurotransmitter that impacts one's emotional state, happiness, and overall wellbeing.Balanced serotonin levels are often the most critical component in helping those who suffer from depression.

Imbalanced serotonin levels have also been linked to an increased risk of anxiety disorders, including social and general anxiety.Lowered Stress LevelsLife is stressful but having high levels of stress on a constant basis can take a toll on your physical, mental, and social health. While there are many ways to relieve stress, one of the most effective options is CBD oil.Various studies have found is proventil and ventolin the same thing that CBD works to reduce anxiety and stress by changing the brainâs reaction to anxiety. One study even found that CBD may change blood flow patterns in the regions of the brain that are associated with anxiety and stress.When youâre less stressed and worried, youâll find that life is much more enjoyable. Waking up feeling focused and energized instead of worn down and tired can make such a difference in your health and happiness.A few drops of CBD oil can take the edge off after a long, stressful day.Improved SleepSleep disturbances impact millions of people each night is proventil and ventolin the same thing.

Whether racing thoughts or aches and pains keep you up at night, CBD can help. Because CBD quells many of the underlying factors that cause poor sleep, itâs a great supplement to take in order to sleep better at night.There are even CBD oil products on the market that are infused with calming, sleep-inducing ingredients such as melatonin, valerian root, HTP-5, and tryptophan.When you get the sleep that your mind and body need, youâll be more productive, more energetic, and healthier.Other BenefitsThese benefits only scratch the surface. While there is still much is proventil and ventolin the same thing more to learn about CBD, existing research has uncovered all sorts of positive side effects. Aside from those discussed above, some of the other benefits that CBD may offer includes:â Eliminates and prevents acneâ Reduces blood pressureâ Protects the brainâ Potential treatment for drug addictionâ May help to fight cancerItâs important to note that everyone reacts differently to CBD.

In order to get the best results possible, itâs crucial to find a product that contains high quality CBD while also figuring out the dose is proventil and ventolin the same thing that best meets your needs.If youâre interested in trying CBD to ease pain or to keep your anxiety at bay, youâve come to the right place. Keep reading to learn about some of the best CBD oils on the market.Must-Try CBD OilsWhen it comes to CBD oil or any other CBD product, Verma Farms offers the best of the best. While they may be most known for their Hawaii-inspired gummies, Verma Farms also sells delicious CBD oil that is made with all natural, high-quality ingredients.All Verma Farms products are made using broad spectrum CBD extract that comes from pure, pesticide-free, non-GMO hemp. Whatâs great about this brandâs CBD is proventil and ventolin the same thing oil is that itâs available in a variety of flavors.

Whether youâre in the mood for watermelon, mango, strawberry, or mint, youâll find just the oil for you at Verma Farms.Penguin is another top-rated company in the CBD industry. In fact, the brand is proventil and ventolin the same thing has been rated #1 by Rolling Stone. Penguin offers some of the best CBD oil on the market, which is made with premium broad-spectrum CBD extract. All of their CBD is harvested from Oregon-grown hemp thatâs cultivated using rich soil along with safe, sensible farming practices.Penguin CBD oil not only contains refined CBD extract, but other quality ingredients such as MCT oil, hemp oil, terpenes, and natural flavor.

Oil is available in palate-pleasing flavors, is proventil and ventolin the same thing including Citrus, Mint, Strawberry, and Cookies &. Cream.With CBD oil from Penguin, you can embrace the cool, chill life of a penguin.Evn CBD creates all sorts of CBD-infused products, including gummies, capsules, and oils. Their CBD oil is meant to help you stay calm and collected, even during the most stressful is proventil and ventolin the same thing scenarios. Evn CBD oil is made with premium broad spectrum CBD oil, along with MCT oil, and stevia extract for a little sweetness.Each bottle of oil is also vegan, contains 0 THC, gluten-free, and non-GMO.

Evn CBD products are also lab tested to is proventil and ventolin the same thing ensure safety, quality, efficacy, and potency. Oil is available in two flavors. Mint and Natural, with Mint being the more popular flavor.While there isnât a huge assortment of flavors to choose from, what Evn CBD lacks in variety is made up in quality.Final ThoughtsCBD oil offers all sorts of therapeutic benefits that can be life changing for some people. While the cannabinoid is best known for its pain-relieving side effects, it also offers other benefits, including better sleep, clear skin, and lowered stress and anxiety.No is proventil and ventolin the same thing matter the benefits that you seek, the best experience comes from buying high-quality CBD oil.

Buy from the brands above if youâre looking for CBD oil that is pure and potent.When weâre stressed out, our bodyâs internal chemistry changes. Cortisol, the is proventil and ventolin the same thing primary stress hormone alongside adrenaline and norepinephrine, surges. As a result, blood sugar levels increase and more of that glucose is allocated to the brain.Thatâs good â the chain reaction helps our bodies in the so-called âfight-or-flightâ response, which has a deep evolutionary history and dwells within us even today. When potential predators were around, our ancient ancestors needed that extra boost to figure out whether to take them on or run away.

Nowadays, the same biochemical responses spring into action to help us react quickly when weâre under pressure.Our bodies, however, no longer only do this when weâre seriously threatened is proventil and ventolin the same thing. The same processes are triggered when weâre late for work or arguing with family members. And after dealing with a ventolin for over a year, many more Americans are becoming acquainted with prolonged psychological stress, according is proventil and ventolin the same thing to the American Psychological Association's latest Stress in America poll. Often times, our response to this stress can be more harmful than helpful.

ÂWe know that the immune system is capable of looking at these proteins and reacting,â says Willem van Eden, an immunologist at Utrecht University in the Netherlands. Protracted exposure to higher levels of stress hormones comes along with myriad side effects within the immune system.Largely speaking, stress can be divided into is proventil and ventolin the same thing two camps. The psychological and the physical, also known as physicochemical stress. While psychological stress is caused by worrying about something (whether itâs a predator or a looming deadline), physical stress comes from environmental factors such as air pollution, poor nutrition or exhaustion.Chronic is proventil and ventolin the same thing psychological stress has been linked to a subdued immune system.

But if the immune system becomes compromised and is no longer capable of dealing with physical stresses, this can promote the onset of disease.Scientists first noticed a link between stress and the strength of immune systems during animal experiments in the early 1980s. The experiments quickly progressed to humans when researchers began observing is proventil and ventolin the same thing medical students. They found that studentsâ immunity dropped around exam time with depleted levels of T-cells, some of the immune systemâs most important weapons in the fight against .Additional studies showed that chronic stress interferes with the molecular signals that immune cells use to communicate with each other. More recently, Scott Mueller, a professor at the University of Melbourne in Australia, demonstrated that stress can even stop immune cells from moving, physically blocking them from thwarting s and cancers.In a 2021 mouse-based study, Mueller and his colleagues used a special microscope â able to observe biological processes within living organisms â to create real-time images of a chemical messenger protein called noradrenaline.

The protein is found in higher concentrations under stressful conditions and obstructs the movement of various white blood cells that are important in the immune is proventil and ventolin the same thing response. This âexplains at least in part the widely observed relationship between stress and impaired immunity,â Mueller concludes in the study.Another study, published in Frontiers in Immunology in 2018, demonstrated the impact of stress on the immune system by inducing stress and cancerous tumor growth in mice â some of whom were additionally given an antidepressant. The results is proventil and ventolin the same thing showed a marked difference. The mice treated with antidepressants had significantly reduced cancer progression compared to those who werenât.While itâs possible that the antidepressants themselves possess cancer-fighting mechanisms, the researchers concluded that the inhibition of psychological distress (thanks to the antidepressant) is likely what restored antitumor immunity.Cancer isnât the only disease that seems to progress more rapidly under stressed environments.

Research has shown that chronic stress also increases a personâs risk of heart disease, weight gain, digestive issues, headaches, muscle pain and, of course, mental health problems such as anxiety and depression.In short, our immune systems are at their best when weâre not beset with high levels of cortisol pumping through our veins.This article contains affiliate links to products. We may receive a commission for purchases made through these links.CBD has become one of the most popular wellness products on the planet, is proventil and ventolin the same thing and for good reason. The chemical compounds that comprise CBD oil have a wide array of benefits, from sleep support to pain relief to calming properties that help with stress and anxiety, and more. Itâs no wonder that more and more people are turning to CBD oil as a part of their daily health regimen is proventil and ventolin the same thing.

But what exactly is CBD, and why does it interact the way it does with the human body?. Before we explore the world of cannabis and cannabinoids, such as CBD and THC, letâs take a look at some of the best CBD oils for sale in the UK. The Best CBD Oils UK When shopping for CBD oils, the key is to look is proventil and ventolin the same thing for quality. There are a lot of unscrupulous CBD companies out there looking to make a quick pound by selling CBD products with poor-quality CBD oil.

Here are some things to look for when shopping for is proventil and ventolin the same thing CBD oil. Organic CBD CBD companies canât legally advertise their products in the UK as being organic, but that doesnât mean itâs not important. The hemp plant, from which CBD oil is derived, is whatâs known as a bioaccumulator, meaning that it pretty much sucks everything up from its surrounding soil that it can. This is great for soaking in nutrients, but if there are pesticides or other chemicals in the soil, those will be pulled into the cannabis hemp plant as well, and end up in is proventil and ventolin the same thing your CBD oil product.

Thatâs why itâs vital to find a CBD company that uses naturally grown, organic hemp. CBD Extraction is proventil and ventolin the same thing Methods Originally, CBD oil was extracted from the hemp plant by means of steam distillation. This was clean, but inefficient. Then, manufacturers began to use various chemical is proventil and ventolin the same thing solvents to derive their CBD oil.

This was efficient, but not necessarily clean, as some of those solvents left a chemical residue behind in the oil. CO2 extraction provides the best of both worlds. Itâs efficient, pulling all of the is proventil and ventolin the same thing cannabinoids, terpenes and flavonoids from the cannabis hemp plant, and itâs clean, leaving no chemical residue behind. The need for purity doesnât end at the cannabis fields.

Insist on CBD oil extracted is proventil and ventolin the same thing with clean CO2. Third-Party Laboratory Testing Thereâs only one way to know if your CBD oil was organically grown and cleanly extracted with CO2, and thatâs by being able to see a lab report, produced by an independent third-party laboratory. Every legitimate CBD brand will make one of these reports readily available for each of its CBD products. This report will tell you whether youâre getting the potency of CBD youâve been promised, by giving you the exact amount of CBD and is proventil and ventolin the same thing other cannabinoids in your product.

It will also tell you if there are any chemical contaminants in your CBD product. If you donât see third-party lab reports on is proventil and ventolin the same thing a CBD companyâs website, find another CBD company!. Natural Ingredients Many CBD products, including CBD oil drops, contain ingredients other than cannabidiol oil. For instance, many CBD oil tinctures will contain a second carrier oil to help the body to better absorb the CBD.

But there are a vast variety of botanicals is proventil and ventolin the same thing and other ingredients that are used in CBD products, as well. Make sure to check the ingredients on the label to ensure that theyâre all natural. Unnecessary fillers or unhealthy chemicals can sink a CBD product just as easily as a is proventil and ventolin the same thing bad CBD oil. Based on the four criteria above â organic cultivation, CO2 extraction, third-party lab testing, and natural ingredients â the CBD oil drops from CBDfx hit the mark every time.

This shouldnât is proventil and ventolin the same thing come as a surprise. CBDfx has been doing this since 2014, and is one of the most respected brands in the business. They use only organically sourced CBD oil, extracted by clean CO2, and provide the independent, third-party lab reports to back it up. They also use natural ingredients, including is proventil and ventolin the same thing flavourings and colours, on all of their CBD products.

CBDfx sells two quality CBD oil tinctures in the UK. CBDfx CBD is proventil and ventolin the same thing Oil Hemp Tincture Itâs pretty much impossible to find a cleaner ingredient profile on a CBD oil product. The only two ingredients in CBDfxâs CBD Oil Hemp Tincture are broad spectrum CBD oil and all-natural, coconut-derived medium-chain triglyceride oil to help with absorption. And thatâs it.

If youâre looking for a pure CBD experience with no is proventil and ventolin the same thing flashy add-ons, these are the perfect CBD oil drops. Pure, potent, and reasonably priced!. CBDfx CBD + CBG Oil Wellness Tincture Mother Nature provides CBD oil with a special is proventil and ventolin the same thing feature called the Entourage Effect. This is the phenomenon by which cannabinoids, terpenes and flavonoids work harder together than they would if taken individually.

Broad spectrum CBD provides a rich Entourage Effect experience on its own. But with their CBD + CBG Oil Wellness Tincture, CBDfx gives Mother Nature herself a little boost, by is proventil and ventolin the same thing blending CBD and the âMother of All Cannabinoids,â CBG, in an ideal 2:1 ratio, which helps your CBD to work as hard as it possibly can. But they donât stop there. These oil drops also contain curcumin and coenzyme Q10, commonly used in homeopathic remedies, coconut-derived MCT oil, and a special blend of terpenes for added is proventil and ventolin the same thing wellness benefits.

