Brindusa Truta, M.A.S., M.D.
- Assistant Professor of Medicine
https://www.hopkinsmedicine.org/profiles/results/directory/profile/9511115/brindusa-truta
If breakage is or by grasping with a simultaneous twisting indicated doctor of medicine buy cheap betahistine 16 mg on-line, use mechanical device such as forceps or and pulling action treatment laryngitis generic betahistine 16mg without a prescription. To guard against Obtain appropriate medical attention in the backflow treatment 3rd stage breast cancer 16mg betahistine with amex, the following precautions should be taken event of any exposure to biologic samples (for when drawing blood into the tube: 2 b medications hair loss buy cheap betahistine 16mg on line. Place succeeding tubes in holder, puncturing as soon as blood diaphragm to initiate flow. While each successive tube is filling invert previous tube 8 to 10 times to mix anticoagulant additive with blood. Collection Tubes (see Venipuncture Technique & Sample Collection section and Prevention of 8. If no should be centrifuged within two hours of blood blood flows into the tube or if blood ceases to collection for best results. Temperature Whole Blood Since the principle of separation depends on a Plasma density gradient, and the density of the components varies with temperature, the temperature of the Mononuclear Cells system should be controlled between 18-25? The time of platelets will be in a whitish layer just under centrifugation should be a minimum of 15 minutes. Aspirate (As noted in the trouble shooting section, some approximately half of the plasma without specimens may require up to 30 minutes for optimal separation). Centrifugation beyond cells immediately following centrifugation will 30 minutes has little additional effect. Red blood cell this is the preferred method for storing or contamination in the separated mononuclear cell transporting the separated sample for up to 24 fraction increases with longer delays in sample separation. Aspirate where the subject is leucopenic or lymphopenic, the as much supernatant as possible without selective loss of one subset may alter proportions disturbing cell pellet. Resuspend cell pellet by gently vortexing or Certain disease states and/or drugs may also alter tapping tube with index finger. Purity # of mononuclear cells expressed as a % of Platelet Contamination lymphocytes and monocytes in the separated white blood cells. Estimates of variability due to Results are obtained following the procedures repeated measurements are shown for within tube recommended by the manufacturer. Granulocyte Centrifuge not at Adjust centrifuge speed Micromethod for rapid separation of Contamination proper speed. Enumeration of Abnormal sample with Subsequent separation absolute numbers of T and B cells in human high granulocyte ratio. Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. Protection of Laboratory Workers from Infectious Disease Transmitted by Blood Tissue. Coulter and Coulter Counter are trademarks of - this End Up Coulter International Corp. College students inventsalad spinnercentrifuge R ice U niversity undergraduates L ila K errand L auren Theis turned an ordinary salad spinnerinto a device for diagnosing anem ia. P art1: The M etabolic and P hysiologic R esponses to Anem ia O xygen D elivery: O xygen S ensitive (heart,brain, m uscle) ClinicalF indings: P allor To Increase O xygen D elivery: He w entto an urgentcare center2days ago w here he w as prescribed trim ethroprim -sulfam ethoxazole forsuspected prostatitis. He also notes thathe w orks ata fastfood restaurant, w here he eats tw o m eals perday(usually ham burgers). F urthertesting is perform ed w hich reveals a negative directantiglobulin test,a negative G6P D screen,and a hem oglobin electrophoresis thatshow s 59% HbA,40% HbS,and 1% HbF. Ifth e curve issh ifted to th e righ t, P isincreased and oxygenaffinity isdecreased (oxygen 50 unloadingisincrease). Ifth e curve issh ifted to th e righ t, P isincreased and oxygenaffinity is 50 decreased. N O > sm ooth m uscle, activates guanylate cyclase > vasodilation P art2: Classif ication of Anem ia D iagnostic Approach To Anem ia: Generalconsiderations 1. P art2: Classif ication of Anem ia D iagnostic Approach To Anem ia: GeneralConsiderations: 3. T hese questions can be answ ered using a f ew readily available clinicaltests: 1. The reticulocyte count is used to assess the appropriateness of the bone m arrow response to anem ia. S he m ay adm itto pagophagia or restless legs Q :A 72-year-old gentlem an w ith a history of hypertension,coronary disease, and a m itralvalve replacem entpresents com plaining of fatigue and dyspnea on exertion. School of Medicine and Medical Science, University College Dublin, Ireland Irish Blood Transfusion Service, Ireland article info abstract Available online xxxx Men and women have different mean haemoglobin levels in health in venous blood women have mean levels approximately 12% lower than men. A similar sex-related