fibromyalgia and covid vaccine uk

The study looked at 3,975 participants at eight sites. When they do happen, some of the most common vaccine side effects. Learn about the National Juvenile Arthritis Conference, a place for families to connect, share and learn. MeSH The https:// ensures that you are connecting to the They found, however, that in lab analysis of 18 samples of a popular plant-based meat alternative to 18 grass-fed ground beef samples from an Idaho ranch, 171 of the 190 metabolites they measured varied between the two types of products. I am not a medical professional. A study of the viral variant by the University of Washington School of Medicine/UW Medicine found three mutations in the Epsilon coronavirus spike protein that is able to neutralize the potency of antibodies induced by the current vaccines or past COVID-19 infections. They also found that the blood glucose levels of all the patients were much higher than the levels in normal people. Go online or use apps on your phone to guide you through these practices. A rheumatoid arthritis and fibromyalgia patient shares her experience getting the COVID-19 vaccine. Working with mice, they injected antibodies from people living with FMS and the mice quickly became sensitive to pressure and cold and had reduced movement grip strength. Join us and become a Champion of Yes. How Long Do Coronaviruses Live on Surfaces? Think you may have arthritis? Does Depression Qualify for Assisted Suicide? As we know, the causes of fibromyalgia are unknown, but it is certain that, at least in part, they are linked to a pain control dysfunction, which in turn is linked to a genetic and stress-facilitated deficit in opioid production and to a dysfunction of the central dopaminergic system of pain control. - Develop programs to meet the needs of you and your community The symptoms of fibromyalgia and of chronic fatigue syndrome are very similar, if not superimposable to some forms of long Covid Syndrome Near-Meat and Meat Products are Not Nutritionally the Same. Use of the Janssen (Johnson & Johnson) COVID-19 vaccine: Updated interim recommendations from the advisory committee on immunization practices United States, December 2021. This is because mRNA vaccines are more effective and have a better overall safety profile than the J&J vaccine. Fibromyalgia: Pathogenesis, mechanisms, diagnosis, and treatment options update. trouble with thinking, concentration, and memory, often called , pain, redness, or swelling at the injection site. A plant-based diet with lots of fruits and vegetables is a healthier option that also helps with joint pain and stiffness. The Arthritis Foundations JA camp programs give kids with arthritis and related childhood rheumatic diseases the chance to make lasting memories. Body-wide inflammation is at the root of most chronic diseases and you may have more control over it than you think. Join us today and help lead the way as a Champion of Yes. A 2021 study involving 1,519 people with arthritis and other musculoskeletal conditions found that only 5 in 100 of the participants experienced flare-ups following the COVID-19 vaccine, and. While their effectiveness at preventing infections has dropped, mRNA vaccines still prevent severe illness and hospitalization. Research from 2021 has found that fibromyalgia itself doesnt put you at an increased risk of severe COVID-19. The COVID-19 pandemic has been particularly challenging for people living with fibromyalgia, a condition characterized by widespread pain and tenderness throughout the body. "RA with a Side of Fibromyalgia. Two recent studies, which have yet to be published or peer-reviewed, suggest that people with COVID-19 can spread it to their dogs and cats, especially if they share a bed with the cats. Autoimmune inflammatory rheumatic diseases post-COVID-19 vaccination. Distinguishing Fibromyalgia Symptoms from Coronavirus Symptoms Many of the symptoms you may experience with fibromyalgia including chest pain, body aches, fatigue, and malaise can also be symptoms of COVID-19. If you score 30 or below on the functional capacity scale shown below feel free to take both polls but if you take just one poll please take the poll for the severely ill. 30: Moderate to severe symptoms at rest. Get informed about symptoms, medication, diagnosis, diet, and, Though research is limited, the evidence shows that some diets reduce pain and symptoms related to fibromyalgia. New-Onset Acute Kidney Disease Post COVID-19 Vaccination. When you have fibromyalgia, you could be at higher risk for COVID-19 if you also have an autoimmune disease like rheumatoid arthritis or lupus. The BBC is not responsible for the content of external sites. Most people had still failed to fully