All of these ingredients combine to make a great daily wellness supplement, ideal for morning health regimens. Now that you have a sense of what to look for in a CBD oil â as well as two fantastic oils to get you started â letâs dig a little deeper into what CBD is, how CBD oil works, and what are some of the benefits of CBD oil. CBD Oil Benefits is proventil and ventolin the same thing. An Intro to CBD and Cannabis CBD is short for cannabidiol, and itâs one of over a hundred different compounds found in the cannabis plant, called cannabinoids.

Other cannabinoids include THC, CBG, CBN, CBG, and CBC is proventil and ventolin the same thing. Cannabinoids, like CBD, are created by structures on the surface of the cannabis plant called trichomes. Trichomes also produce terpenes is proventil and ventolin the same thing and flavonoids. All of these compounds are produced to protect the cannabis plant from the elements, as well animals that pose a threat.

Some of these compounds also attract pollinators, which helps the cannabis plant to thrive and replenish. CBD and Its Effects on the Endocannabinoid System Your body is proventil and ventolin the same thing produces its own cannabinoids. These are called endocannabinoids, and theyâre part of the endocannabinoid system. The ECS is a cell-signaling system that helps systems and organs throughout the body to maintain homeostasis, or is proventil and ventolin the same thing balance.

CBD and other cannabinoids mimic endocannabinoids, when introduced into the body. Interacting with receptors in the central and peripheral nervous systems, among others, they send signals to help regulate such crucial functions as memory, mood, appetite, motor control, sleep, pain, stress, and much more. It is the potential benefits is proventil and ventolin the same thing of this interaction with the endocannabinoid system that make CBD such an intriguing wellness supplement. The Benefits of CBD Oil Because hemp was historically lumped in with its high-THC sibling, marijuana, by the Home Office, research on its wellness benefits didnât begin in earnest until recent decades.

And even now, not enough research has been done for the government in the UK is proventil and ventolin the same thing to allow CBD to be used for medical purposes. In fact, CBD brands are not legally allowed to make any medical claims at all regarding its medicinal use. However, that doesnât mean that research isnât being done. And it certainly doesnât sweep aside, literally, thousands of years of use is proventil and ventolin the same thing for a variety of purposes.

Here are some of the areas where people have experienced the benefits of CBD or hemp oil. CBD Oil for Pain and Inflammation We mentioned that CBD interacts with the bodyâs endocannabinoid system, triggering support for the central and peripheral nervous systems is proventil and ventolin the same thing. The peripheral nervous system helps the body to manage pain and inflammation. Recent studies have shown that CBD has a wealth of potential in is proventil and ventolin the same thing helping to ease aches and pains, and to fight inflammation.

This is why youâll not only see products like CBD oil tinctures used for skin or muscle and joint issues, but youâll also see CBD creams and balms used as well. CBD Oil for Sleep One of the most desirable qualities of CBD is its calming properties. It relaxes the nerves and calms the mind and body is proventil and ventolin the same thing. This makes CBD an ideal supplement for sleep.

CBD oil before bed can help prepare the body for rest and allow you to sleep more is proventil and ventolin the same thing soundly through the night. CBD Oil for Stress and Anxiety Those same calming properties we mentioned above can also help to settle the nerves and ease stress. As long-term stressors can lead to anxiety, it can be incredibly beneficial to head them off at the pass with calming CBD oil. CBD Oil for General Wellness It really bears repeating just how promising is proventil and ventolin the same thing the potential benefits are regarding CBDâs interaction with the endocannabinoid system.

This system has such a wide reach in regulating many of the bodyâs most important functions. By helping to keep the ECS working consistently, CBD oil has the potential to make a huge difference in your is proventil and ventolin the same thing overall wellness. This is why, for many, CBD oil is a must for their daily health regimen. Can CBD Oil Benefit Your Health?.

For thousands of years, people have used cannabis is proventil and ventolin the same thing for a variety of health benefits. CBD oil has been a popular natural product used for issues ranging from pain and stress to sleep and more. Can CBD is proventil and ventolin the same thing oil benefit you?. Thereâs only one way to find out, and thatâs to experience it for yourself!.

This article contains affiliate http://blackshirtseo.com/best-online-flagyl/ links to can i buy ventolin over the counter uk products. We may receive a commission for purchases made through these links.CBD and THC are definitely two of the most well-known cannabinoids. CBD is known for its calming, can i buy ventolin over the counter uk therapeutic effects while THC is famous for its psychoactive effects that cause feelings of euphoria and sometimes confusion.

While CBD and THC have both had plenty of time in the spotlight, lesser-known cannabinoids, such as CBG, are capturing interest from consumers and scientists alike.Initial studies show that CBG may have similar characteristics of CBD. Both of these cannabinoids can i buy ventolin over the counter uk have no psychoactive properties. Instead, they offer antioxidant, anti-inflammatory, neuroprotective, and analgesic properties.Hereâs what you need to know about the similarities and differences between CBG and CBD.

We'll also take a look at some of the top CBD products on the market.What is CBG?. CBG, which stands for cannabigerol, is one of more than 100 cannabinoids found in hemp and cannabis can i buy ventolin over the counter uk plants. Young hemp plants produce cannabigerolic acid (CBGA).

As the plant matures, can i buy ventolin over the counter uk CBGA breaks down into cannabidiolic acid (CBDA) and tetrahydrocannabinolic acid (THCA). These two compounds are then converted into CBD and THC. Any leftover CBGA is converted into CBG.Even though CBG was first isolated back in 1964, the cannabinoid didnât get a lot of attention, so there are very few studies about the compound.

Modern research is in preclinical stages, but from what we know so far, CBG may have various therapeutic side effects.Itâs can i buy ventolin over the counter uk possible that CBG has strong pain-relieving properties that may be more effective than THC. CBG may interact with the CB1 and CB2 receptors of the endocannabinoid system, which influence inflammation, pain, and even heat sensitivity. The cannabinoid may also have antidepressant, anticancer, and antibacterial qualities.What can i buy ventolin over the counter uk is CBD?.

CBD, which stands for cannabidiol, naturally occurs in high concentrations in hemp and cannabis plants. CBD was first isolated all the way back in the 1930s but was mostly put aside until the 1970s when scientists determined it may be an effective anti-convulsant.Over the years, research has confirmed many of the therapeutic benefits that CBD offers, including anti-anxiety, pain-relieving, anti-nausea, and sedative qualities. CBD has also shown to be an effective treatment for severe forms can i buy ventolin over the counter uk of childhood epilepsy and is used in an FDA approved drug, Epidiolex.

Over the last few years, CBD has become the cannabinoid of choice, not only for the many therapeutic benefits it offers, but also because it has no psychoactive properties. Unlike THC, CBD offers pain relief and other benefits without the risk of paranoia, anxiety, can i buy ventolin over the counter uk or impaired cognitive function. Like CBG, CBD interacts with the CB1 and CB2 receptors.Differences Between CBG &.

CBDThough they offer very similar therapeutic properties, CBG can i buy ventolin over the counter uk and CBD do have some differences. For example, the two cannabinoids have different molecular structures. This means that the arrangement of carbon, hydrogen, and oxygen is different.

Molecular structure can i buy ventolin over the counter uk impacts how the cannabinoid binds with receptors and also impacts bioavailability.CBG and CBD are also unique in how they activate receptors. One study looked at how CBG and CBD interact with the 5-HT1A serotonin receptor. CBG behaves as an antagonist at that receptor, where CBD has strong anti-nausea effects, which means it acts like an agonist.So even though the two cannabinoids are similar, when bound to the same place, they have opposing effects on this specific receptor.CBG and CBD can i buy ventolin over the counter uk differ in how they stimulate the appetite.

A study conducted on rats found that CBG encouraged the animals to eat two times their normal food intake. But, a study conducted on CBD found that the cannabinoid significantly reduces total food intake.Therapeutic Benefits of CBG vs CBDThere isnât a lot of research that has delved into the therapeutic effects of CBG. However, preclinical studies offer a little bit of insight as to how can i buy ventolin over the counter uk the cannabinoid may interact with the body.

Like CBD, CBG doesnât have any psychoactive properties. Instead, it offers other therapeutic benefits, including:â Appetite stimulationâ Anti-cancer propertiesâ Antibiotic propertiesâ Potential treatment for MRSA bacterial sAs interest in CBG continues to grow, we can expect to learn more about the cannabinoid can i buy ventolin over the counter uk over the next few years. The hope is that more clinical studies and research will be conducted so that we can get a better understanding of the benefits that CBG offers.CBD is in a similar situation, but there are far more studies that have been conducted.

Research has found that CBD offers a host of therapeutic benefits, including:â Pain reliefâ Improved sleepâ Lowered stress and anxietyâ Neuroprotective propertiesBut as with any cannabinoid, there is always more to learn. Most studies have can i buy ventolin over the counter uk been conducted on animals, so human trials are crucial to fully understand how CBG and CBD interact in the body.Are you interested in trying CBD, CBG, or maybe a product that contains both?. Here are some of the best hemp-derived products available on the market today.Top 4 CBD ProductsVerma Farms is one of the highest-quality CBD brands that weâve found.

All of their products are made with can i buy ventolin over the counter uk top notch ingredients that are organic and all natural. They offer an extensive collection of items to choose from, including gummies, oils, capsules, topicals, and even tropical dried fruit!. Verma Farms uses broad spectrum extract, which contains all of the wellness-boosting plant can i buy ventolin over the counter uk compounds, with the exception of THC.

This means you can enjoy the benefits of minor cannabinoids, terpenes, flavonoids, and fatty acids!. This is a brand that takes a Hawaiian approach to making CBD. All of their can i buy ventolin over the counter uk products are influenced by the islands, so you can drift off to your own tropical paradise.Penguin is another top brand that we highly recommend.

They offer some of the purest and most potent CBD products on the markets. With a well-rounded selection of products, youâre sure to find the CBD that best meets your can i buy ventolin over the counter uk lifestyle needs. Choose from gummies, oils, topicals, and capsules.Penguin only uses the best ingredients, including broad-spectrum CBD oil that is extracted from Oregon grown hemp.

Because these products contain no THC, you can enjoy peak mental performance while also enjoying the many therapeutic benefits that CBD has to offer.Whatâs even better is that the brand offers some delicious flavors. Penguinâs CBD gummy worms are coated can i buy ventolin over the counter uk in a tangy sugar that will make your taste buds go wild. Thereâs also deliciously flavored CBD oil, including options such as Cookies &.

Cream, Citrus, Strawberry, and can i buy ventolin over the counter uk Mint.Feel more balanced and in sync with Evn CBD. This is the go-to brand for anyone who wants a natural sense of calm and relaxation. These products are formulated to boost focus, restore balance, aid in recovery, and even improve endurance.Evn CBD products are all made with broad spectrum extract, which is rich in cannabinoids, terpenes, phytonutrients, and other health-boosting compounds.

Whether you enjoy the brandâs CBD gummy bears or mint-flavored tincture, youâre sure to feel better can i buy ventolin over the counter uk than ever.Aside from oils and gummies, Evn CBD also offers topical products as well as capsules so that you can enjoy CBD on the go.Medterra uses the highest-quality CBD in all of its product formulations. In fact, the brand is one of the few that are U.S. Hemp Authorityâ¢ Certified, which shows that Medterra is dedicated to creating safe, effective, and legal CBD products.Medterra offers one of the can i buy ventolin over the counter uk biggest collections of products, including:â CBD gummiesâ CBD oilâ CBD supplementsThe brand also offers three distinct collections.

The CBD Full Spectrum collection is a line of products that are made with high quality full spectrum, whole plant CBD extract. The Ua Broad Spectrum + CBG collection offers the added benefits of CBG. Last is the CBD Wellness collection, which can i buy ventolin over the counter uk combines CBD with superfoods, botanicals, adaptogens, and medicinal mushrooms.Final ThoughtsCBD and CBG are two similar yet unique cannabinoids.

While hemp plants contain a much higher dose of CBD, CBG can also be extracted and used in all sorts of products. These two cannabinoids offer a variety of therapeutic benefits, and when combined, can provide highly effective relief that keeps you feeling your best.Synthetic cannabinoids, commonly known as âspiceâ and âK2,â are substances that mimic the can i buy ventolin over the counter uk psychoactive chemical compounds present in cannabis. They're commonly used by vulnerable populations, including people experiencing homelessness, and have triggered mass overdoses.

Though traditionally advertised as a harmless can i buy ventolin over the counter uk alternative to marijuana, they can do far more serious damage than their naturally occurring predecessors. Studies suggest that synthetic cannabinoids can cause acute anxiety, panic and psychosis. These compounds also have high abuse and addiction potential, according to research published in Psychopharmacology this September.