difference in haemoglobin levels in adult animals is Keywords: found in many species of mammals, birds and reptiles, indicating that it is an important physiological phenom Erythropoiesis enon. It is probably a direct effect of sex hormones, both oestrogen and androgens, on erythropoiesis. However, Oestrogen since there is no difference in erythropoietin levels between the sexes, this effect most likely takes place in the Androgen kidney, rather than in the bone marrow. Oestrogens dilate and androgens constrict the renal microvasculature: Phylogeny Fahraeus effect dilation and vasoconstriction in vessels below 300? Introduction even further back in phylogenetics remains to be determined, but it is an ancient or recurring feature in evolution, which raises profound the long phylogenetic history of the sex difference in haemoglobin questions of what its importance may be. How and why these differences are maintained, adulthood male mammals and birds diverge from the juvenile state, and their relevance in medical practice, have not been fully de? This sex difference is independent of iron status iron replete premenopausal women have mean haemoglobin levels approx 2. Mechanisms producing the sex difference in venous haemoglobin imately 12% lower than age & race matched men [1,4]. The mean levels in adult animals circulating erythropoietin (Epo) level does not differ between men and women, and in women does not differ between pre and postmeno In general, in healthy humans, the venous haemoglobin level pausal women [5,6], indicating that the sex difference is constitutive, correlates to a modest extent with the red cell mass, though the corre and that women do not attempt to achieve male levels in health [5,7]. The two values are determined by largely by the same factors Mammalia a higher adult male haemoglobin level occurs in almost all (the tissue demand for oxygen determined at the juxtaglomerular mammal species studied to date, including non-menstruating and apparatus), but are subject to some independent modulators genetic non-placental species: chimpanzees [8], rhesus macaques [9], vervet and physiological, and are not directly interdependent. The physiological [10],cynomolgus[11] & capuchin monkeys [12], baboons [13], rodents factors may be constitutive or chronic, such as puberty and menopause, [14],dogs[15], marsupials & monotremes [16],andinseals[17]. Thus while red cell mass is on average lower per unit mass of tissue in females, the red cell mass in? Nevertheless for most clinical purposes venous 0268-960X/$ see front matter 2014 Published by Elsevier Ltd. Murphy / Blood Reviews xxx (2014) xxx?xxx haemoglobin levels can be used to imply red cell mass in individual haemoglobin levels evolved for different purposes would hardly be rev patients, although the imprecision in this approach becomes apparent olutionary. Indeed an absence of independently evolved haemoglobin in the management of the apparent polycythaemia of chronic hypoxic levels might be more puzzling given the profound differences in the lung or cardiac disease. Other mechanisms also play a part including a populations of healthy individuals, and within individuals over short baseline marrow erythroid activity that maintains a haemoglobin level periods of measurement, though not reliably outside that. Women with end effect of androgen in men in the bone marrow in association with stage renal disease are Epo resistant compared to age-matched males erythropoietin, a stimulatory effect of androgen on erythropoietin with end stage renal disease, requiring greater doses of Epo to achieve production in the kidney, and an inhibitory effect of oestrogen on the same (sub-physiologic) haemoglobin level, consistent with the the bone marrow in women [20,21]. These effects have been demon synergistic effect of androgen on erythropoietic dynamics in the bone strated in vitro [22?24], and also work directly in vivo androgens marrow [40]. This however emphasises that females could achieve the raise the haemoglobin level in males and females [25?29],and same levels of haemoglobin by increasing Epo production they oestrogen lowers it [24,30]. Testosterone in male animals may enable them to reach a lower levels in healthy adult females. Red cells in adult females could deliver more oxygen per cell the same effect in some other way, should there be an advantage in than in adult males. Females adult human females at least can raise their [41?44], a difference in oxygen dissociation has not been shown to venous haemoglobin levels in response to additional erythropoietic exist, so that a difference in oxygen unloading is unlikely to account stimuli. In addition ing the sex difference with males at the same altitude, as do Tibetan the ability of the microvasculature to transfer oxygen from red cells to women living at very high altitudes [31,32]. In addition, sex differences may exist in the levels by increasing erythropoietic drive. While these the prevailing lower haemoglobin level in females cannot be ascribed to effects cannot be ruled out, there are separate lines of evidence for a a lack of bone marrow or renal erythropoietic capability: they indicate sex difference in blood? Of course these factors may also indicate that males set venous haemoglobin level.