recover from the initial infection (25% much worse off, 16% moderately worse off, 19% somewhat worse off.) That's why we need large studies of real-world data, like this one, which looked at the healthcare records of millions of people. Gout is an inflammatory type of arthritis that can come and go. 2 Learn about the different types of arthritis, how they differ and why its important. The table below shows the current COVID-19 vaccine recommendations at the time of publication. It's important to keep taking your fibromyalgia medicines to avoid flares. Fibromyalgia, also called fibromyalgia syndrome (FMS), is a long-term condition that causes pain all over the body. There are many volunteer opportunities available. If you can't see your doctor in person, call their office to schedule a telemedicine visit. "It may. Initially it was less susceptible to antibody treatments available, but several months later the CDC downgraded it from a Variant of Concern to a Variant of Interest because it found the vaccines and other treatments were effective against it. By Mark Terry. Get the most in-depth information available on the latest ME/CFS and FM treatment and research findings by registering for Health Rising's free ME/CFS and Fibromyalgia blog here. By sharing your experience, youre showing decision-makers the realities of living with arthritis, paving the way for change. Video, At the crash site of 'no hope' - BBC reporter in Greece, Record numbers of guide dog volunteers after BBC story. amzn_assoc_height = 250; Island-hopping cougars swim kilometres through icy water off US coast. Become a Volunteer Fibromyalgia treatments like antidepressants and antiseizure drugs shouldn't affect your immune system or your risk for COVID-19. Rare neurological conditions may occur after Covid vaccination, but the risk is far higher in people who catch Covid, new research suggests. "Guillain-Barre syndrome, myasthenia-like disease, subarachnoid haemorrhage, encephalitis, and Bell's palsy were all quite common, especially in the first two weeks after testing positive for Sars-Cov-2.". Oliver SE, et al. We previously included summaries of latest COVID-19 information, including in the November 2022, December 2022 and January 2023 issues of Drug Safety Update. Effectiveness of BNT162b2 vaccine against Omicron variant in South Africa. We avoid using tertiary references. EClinicalMedicine. As a partner, you will help the Arthritis Foundation provide life-changing resources, science, advocacy and community connections for people with arthritis, the nations leading cause of disability. Exercise helps to relieve fibromyalgia pain and stiffness. RA and Fibro Patient Experience with COVID-19 Vaccine Tiffani's Story Tiffani Weatherford, a health care worker and rheumatoid arthritis and fibromyalgia patient, shares her experiences preparing for and getting both doses of the COVID-19 vaccine. today with our introductory offers. They found that lumican, a protein-sugar combination secreted by fibroblasts promotes immune system responses in macrophages. This has left people who don't develop side effects. Symptoms of fibromyalgia As well as widespread pain, other symptoms of fibromyalgia include: increased sensitivity to pain muscle stiffness difficulty getting to sleep or staying asleep, which can make you feel very tired (fatigue) Also, a 2015 study found that fibromyalgia symptoms didnt change after participants received the flu vaccine, which has similar side effects to the COVID-19 vaccine. You can learn more about how we ensure our content is accurate and current by reading our. In the U.K. (7.6 million) and Canada (887,000), almost 11% and about 1.4% of the population has received at least one shot. 81872687/National Natural Science Foundation of China, 2021zhyx-B04/Research Fund of Anhui Institute of Translational Medicine, 2108085Y26/Natural Science Foundation of Anhui Province, 2108085QH361/Natural Science Foundation of Anhui Province. We can only achieve these goals with your help. RA and Fibro Patient Experience with COVID-19 Vaccine. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Like the blog you're reading? Webinar: Touch Therapies for Pain Management, Webinar: Arthritis Fatigue Causes and Solutions. Image by torstensimon from Pixabay. Front Immunol. Online resource that helps patients better understand health coverage options, choose the right coverage, manage the denial process and reduce health care costs. Accessibility And all it takes is just 10 minutes. Vaccination is no longer required for the majority of P&O UK's voyages, but the company still "highly recommends" all passengers are up-to-date with vaccinations/boosters when eligible/where available. Hawara: 'What happened was horrific and barbaric'. Tighten and then relax one body part at a time, from your feet up to your legs, belly, chest, shoulders, arms, neck, and head. Its cause is still unknown, although a combination of genetics and environmental triggers is believed to play a role. Prevalence of comorbid diseases in patients with fibromyalgia: A retrospective cross-sectional study. The cause is thought to be related to abnormal levels of certain chemicals in the brain and changes in the way the central nervous system processes pain messages carried around the body. Alarm bells only start to ring if a complication is seen more often than might expected in a population. One of the yummiest gluten free treats ever! Researchers hope to expand their study to consider second vaccine doses and booster doses. "Yes, individuals with fibromyalgia should get a COVID vaccine when this is made available to them. Powered by Madgex Job Board Software. None of the 2,195 fibromyalgia patients who were tested for COVID-19 antibodies as part of the study has died as a result of a COVID-19 infection and only one was hospitalized. (2020). Strong, outspoken and engaged volunteers will help us conquer arthritis. The Food and Drug Administration's (FDA) advisory committee voted unanimously in favor of the vaccine, saying the company's clinical study data showed the shot was effective in preventing lower respiratory tract disease caused by RSV in adults aged 60 and above. The Coronavirus Vaccine Side Effects Poll for the Severely Ill, Ten Ways to Prove ME/CFS is a Serious Illness, Fibromyalgia Central: Basic Introductions to FM, 10 Ways to Prove FM is a Real and Serious Disease, Small Fiber Neuropathy (SFN) Resource Center, Profound Immune Dysregulation and Inflammation Found in Long COVID but no Autoimmunity, The Coronavirus Vaccine Side Effects Poll. ", Pain Medicine: "Moderate alcohol consumption is associated with reduced pain and fibromyalgia symptoms in chronic pain patients. Baden LR, et al. Unable to perform any strenuous tasks. The data also showed the vaccines were 81% effective in decreasing risk for infection after partial vaccination two weeks after the first dose, but before the second dose. 2005-2023 Healthline Media a Red Ventures Company. Medications, lifestyle changes, and more. ", Mayo Clinic: "Fibromyalgia: Diagnosis & treatment," "Fibromyalgia: Does Exercise Help or Hurt?" And, only one of those 82 individuals was hospitalized and placed on a ventilator for severe COVID-19 infection. The Arthritis Foundation is mobilizingpatients and their familiesto engagein studiescomparing the effectivenessof treatments for juvenile arthritisand funding researchfor more options. eCollection 2022. Ozaka S, Kobayashi T, Mizukami K, Murakami K. World J Gastroenterol. Fibromyalgia and COVID-19 vaccine side effects, COVID-19 vaccine guidelines for people with fibromyalgia, Centers for Disease Control and Prevention (CDC). have as well. (2021). Doctors say the landmark UK study provides further reassurance that being vaccinated offers the best protection for overall health. The site is secure. Here, we summarize the emerging evidence about autoimmune manifestations occurring in response to certain COVID-19 vaccines. 2022 May 9;10(5):742. doi: 10.3390/vaccines10050742. Talk to your doctor first. Treatment for fibromyalgia includes medication such as antidepressants and painkillers, talking therapies, exercise and relaxation techniques. The variant accounted for about 15% of cases across the U.S in February. Safary A, Esalatmanesh K, Eftekharsadat AT, Jafari Nakjavani MR, Khabbazi A. Int Immunopharmacol. Possible side effects after getting a COVID-19 vaccine. DMARDs and steroids lower your immune system response so that it doesn't attack your joints and other healthy tissues. GBS causes inflammation of the nerves and can lead to numbness, weakness and pain, usually in the feet, hands and limbs and can spread to the chest and face. *Cancel anytime within 14 days of payment to receive a refund on unserved issues. The fact that the stats were almost identical to the one-month reports suggested that time was not being the healer one might have hoped for. The Effects of Covid-19 Pandemic on The Patients With Fibromyalgia - Full Text View - ClinicalTrials.gov We're building a better ClinicalTrials.gov. If you are avoiding pharmacies, some pharmacies have curbside delivery or will deliver your medicine to you so that you don't have to go into the store. Lumican also protects tissues by moderating an immune response to DNA, whether from an invading virus or from human cells that are dying and release their DNA. Researchers examined the gut bacteria of people with fibromyalgia and found that they differ from those of people without the