Based on can i buy ventolin over the counter uk data gathered between 2015 and 2016, this study represents the most comprehensive analysis so far of spice withdrawal symptoms and the first to compare their severity with cannabis withdrawals. The crucial finding. Continued spice consumption produces can i buy ventolin over the counter uk worse cravings than cannabis.

The survey data included 284 people who said they had consumed synthetic cannabinoids 10 times or more and made attempts to stop within the previous year. Most respondents noted that their attempts triggered three or more withdrawal symptoms, including insomnia, irritability, despondency and craving â and that these symptoms were serious.âAlthough originally produced as a legal alternative to cannabis, our findings show that spice is a far more harmful drug,â lead study author and psychology Ph.D. Student Sam Craft said in a statement can i buy ventolin over the counter uk last month.

ÂItâs therefore important that greater effort is made to ensure that spice is not used as a substitute for cannabis, or any other drug, and that people experiencing problems with spice should be supported with treatment.â What Are Synthetic Cannabinoids?. These lab-made alternatives can i buy ventolin over the counter uk weren't developed with recreational use in mind. In the 1990s, John W.

Huffman and a team of fellow chemists at Clemson University created some of the first formulas for synthetic cannabinoid receptor agonists (SCRAs), a family of substances that imitate the physiological and psychological impacts of cannabis on our systems. Huffman created hundreds of these substances to study naturally occurring can i buy ventolin over the counter uk cannabinoids, the chemical compounds found in marijuana. âThese are all drugs that he synthesized for scientific pursuits,â says Deepak Cyril DâSouza, a practicing psychiatrist and professor at Yale University School of Medicine.

ÂWhen he synthesized these compounds, he published scientific papers where he described in exquisite detail how these compounds were synthesized.â In almost no time at can i buy ventolin over the counter uk all, chemists abused these instructions. Starting in the 2000s, chemical companies (that some specialists believe to be based in China) produced massive quantities of powdered synthetic cannabinoids, which they then submerged in acetone solutions and sprayed over shreds of plant matter. These businesses then packaged the product and sold it, says DâSouza, sometimes as incense and potpourri and sometimes as âspice,â a recreational smoking mixture which would supposedly produce psychoactive responses similar can i buy ventolin over the counter uk to marijuana â without the health and legal risks.

"There are these unscrupulous chemists out there in the world working in unsanctioned, illegal labs, who have used their creativity and ingenuity to come up with new molecules every morning,â says Ruben Baler, who serves as the health scientist administrator at the National Institute on Drug Abuse. ÂThere is an infinite array of possibilities for these chemists to come up with.âWhy Spice Is So StrongUltimately, thousands of synthetic cannabinoid users appeared at medical centers in the U.S. Throughout the can i buy ventolin over the counter uk 2000s and 2010s.

They complained of chest pains, palpitations, arrhythmia, nausea, vomiting, twitches, tremors and seizures. Some patients can i buy ventolin over the counter uk lost their coordination and consciousness. Others faced changes in mood and memory and felt anxious, aggressive, paranoid and suicidal.

Those who consumed spice repeatedly saw the worst symptoms, including prolonged psychotic bouts. Initially, doctors didn't fully can i buy ventolin over the counter uk understand what was going on, says DâSouza, because these were such new compounds.In 2008, chemists determined that the active ingredient in several spice mixtures was a compound called JWH-018, one of Huffmanâs first synthetic cannabinoids â an essential finding in explaining the patientsâ mysterious, extreme reactions. Several factors contribute to synthetic cannabinoidsâ intensity, says DâSouza, who co-authored a comprehensive overview of these substances in 2013.

First and foremost, though synthetic cannabinoids imitate marijuanaâs principal psychoactive cannabinoid, tetrahydrocannabinol (THC), DâSouza says they are 10 to 200 times more can i buy ventolin over the counter uk potent than the original. This fact accounts for their significant side effects. Synthetic cannabinoids are also absorbed differently within the brain and throughout the body.

When someone consumes cannabis, can i buy ventolin over the counter uk the THC travels through their system and activates cannabinoid receptors. This drives the psychoactive effects, DâSouza explains. THC acts as a âpartial agonist,â meaning can i buy ventolin over the counter uk that the compound stimulates the cannabinoid receptors only partially.

But synthetic cannabinoids attach and respond to these receptors much more thoroughly as âfull agonists.â âLet's say you have a tap,â DâSouza says. ÂIf you open the tap only halfway, you're only going to get about half the amount of water flowing through the tap â¦ a partial agonist would be the tap that's half opened.â Meanwhile, can i buy ventolin over the counter uk full agonists such as synthetic cannabinoids would supply a flood of water and, thus, a surge of stronger symptoms. The chemical structure of synthetic cannabinoids may deliver feelings of relaxation and calm similar to those that accompany marijuana.

But they could also confer heightened danger and unpredictability. While the high will be much higher, so will the anxiety, paranoia and can i buy ventolin over the counter uk psychosis. Purity issues only make matters worse.

Synthetic cannabinoids can also cause severe health outcomes due to their unregulated production process, can i buy ventolin over the counter uk says Peter H. Addy, a professional counselor in Oregon and a co-author on DâSouzaâs 2013 paper. ÂTheir creation process and testing process are unregulated,â he says.

ÂSo, thereâs all sorts of reasons why synthetic cannabinoids are bad for you.â It isnât clear how pure or potent these substances are, nor can users know what synthetic can i buy ventolin over the counter uk cannabinoids have been mixed with.Regulating Synthetic CannabinoidsSince 2008, several countries have passed restrictions against JWH-018 and similar synthetic substances. In the U.S., for instance, the Synthetic Drug Abuse Prevention Act of 2012 placed several synthetic cannabinoids, including JWH-018, into the strictest classification of illicit drugs. Yet, these regulations have their limits â synthetic cannabinoid manufacturers can can i buy ventolin over the counter uk make minor adjustments to their productsâ chemical structure to circumvent these laws.

Because the first generation of synthetic cannabinoids were made illegal in the U.S., Addy says, manufacturers came up with a second generation. Cannabinoid molecules can be altered with the tiniest tweak (like moving a specific moleculeâs position) and become an entirely different chemical, he explains. This scenario can i buy ventolin over the counter uk prompts chemical companies to constantly produce newer, non-regulated compounds.

ÂItâs this ridiculous cat-and-mouse game where state or federal governments will outlaw certain compounds, but there's many more to choose from,â he says. In can i buy ventolin over the counter uk 2012, five percent of adults in the U.S. Aged 19 to 30 said that they had consumed synthetic cannabinoids at some point in the previous year, according to a 2021 survey by the National Institute on Drug Abuse.

That said, these substances are not as prevalent today as around a decade ago. Last year, only 1.2 percent of people in the same age can i buy ventolin over the counter uk range reported consuming them in 2020. This decline may relate to recent shifts in cannabis regulation.

Most people would likely pick natural cannabis over synthetic cannabinoids whenever legally accessible, says Addy, meaning that the movement to decriminalize marijuana may diminish many peopleâs demand for can i buy ventolin over the counter uk synthetic cannabinoids as an alternative. ÂThe main point is that this phenomenon is a direct result of the criminalization of cannabis,â he says. ÂCriminalizing cannabis is can i buy ventolin over the counter uk just making things worse for everyone.

K2 is an obvious and extreme example of that.â While it emerged in the increasingly foregone era of criminalized cannabis, DâSouza says synthetic cannabinoid use (and the resulting health risks) may never disappear completely. Fully decriminalized cannabis may discourage potential users from trying synthetic cannabinoids for the first time, yet the drugâs potency could encourage prior users to stick with synthetics. When people who use cannabis try spice, they subsequently don't feel any effects if they return to the relatively weaker cannabis, says DâSouza.The crux can i buy ventolin over the counter uk of the issue.

Synthetic cannabinoids have higher risks than those forged in nature. In fact, the can i buy ventolin over the counter uk threat posed by these substances is so immense itâs built into their identity and marketed to thrill seekers. ÂThey were initially sold as âK2,ââ says DâSouza.

ÂK2 is one of the most treacherous mountains â¦ The name speaks for itself. It can get you really high but can i buy ventolin over the counter uk can also be really dangerous.âThis article contains affiliate links to products. We may receive a commission for purchases made through these links.CBD is here to stay.

In fact, over the can i buy ventolin over the counter uk last few years, the popularity of CBD products has only continued to grow. CBD is an effective alternative treatment for some of the most common ailments, including pain, poor sleep, stress, anxiety, and even depression. Whatâs great about CBD is that it can be infused into all different types of products.

Today, youâll can i buy ventolin over the counter uk find CBD-infused gummies, capsules, and edible options such as gummies. Oils and tinctures are also popular, offering the power of CBD in just a few drops.Interested in trying CBD but donât know where to start?. Weâve got you can i buy ventolin over the counter uk covered!.

Keep reading to learn the ins and outs of what CBD is and what the cannabinoid can be used for. Weâll also discuss some of the top CBD products on the market.What is can i buy ventolin over the counter uk CBD?. CBD, also known as cannabidiol, is a cannabinoid that is extracted from hemp.

CBD has no psychoactive properties, which means it wonât get you high or cause you to feel mentally altered in any way. Instead, the cannabinoid is best known for its therapeutic benefits, including the ability to calm the mind and body.When ingested, CBD reacts with the CB1 and CB2 receptors of the endocannabinoid can i buy ventolin over the counter uk system (ECS). This system spans throughout the body and helps to regulate key bodily functions.

Research has found that ECS plays a role in many physiological functions, including:â Chronic can i buy ventolin over the counter uk painâ Appetite stimulationâ Metabolismâ Inflammationâ Immune system responseBy interacting with the ECS, CBD is able to promote healthy responses to stress, reduce inflammation, and offer a host of other benefits.What Are the Benefits of Taking CBD Oil?. One of the quickest and most convenient ways to use CBD is in oil form. All you have to do is place a few drops under your tongue.

This method offers quick results that can last for up to a few can i buy ventolin over the counter uk hours. CBD oil can also be mixed into food or your favorite drink, such as a smoothie.Here are some of the top benefits that CBD oil offers.Natural Pain ReliefOne of the most widely sought therapeutic benefits that CBD offers is relief from aches and pains, including chronic pain caused by underlying health conditions. For those who suffer from arthritis, fibromyalgia, and even neuropathic pain, CBD may be an effective all-natural alternative for living a pain-free life.More often than not, people use over-the-counter options, can i buy ventolin over the counter uk such as NSAIDs to treat their pain.

Others require stronger treatments, such as prescription painkillers in order to get through the day.The problem with these conventional options is that they pose all sorts of health risks and negative side effects, including the risk of substance abuse and addiction. Thereâs a reason why the U.S. Continues to struggle with its opioid epidemic.CBD on the other hand, has a very low risk of minor side effects, such as can i buy ventolin over the counter uk dry mouth or appetite changes.

CBD also has no addictive properties, so the risk of a negative experience is all but zero.Reduced Anxiety &. DepressionDid you know that over 300 million people suffer from depression can i buy ventolin over the counter uk and/or anxiety?. While most mental health conditions are treated using prescription medications, such as SSRIs, CBD may be a promising alternative option.Research has found that CBD may reduce the symptoms of anxiety and depression.

A 2014 study found that CBD has positive interactions with serotonin receptors in the brain. This is the neurotransmitter that impacts one's emotional state, happiness, and overall wellbeing.Balanced serotonin levels are can i buy ventolin over the counter uk often the most critical component in helping those who suffer from depression. Imbalanced serotonin levels have also been linked to an increased risk of anxiety disorders, including social and general anxiety.Lowered Stress LevelsLife is stressful but having high levels of stress on a constant basis can take a toll on your physical, mental, and social health.

While there are many can i buy ventolin over the counter uk ways to relieve stress, one of the most effective options is CBD oil.Various studies have found that CBD works to reduce anxiety and stress by changing the brainâs reaction to anxiety. One study even found that CBD may change blood flow patterns in the regions of the brain that are associated with anxiety and stress.When youâre less stressed and worried, youâll find that life is much more enjoyable. Waking up feeling focused and energized instead of worn down and tired can make such a difference in your health and happiness.A few drops of CBD oil can take the edge off after a long, stressful day.Improved SleepSleep disturbances impact millions of can i buy ventolin over the counter uk people each night.

Aside from those discussed above, some of the other benefits that CBD may offer includes:â Eliminates and prevents acneâ Reduces blood pressureâ Protects the brainâ Potential treatment for drug addictionâ May help to fight cancerItâs important to note that everyone reacts differently to CBD. In order to get the best results possible, itâs crucial to find a product that contains high quality CBD while also figuring out the dose that best meets your needs.If youâre interested in trying CBD to ease pain or to keep your anxiety at bay, youâve come to can i buy ventolin over the counter uk the right place. Keep reading to learn about some of the best CBD oils on the market.Must-Try CBD OilsWhen it comes to CBD oil or any other CBD product, Verma Farms offers the best of the best.