Diseases
- Giant papillary conjunctivitis
- Nasodigitoacoustic syndrome
- Berardinelli Seip congenital lipodystrophy
- Mitochondrial trifunctional protein deficiency
- Rhizomelic pseudopolyarthritis
- Holoprosencephaly
- Jacobsen syndrome
- Hemihypertrophy in context of NF
Thus symptoms questions order betahistine with paypal, a modified approach that will include a different combination of the components personalized for the patient may be warranted for specific groups of patients symptoms vitamin d deficiency buy discount betahistine 16 mg on-line. Moreover medications 122 discount 16mg betahistine with mastercard, in the real life of clinical practice medications given during dialysis generic 16 mg betahistine with amex, patients have other health problems that may influence the effectiveness of their coping with 2 lymphedema and consequently the outcome of their treatments. The next chapter (Chapter Two, a published manuscript) will discuss meaningful outcomes in lymphedema management. In order to be able to give the best treatment to the right patient, clinicians need to know how to assess and to precisely evaluate the outcomes of their intervention. Seeking what is clinically important is vital for true evaluation of the patient status, improvement, stability, and exacerbation. Chapter Four is a published chapter in a book on the assessment of lymphedema; the detailed assessment that is described is the basis of the work of a physical therapist who treats people with lymphedema. Chapter Five, a published manuscript, presents findings from a preliminary study on the reliability of measurements of physical therapists within the health system, Maccabi Health Services (Maccabi), in which the dissertation research was carried out. Volume is the main clinical outcome in lymphedema management; therefore, the physical therapist has to know what his/her measurement error is and how to use this information in routine practice. Documenting the crucial participation by the Maccabi lymphedema physical therapists, findings from an accuracy test is presented, as well, in which the therapists had to accurately select treatment codes for 10 treatment vignettes. This study was conducted to validate the use of a tool which is routinely used to measure function in Maccabi clinical practice but was never validated with people with lymphedema. Chapter Eight (manuscript in preparation) describes the population of persons with lymphedema who were treated in the Maccabi; their proportion within the Maccabi members; and their demographic, health, and treatment characteristics over a period of eight years from 2010-2017. Chapter Nine is a conclusion which briefly discusses and summarizes the findings reported in this dissertation, lessons learned, and conclusions with recommendations for future clinical, practice, education, policy and research. Enhancing supportive-educative nursing systems to reduce risk of post-breast cancer lymphedema. Lymphedema beyond breast cancer: A systematic review and meta analysis of cancer-related secondary lymphedema. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the international society of lymphology. A Review of Treatment for Breast Cancer-Related Lymphedema: Paradigms for Clinical Practice. Abstract Objective: To summarize published reports on the clinical effectiveness of conservative lymphedema management by reporting on outcomes which use anchor-based and distribution-based approaches. Data Synthesis: Twenty-four articles involving 938 patients met our inclusion criteria. Data were stratified according to different outcomes: limb volume (20 studies, 785 patients), symptoms (6 studies, 288 patients), skin changes (1 study, 28 patients), infection rate (5 studies, 255 patients), quality of life (4 studies, 148 patients), strength, function, endurance, fitness, and disability (3 studies, 89 patients). Most studies covered cancer-related lymphedema (22/23), especially as related to breast cancer (19/22). Large heterogeneity was found in the methods of estimations with regards to improvement, exacerbation, and stability of lymphedema. Further studies are needed to facilitate the process of improving clinical care of lymphedema. Lymphedema can manifest as primary or secondary impairment of the lymphatic system, where the secondary origin is the most common. Other conservative treatments that have been examined are the use of intermittent compression pumps (Feldman et al. Complex Decongestive Therapy is commonly administered in three phases: intensive; intermediate; and long-term. The purpose of the intensive phase is to reduce the affected limb to a normal size. Other goals may be improving range of motion, symptoms