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High burden of buy levitra professional online antibiotic-resistant Mycoplasma genitalium in symptomatic urethritisMycoplasma genitalium is an aetiological agent of sexually 10mg levitra online transmitted urethritis. A cohort study investigated M. Genitalium prevalence, antibiotic resistance and association with previous macrolide exposure among 1816 Chinese 10mg levitra online men who presented with symptomatic urethritis between 2011 and 2015. was diagnosed by PCR, and sequencing was used to detect mutations that confer resistance to macrolides and fluoroquinolones.

In 11% 10mg levitra online of men, M. Genitalium was the sole pathogen identified. Nearly 90% of s were resistant 10mg levitra online to macrolides and fluoroquinolones. Previous macrolide exposure was associated with higher prevalence of resistance (97%).

The findings point to 10mg levitra online the need for routine screening for M. Genitalium in symptomatic men with urethritis. Treatment strategies to overcome antibiotic resistance in 10mg levitra online M. Genitalium are needed.Yang L, Xiaohong S, Wenjing L, et al.

Mycoplasma genitalium in symptomatic male 10mg levitra online urethritis. Macrolide use is associated with increased resistance. Clin Infect Dis 2020;5:805–10. Doi:10.1093/cid/ciz294.A new entry inhibitor offers promise for treatment-experienced patients with multidrug-resistant 10mg levitra online HIVFostemsavir, the prodrug of temsavir, is an attachment inhibitor.

By targeting the gp120 protein on the HIV-1 envelope, it prevents viral interaction with the CD4 receptor. No cross-resistance has been described with other 10mg levitra online antiretroviral agents, including those that target viral entry by other modalities. In the phase III BRIGHTE trial, 371 highly treatment-experienced patients who had exhausted ≥4 classes of antiretrovirals received fostemsavir with an optimised regimen. After 48 weeks, 54% of those with 1–2 additional active drugs achieved viral load suppression <40 copies/mL 10mg levitra online.

Response rates were 38% among patients lacking other active agents. Drug-related adverse events included nausea (4%) and 10mg levitra online diarrhoea (3%). As gp120 substitutions reduced fostemsavir susceptibility in up to 70% of patients with virological failure, fostemsavir offers the most valuable salvage option in partnership with other active drugs.Kozal M, Aberg J, Pialoux G, et al. Fostemsavir in adults with 10mg levitra online multidrug-resistant HIV-1 .

N Engl J Med 2020;382:1232–43. Doi. 10.1056/NEJMoa1902493Novel tools to aid identification of hepatitis C in primary careHepatitis C can now be cured with oral antiviral treatment, and improving diagnosis is a key element of elimination strategies.1 A cluster randomised controlled trial in South West England tested performance and cost-effectiveness of an electronic algorithm that identified at-risk patients in primary care according to national recommendations,2 coupled with educational activities and interventions to increase patients’ awareness. Outcomes were testing uptake, diagnosis and referral to specialist care.

Practices in the intervention arm had an increase in all outcome measures, with adjusted risk ratios of 1.59 (1.21–2.08) for uptake, 2.24 (1.47–3.42) for diagnosis and 5.78 (1.60–21.6) for referral. The intervention was highly cost-effective. Electronic algorithms applied to practice systems could enhance testing and diagnosis of hepatitis C in primary care, contributing to global elimination goals.Roberts K, Macleod J, Metcalfe C, et al. Cost-effectiveness of an intervention to increase uptake of hepatitis C levitra testing and treatment (HepCATT).

Cluster randomised controlled trial in primary care. BMJ 2020;368:m322. Doi:10.1136/bmj.m322Low completion rates for antiretroviral postexposure prophylaxis (PEP) after sexual assaultA 4-week course of triple-agent postexposure prophylaxis (PEP) is recommended following a high-risk sexual assault.3 4 A retrospective study in Barcelona identified 1695 victims attending an emergency room (ER) between 2006 and 2015. Overall, 883 (52%) started prophylaxis in ER, which was mostly (43%) lopinavir/ritonavir based.

Follow-up appointments were arranged for those living in Catalonia (631, 71.5%), and of these, only 183 (29%) completed treatment. Loss to follow-up was more prevalent in those residing outside Barcelona. PEP non-completion was associated with a low perceived risk, previous assaults, a known aggressor and a positive cocaine test. Side effects were common, occurring in up to 65% of those taking lopinavir/ritonavir and accounting for 15% of all discontinuations.