While they may be most known for their Hawaii-inspired gummies, Verma Farms also sells delicious CBD oil that is made with all natural, high-quality ingredients.All Verma Farms products are made using broad spectrum CBD extract that comes from pure, pesticide-free, non-GMO hemp. Whatâs great about can i buy ventolin over the counter uk this brandâs CBD oil is that itâs available in a variety of flavors. Whether youâre in the mood for watermelon, mango, strawberry, or mint, youâll find just the oil for you at Verma Farms.Penguin is another top-rated company in the CBD industry.

In fact, can i buy ventolin over the counter uk the brand has been rated #1 by Rolling Stone. Penguin offers some of the best CBD oil on the market, which is made with premium broad-spectrum CBD extract. All of their CBD is harvested from Oregon-grown hemp thatâs cultivated using rich soil along with safe, sensible farming practices.Penguin CBD oil not only contains refined CBD extract, but other quality ingredients such as MCT oil, hemp oil, terpenes, and natural flavor.

Oil is available in palate-pleasing flavors, including Citrus, can i buy ventolin over the counter uk Mint, Strawberry, and Cookies &. Cream.With CBD oil from Penguin, you can embrace the cool, chill life of a penguin.Evn CBD creates all sorts of CBD-infused products, including gummies, capsules, and oils. Their CBD can i buy ventolin over the counter uk oil is meant to help you stay calm and collected, even during the most stressful scenarios.

Evn CBD oil is made with premium broad spectrum CBD oil, along with MCT oil, and stevia extract for a little sweetness.Each bottle of oil is also vegan, contains 0 THC, gluten-free, and non-GMO. Evn CBD products are also lab tested to ensure safety, quality, efficacy, can i buy ventolin over the counter uk and potency. Oil is available in two flavors.

Mint and Natural, with Mint being the more popular flavor.While there isnât a huge assortment of flavors to choose from, what Evn CBD lacks in variety is made up in quality.Final ThoughtsCBD oil offers all sorts of therapeutic benefits that can be life changing for some people. While the cannabinoid is best known for can i buy ventolin over the counter uk its pain-relieving side effects, it also offers other benefits, including better sleep, clear skin, and lowered stress and anxiety.No matter the benefits that you seek, the best experience comes from buying high-quality CBD oil. Buy from the brands above if youâre looking for CBD oil that is pure and potent.When weâre stressed out, our bodyâs internal chemistry changes.

Cortisol, the primary stress hormone alongside can i buy ventolin over the counter uk adrenaline and norepinephrine, surges. As a result, blood sugar levels increase and more of that glucose is allocated to the brain.Thatâs good â the chain reaction helps our bodies in the so-called âfight-or-flightâ response, which has a deep evolutionary history and dwells within us even today. When potential predators were around, our ancient ancestors needed that extra boost to figure out whether to take them on or run away.

Nowadays, the same biochemical responses spring into action to help us react quickly when weâre under pressure.Our bodies, however, no longer only do can i buy ventolin over the counter uk this when weâre seriously threatened. The same processes are triggered when weâre late for work or arguing with family members. And after dealing with a ventolin for over a year, many can i buy ventolin over the counter uk more Americans are becoming acquainted with prolonged psychological stress, according to the American Psychological Association's latest Stress in America poll.

Often times, our response to this stress can be more harmful than helpful. ÂWe know that the immune system is capable of looking at these proteins and reacting,â says Willem van Eden, an immunologist at Utrecht University in the Netherlands. Protracted exposure to higher can i buy ventolin over the counter uk levels of stress hormones comes along with myriad side effects within the immune system.Largely speaking, stress can be divided into two camps.

The psychological and the physical, also known as physicochemical stress. While psychological stress is caused by worrying about something (whether itâs a predator or a looming deadline), physical stress comes from environmental factors such as air pollution, can i buy ventolin over the counter uk poor nutrition or exhaustion.Chronic psychological stress has been linked to a subdued immune system. But if the immune system becomes compromised and is no longer capable of dealing with physical stresses, this can promote the onset of disease.Scientists first noticed a link between stress and the strength of immune systems during animal experiments in the early 1980s.

The experiments quickly progressed to humans when researchers can i buy ventolin over the counter uk began observing medical students. They found that studentsâ immunity dropped around exam time with depleted levels of T-cells, some of the immune systemâs most important weapons in the fight against .Additional studies showed that chronic stress interferes with the molecular signals that immune cells use to communicate with each other. More recently, Scott Mueller, a professor at the University of Melbourne in Australia, demonstrated that stress can even stop immune cells from moving, physically blocking them from thwarting s and cancers.In a 2021 mouse-based study, Mueller and his colleagues used a special microscope â able to observe biological processes within living organisms â to create real-time images of a chemical messenger protein called noradrenaline.

The protein can i buy ventolin over the counter uk is found in higher concentrations under stressful conditions and obstructs the movement of various white blood cells that are important in the immune response. This âexplains at least in part the widely observed relationship between stress and impaired immunity,â Mueller concludes in the study.Another study, published in Frontiers in Immunology in 2018, demonstrated the impact of stress on the immune system by inducing stress and cancerous tumor growth in mice â some of whom were additionally given an antidepressant. The results showed a marked can i buy ventolin over the counter uk difference.

The mice treated with antidepressants had significantly reduced cancer progression compared to those who werenât.While itâs possible that the antidepressants themselves possess cancer-fighting mechanisms, the researchers concluded that the inhibition of psychological distress (thanks to the antidepressant) is likely what restored antitumor immunity.Cancer isnât the only disease that seems to progress more rapidly under stressed environments. Research has shown that chronic stress also increases a personâs risk of heart disease, weight gain, digestive issues, headaches, muscle pain and, of course, mental health problems such as anxiety and depression.In short, our immune systems are at their best when weâre not beset with high levels of cortisol pumping through our veins.This article contains affiliate links to products. We may receive a commission for purchases made through these links.CBD has become one of the most popular wellness products on the planet, and for good reason can i buy ventolin over the counter uk.

The chemical compounds that comprise CBD oil have a wide array of benefits, from sleep support to pain relief to calming properties that help with stress and anxiety, and more. Itâs no wonder that more can i buy ventolin over the counter uk and more people are turning to CBD oil as a part of their daily health regimen. But what exactly is CBD, and why does it interact the way it does with the human body?.

Before we explore the world of cannabis and cannabinoids, such as CBD and THC, letâs take a look at some of the best CBD oils for sale in the UK. The Best CBD Oils UK When shopping for CBD oils, the key is can i buy ventolin over the counter uk to look for quality. There are a lot of unscrupulous CBD companies out there looking to make a quick pound by selling CBD products with poor-quality CBD oil.

Here are some things to look for when shopping for can i buy ventolin over the counter uk CBD oil. Organic CBD CBD companies canât legally advertise their products in the UK as being organic, but that doesnât mean itâs not important. The hemp plant, from which CBD oil is derived, is whatâs known as a bioaccumulator, meaning that it pretty much sucks everything up from its surrounding soil that it can.

This is great for can i buy ventolin over the counter uk soaking in nutrients, but if there are pesticides or other chemicals in the soil, those will be pulled into the cannabis hemp plant as well, and end up in your CBD oil product. Thatâs why itâs vital to find a CBD company that uses naturally grown, organic hemp. CBD Extraction Methods Originally, CBD oil was extracted from the hemp plant can i buy ventolin over the counter uk by means of steam distillation.

This was clean, but inefficient. Then, manufacturers began can i buy ventolin over the counter uk to use various chemical solvents to derive their CBD oil. This was efficient, but not necessarily clean, as some of those solvents left a chemical residue behind in the oil.

CO2 extraction provides the best of both worlds. Itâs efficient, pulling all of the cannabinoids, terpenes can i buy ventolin over the counter uk and flavonoids from the cannabis hemp plant, and itâs clean, leaving no chemical residue behind. The need for purity doesnât end at the cannabis fields.

Insist on CBD oil extracted can i buy ventolin over the counter uk with clean CO2. Third-Party Laboratory Testing Thereâs only one way to know if your CBD oil was organically grown and cleanly extracted with CO2, and thatâs by being able to see a lab report, produced by an independent third-party laboratory. Every legitimate CBD brand will make one of these reports readily available for each of its CBD products.

This report can i buy ventolin over the counter uk will tell you whether youâre getting the potency of CBD youâve been promised, by giving you the exact amount of CBD and other cannabinoids in your product. It will also tell you if there are any chemical contaminants in your CBD product. If you donât can i buy ventolin over the counter uk see third-party lab reports on a CBD companyâs website, find another CBD company!.

Natural Ingredients Many CBD products, including CBD oil drops, contain ingredients other than cannabidiol oil. For instance, many CBD oil tinctures will contain a second carrier oil to help the body to better absorb the CBD. But there are a vast variety of botanicals can i buy ventolin over the counter uk and other ingredients that are used in CBD products, as well.

Make sure to check the ingredients on the label to ensure that theyâre all natural. Unnecessary fillers or unhealthy chemicals can sink a CBD product just can i buy ventolin over the counter uk as easily as a bad CBD oil. Based on the four criteria above â organic cultivation, CO2 extraction, third-party lab testing, and natural ingredients â the CBD oil drops from CBDfx hit the mark every time.

This shouldnât can i buy ventolin over the counter uk come as a surprise. CBDfx has been doing this since 2014, and is one of the most respected brands in the business. They use only organically sourced CBD oil, extracted by clean CO2, and provide the independent, third-party lab reports to back it up.

They also use natural ingredients, can i buy ventolin over the counter uk including flavourings and colours, on all of their CBD products. CBDfx sells two quality CBD oil tinctures in the UK. CBDfx CBD Oil Hemp Tincture can i buy ventolin over the counter uk Itâs pretty much impossible to find a cleaner ingredient profile on a CBD oil product.

The only two ingredients in CBDfxâs CBD Oil Hemp Tincture are broad spectrum CBD oil and all-natural, coconut-derived medium-chain triglyceride oil to help with absorption. And thatâs it. If youâre looking for can i buy ventolin over the counter uk a pure CBD experience with no flashy add-ons, these are the perfect CBD oil drops.

Pure, potent, and reasonably priced!. CBDfx CBD + CBG Oil Wellness Tincture Mother Nature provides can i buy ventolin over the counter uk CBD oil with a special feature called the Entourage Effect. This is the phenomenon by which cannabinoids, terpenes and flavonoids work harder together than they would if taken individually.

Broad spectrum CBD provides a rich Entourage Effect experience on its own. But with their CBD + CBG Oil Wellness Tincture, CBDfx gives can i buy ventolin over the counter uk Mother Nature herself a little boost, by blending CBD and the âMother of All Cannabinoids,â CBG, in an ideal 2:1 ratio, which helps your CBD to work as hard as it possibly can. But they donât stop there.

These oil drops also contain curcumin and coenzyme Q10, commonly used in homeopathic remedies, coconut-derived MCT oil, and a special can i buy ventolin over the counter uk blend of terpenes for added wellness benefits. All of these ingredients combine to make a great daily wellness supplement, ideal for morning health regimens. Now that you have a sense of what to look for in a CBD oil â as well as two fantastic oils to get you started â letâs dig a little deeper into what CBD is, how CBD oil works, and what are some of the benefits of CBD oil.

CBD Oil can i buy ventolin over the counter uk Benefits. An Intro to CBD and Cannabis CBD is short for cannabidiol, and itâs one of over a hundred different compounds found in the cannabis plant, called cannabinoids. Other cannabinoids can i buy ventolin over the counter uk include THC, CBG, CBN, CBG, and CBC.

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Is ventolin same as proair

Both evolutions have resulted in an increasing number of CHD survivors.2â5 In adolescence, patients transition from being a dependent child to an independent adult. They are also advised to transfer from paediatrics to is ventolin same as proair adult care. There is no universal consensus regarding how transitional care should be provided and how transfer should be organized.

This consensus document describes issues is ventolin same as proair and practices of transition and transfer of adolescents with CHD, accounting for different possibilities in high-, middle-, and low-income countries. Transitional care ought to be provided to all adolescents with CHD, taking into consideration the available resources. When reaching adulthood, patients ought to be transferred to adult care facilities/providers capable of managing their needs, and systems must be in place to make sure that continuity of high-quality care is ensured after leaving paediatric cardiology.

Figure 1Suggested anticoagulation strategy for women with a prosthetic mechanical heart valve is ventolin same as proair and (A) low-dose pre-conception vitamin K antagonist or (B) high-dose pre-conception vitamin K antagonist (from Egidy Assenza G, Dimopoulos K, Budts W, Donti A, Economy KE, Gargiulo GD, Gatzoulis M, Landzberg MJ, Valente AM, Roos-Hesselink J. Management of acute cardiovascular complications in pregnancy. See pages 4224â4240).Figure is ventolin same as proair 1Suggested anticoagulation strategy for women with a prosthetic mechanical heart valve and (A) low-dose pre-conception vitamin K antagonist or (B) high-dose pre-conception vitamin K antagonist (from Egidy Assenza G, Dimopoulos K, Budts W, Donti A, Economy KE, Gargiulo GD, Gatzoulis M, Landzberg MJ, Valente AM, Roos-Hesselink J.