such as heaviness and pain, and function, and providing self management tools for the long-term management of the condition (Larouche K & M F, 2011; Stout et al. The results suggest an achievable reduction in limb volume between 17% to 60% (McNeely et al. Results vary due to different approaches of delivering this treatment (frequencies, session time), measurement tools (tape measurement, water displacement, bio-impedance spectroscopy, perometer), definitions of inclusion criteria (mild, moderate, severe), 10 and population diversity (Lasinski et al. The intermediate phase is administered when the patient has difficulty in maintaining the results of the intensive treatment, and needs further guidance on garment use, self-administered compression bandaging, and performing exercises. Health care providers need to act responsibly while making decisions for their patients? care. To be able to accomplish these tasks, therapists need answers to the following questions: What should be expected from this treatment? Statistical significance of a treatment effect can depend on sample size and lacks the point of view of clinical importance. When clinical interpretation is not made clear, research data may be confusing to clinicians and may be misinterpreted. It is the authors? responsibility to make their results understandable to the readers and, in addition to providing the statistical significance, to interpret the clinical meaningfulness of the results (De Vet et al. The statistical significance only represents the fact that the results were most likely not obtained by chance. It does not prove that the hypothesis which was generated by the researcher is true or false (Lydick & Epstein, 1993). However, the average 12 edema volume of the participants was over 700ml at the beginning of intervention. The authors did not discuss whether a 10% reduction after a 3-week period is a meaningful enough outcome for patients who invest money and time in daily treatment. Minimal clinically important difference is the threshold value of a change in which its definition for each outcome is critical when assessing side effects, costs, and efforts, but, most importantly, success of an intervention (Man Son-Hing et al. Therefore, patients should invest their effort in an effective and meaningful intervention. The distribution-based method uses statistical 13 properties of the investigating tool without considering external measures (De Vet et al. This approach does not consider whether the change is important or meaningful to the patient or to the health system. Anchor-based methods use an external anchor or indicator such as a patient response or a clinician opinion to validate a change as important (De Vet et al. Distribution-based Methods Standard error of measurement represents the error of measurement for a specific tool and is given in the same units as the measurement instrument. Standard error of measurement is directly correlated to the reliability of the test. The numerator represents the mean change from baseline and the 14 denominator is the standard deviation. The effect size can be used as a guide to assess the magnitude of the change (Lydick & Epstein, 1993). The disadvantages of distribution-based approaches are that, by themselves, they do not consider whether there was a clinically important change. Anchor-Based Methods Global rating of change scales are commonly used in clinical studies (Kamper, Maher, & Mackay, 2009). Different scales for assessing the perceived change by the patient or clinician have been introduced over the years and found to be sensitive to both negative and positive changes (Copay et al. The areas of change can include quality of life, function, symptoms, general health, and more (Hart et al. Different cutoffs can be used to divide the population into two groups (Turner et al. In addition, the area under the curve represents the probability that the results will distinguish between "improved" and "unchanged. If there is no accessible way to compare results to an anchor-based method, a distribution-based approach can be used (Turner et al. However, the majority of studies do not include recommendations of what meaningful changes clinicians 16 should expect or aspire to . The objectives of this systematic review are to locate reports on the clinical effectiveness of conservative lymphedema management by reporting on outcomes which use anchor-based and distribution-based approaches. The key words for the search were "lymphedema" or "lymphoedema" and "responsiveness" or "clinically significant" or "clinically important" or "measurement error" or "minimally clinical important change" or "minimal clinical change" or "small real difference. After title and abstract screening, 416 of 483 articles were excluded where there was no report on conservative interventions. Articles that used imaging procedures as an outcome were excluded, as well, since they are used more as research tools than clinical assessment tools.