More tolerable PEP regimens, accessible follow-up and provision of 1-month supply may improve completion rates.Inciarte A, Leal L, Masfarre L, et al. Postexposure prophylaxis for HIV in sexual assault victims. HIV Med 2020;21:43–52. Doi:10.1111/hiv.12797.Effective antiretroviral therapy reduces anal high-risk HPV and cancer riskAmong people with HIV, effective antiretroviral therapy (ART) is expected to improve control of anal with high-risk human papillomalevitra (HR-HPV) and reduce the progression of HPV-associated anal lesions.

The magnitude of the effect is not well established. By meta-analysis, people on established ART (vs ART-naive) had a 35% lower prevalence of HR-HPV , and those with undetectable viral load (vs detectable viral load) had a 27% and 16% reduced risk of low and high-grade anal lesions, respectively. Sustained virological suppression on ART reduced by 44% the risk of anal cancer. The role of effective ART in reducing anal HR-HPV and cancer risks is especially salient given current limitations in anal cancer screening, high rates of anal lesion recurrence and access to vaccination.Kelly H, Chikandiwa A, Alemany Vilches L, et al.

Association of antiretroviral therapy with anal high-risk human papillomalevitra, anal intraepithelial neoplasia and anal cancer in people living with HIV. A systematic review and meta-analysis. Lancet HIV. 2020;7:e262–78.

Doi:10.1016/S2352-3018(19)30434-5.The impact of sex work laws and stigma on HIV prevention among female sex workersSex work laws and stigma have been established as structural risk factors for HIV acquisition among female sex workers (FSWs). However, individual-level data assessing these relationships are limited. A study examined individual-level data collected in 2011–2018 from 7259 FSWs across 10 sub-Saharan African countries. An association emerged between HIV prevalence and increasingly punitive and non-protective laws.

HIV prevalence among FSWs was 11.6%, 19.6% and 39.4% in contexts where sex work was partly legalised, not recognised or criminalised, respectively. Stigma measures such as fear of seeking health services, mistreatment in healthcare settings, lack of police protection, blackmail and violence were associated with higher HIV prevalence and more punitive settings. Sex work laws that protect sex workers and reduce structural risks are needed.Lyons CE, Schwartz SR, Murray SM, et al. The role of sex work laws and stigmas in increasing HIV risks among sex workers.

Nat Commun 2020;11:773. Doi:10.1038/s41467-020-14593-6.BackgroundCumbria Sexual Health Services (CSHS) in collaboration with Cumbria Public Health and local authorities have established a erectile dysfunction treatment contact tracing pathway for Cumbria. The local system was live 10 days prior to the national system on 18 May 2020. It was designed to interface and dovetail with the government’s track and trace programme.Our involvement in this initiative was due to a chance meeting between Professor Matt Phillips, Consultant in Sexual Health and HIV, and the Director of Public Health Cumbria, Colin Cox.

Colin knew that Cumbria needed to act fast to prevent the transmission of erectile dysfunction treatment and Matt knew that sexual health had the skills to help.ProcessDespite over 90% of the staff from CSHS being redeployed in March 2020, CSHS maintained urgent sexual healthcare for the county and a phone line for advice and guidance. As staff began to return to the service in May 2020 we had capacity to spare seven staff members, whose hours were the equivalent of four full-time staff. We had one system administrator, three healthcare assistants, one nurse, Health Advisor Helen Musker and myself.CSHS were paramount to the speed with which the local system began. Following approval from the Trust’s chief executive officer we had adapted our electronic patient records (EPR) system, developed a standard operating procedure and trained staff, using a stepwise competency model, within just 1 day.In collaboration with the local laboratories we developed methods for the input of positive erectile dysfunction treatment results into our EPR derivative.

We ensured that labs would be able to cope with the increase in testing and that testing hubs had additional capacity. Testing sites and occupational health were asked to inform patients that if they tested positive they would be contacted by our teams.This initiative involved a multiagency system including local public health (PH) teams, local authority, North Cumbria and Morecambe Bay CCGs, Public Health England (PHE) and the military. If CSHS recognise more than one positive result in the same area/organisation, they flag this with PH at the daily incident management meeting and environmental health officers (EHOs) provide advice and guidance for the organisation. We have had an active role in the contact tracing for clusters in local general practices, providing essential information to PH to enable them to initiate outbreak control and provide accurate advice to the practices.