Management of acute cardiovascular complications in pregnancy. See pages 4224â4240).In a State of the Art Review article entitled âManagement of acute cardiovascular complications in pregnancyâ, Gabriele Egidy Assenza from the IRCCS Azienda Ospedaliero-Universitaria di Bologna in Italy and colleagues note that the growing population of women of reproductive age with is ventolin same as proair heart disease has been associated with an increasing number of high-risk pregnancies.6 Pregnant women with heart disease are a very heterogeneous population, with different risks for maternal cardiovascular, obstetric, and foetal complications.7â11 Adverse cardiovascular events during pregnancy pose significant clinical challenges, with uncertainties regarding diagnostic and therapeutic approaches potentially compromising maternal and foetal health. This review provides a summary of recommendations on the management of acute cardiovascular complications during pregnancy, based on available literature and expert opinion.

The authors cover the diagnosis, risk stratification, and therapy, and the review is organized according to the clinical presentation and the type of complication, providing a reference for the practising cardiologist, obstetrician, and acute medicine specialist, while highlighting areas of need and potential future research. Topics covered include heart failure (HF), arrhythmias, coronary artery disease, aortic and is ventolin same as proair thrombo-embolic events, and the management of mechanical heart valves during pregnancy (Figure 1). Figure 2Graphical Abstract (from Diller GP, Orwat S, Lammers AE, Radke RM, De-Torres-Alba F, Schmidt R, Marschall U, Bauer UM, Enders D, Bronstein L, Kaleschke G, Baumgartner H.

Lack of specialist care is associated with increased morbidity and mortality in adult congenital is ventolin same as proair heart disease. A population-based study. See pages 4241â4248).Figure 2Graphical Abstract (from Diller GP, Orwat S, Lammers AE, Radke RM, De-Torres-Alba F, Schmidt R, Marschall U, Bauer UM, Enders is ventolin same as proair D, Bronstein L, Kaleschke G, Baumgartner H.

Lack of specialist care is associated with increased morbidity and mortality in adult congenital heart disease. A population-based is ventolin same as proair study. See pages 4241â4248).In a Clinical Research article entitled âLack of specialist care is associated with increased morbidity and mortality in adult congenital heart disease.

A population-based studyâ, Gerhard-Paul Diller from the University Hospital MÃ¼nster in Germany, and colleagues aimed to provide population-based data on the healthcare provision for adults with congenital heart disease (ACHD) and the impact of cardiology care on morbidity and mortality in this vulnerable population.12 Based on administrative data from one of the largest German Health Insurance Companies, all insured ACHD patients (<70âyears of age) were included. Patients were stratified into those followed exclusively by primary care physicians (PCPs) and those with additional is ventolin same as proair cardiology follow-up between 2014 and 2016. Associations between level of care and outcome were assessed by multivariable/propensity score Cox analyses.

Overall, 24 is ventolin same as proair 139 patients (median age 43âyears, 54.8% female) were included. Of these, only 50% had cardiology follow-up during the 3-year period, with 49% of patients only being cared for by PCPs and 1% having no contact with either. After comprehensive multivariable and propensity score adjustment, ACHD patients under cardiology follow-up had a significantly lower is ventolin same as proair risk of death [hazard ratio (HR) 0.81.

Pâ=â0.03] or major events (HR 0.85. Pâ<â0.001) compared with those only followed by PCPs. At 3-year follow-up, the absolute risk difference for mortality was 0.9% higher in ACHD patients with moderate/severe complexity lesions is ventolin same as proair under the care of PCPs compared with those under cardiology follow-up (Figure 2).

The authors conclude that cardiology care compared with primary care is associated with superior survival and lower rates of major complications in ACHD. It is alarming that even in a high-resource setting with well-established specialist ACHD care, â¼50% of is ventolin same as proair contemporary ACHD patients are still not linked to regular cardiac care. Thus, more efforts are required to alert PCPs and patients to appropriate ACHD care.

The manuscript is accompanied by an Editorial by Anne Marie Valente from the Brigham and Womenâs Hospital in Boston, MA, USA and Abigail Khan from the Oregon Health and Science University in Portland, OR, USA.13 The authors conclude that it is ventolin same as proair is clear that cardiology care matters for adults living with CHD. The next step for us all is to take this message forward, educating providers, empowering patients, and developing better care networks to support this growing population of individuals with complex care needs.In a Clinical Research article entitled âMaternal and neonatal complications in women with congenital heart disease. A nationwide analysisâ, Astrid Elisabeth Lammers from the University Hospital MÃ¼nster in Germany, and colleagues provide population-based data on maternal and neonatal complications and outcome in pregnancies of women with congenital is ventolin same as proair heart disease (CHD).14 Based on administrative data from one of the largest German Health Insurance Companies (BARMER GEK, â¼9 million members representative for Germany), all pregnancies in women with CHD between 2005 and 2018 were analysed.

In addition, an age-matched non-CHD control group was included for comparison, and the association between ACHD and maternal or neonatal outcomes was investigated. Overall, 7512 pregnancies occurred in 4015 women with CHD. The matched non-CHD control group included 6502 is ventolin same as proair women with 11 225 pregnancies.

Caesarean deliveries were more common in CHD patients (40.5% vs. 31.5% in the control group is ventolin same as proair. P <.

0.001). There was no excess mortality. Although the maternal complication rate was low in absolute terms, women with CHD had a significantly higher rate of stroke, HF, and cardiac arrhythmias during pregnancy (P <0.001 for all).

Neonatal mortality was low but also significantly higher in the ACHD group (0.83% vs. 0.22%. P = 0.001), and neonates to CHD mothers had significantly low/extremely low birth weight or extreme immaturity, or required resuscitation and mechanical ventilation more often compared with non-CHD offspring.

On multivariate logistic regression, maternal defect complexity, arterial hypertension, HF, prior fertility treatment, and anticoagulation with vitamin K antagonists emerged as significant predictors of adverse neonatal outcome. Recurrence of CHD was 6.1 times higher in infants to ACHD mothers compared with controls.The authors conclude that this population-based study illustrates a reassuringly low maternal mortality rate in a highly developed healthcare system. Nevertheless, maternal morbidity and neonatal morbidity/mortality were significantly increased in women with ACHD, highlighting the need for specialized care and pre-pregnancy counselling.

This manuscript is accompanied by an Editorial by Jolien W. Roos-Hesselink from Erasmus MC in Rotterdam, the Netherlands, and colleagues.15 The authors note that the study by Lammers et al. Is an excellent and clinically relevant contribution to the existing literature on pregnancy in women with CHD.

The study shows that a good healthcare system, a multidisciplinary approach, and decisive pre-pregnancy counselling are effective in achieving safe pregnancies. Pre-pregnancy counselling with an individualized approach is a crucial step in this process, because both maternal and perinatal outcomes vary largely by the complexity of maternal illness, and further studies dedicated to specific congenital diagnoses are still warranted.Left ventricular non-compaction (LVNC) cardiomyopathy is a devastating genetic disease caused by insufficient consolidation of ventricular wall muscle that can result in inadequate cardiac performance.16 Despite being the third most common cardiomyopathy, the mechanisms underlying the disease, including the cell types involved, are poorly understood. In a Translational Research article entitled âEndocardial/endothelial angiocrines regulate cardiomyocyte development and maturation and induce features of ventricular non-compactionâ, Siyeon Rhee from Stanford University in Stanford, CA, USA, and colleagues aimed to identify candidate angiocrines expressed by endocardial and endothelial cells in embryonic hearts of Tie2Cre;Ino80fl/fl transgenic mouse (an experimental model of LVNC).

Then they tested the effect of these candidates on cardiomyocyte proliferation and maturation.17 The authors observed a pathological endocardial cell population in non-compacted hearts and identified multiple dysregulated angiocrine factors that dramatically affected cardiomyocyte behaviour. They identified Col15a1 as a coronary vessel-secreted angiocrine factor, down-regulated by Ino80 deficiency, that functioned to promote cardiomyocyte proliferation. Furthermore, mutant endocardial and endothelial cells up-regulated expression of secreted factors, such as Tgfbi, Igfbp3, Isg15, and Adm, which decreased cardiomyocyte proliferation.The authors conclude that these findings support a model where coronary endothelial cells normally promote myocardial compaction through secreted factors, but that endocardial and endothelial cells can secrete factors that contribute to non-compaction under pathological conditions.

The contribution is accompanied by an Editorial by Stefanie Dimmeler and Julian Wagner from the Goethe University in Frankfurt, Germany.18 The authors note that the study by Rhee et al. Elegantly identifies the importance of a timely orchestrated and well-balanced repertoire of extracellular factors that coordinate the proper development of the left ventricle. It will be important to learn more about the cellular cross-talk to understand the mechanisms of cardiac development and homeostasis.

The interplay between endothelial cells and other vascular cells such as pericytes and smooth muscle cells, and fibroblasts and immune cells, with cardiomyocytes has to be taken into account. The modulation of extracellular matrix proteins and paracrine factors may also be a therapeutic strategy promoting cardiac repair and regeneration, but probably needs to be carefully adapted to the underlying stage and type of heart disease.The issue is also complemented by two Discussion Forum contributions. In a commentary entitled âBig cohort studies offer insights into preventable risk factorsâ, Karolina Agnieszka Wartolowska and Alastair John Stewart Webb from the John Radcliffe Hospital in Oxford, UK comment on the recent Editorial âOn cerebrotoxicity of antihypertensive therapy and risk factor cosmeticsâ by Franz H.

Messerli from the University of Bern in Switzerland.19,20 Messerli et al. Respond in a separate comment.21The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article. References1Moons P, Bratt EL, De Backer J, Goossens E, Hornung T, Tutarel O, ZÃ¼hlke L, Araujo JJ, Callus E, Gabriel H, Shahid N, Sliwa K, Verstappen A, Yang HL, Thomet C.

Transition to adulthood and transfer to adult care of adolescents with congenital heart disease. A global consensus statement of the ESC Association of Cardiovascular Nursing and Allied Professions (ACNAP), the ESC Working Group on Adult Congenital Heart Disease (WG ACHD), the Association for European Paediatric and Congenital Cardiology (AEPC), the Pan-African Society of Cardiology (PASCAR), the Asia-Pacific Pediatric Cardiac Society (APPCS), the Inter-American Society of Cardiology (IASC), the Cardiac Society of Australia and New Zealand (CSANZ), the International Society for Adult Congenital Heart Disease (ISACHD), the World Heart Federation (WHF), the European Congenital Heart Disease Organisation (ECHDO), and the Global Alliance for Rheumatic and Congenital Hearts (Global ARCH). Eur Heart J 2021;42:4213â4223.2Chessa M, Brida M, Gatzoulis MA, Diller GP, Roos-Hesselink JW, Dimopoulos K, Behringer W, MÃ¶ckel M, Giamberti A, Galletti L, Price S, Baumgartner H, Gallego P, Tutarel O.

asthma disease 2019 in adults with congenital heart disease. A position paper from the ESC working group of adult congenital heart disease, and the International Society for Adult Congenital Heart Disease. Eur Heart J 2021;42:1858â1865.4Diller GP, Lammers AE, Enders D, Baumgartner H.

Maternal and neonatal complications in women with congenital heart disease. Results from a nationwide analysis including 7,231 pregnancies. Eur Heart J 2020;41(Suppl_2).

Doi:10.1093/eurheartj/ehaa946.2215.5Playan Escribano J, Segura De La Cal T, Segovia Cubero J, Rueda Soriano J, Garcia Hernandez FJ, Lopez Meseguer M, Perez Penate GM, Lara Padron A, Campo Ezquibela A, Sala Llinas E, Mombiela T, Guerra Ramos FJ, Samper GJ, Blanco I, Escribano Subias P, REHAP Investigators. Pulmonary hypertension and congenital heart disease. Medical treatment and risk factors for survival.

Eur Heart J 2020;41(Suppl_2). Doi:10.1093/eurheartj/ehaa946.2299.6Egidy Assenza G, Dimopoulos K, Budts W, Donti A, Economy KE, Gargiulo GD, Gatzoulis M, Landzberg MJ, Valente AM, Roos-Hesselink J. Management of acute cardiovascular complications in pregnancy.

Eur Heart J 2021;42:4224â4240.7Maas A, Rosano G, Cifkova R, Chieffo A, van Dijken D, Hamoda H, Kunadian V, Laan E, Lambrinoudaki I, Maclaran K, Panay N, Stevenson JC, van Trotsenburg M, Collins P. Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions. A consensus document from European cardiologists, gynaecologists, and endocrinologists.