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Notwithstanding any other provision of law treatment croup betahistine 16 mg without a prescription, and subject to the availability of appropriations medications zetia cheap betahistine 16 mg with visa, funds made available to an agency by this Act or any other Act may be used by such agency to modify the terms and conditions of a contract denivit intensive treatment 16 mg betahistine free shipping, or other agreement treatment solutions buy discount betahistine 16mg line, without consideration, to reimburse at the minimum applicable contract billing rates not to exceed an average of 40 hours per week any paid leave, including sick leave, a contractor provides to keep its employees or subcontractors in a ready state, including to protect the life and safety of Government and contractor per sonnel, but in no event beyond September 30, 2020. Such pay ment methods shall be based on payment rates that are similar to the national average payment rates for comparable telehealth services under the physician fee schedule under section 1848. Notwithstanding any other provision of law, the Secretary may implement such payment methods through program instruction or otherwise. With respect to home health services (as defined in section 1861(m) of the Social Security Act (42 U. The Secretary shall promulgate an interim final rule if necessary, to comply with the required effective date. The Secretary shall identify a discharge of such an indi vidual through the use of diagnosis codes, condition codes, or other such means as may be necessary. Activities authorized by section 2008 of the Social Security Act shall continue through November 30, 2020, in the manner authorized for fiscal year 2019, and out of any money in the Treasury of the United States not otherwise appropriated, there are hereby appropriated such sums as may be necessary for such purpose. Grants and payments may be made pursuant to this authority through the date so specified at the pro rata portion of the total amount authorized for such activities in fiscal year 2019. Expenditures made under any provision of law amended in this title pursuant to the amendments made by the Continuing Appropriations Act, 2020, and Health Extenders Act of 2019 (Public Law 116?59), the Further Continuing Appropriations Act, 2020, and Further Health Extenders Act of 2019 (Public Law 116?69), and the Further Consolidated Appropriations Act, 2020 (Public Law 116?94) for fiscal year 2020 shall be charged to the applicable appropriation or authorization provided by the amendments made by this title to such provision of law for such fiscal year. If a hearing is sought, such person must submit a request for a hearing, which shall be based solely on information in the administrative record, to the Secretary not later than 30 calendar days after receiving notice of the final decision of the formal dispute resolution procedure. In making such a determination, the Secretary may consider only information and data that are based on relevant and reliable scientific principles and methodologies. Where appropriate, the presiding officer may require that cross-examina tion by parties representing substantially the same interests be consolidated to promote efficiency and avoid duplication. Not withstanding any other provision of this section, if such request is withdrawn, the Secretary may cease proceedings under this subparagraph. Such requirements may include unit dose packaging, requirements for products intended for use by pediatric popu lations, requirements to reduce risk of harm from unsupervised ingestion, and other appropriate requirements. This paragraph does not authorize the Food and Drug Administration to require standards or testing procedures as described in part 1700 of title 16, Code of Federal Regulations. A determination under this section that a drug is not subject to section 503(b)(1), is generally H. The Secretary shall establish or modify such regu lations by means of rulemaking in accordance with section 553 of title 5, United States Code. The Secretary shall convene a confidential meeting with such sponsor in a reasonable time period. If a sponsor requests more than one confidential meeting for the same proposed sunscreen order, the Secretary may refuse to grant an additional confidential meeting request if the Secretary determines that such additional confidential meeting is not reasonably necessary for the sponsor to advance its proposed sunscreen order, or if the request for a confidential meeting fails to include sufficient information upon which to base a substantive discussion. The