We are an integral part in recognising cases in large organisations and ensuring prompt action is taken to stem the spread of the disease. The team have provided out-of-hours work to ensure timely and efficient action is taken for all contacts.The local contact tracing pilot has evolved and a database was established by local authorities. Our data fed directly into this from the end of May 2020. This enables the multiagency team to record data in one place, improving recognition of patterns of transmission.DiscussionCumbria is covered by three National Health Service Trusts, which meant accessing data outside of our Trust was challenging and took more time to establish.

There are two CCGs for Cumbria, which meant discussions regarding testing were needed with both North and South CCGs and variations in provision had to be accounted for. There are six boroughs in Cumbria with different teams of EHOs working in each. With so many people involved, not only is there need for large-scale frequent communication across a multisystem team, there is also inevitable duplication of work.Lockdown is easing and sexual health clinics are increasing capacity in a new world of virtual appointments and reduced face-to-face consultations. Staff within the contact tracing team are now balancing their commitments across both teams to maintain their skills and keep abreast of the rapid developments within our service due to erectile dysfunction treatment.

We are currently applying for funding from PH in order to second staff and backfill posts in sexual health.ConclusionCSHS have been able to lend our skills effectively to the local contact tracing efforts. We have expedited the contact tracing in Cumbria and provided crucial information to help contain outbreaks. It has had a positive effect on staff morale within the service and we have gained national recognition for our work. We have developed excellent relationships with our local PH team, PHE, Cumbria Council, EHOs and both CCGs.Cumbria has the infrastructure to meet the demands of a second wave of erectile dysfunction treatment.

The beauty of this model is that if we are faced with a second lockdown, sexual health staff will inevitably be available to help with the increased demand for contact tracing. Our ambition is that this model will be replicated nationally..

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Health concierge startup Accolade announced this week that it will buy the telemedicine vendor 2nd.MD for about $460 million.According to a Thursday press announcement, Accolade intends to strengthen its ability to site provide users second opinions through the acquisition of Innovation levitra alternatives Specialists, the Houston-based parent company of 2nd.MD. The company will also continue to offer 2nd.MD's service on a stand-alone basis."Bringing 2nd.MD’s world-class Care Team and digital approach with expert medical consultation into Accolade, and continuing to offer it on a stand-alone basis, will have an immediate and measurable impact for our customers, their employees, and the health plans we work with,” said Rajeev Singh, chief executive officer at Accolade, in a statement.WHY IT MATTERSSeattle-based Accolade acts as an on-demand healthcare concierge tool, allowing employers to offer employees and their families personalized health and benefits levitra alternatives solutions. 2nd.MD, meanwhile, works to connect patients with board-certified experts around the country for a medical consultation via video call or phone within three to levitra alternatives five days. Currently, the company says it serves more than 300 employer-customers and more than 7 million employee-members, and that employer-customers save an average of $5,000 per consultation and $27,000 per consultation when a surgery is involved.“Both companies have built deep relationships with employers and health plans by helping employees navigate levitra alternatives the increasingly complex and inconsistent healthcare system," said Singh.The transaction is expected to close by the end of February, with a purchase price of $230 million in cash, $130 million in Accolade common stock and up to $100 million in Accolade common stock contingent on revenue milestones."We are enthusiastic about the business benefits that 2nd.MD will bring to Accolade.

In addition to the expanded services and clinical levitra alternatives capabilities we will be able to offer our customers, 2nd.MD brings new industry distribution relationships to help grow our business and expands our addressable market by an estimated $22 billion," said Steve Barnes, chief financial officer at Accolade.THE LARGER TRENDIt's been a busy year or so for telehealth from a merger and acquisition perspective. In August of last year, Teladoc Health announced that it would absorb chronic care company Livongo to the tune of $18.5 billion, following its absorption of InTouch Health's enterprise telehealth business valued at $600 million eight months prior.Teladoc and Livongo's leaders levitra alternatives said in October that they see the deal as a way to offer a longitudinal relationship between clinicians and patients."Rather than a checkup once a year or two visits for sore throat or the flu and no interactions in between that, this becomes a longitudinal relationship that brings [together] multiple professionals, digital assets and data science all to bear for the consumer," said Teladoc CEO Jason Gorevic.ON THE RECORD"Combining our Care Teams and technology with Accolade will enhance the reach and quality of support to members from the moment of crisis to the other side of treatment on the path to wellness," said Jason Melton, chief executive officer, 2nd.MD. "We share a common levitra alternatives business vision, our cultures are highly aligned around employee purpose and we share a common mission to change healthcare for the benefit of all consumers," Melton continued. Kat Jercich levitra alternatives is senior editor of Healthcare IT News.Email.