Eur Heart J 2021;42:967â984.8Al-Hussaini A. Pregnancy and aortic dissections. Eur Heart J 2020;41:4243â4244.9Beyer SE, Dicks AB, Shainker SA, Feinberg L, Schermerhorn ML, Secemsky EA, Carroll BJ.

Pregnancy-associated arterial dissections. A nationwide cohort study. Eur Heart J 2020;41:4234â4242.10Roos-Hesselink J, Baris L, Johnson M, De Backer J, Otto C, Marelli A, Jondeau G, Budts W, Grewal J, Sliwa K, Parsonage W, Maggioni AP, van Hagen I, Vahanian A, Tavazzi L, Elkayam U, Boersma E, Hall R.

Pregnancy outcomes in women with cardiovascular disease. Evolving trends over 10 years in the ESC Registry Of Pregnancy And Cardiac disease (ROPAC). Eur Heart J 2019;40:3848â3855.11Koenig T, Hilfiker-Kleiner D.

Future cardiovascular risk prediction in women with pregnancy complications. The HUNT is on. Eur Heart J 2019;40:1121â1123.12Diller GP, Orwat S, Lammers AE, Radke RM, De-Torres-Alba F, Schmidt R, Marschall U, Bauer UM, Enders D, Bronstein L, Kaleschke G, Baumgartner H.

Lack of specialist care is associated with increased morbidity and mortality in adult congenital heart disease. A population-based study. Eur Heart J 2021;42:4241â4248.13Khan AD, Valente AM.

Donât be alarmed. The need for enhanced partnerships between medical communities to improve outcomes for adults living with congenital heart disease. Eur Heart J 2021;42:4249â4251.14Lammers AE, Diller G-P, Lober R, MÃ¶llers M, Schmidt R, Radke RM, De-Torres-Alba F, Kaleschke G, Marschall U, Bauer UM, GerÃ J, Enders D, Baumgartner H.

Maternal and neonatal complications in women with congenital heart disease. A nationwide analysis. Eur Heart J 2021;42:4252â4260.15Ramlakhan KP, Roos-Hesselink JW.

Promising perspectives on pregnancy in women with congenital heart disease. Eur Heart J 2021;42:4261â4263.16Ross SB, Jones K, Blanch B, Puranik R, McGeechan K, Barratt A, Semsarian C. A systematic review and meta-analysis of the prevalence of left ventricular non-compaction in adults.

Eur Heart J 2020;41:1428â1436.17Rhee S, Paik DT, Yang JY, Nagelberg D, Williams I, Tian L, Roth R, Chandy M, Ban J, Belbachir N, Kim S, Zhang H, Phansalkar R, Wong KM, King DA, Valdez C, Winn VD, Morrison AJ, Wu JC, Red-Horse K. Endocardial/endothelial angiocrines regulate cardiomyocyte development and maturation and induce features of ventricular non-compaction. Eur Heart J 2021;42:4264â4276.18Wagner JUG, Dimmeler S.

The endothelial niche in heart failure. From development to regeneration. Eur Heart J 2021;42:4277â4279.19Wartolowska KA, Webb AJS.

Big cohort studies offer insights into preventable risk factors. Eur Heart J 2021;42:4280â4281.20Huang HK, Liu PP, Hsu JY, Lin SM, Peng CC, Wang JH, Loh CH. Fracture risks among patients with atrial fibrillation receiving different oral anticoagulants.

A real-world nationwide cohort study. Eur Heart J 2020;41:1100â1108.21Messerli FH, Bavishi C, Messerli AW, Siontis GCM. Cerebrotoxicity of antihypertensive therapy in the UK Biobank Cohort Study.

Â© The Author(s) 2021. For permissions, please email. Journals.permissions@oup.com.This editorial refers to âMaternal and neonatal complications in women with congenital heart disease.

In earlier times, concerns were raised about the risks of pregnancy, as pregnancy is associated with impressive hormonal changes and haemodynamic impact. Older studies reported high rates of maternal complications, including maternal mortality, and substantial rates of perinatal complications.1â3 In addition, there were concerns about the hereditable recurrence risk of congenital heart disease for the baby. However, studies were limited by small sample size or retrospective study design, and for a long time only the reported data from Nora and Nora were available.4 As a result, many physicians and, thus patients, were reluctant to embark on pregnancy, especially in more complex congenital heart disease, such as women with a systemic right ventricle, but also in severe aortic stenosis.

The risks were deemed very high or too high, and these women were typically advised against pregnancy. Although research in the field of pregnancy and congenital heart disease is hampered by small numbers, often with retrospective design, over the past decades gradually some larger studies and registries became available, elucidating the risks of pregnancy and in fact showing relatively good results. A clear development over time in adult patients with congenital heart disease (ACHD) was seen for instance in women with transposition of the great arteries corrected with the Mustard and Senning operation, which started as being seen as very high risk, to high risk, and now to moderate risk.

The trend for women with aortic stenosis is now also to allow pregnancy, even when the stenosis is severe, as long as the woman is asymptomatic.5â7The study of Lammers et al. In this issue of the European Heart Journal provides an important contribution to the existing literature.8 Not only is this the largest study, but it includes all women with ACHD, without a possible bias of only including patients seen at a tertiary centre or including patients with other kinds of heart disease. Furthermore, because it is performed in a western country with an optimal healthcare system, the results are applicable to other western countries with comparable systems of care organization with appropriate counselling in place and good collaboration between cardiac and obstetric care.

The pregnancy outcomes in studies with a global perspective, including patients from developing countries, show less favourable results (Graphical Abstract).8,9 These differences illustrate how the healthcare system and environment of women have great impact on their pregnancy outcomes and show that we still need to work to improve these outcomes for all women worldwide.10 A possible step forward is to utilize the expertise in the specialized healthcare centres such as described by Lammers et al., by providing long-distance digital or telephone consultations to rural centres in developing countries. Lammers et al. Also describe better pregnancy outcomes than an older study (1980â2007) in a Dutch and Belgian healthcare system similar to the German system, which may be due to advances in medical care for both the treatment of the original heart defect in the mother, and the management of pregnancy in heart disease, which includes the introduction of multidisciplinary pregnancy heart teams and the establishment of international guidelines (Graphical Abstract).8,11 Graphical AbstractComparison of studies on pregnancy outcomes of women with congenital heart disease.

ACHD. Adult congenital heart disease.Graphical AbstractComparison of studies on pregnancy outcomes of women with congenital heart disease. ACHD.

Adult congenital heart disease.The most important finding of this well-performed and excellently written study is the zero maternal mortality in women with congenital heart disease.8 This is unexpected and fantastic news. As the authors point out, this is partly the result of good counselling, where the high-risk patients were advised against pregnancy and most probably did not become pregnant. However, other studies show that some women at highest risk (mWHO IV) will actually still become pregnant, irrespective of counselling.

In any case, this important finding makes it possible to reassure the large majority of ACHD patients about the mortality risk of pregnancy. This is an important message and should lead to a change in policy from approaching pregnancy as potentially very dangerous, to considering pregnancy as relatively safe and explaining the possible risks, on the condition that women in mWHO IV should not become pregnant. Of course morbidity is increased, but the rates are relatively low.

The prevalence of heart failure in pregnancy might be under-reported in the study of Lammers et al., because pregnancies in women who had heart failure in the year before the pregnancy were not considered to be complicated by heart failure, probably because of the limitations of the method of registration with ICD codes. The relationship between the occurrence of stroke and having a co-existent atrial septal defect or patent foramen ovale is shown nicely and should lead to a more proactive approach in taking lifestyle measures and considering a low threshold to prescribing antiplatelet drugs in these women. As in other studies, the mode of delivery is more often by Caesarean section in women with congenital heart disease, while this is not advised in the latest guidelines.6 An attempt must be made to change this policy, because planned Caesarean section in women with heart disease does not improve maternal outcome over vaginal delivery and can be harmful for neonatal outcome.12Another important finding of this study is the relatively high risk of the baby also having congenital heart disease.8 This study provides data on the numbers of children needing cardiac surgery with the use of cardiopulmonary bypass at young age, as a nice surrogate marker for congenital heart disease needing treatment, and reports 6% in ACHD patients vs.

0.4% in the general population. Scarce data were available on this topic, and for many years we had to rely on old studies.4 In particular, the comparison with the age-matched control group in this study provides the opportunity to finally gain reliable estimates. In counselling we can now inform our patients that the risk for their baby to also have congenital heart disease requiring surgery within â¤6 years is â¼15 times higher, compared with the general population (6% vs.

In addition to the high rates of miscarriage and maternal and foetal complications and the fear of the long-term impact on the maternal condition, now the high rate of foetal congenital defects also has to be taken into account when deciding on pregnancy in these high-risk women. It would be of interest to study trends over time, as earlier and better prenatal diagnostics and changes in termination management might have an impact, not only in these complex defects but also in less complex cardiac defects.In conclusion, the study by Lammers et al. Is an excellent and clinically relevant contribution to the existing literature on pregnancy in women with congenital heart disease.

References1Mendelson CL. Pregnancy and coarctation of the aorta. Am J Obstet Gynecol 1940;39:1014â1021.2Arias F, Pineda J.

Aortic stenosis and pregnancy. J Reprod Med 1978;20:229â232.3Presbitero P, Somerville J, Stone S, Aruta E, Spiegelhalter D, Rabajoli F. Pregnancy in cyanotic congenital heart disease.

Outcome of mother and fetus. Circulation 1994;89:2673â2676.4Nora JJ, Nora AH. Recurrence risks in children having one parent with a congenital heart disease.

Circulation 1976;53:701â702.5Orwat S, Diller GP, van Hagen IM, Schmidt R, Tobler D, Greutmann M, Jonkaitiene R, Elnagar A, Johnson MR, Hall R, Roos-Hesselink JW, Baumgartner H. ROPAC Investigators. Risk of pregnancy in moderate and severe aortic stenosis.

From the multinational ROPAC registry. J Am Coll Cardiol 2016;68:1727â1737.6Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, BlomstrÃ¶m-Lundqvist C, CÃfkovÃ¡ R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. ESC Scientific Document Group.

2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018;39:3165â241.7Roos-Hesselink J, Baris L, Johnson M, De Backer J, Otto C, Marelli A, Jondeau G, Budts W, Grewal J, Sliwa K, Parsonage W, Maggioni AP, van Hagen I, Vahanian A, Tavazzi L, Elkayam U, Boersma E, Hall R. Pregnancy outcomes in women with cardiovascular disease.

Evolving trends over 10 years in the ESC Registry Of Pregnancy And Cardiac disease (ROPAC). Eur Heart J 2019;40:1â8.8Lammers AE, Diller GP, Lober R, MÃ¶llers M, Schmidt R, Radke RM, De-Torres-Alba F, Kaleschke G, Marschall U, Bauer UM, GerÎ² J, Enders D, Baumgartner H. Maternal and neonatal complications in women with congenital heart disease.

Int J Cardiol Congenital Heart Dis 2021;3:100107.10Independent Group of Scientists appointed by the Secretary-General. Global Sustainable Development Report 2019. The Future is Now.

Science for Achieving Sustainable Development. New York. 2019.11Drenthen W, Boersma E, Balci A, Moons P, Roos-Hesselink JW, Mulder BJ, Vliegen HW, van Dijk AP, Voors AA, Yap SC, van Veldhuisen DJ, Pieper PG.

ZAHARA Investigators. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010;31:2124â2132.12Ruys TP, Roos-Hesselink JW, Pijuan-Domenech A, Vasario E, Gaisin IR, Iung B, Freeman LJ, Gordon EP, Pieper PG, Hall R, Boersma E, Johnson MR.

ROPAC investigators. Is a planned caesarean section in women with cardiac disease beneficial?. Heart 2015;101:530â536.

For permissions, please email. Journals.permissions@oup.com..

ÂFor the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This Focus Issue on congenital heart disease contains the Special Article âTransition to adulthood and transfer can i buy ventolin over the counter uk to adult care of adolescents with congenital heart disease. A global consensus statementâ.1 Most children with congenital heart disease (CHD) in high-income countries survive into adulthood. Further, paediatric can i buy ventolin over the counter uk cardiac services have expanded in middle-income countries. Both evolutions have resulted in an increasing number of CHD survivors.2â5 In adolescence, patients transition from being a dependent child to an independent adult. They are can i buy ventolin over the counter uk also advised to transfer from paediatrics to adult care.