condition. All the patients experienced reduced pain, the scientists said. It was 86% effective in preventing serious illnesses. I am a retired Italian doctor who, for the last few months, without the certainty of having had Covid, has been presenting the symptoms of Long Covid syndrome. That means millions of Americans have a, There's been so much focus on vaccine side effects meaning your immune system is doing its job. According to the CDC, the Pfizer-BioNTech and Moderna vaccines, both mRNA vaccines, are preferable to the Johnson & Johnson (J&J) vaccine. November 16, 2020 at 10:56 pm CST. Local woman says she had severe reactions after getting COVID-19 vaccine. Please enable it to take advantage of the complete set of features! "Adjustment for the patients' age was critical in highlighting the differences between patients and control subjects.". Learn more about our FREE COVID-19 Patient Support Program for chronic illness patients and their loved ones. Zhang Q, Wang Z, Lv Y, Zhao J, Dang Q, Xu D, et al. Receiving a COVID-19 vaccine significantly reduces the likelihood of becoming severely ill with COVID-19. Competing interests: Today, the infamous study that claimed to link the MMR vaccine to autism, published in the . Long covid is one of many chronic conditions that can be triggered, at least in part, by infections, mostly by viruses. ", CreakyJoints.org: "Fibromyalgia and Coronavirus: What Patients Need to Know. U nder-30s should not hesitate to take the coronavirus vaccine amid a . TULSA, Okla. A lab conducting a COVID-19 study on patients with fibromyalgia says it's finding people who suffer from the . As such, the COVID-19 vaccine may have the added benefit of helping prevent a worsening of the fibromyalgia symptoms that you may already cope with daily. But these records on their own cannot tell us whether they were caused by the jab. Even so, COVID-19 can still cause some worries if you live with fibromyalgia, a long-term pain condition. Both the diseases themselves, and the disease-modifying drugs (DMARDs) or corticosteroids you take to treat them, can raise your odds of getting infections. Surprise! J Autoimmun. Both PCR and antigen tests can detect current infections. I've had manageable fibromyalgia for over 30 years (I take Celexa and Trazodone at bedtime). amzn_assoc_tracking_id = "patientrising-20"; 'My long Covid symptoms overlap with fibromyalgia' Revealing their findings, scientists from the University of Texas said they identified people with fibromyalgia using a common blood test, A1c, for insulin resistance, or pre-diabetes. Researchers in Canada identified 19 species of gut bacteria . The recommendation for GSK's vaccine follows the panel's vote in favor of Pfizer's RSV shot on Tuesday. (2015). (2016). A genetic researcher said: Its amazing and terrifying how quickly it came to dominate (in South Africa), and it does feel like were in the beginning stages of watching this variant and other new ones, come to dominate around the world. government site. Deaths registered as attributed to the COVID-19 vaccine can be found in table 14 of Monthly mortality analysis, England and Wales. 2023 Jan;134:102980. doi: 10.1016/j.jaut.2022.102980. Every gift to the Arthritis Foundation will help people with arthritis across the U.S. live their best life. Autoimmune hepatitis after COVID-19 vaccination. 2022 Dec 28;11(1):69. doi: 10.3390/vaccines11010069. FOIA They contribute $250,000 to $499,999. Check with your provider for specifics. Thus far, 6 1/2% of the people in the U.S. have received their first shot of the vaccine and 1.3% have received two shots. Some of the symptoms of COVID-19 are similar to those you may experience with fibromyalgia, including: However, several other symptoms can indicate you may have contracted SARS-CoV-2, the virus that causes COVID-19. Please, make your urgently-needed donation to the Arthritis Foundation now! PMC The Pfizer vaccine is an mRNA vaccine that has a 95% effectiveness rate. Get Started. But he's also got some more specific . Acupuncture may be one way to reduce fibromyalgia pain especially when combined with other forms of treatment. Plant and animal foods can be complementary, because they provide different nutrients., 1985 - 2023 BioSpace.com. And even a mild case of COVID-19 may cause fibromyalgia symptoms to flare up. The biggest variations were in amino acids, dipeptides, vitamins, phenols, and types of saturated and unsaturated fatty acids. Millions of people worldwide may have experienced long covid, with some having symptoms that have lingered for several years. Mice injected with antibodies from healthy people were unaffected. No symptoms after 1st moderna covid vaccine other than a sore arm. Arthritis is not one