Secretary shall publish a post meeting summary of each confidential meeting under this subparagraph that does not disclose confidential commer cial information or trade secrets. This subparagraph does not authorize the disclosure of confidential commercial information or trade secrets subject to 552(b)(4) of title H. The Secretary shall have the sole discretion to refund a fee or a portion of the fee under this subparagraph. A determination by the Secretary concerning a refund under this subparagraph shall not be reviewable. Such sums as may be necessary may be transferred from the Food and Drug Administration salaries and expenses appropria tion account without fiscal year limitation to such appropriation account for salaries and expenses with such fiscal year limita tion. This subtitle may be cited as the ?Coronavirus Economic Sta bilization Act of 2020?. Any loans made by the Secretary under this section shall be at a rate determined by the Secretary based on the risk and the current average yield on outstanding marketable obligations of the United States of comparable maturity. If the Secretary exercises a waiver under this clause, the Secretary shall make himself available to testify before the Committee on Banking, Housing, and Urban Affairs of the Senate and the Committee on Financial Services of the House of Representatives regarding the reasons for the waiver. For the first 6 months after any such direct loan is made, or for such longer period as the Secretary may determine in his discretion, no principal or interest shall be due and payable. The Secretary shall not exercise voting power with respect to any shares of common stock acquired under this section. The Secretary is authorized to take such actions as the Sec retary deems necessary to carry out the authorities in this subtitle, including, without limitation? (1) using direct hiring authority to hire employees to admin ister this subtitle; (2) entering into contracts, including contracts for services authorized by this subtitle; (3) establishing vehicles that are authorized, subject to supervision by the Secretary, to purchase, hold, and sell assets and issue obligations; and (4) issuing such regulations and other guidance as may be necessary or appropriate to carry out the authorities or purposes of this subtitle. Such institutions shall? (1) perform all reasonable duties the Secretary determines necessary to respond to the coronavirus; and H. The Secretary of Transportation is authorized to require, to the extent reasonable and practicable, an air carrier receiving loans and loan guarantees under section 4003 to maintain scheduled air transportation service as the Secretary of Transportation deems necessary to ensure services to any point served by that carrier before March 1, 2020. When considering whether to exercise the authority granted by this section, the Secretary of Transportation shall take into consideration the air transportation needs of small and remote communities and the need to maintain well-functioning health care and pharmaceutical supply chains, including for medical devices and supplies. The authority under this section, including any requirement issued by the Secretary under this section, shall terminate on March 1, 2022. In implementing this subtitle with respect to air carriers, the Secretary shall coordinate with the Secretary of Transportation. The preceding sentence shall not apply to amounts paid on or before the date of the enactment of this Act. Notwithstanding any other provision of law? (1) during the 2-year period beginning on the date of enact ment of this Act, the requirements described in sections 303(a)(6)(C) and 304(e) of the Defense Production Act of 1950 (50 U. The nomination of an individual as Special Inspector General shall be made as soon as practicable after any loan, loan guarantee, or other investment is made under section 4003. For the purpose of determining whether an entity is a covered entity, the securities owned, controlled, or held by 2 or more individuals who are related as described in paragraph (3)(B) shall be aggregated. Upon request of the Chairperson of the Oversight Commission, the head of that department or agency shall fur nish that information to the Oversight Commission. Nothing in this subtitle shall be construed to allow the Sec retary to provide relief to eligible businesses, States, and municipali ties except in the form of loans, loan guarantees, and other invest ments as provided in this subtitle and under terms and conditions that are in the interest of the Federal Government. Unless otherwise specified, the terms in section 40102(a) of title 49, United