There is no universal consensus regarding how transitional care should be provided and how transfer should be organized. This consensus document can i buy ventolin over the counter uk describes issues and practices of transition and transfer of adolescents with CHD, accounting for different possibilities in high-, middle-, and low-income countries. Transitional care ought to be provided to all adolescents with CHD, taking into consideration the available resources. When reaching adulthood, patients ought to be transferred to adult care facilities/providers capable of managing their needs, and systems must be in place to make sure that continuity of high-quality care is ensured after leaving paediatric cardiology. Figure 1Suggested anticoagulation strategy for women with a prosthetic mechanical heart valve and (A) can i buy ventolin over the counter uk low-dose pre-conception vitamin K antagonist or (B) high-dose pre-conception vitamin K antagonist (from Egidy Assenza G, Dimopoulos K, Budts W, Donti A, Economy KE, Gargiulo GD, Gatzoulis M, Landzberg MJ, Valente AM, Roos-Hesselink J.

Management of acute cardiovascular complications in pregnancy. See pages 4224â4240).Figure 1Suggested anticoagulation strategy for women with a prosthetic mechanical heart valve and (A) low-dose pre-conception vitamin K antagonist or (B) high-dose pre-conception vitamin K antagonist (from Egidy Assenza G, Dimopoulos K, Budts W, Donti A, Economy KE, Gargiulo GD, Gatzoulis M, Landzberg can i buy ventolin over the counter uk MJ, Valente AM, Roos-Hesselink J. Management of acute cardiovascular complications in pregnancy. See pages 4224â4240).In a State of the Art Review article entitled âManagement of acute cardiovascular complications in pregnancyâ, Gabriele Egidy Assenza from the IRCCS Azienda Ospedaliero-Universitaria di Bologna in Italy and colleagues note that the growing population of women of reproductive age with heart disease has been associated with an increasing number of high-risk pregnancies.6 Pregnant women with heart disease are a very heterogeneous population, with different risks for maternal cardiovascular, obstetric, and foetal complications.7â11 Adverse cardiovascular events can i buy ventolin over the counter uk during pregnancy pose significant clinical challenges, with uncertainties regarding diagnostic and therapeutic approaches potentially compromising maternal and foetal health. This review provides a summary of recommendations on the management of acute cardiovascular complications during pregnancy, based on available literature and expert opinion.

The authors cover the diagnosis, risk stratification, and therapy, and the review is organized according to the clinical presentation and the type of complication, providing a reference for the practising cardiologist, obstetrician, and acute medicine specialist, while highlighting areas of need and potential future research. Topics covered include heart failure can i buy ventolin over the counter uk (HF), arrhythmias, coronary artery disease, aortic and thrombo-embolic events, and the management of mechanical heart valves during pregnancy (Figure 1). Figure 2Graphical Abstract (from Diller GP, Orwat S, Lammers AE, Radke RM, De-Torres-Alba F, Schmidt R, Marschall U, Bauer UM, Enders D, Bronstein L, Kaleschke G, Baumgartner H. Lack of specialist care can i buy ventolin over the counter uk is associated with increased morbidity and mortality in adult congenital heart disease. A population-based study.

See pages 4241â4248).Figure 2Graphical Abstract (from Diller GP, can i buy ventolin over the counter uk Orwat S, Lammers AE, Radke RM, De-Torres-Alba F, Schmidt R, Marschall U, Bauer UM, Enders D, Bronstein L, Kaleschke G, Baumgartner H. Lack of specialist care is associated with increased morbidity and mortality in adult congenital heart disease. A population-based study can i buy ventolin over the counter uk. See pages 4241â4248).In a Clinical Research article entitled âLack of specialist care is associated with increased morbidity and mortality in adult congenital heart disease. A population-based studyâ, Gerhard-Paul Diller from the University Hospital MÃ¼nster in Germany, and colleagues aimed to provide population-based data on the healthcare provision for adults with congenital heart disease (ACHD) and the impact of cardiology care on morbidity and mortality in this vulnerable population.12 Based on administrative data from one of the largest German Health Insurance Companies, all insured ACHD patients (<70âyears of age) were included.

Patients were can i buy ventolin over the counter uk stratified into those followed exclusively by primary care physicians (PCPs) and those with additional cardiology follow-up between 2014 and 2016. Associations between level of care and outcome were assessed by multivariable/propensity score Cox analyses. Overall, 24 139 patients (median age 43âyears, 54.8% can i buy ventolin over the counter uk female) were included. Of these, only 50% had cardiology follow-up during the 3-year period, with 49% of patients only being cared for by PCPs and 1% having no contact with either. After comprehensive multivariable and propensity score adjustment, ACHD patients under can i buy ventolin over the counter uk cardiology follow-up had a significantly lower risk of death [hazard ratio (HR) 0.81.

Pâ=â0.03] or major events (HR 0.85. Pâ<â0.001) compared with those only followed by PCPs. At 3-year follow-up, the absolute risk difference for mortality was 0.9% higher can i buy ventolin over the counter uk in ACHD patients with moderate/severe complexity lesions under the care of PCPs compared with those under cardiology follow-up (Figure 2). The authors conclude that cardiology care compared with primary care is associated with superior survival and lower rates of major complications in ACHD. It is alarming that even in a high-resource setting with can i buy ventolin over the counter uk well-established specialist ACHD care, â¼50% of contemporary ACHD patients are still not linked to regular cardiac care.

Thus, more efforts are required to alert PCPs and patients to appropriate ACHD care. The manuscript is accompanied by an Editorial by Anne Marie Valente from the Brigham and Womenâs Hospital in Boston, MA, USA and Abigail can i buy ventolin over the counter uk Khan from the Oregon Health and Science University in Portland, OR, USA.13 The authors conclude that it is clear that cardiology care matters for adults living with CHD. The next step for us all is to take this message forward, educating providers, empowering patients, and developing better care networks to support this growing population of individuals with complex care needs.In a Clinical Research article entitled âMaternal and neonatal complications in women with congenital heart disease. A nationwide analysisâ, Astrid Elisabeth Lammers from the University Hospital MÃ¼nster in Germany, and colleagues provide population-based data on maternal and neonatal complications and outcome in pregnancies of women with congenital heart disease (CHD).14 Based on administrative data from one can i buy ventolin over the counter uk of the largest German Health Insurance Companies (BARMER GEK, â¼9 million members representative for Germany), all pregnancies in women with CHD between 2005 and 2018 were analysed. In addition, an age-matched non-CHD control group was included for comparison, and the association between ACHD and maternal or neonatal outcomes was investigated.

Overall, 7512 pregnancies occurred in 4015 women with CHD. The matched non-CHD control group included can i buy ventolin over the counter uk 6502 women with 11 225 pregnancies. Caesarean deliveries were more common in CHD patients (40.5% vs. 31.5% in the control group can i buy ventolin over the counter uk. P <.

P = 0.001), and neonates to CHD mothers had significantly low/extremely low birth weight or extreme immaturity, or required resuscitation and mechanical ventilation more often compared with non-CHD offspring. On multivariate logistic regression, maternal defect complexity, arterial hypertension, HF, prior fertility treatment, and anticoagulation with vitamin K antagonists emerged as significant predictors of adverse neonatal outcome. Recurrence of CHD was 6.1 times higher in infants to ACHD mothers compared with controls.The authors conclude that this population-based study illustrates a reassuringly low maternal mortality rate in a highly developed healthcare system. Nevertheless, maternal morbidity and neonatal morbidity/mortality were significantly increased in women with ACHD, highlighting the need for specialized care and pre-pregnancy counselling. This manuscript is accompanied by an Editorial by Jolien W.

Roos-Hesselink from Erasmus MC in Rotterdam, the Netherlands, and colleagues.15 The authors note that the study by Lammers et al. Is an excellent and clinically relevant contribution to the existing literature on pregnancy in women with CHD. The study shows that a good healthcare system, a multidisciplinary approach, and decisive pre-pregnancy counselling are effective in achieving safe pregnancies. Pre-pregnancy counselling with an individualized approach is a crucial step in this process, because both maternal and perinatal outcomes vary largely by the complexity of maternal illness, and further studies dedicated to specific congenital diagnoses are still warranted.Left ventricular non-compaction (LVNC) cardiomyopathy is a devastating genetic disease caused by insufficient consolidation of ventricular wall muscle that can result in inadequate cardiac performance.16 Despite being the third most common cardiomyopathy, the mechanisms underlying the disease, including the cell types involved, are poorly understood. In a Translational Research article entitled âEndocardial/endothelial angiocrines regulate cardiomyocyte development and maturation and induce features of ventricular non-compactionâ, Siyeon Rhee from Stanford University in Stanford, CA, USA, and colleagues aimed to identify candidate angiocrines expressed by endocardial and endothelial cells in embryonic hearts of Tie2Cre;Ino80fl/fl transgenic mouse (an experimental model of LVNC).

It will be important to learn more about the cellular cross-talk to understand the mechanisms of cardiac development and homeostasis. The interplay between endothelial cells and other vascular cells such as pericytes and smooth muscle cells, and fibroblasts and immune cells, with cardiomyocytes has to be taken into account. The modulation of extracellular matrix proteins and paracrine factors may also be a therapeutic strategy promoting cardiac repair and regeneration, but probably needs to be carefully adapted to the underlying stage and type of heart disease.The issue is also complemented by two Discussion Forum contributions. In a commentary entitled âBig cohort studies offer insights into preventable risk factorsâ, Karolina Agnieszka Wartolowska and Alastair John Stewart Webb from the John Radcliffe Hospital in Oxford, UK comment on the recent Editorial âOn cerebrotoxicity of antihypertensive therapy and risk factor cosmeticsâ by Franz H. Messerli from the University of Bern in Switzerland.19,20 Messerli et al.

Respond in a separate comment.21The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article. References1Moons P, Bratt EL, De Backer J, Goossens E, Hornung T, Tutarel O, ZÃ¼hlke L, Araujo JJ, Callus E, Gabriel H, Shahid N, Sliwa K, Verstappen A, Yang HL, Thomet C. Transition to adulthood and transfer to adult care of adolescents with congenital heart disease. A global consensus statement of the ESC Association of Cardiovascular Nursing and Allied Professions (ACNAP), the ESC Working Group on Adult Congenital Heart Disease (WG ACHD), the Association for European Paediatric and Congenital Cardiology (AEPC), the Pan-African Society of Cardiology (PASCAR), the Asia-Pacific Pediatric Cardiac Society (APPCS), the Inter-American Society of Cardiology (IASC), the Cardiac Society of Australia and New Zealand (CSANZ), the International Society for Adult Congenital Heart Disease (ISACHD), the World Heart Federation (WHF), the European Congenital Heart Disease Organisation (ECHDO), and the Global Alliance for Rheumatic and Congenital Hearts (Global ARCH). Eur Heart J 2021;42:4213â4223.2Chessa M, Brida M, Gatzoulis MA, Diller GP, Roos-Hesselink JW, Dimopoulos K, Behringer W, MÃ¶ckel M, Giamberti A, Galletti L, Price S, Baumgartner H, Gallego P, Tutarel O.

Emergency department management of patients with adult congenital heart disease. A consensus paper from the ESC Working Group on Adult Congenital Heart Disease, the European Society for Emergency Medicine (EUSEM), the European Association for Cardio-Thoracic Surgery (EACTS), and the Association for Acute Cardiovascular Care (ACVC). Eur Heart J 2021;42:2527â2535.3Diller GP, Gatzoulis MA, Broberg CS, Aboulhosn J, Brida M, Schwerzmann M, Chessa M, Kovacs AH, Roos-Hesselink J. asthma disease 2019 in adults with congenital heart disease. A position paper from the ESC working group of adult congenital heart disease, and the International Society for Adult Congenital Heart Disease.

Eur Heart J 2021;42:1858â1865.4Diller GP, Lammers AE, Enders D, Baumgartner H. Maternal and neonatal complications in women with congenital heart disease. Results from a nationwide analysis including 7,231 pregnancies. Eur Heart J 2020;41(Suppl_2). Doi:10.1093/eurheartj/ehaa946.2215.5Playan Escribano J, Segura De La Cal T, Segovia Cubero J, Rueda Soriano J, Garcia Hernandez FJ, Lopez Meseguer M, Perez Penate GM, Lara Padron A, Campo Ezquibela A, Sala Llinas E, Mombiela T, Guerra Ramos FJ, Samper GJ, Blanco I, Escribano Subias P, REHAP Investigators.

Pulmonary hypertension and congenital heart disease. Medical treatment and risk factors for survival. Eur Heart J 2020;41(Suppl_2). Doi:10.1093/eurheartj/ehaa946.2299.6Egidy Assenza G, Dimopoulos K, Budts W, Donti A, Economy KE, Gargiulo GD, Gatzoulis M, Landzberg MJ, Valente AM, Roos-Hesselink J. Management of acute cardiovascular complications in pregnancy.