Kjercich@himss.orgTwitter. @kjercichHealthcare IT News is a HIMSS Media publication..

Health concierge startup Accolade announced this week that it will buy the telemedicine vendor 2nd.MD for about $460 million.According to a Thursday press announcement, Accolade intends to strengthen its ability to provide users second opinions through the acquisition 10mg levitra online of Innovation Specialists, the Houston-based parent company of 2nd.MD. The company will also continue to offer 2nd.MD's service on a stand-alone basis."Bringing 2nd.MD’s world-class Care Team and digital approach with expert medical consultation into Accolade, and continuing to offer it on a stand-alone basis, will have an immediate and measurable impact for our customers, their employees, and the health plans we work with,” said Rajeev Singh, chief executive 10mg levitra online officer at Accolade, in a statement.WHY IT MATTERSSeattle-based Accolade acts as an on-demand healthcare concierge tool, allowing employers to offer employees and their families personalized health and benefits solutions. 2nd.MD, meanwhile, works to connect patients with board-certified experts around the 10mg levitra online country for a medical consultation via video call or phone within three to five days. Currently, the company says it serves more than 300 employer-customers and more than 7 million employee-members, and that employer-customers save an average of $5,000 per consultation and $27,000 per consultation when a surgery is involved.“Both companies have built deep relationships with employers and health plans by helping employees navigate the increasingly complex and inconsistent healthcare system," said Singh.The transaction is expected to close by the end of February, with a purchase price of $230 million in cash, $130 million in Accolade common stock and up to $100 million in Accolade common stock contingent on revenue milestones."We are enthusiastic about the business benefits that 10mg levitra online 2nd.MD will bring to Accolade. In addition to the expanded services and clinical capabilities we will be able to offer our customers, 2nd.MD brings new industry distribution relationships to help grow our business and expands our addressable market by an estimated $22 10mg levitra online billion," said Steve Barnes, chief financial officer at Accolade.THE LARGER TRENDIt's been a busy year or so for telehealth from a merger and acquisition perspective.

In August of last year, Teladoc Health announced that it would absorb chronic care 10mg levitra online company Livongo to the tune of $18.5 billion, following its absorption of InTouch Health's enterprise telehealth business valued at $600 million eight months prior.Teladoc and Livongo's leaders said in October that they see the deal as a way to offer a longitudinal relationship between clinicians and patients."Rather than a checkup once a year or two visits for sore throat or the flu and no interactions in between that, this becomes a longitudinal relationship that brings [together] multiple professionals, digital assets and data science all to bear for the consumer," said Teladoc CEO Jason Gorevic.ON THE RECORD"Combining our Care Teams and technology with Accolade will enhance the reach and quality of support to members from the moment of crisis to the other side of treatment on the path to wellness," said Jason Melton, chief executive officer, 2nd.MD. "We share a common business vision, our cultures are highly aligned around employee purpose and we share 10mg levitra online a common mission to change healthcare for the benefit of all consumers," Melton continued. Kat Jercich 10mg levitra online is senior editor of Healthcare IT News.Email. Kjercich@himss.orgTwitter. @kjercichHealthcare IT News is a HIMSS Media publication..

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Medicaid Services (CMS) determined that the erectile dysfunction treatment emergency presents exceptional circumstances for consumers in accessing health insurance and will provide a Special Enrollment Period (SEP) for individuals and families do you have to have a prescription for levitra to apply and enroll in the coverage they need. This SEP will be available to consumers in the 36 states served by Marketplaces that use the HealthCare.gov platform, and CMS will conduct outreach activities to encourage those who are eligible to enroll in health coverage. CMS strongly encourages states operating their own Marketplace platforms to make a similar enrollment opportunity available to consumers in their states.Starting on February 15, 2021 and continuing through May 15, 2021, Marketplaces using the HealthCare.gov platform will operationalize functionality to make a SEP available to all Marketplace-eligible consumers who are submitting a new application or updating an existing application. These consumers will newly be able to access the SEP do you have to have a prescription for levitra through a variety of channels.

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Outreach efforts will include considerable awareness building efforts to encourage the uninsured and those who come to HealthCare.gov to explore coverage to continue do you have to have a prescription for levitra the process and enroll. CMS plans to spend $50 million on outreach and education, on a mix of tactics to increase awareness, including advertisements on broadcast, digital, and an earned media. Some consumers may already be eligible for other do you have to have a prescription for levitra existing SEPs, Medicaid, or the Children’s Health Insurance Program (CHIP) – they can visit HealthCare.gov now to find out if they can enroll even before this new SEP. Starting February 15, consumers seeking to take advantage of this SEP can find out if they are eligible by visiting HealthCare.gov, and are no longer limited to calling the Marketplace call center to access this SEP.