States Code, shall apply to this subtitle, except that? (1) the term ?airline catering employee? means an employee who performs airline catering services; (2) the term ?airline catering services? means preparation, assembly, or both, of food, beverages, provisions and related supplies for delivery, and the delivery of such items, directly to aircraft or to a location on or near airport property for subsequent delivery to aircraft; (3) the term ?contractor? means? (A) a person that performs, under contract with a passenger air carrier conducting operations under part 121 of title 14, Code of Federal Regulations? (i) catering functions; or (ii) functions on the property of an airport that are directly related to the air transportation of persons, property, or mail, including but not limited to the loading and unloading of property on aircraft; assist ance to passengers under part 382 of title 14, Code of Federal Regulations; security; airport ticketing and check-in functions; ground-handling of aircraft; or air craft cleaning and sanitization functions and waste removal; or H. The Secretary may receive warrants, options, preferred stock, debt securities, notes, or other financial instruments issued by H. In implementing this subtitle the Secretary shall coordinate with the Secretary of Transportation. Notwithstanding any other provision of law, there is appro priated, out of amounts in the Treasury not otherwise appropriated, $32,000,000,000 to carry out this subtitle. Amounts recov ered under this subsection shall be deposited into the general fund of the Treasury. Amounts appropriated under the preceding sentence shall remain avail able until expended. Of the funds made available to the Rural Develop ment mission area in this title, and in addition to funds otherwise made available for such purpose, not more than 3 percent may be used for administrative costs to carry out loan, loan guarantee and grant activities funded in this title to prevent, prepare for, and respond to coronavirus, domestically or internationally: Pro vided, That such funds shall be transferred to , and merged with, the appropriation for ?Rural Development, Salaries and Expenses? and, once transferred, shall be used only to prevent, prepare for, and respond to coronavirus, domestically or internationally: Pro vided further, that this transfer authority is in addition to any other transfer authority provided by law. Of the amounts provided in the Further Consoli dated Appropriations Act, 2020 (Public Law 116?94) under the heading ?Commodity Credit Corporation Fund?Reimbursement for Net Realized Losses?, $14,000,000,000, may be used, prior to the completion of the report described in 15 U. The Secretary may extend the term of a marketing assistance loan authorized by section 1201 of the Agricultural Act of 2014 (7 U. For an additional amount for grants under the pilot program established under section 779 of Public Law 115? 141, to prevent, prepare for, and respond to coronavirus, $100,000,000, to remain available until September 30, 2021: Pro vided, That at least 90 percent of the households to be served by a project receiving a grant shall be in a rural area without sufficient access to broadband: Provided further, That for purposes of such pilot program, a rural area without sufficient access to broadband shall be defined as 10 Mbps downstream and 1 Mbps upstream, and such definition shall be reevaluated and redefined, as necessary, on an annual basis by the Secretary of Agriculture: Provided further, That an entity to which a grant is made under the pilot program shall not use a grant to overbuild or duplicate broadband expansion efforts made by any entity that has received a broadband loan from the Rural Utilities Service: Provided further, That priority consideration for grants shall be given to previous applicants now eligible as a result of adjusted eligibility require ments: Provided further, That such amount is designated by the Congress as being for an emergency requirement pursuant to section 251(b)(2)(A)(i) of the Balanced Budget and Emergency Deficit Con trol Act of 1985. Amounts provided by the Consolidated Appropria tions Act, 2020, (Public Law 116?93) for the Hollings Manufacturing Extension Partnership under the heading ?National Institute of Standards and Technology?Industrial Technology Services? shall not be subject to cost share requirements under 15 U. Funds appropriated by this title may be transferred to , and merged with, other applicable appropriations of the Depart ment of Defense, except for ?Drug Interdiction and Counter-Drug Activities, Defense?, for expenses incurred in preventing, preparing