Eur Heart J 2020;41:4243â4244.9Beyer SE, Dicks AB, Shainker SA, Feinberg L, Schermerhorn ML, Secemsky EA, Carroll BJ. Pregnancy-associated arterial dissections. A nationwide cohort study. Eur Heart J 2020;41:4234â4242.10Roos-Hesselink J, Baris L, Johnson M, De Backer J, Otto C, Marelli A, Jondeau G, Budts W, Grewal J, Sliwa K, Parsonage W, Maggioni AP, van Hagen I, Vahanian A, Tavazzi L, Elkayam U, Boersma E, Hall R. Pregnancy outcomes in women with cardiovascular disease.

Evolving trends over 10 years in the ESC Registry Of Pregnancy And Cardiac disease (ROPAC). Eur Heart J 2019;40:3848â3855.11Koenig T, Hilfiker-Kleiner D. Future cardiovascular risk prediction in women with pregnancy complications. The HUNT is on. Eur Heart J 2019;40:1121â1123.12Diller GP, Orwat S, Lammers AE, Radke RM, De-Torres-Alba F, Schmidt R, Marschall U, Bauer UM, Enders D, Bronstein L, Kaleschke G, Baumgartner H.

Lack of specialist care is associated with increased morbidity and mortality in adult congenital heart disease. A population-based study. Eur Heart J 2021;42:4241â4248.13Khan AD, Valente AM. Donât be alarmed. The need for enhanced partnerships between medical communities to improve outcomes for adults living with congenital heart disease.

Eur Heart J 2021;42:4249â4251.14Lammers AE, Diller G-P, Lober R, MÃ¶llers M, Schmidt R, Radke RM, De-Torres-Alba F, Kaleschke G, Marschall U, Bauer UM, GerÃ J, Enders D, Baumgartner H. Maternal and neonatal complications in women with congenital heart disease. A nationwide analysis. Eur Heart J 2021;42:4252â4260.15Ramlakhan KP, Roos-Hesselink JW. Promising perspectives on pregnancy in women with congenital heart disease.

Eur Heart J 2021;42:4261â4263.16Ross SB, Jones K, Blanch B, Puranik R, McGeechan K, Barratt A, Semsarian C. A systematic review and meta-analysis of the prevalence of left ventricular non-compaction in adults. Eur Heart J 2020;41:1428â1436.17Rhee S, Paik DT, Yang JY, Nagelberg D, Williams I, Tian L, Roth R, Chandy M, Ban J, Belbachir N, Kim S, Zhang H, Phansalkar R, Wong KM, King DA, Valdez C, Winn VD, Morrison AJ, Wu JC, Red-Horse K. Endocardial/endothelial angiocrines regulate cardiomyocyte development and maturation and induce features of ventricular non-compaction. Eur Heart J 2021;42:4264â4276.18Wagner JUG, Dimmeler S.

The endothelial niche in heart failure. From development to regeneration. Eur Heart J 2021;42:4277â4279.19Wartolowska KA, Webb AJS. Big cohort studies offer insights into preventable risk factors. Eur Heart J 2021;42:4280â4281.20Huang HK, Liu PP, Hsu JY, Lin SM, Peng CC, Wang JH, Loh CH.

Fracture risks among patients with atrial fibrillation receiving different oral anticoagulants. A real-world nationwide cohort study. Eur Heart J 2020;41:1100â1108.21Messerli FH, Bavishi C, Messerli AW, Siontis GCM. Cerebrotoxicity of antihypertensive therapy in the UK Biobank Cohort Study. Eur Heart J 2021;42:4282.

Published on behalf of the European Society of Cardiology. All rights reserved. Â© The Author(s) 2021. For permissions, please email. Journals.permissions@oup.com.This editorial refers to âMaternal and neonatal complications in women with congenital heart disease.

A nationwide analysisâ, by A.E. Lammers et al., https://doi.org/10.1093/eurheartj/ehab571.With the increasing survival of children born with congenital heart disease into adult age, the focus has shifted from survival to quality of life. Most patients wish to live a normal life, including participation in sports and also starting a family. In earlier times, concerns were raised about the risks of pregnancy, as pregnancy is associated with impressive hormonal changes and haemodynamic impact. Older studies reported high rates of maternal complications, including maternal mortality, and substantial rates of perinatal complications.1â3 In addition, there were concerns about the hereditable recurrence risk of congenital heart disease for the baby.

However, studies were limited by small sample size or retrospective study design, and for a long time only the reported data from Nora and Nora were available.4 As a result, many physicians and, thus patients, were reluctant to embark on pregnancy, especially in more complex congenital heart disease, such as women with a systemic right ventricle, but also in severe aortic stenosis. The risks were deemed very high or too high, and these women were typically advised against pregnancy. Although research in the field of pregnancy and congenital heart disease is hampered by small numbers, often with retrospective design, over the past decades gradually some larger studies and registries became available, elucidating the risks of pregnancy and in fact showing relatively good results. A clear development over time in adult patients with congenital heart disease (ACHD) was seen for instance in women with transposition of the great arteries corrected with the Mustard and Senning operation, which started as being seen as very high risk, to high risk, and now to moderate risk. The trend for women with aortic stenosis is now also to allow pregnancy, even when the stenosis is severe, as long as the woman is asymptomatic.5â7The study of Lammers et al.

In this issue of the European Heart Journal provides an important contribution to the existing literature.8 Not only is this the largest study, but it includes all women with ACHD, without a possible bias of only including patients seen at a tertiary centre or including patients with other kinds of heart disease. Furthermore, because it is performed in a western country with an optimal healthcare system, the results are applicable to other western countries with comparable systems of care organization with appropriate counselling in place and good collaboration between cardiac and obstetric care. The pregnancy outcomes in studies with a global perspective, including patients from developing countries, show less favourable results (Graphical Abstract).8,9 These differences illustrate how the healthcare system and environment of women have great impact on their pregnancy outcomes and show that we still need to work to improve these outcomes for all women worldwide.10 A possible step forward is to utilize the expertise in the specialized healthcare centres such as described by Lammers et al., by providing long-distance digital or telephone consultations to rural centres in developing countries. Lammers et al. Also describe better pregnancy outcomes than an older study (1980â2007) in a Dutch and Belgian healthcare system similar to the German system, which may be due to advances in medical care for both the treatment of the original heart defect in the mother, and the management of pregnancy in heart disease, which includes the introduction of multidisciplinary pregnancy heart teams and the establishment of international guidelines (Graphical Abstract).8,11 Graphical AbstractComparison of studies on pregnancy outcomes of women with congenital heart disease.

ACHD. Adult congenital heart disease.Graphical AbstractComparison of studies on pregnancy outcomes of women with congenital heart disease. ACHD. Adult congenital heart disease.The most important finding of this well-performed and excellently written study is the zero maternal mortality in women with congenital heart disease.8 This is unexpected and fantastic news. As the authors point out, this is partly the result of good counselling, where the high-risk patients were advised against pregnancy and most probably did not become pregnant.

However, other studies show that some women at highest risk (mWHO IV) will actually still become pregnant, irrespective of counselling. In any case, this important finding makes it possible to reassure the large majority of ACHD patients about the mortality risk of pregnancy. This is an important message and should lead to a change in policy from approaching pregnancy as potentially very dangerous, to considering pregnancy as relatively safe and explaining the possible risks, on the condition that women in mWHO IV should not become pregnant. Of course morbidity is increased, but the rates are relatively low. The prevalence of heart failure in pregnancy might be under-reported in the study of Lammers et al., because pregnancies in women who had heart failure in the year before the pregnancy were not considered to be complicated by heart failure, probably because of the limitations of the method of registration with ICD codes.

The relationship between the occurrence of stroke and having a co-existent atrial septal defect or patent foramen ovale is shown nicely and should lead to a more proactive approach in taking lifestyle measures and considering a low threshold to prescribing antiplatelet drugs in these women. As in other studies, the mode of delivery is more often by Caesarean section in women with congenital heart disease, while this is not advised in the latest guidelines.6 An attempt must be made to change this policy, because planned Caesarean section in women with heart disease does not improve maternal outcome over vaginal delivery and can be harmful for neonatal outcome.12Another important finding of this study is the relatively high risk of the baby also having congenital heart disease.8 This study provides data on the numbers of children needing cardiac surgery with the use of cardiopulmonary bypass at young age, as a nice surrogate marker for congenital heart disease needing treatment, and reports 6% in ACHD patients vs. 0.4% in the general population. Scarce data were available on this topic, and for many years we had to rely on old studies.4 In particular, the comparison with the age-matched control group in this study provides the opportunity to finally gain reliable estimates. In counselling we can now inform our patients that the risk for their baby to also have congenital heart disease requiring surgery within â¤6 years is â¼15 times higher, compared with the general population (6% vs.

0.4%).8 What is astonishing is the reported rate for a univentricular heart being as high as 26.5%. Until now there was no reliable information on this specific congenital defect, because most women did not have children. However, this high rate fuels the discussion on pregnancy for women after Fontan correction. In addition to the high rates of miscarriage and maternal and foetal complications and the fear of the long-term impact on the maternal condition, now the high rate of foetal congenital defects also has to be taken into account when deciding on pregnancy in these high-risk women. It would be of interest to study trends over time, as earlier and better prenatal diagnostics and changes in termination management might have an impact, not only in these complex defects but also in less complex cardiac defects.In conclusion, the study by Lammers et al.

Is an excellent and clinically relevant contribution to the existing literature on pregnancy in women with congenital heart disease. The study shows that a good healthcare system, a multidisciplinary approach, and decisive pre-pregnancy counselling are effective in achieving safe pregnancies. Pre-pregnancy counselling with an individualized approach is a crucial step in this process, because both maternal and perinatal outcomes vary greatly by the complexity of maternal illness, and further studies dedicated to specific congenital diagnoses remain warranted.Conflict of interest. None declared.The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. References1Mendelson CL.

Pregnancy and coarctation of the aorta. Am J Obstet Gynecol 1940;39:1014â1021.2Arias F, Pineda J. Aortic stenosis and pregnancy. J Reprod Med 1978;20:229â232.3Presbitero P, Somerville J, Stone S, Aruta E, Spiegelhalter D, Rabajoli F. Pregnancy in cyanotic congenital heart disease.

Outcome of mother and fetus. Circulation 1994;89:2673â2676.4Nora JJ, Nora AH. Recurrence risks in children having one parent with a congenital heart disease. Circulation 1976;53:701â702.5Orwat S, Diller GP, van Hagen IM, Schmidt R, Tobler D, Greutmann M, Jonkaitiene R, Elnagar A, Johnson MR, Hall R, Roos-Hesselink JW, Baumgartner H. ROPAC Investigators.

Risk of pregnancy in moderate and severe aortic stenosis. From the multinational ROPAC registry. J Am Coll Cardiol 2016;68:1727â1737.6Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, BlomstrÃ¶m-Lundqvist C, CÃfkovÃ¡ R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. ESC Scientific Document Group. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy.

Eur Heart J 2018;39:3165â241.7Roos-Hesselink J, Baris L, Johnson M, De Backer J, Otto C, Marelli A, Jondeau G, Budts W, Grewal J, Sliwa K, Parsonage W, Maggioni AP, van Hagen I, Vahanian A, Tavazzi L, Elkayam U, Boersma E, Hall R. Pregnancy outcomes in women with cardiovascular disease. Evolving trends over 10 years in the ESC Registry Of Pregnancy And Cardiac disease (ROPAC). Eur Heart J 2019;40:1â8.8Lammers AE, Diller GP, Lober R, MÃ¶llers M, Schmidt R, Radke RM, De-Torres-Alba F, Kaleschke G, Marschall U, Bauer UM, GerÎ² J, Enders D, Baumgartner H. Maternal and neonatal complications in women with congenital heart disease.

A nationwide analysis. Eur Heart J 2021;42:4252â4260.9Ramlakhan KP, Johnson MR, Lelonek M, Saadd A, Gasimove Z, Sharashkinaf NV, Thorntong P, Arstallh M, Halli R, Roos-Hesselinka JW, on behalf of the ROPAC Investigators Group, ROPAC Executive Committee, ROPAC Investigators. Congenital heart disease in the ESC EORP Registry of Pregnancy and Cardiac disease (ROPAC). Int J Cardiol Congenital Heart Dis 2021;3:100107.10Independent Group of Scientists appointed by the Secretary-General. Global Sustainable Development Report 2019.

The Future is Now. Science for Achieving Sustainable Development. New York. 2019.11Drenthen W, Boersma E, Balci A, Moons P, Roos-Hesselink JW, Mulder BJ, Vliegen HW, van Dijk AP, Voors AA, Yap SC, van Veldhuisen DJ, Pieper PG. ZAHARA Investigators.

Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 2010;31:2124â2132.12Ruys TP, Roos-Hesselink JW, Pijuan-Domenech A, Vasario E, Gaisin IR, Iung B, Freeman LJ, Gordon EP, Pieper PG, Hall R, Boersma E, Johnson MR. ROPAC investigators. Is a planned caesarean section in women with cardiac disease beneficial?. Heart 2015;101:530â536.