disease. Our Pacesetters ensure that we can chart the course for a cure for those who live with arthritis. Watch your diet. To view the results scroll down to the bottom of the poll and click view results. There are currently no reports in the scientific or medical literature of fibromyalgia flare-ups following the COVID-19 vaccine. There arent any specific COVID-19 vaccine guidelines for people with fibromyalgia. Since the needs of thejuvenile arthritis (JA) communityare unique, we are currently working with experts to develop a customized experience for JA families. Bookshelf Pharmacol Res. Ablin JN, et al. 2022 Dec 28;28(48):6791-6810. doi: 10.3748/wjg.v28.i48.6791. They should go away within a few days. Bilge U, et al. The AstraZeneca adenovirus vaccine is from 70-90% effective. The beef contained 22 metabolites that the plant substitute didnt. It is important for consumers to understand that these products should not be viewed as nutritionally interchangeable, but thats not to say that one is better than the other, said Stephen van Vliet, a postdoctoral researcher at the Duke Molecular Physiology Institute who led the research. Read about our approach to external linking. That may not seem like a lot, but in a country of the U.S.'s size, that's still 26 million doses. The cases of Lyme disease, mycoplasma, hepatits C and HIV are detailed. ", Stanford Medicine: "Gastrointestinal symptoms common in COVID-19 patients, Stanford Medicine study reports. Widespread cases of long covid have shone a spotlight on the role viral infections play in previously neglected conditions like chronic fatigue syndrome and fibromyalgia, Insight During their study they treated fibromyalgia patients with metformin, a drug used to combat insulin resistance in diabetics. What is the Venus-Jupiter conjunction and how can you view it? The @1,700 participants in the first Health Rising coronavirus vaccine poll reported that most people (69%) are at least leaning towards taking the vaccine (29% say they will definitely take the vaccine, 19% probably will, and 21% are leaning towards taking it.). 3 Healthcare providers recommend exercise, relaxation techniques, and finding a way to connect with loved ones and a social network to manage anxiety, ease chronic pain, and overcome fatigue. with just 40% back to baseline. There are no specific COVID-19 vaccination recommendations for people with fibromyalgia. Fibromyalgia is a chronic health condition characterized by widespread muscle pain accompanied by fatigue, sleep disturbances, mood-related disorders, memory problems and more. Polack FP, et al. Establishing that fibromyalgia is an autoimmune disorder will transform how we view the condition and should pave the way for more effective treatments for the millions of people affected. Coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented setback for global economy and health. They found that although the taste and texture may be similar, the nutritional content was not. Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Bird Flu Deaths Prompt U.S. to Test Vaccine in Poultry, COVID Treatment in Development Appears Promising, Marriage May Help Keep Your Blood Sugar in Check, Getting Outdoors Might Help You Take Fewer Meds, New Book: Take Control of Your Heart Disease Risk, MINOCA: The Heart Attack You Didnt See Coming, Health News and Information, Delivered to Your Inbox, Fibromyalgia Health Check: Get a Personalized Report. immune thrombotic thrombocytopenia, autoimmune liver diseases, Guillain-Barr syndrome, IgA nephropathy, rheumatoid arthritis and systemic lupus erythematosus). 2023 BBC. Advice for people at high risk from COVID-19. Our Trailblazers are committed partners ready to lead the way, take action and fight for everyday victories. In these challenging times of COVID-19, anxiety increased among the general population. Get our daily health briefing with all the news you need to know direct to your inbox. There are currently no reports of significant side effects in individuals with fibromyalgia whove been vaccinated. COVID-19 Vaccine (horsepox-based live virus vaccine) Preclinical TNX-2300 13. The Osteoarthritis Clinical Studies Forum Series features OA thought leaders from across the globe discussing the future of how the disease can be treated to improve patient outcomes. Condition or disease. Unauthorized use of these marks is strictly prohibited. amzn_assoc_bg_color = "FFFFFF"; The information found on Health Rising is mostly put together by people with ME/CFS and/or FM. All information contained on this website is for informational purposes only. "I also work as a GP and we want to make sure people are taking up the vaccine and booster jabs, and by doing that we will protect the health