for, or responding to coronavirus, including expenses of the Depart ment of Defense incurred in support of other Federal Departments and agencies, and State, local, and Indian tribal governments, to be merged with and to be available for the same purposes, and for the same time period, as the appropriation or fund to which transferred: Provided, That upon a determination that all or part of the funds transferred pursuant to this section that are not necessary for the purposes provided herein, such funds shall be transferred back to the original appropriation: Provided further, That the transfer authority provided by this section is in addition to any other transfer authority provided by law. Funds appropriated in this title may be made available to restore amounts, either directly or through reimburse ment, for obligations incurred to prevent, prepare for, and respond to coronavirus prior to the date of enactment of this Act. Any discretionary appropriation for the Corps of Engineers derived from the Harbor Maintenance Trust Fund (not to exceed the total amount deposited in the Harbor Maintenance Trust Fund in the prior fiscal year) shall be subtracted from the estimate of discretionary budget authority and outlays for any estimate of an appropriations Act under the Congressional Budget and Impoundment Control Act of 1974 or the Balanced Budget and Emergency Deficit Control Act of 1985: Provided, That the modifications described in this section shall not take effect until the earlier of January 1, 2021 or the date of enactment of legislation authorizing the development of water resources and shall remain in effect thereafter. In addition to the amounts otherwise available to the Internal Revenue Service in fiscal year 2020, $250,000,000, to remain available until September 30, 2021, shall be available to prevent, prepare for, and respond to coronavirus, domestically H. Notwithstanding any other provision of law, funds made available under each heading in this title, except for ?Federal Emergency Management Agency?Disaster Relief Fund?, shall only be used for the purposes specifically described under that heading. Notwithstanding any other provision of law, any amounts appropriated for ?Federal Emergency Management Agency?Disaster Relief Fund? in this Act are available only for the purposes for which they were appropriated. Section 5 of the Protecting and Securing Chemical Facilities from Terrorist Attacks Act of 2014 (Public Law 113? 254; 6 U. Kennedy Center for the Performing Arts and its affiliates, including for employee compensa tion and benefits, grants, contracts, payments for rent or utilities, fees for artists or performers, information technology, and other administrative expenses: Provided further, That no later than October 31, 2020, the Board of Trustees of the Center shall submit a report to the Committees on Appropriations of the House of Representatives and Senate that includes a detailed explanation of the distribution of the funds provided herein: Provided further, That such amount is designated by the Congress as being for an emergency requirement pursuant to section 251(b)(2)(A)(i) of the Balanced Budget and Emergency Deficit Control Act of 1985. Commissioned Corps, and other preparedness and response activities: Provided, That funds appropriated under this paragraph in this Act may be used to develop and demonstrate innovations and enhancements to manufacturing platforms to sup port such capabilities: Provided further, That the Secretary of Health and Human Services shall purchase vaccines developed using funds made available under this paragraph in this Act to respond to an outbreak or pandemic related to coronavirus in quan tities determined by the Secretary to be adequate to address the public health need: Provided further, That products purchased by the Federal government with funds made available under this para graph in this Act, including vaccines, therapeutics, and diagnostics, shall be purchased in accordance with Federal Acquisition Regula tion guidance on fair and reasonable pricing: Provided further, That the Secretary may take such measures authorized under cur rent law to ensure that vaccines, therapeutics, and diagnostics developed from funds provided in this Act will be affordable in the commercial market: Provided further, That in carrying out the previous proviso, the Secretary shall not take actions that H. The Secretary shall issue a notice inviting applications not later than 30 days of enactment of this Act and shall approve or deny applications not later than 30 days after receipt.
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