of the nation in the best way we can.". The Johnson and Johnson one-shot vaccine as approved for use in the U.S. on Feb 27th. Researchers say wearing green-tinted eyeglasses for several hours a day can help people with fibromyalgia reduce pain-related anxiety. Chronic pain and headaches are among the symptoms of fibromyalgia, Fibromyalgia could be treated using a common drug taken by diabetics, The exact cause of fibromyalgia is unknown and there is no cure. The plant-based substitute contained 31 metabolites meat didnt. official website and that any information you provide is encrypted They contribute $1,000,000 to $1,499,999. This would make fibromyalgia essentially an autoimmune disease, rather than the current theory that itoriginates in the brain. New-onset IgA nephropathy following COVID-19 vaccination. We also may change the frequency you receive our emails from us in order to keep you up to date and give you the best relevant information possible. Consistent with other studies, the University of Utah Health issued the results of a study that found individuals who received mRNA COVID-19 vaccines in other words, the Pfizer-BioNTech or Moderna vaccines are up to 91% less likely to develop COVID-19 than people who are unvaccinated. However, many people with fibromyalgia have other health conditions (comorbidities) that do raise the risk for severe COVID-19. Worries over COVID-19 can stress you out. Neurology professor Dr Miguel Pappolla said previous studies had overlooked the connection between fibromyalgia and A1c levels. - Shape a powerful agenda that fights for you Meditate or practice deep breathing for a few minutes each day. Fibromyalgia Action UK says of the condition: "The pain tends to be felt as diffuse aching or burning, often described as head to toe. Take a walk, ride a bike, or do another aerobic exercise for 30 minutes a day at least three times a week. The scientists, from the Universities of Oxford and Edinburgh, compared the levels of neurological conditions seen within a month of having a first Covid jab, to those seen within a month of a positive coronavirus test. Getting vaccinated can help provide peace of mind, which benefits your physical and mental health. Millions of people worldwide may have experienced long covid, with some having symptoms that have lingered for several years. Its estimated that fibromyalgia impacts about 5 percent of the worlds population. HHS Vulnerability Disclosure, Help In an attempt to find out how more severely ill ME/CFS/FM patients are doing Health Rising now has a side effects poll just for them. Developing COVID-19 may cause the symptoms of fibromyalgia to worsen. Overall, the CDC recommends that everyone age 5 and older receive a full vaccination series and boosters. amzn_assoc_placement = ""; More Clues to the Mystery of Fibromyalgia. Fibromyalgia Action UK says of the condition: "The pain tends to be felt as diffuse aching or burning, often described as head to toe. Most people are breezing through the first Pfizer/Moderna vaccination shots with about 2/3rds reporting mild or non-existent symptoms. reumatismo.org/index.php/reuma/article/view/823, journals.plos.org/plosone/article?id=10.1371/journal.pone.0261772, jpma.org.pk/article-details/8683?article_id=8683, cdc.gov/media/releases/2022/s0519-covid-booster-acip.html, sciencedirect.com/science/article/abs/pii/S0049017221000275, cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html, cdc.gov/coronavirus/2019-ncov/vaccines/expect/after.html, arthritis.org/health-wellness/about-arthritis/related-conditions/other-diseases/fibro-patient-experience-with-covid-19-vaccine, clinexprheumatol.org/abstract.asp?a=16454, ncbi.nlm.nih.gov/pmc/articles/PMC8068842/, cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html, cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html, academic.oup.com/painmedicine/article/17/3/463/1888231, Everything You Need to Know About Fibromyalgia, 60% of Americans Have an Underlying Condition That Increases COVID-19 Risk, Your COVID-19 Vaccine Is Still Working Even If You Dont Have Side Effects. What Im proposing, therefore, is the following: that it is not the Sars-CoV-2 virus that determines the Long-Covid syndrome due to some peculiar characteristics of the virus itself, but that it depends on the predisposition of the affected patients to the still mysterious condition of fibromyalgia and/or of chronic fatigue syndrome. Arthritis Foundation: "Fibromyalgia, Lupus, or Both?" Comprehensive description of adult-onset Still's disease after COVID-19 vaccination. See how we're aiming to address the growing shortage of arthritis specialists, especially in under-served parts of the country.
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