Consumers who are eligible and enroll under this SEP will be able to select a plan with coverage that starts prospectively the first of the month after plan selection. Consumers will have do you have to have a prescription for levitra 30 days after they submit their application to choose a plan. Current enrollees will be able to change to any available plan in their area without restriction to the same level of coverage as their current plan. In order to use this SEP, current enrollees will need to step through their application and do you have to have a prescription for levitra make any changes if needed to their current information and submit their application in order to receive an updated eligibility result that provides the SEP before continuing on to enrollment.

This SEP opportunity will not involve any new application questions, or require consumers or enrollment partners to provide any new information not otherwise required to determine eligibility and enroll in coverage. In addition, consumers won’t need to provide do you have to have a prescription for levitra any documentation of a qualifying event (e.g., loss of a job or birth of a child), which is typically required for SEP eligibility. As always, consumers found eligible for Medicaid or CHIP will be transferred to their state Medicaid and CHIP agencies for enrollment in those programs. For more information about the Health Insurance Marketplace®[1], visit.

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Comments may be sent by mail do you have to have a prescription for levitra. The Office of Management and Budget, Attn. OFFM, 725 17th do you have to have a prescription for levitra Street NW, Washington, DC 20503. Start Further Info Regina Kearney at (202) 395-3993.

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At § 3354(b)(2)(B) do you have to have a prescription for levitra. For additional analysis and information pertaining to aforementioned databases, please refer to Regulations.gov. We invite public comments on the proposed designation of each of the twelve databases identified in this notice. Start Signature Russell do you have to have a prescription for levitra T.

Vought, Director. End Signature End Supplemental Information [FR Doc do you have to have a prescription for levitra. 2021-01327 Filed 1-21-21. 8:45 am]BILLING CODE 3110-01-P.

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CMS strongly encourages states operating their own Marketplace platforms to make a similar enrollment opportunity available to consumers in their states.Starting on February 15, 2021 and continuing through May 15, 2021, Marketplaces using the HealthCare.gov platform will operationalize functionality to make a SEP available to all Marketplace-eligible consumers who are submitting a new application or updating an existing application. These consumers will newly be able to access the SEP through a variety of channels 10mg levitra online. Through HealthCare.gov directly, the Marketplace call center, or direct enrollment channels.

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Outreach efforts will include considerable awareness building efforts to encourage the uninsured and those who 10mg levitra online come to HealthCare.gov to explore coverage to continue the process and enroll. CMS plans to spend $50 million on outreach and education, on a mix of tactics to increase awareness, including advertisements on broadcast, digital, and an earned media. Some consumers may already be eligible for other existing SEPs, Medicaid, or the Children’s Health Insurance Program (CHIP) – they can visit HealthCare.gov now to find out if they can enroll 10mg levitra online even before this new SEP.

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Current enrollees will be able to change to any available plan in their area without restriction to the same level of coverage as their current plan. In order to use this SEP, current enrollees will need to step through their application and make any changes if needed to their current information and submit their application in order to receive an updated eligibility result that provides 10mg levitra online the SEP before continuing on to enrollment. This SEP opportunity will not involve any new application questions, or require consumers or enrollment partners to provide any new information not otherwise required to determine eligibility and enroll in coverage.

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Https://www.healthcare.gov/quick-guide/getting-marketplace-health-insurance/ ###Start Preamble Office of Management and Budget 10mg levitra online. Notice of proposed designation. The Payment Integrity Information Act of 2019 (PIIA) authorizes the Office of Management and 10mg levitra online Budget (OMB) to designate databases for inclusion in Treasury's Working System under the Do Not Pay (DNP) Initiative.

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At § 3354(b)(2)(B) 10mg levitra online. For additional analysis and information pertaining to aforementioned databases, please refer to Regulations.gov. We invite public comments on the proposed designation of each of the twelve databases identified in this notice.

Start Signature Russell 10mg levitra online T. Vought, Director. End Signature End Supplemental Information 10mg levitra online [FR Doc.

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Choice is probably one Get kamagra of the most often discussed areas in bioethics, alongside the related concepts of informed consent and levitra pills over the counter autonomy. It is levitra pills over the counter generally, prima facie, portrayed as a good thing. In healthcare, the 2000s saw the UK Prime Minister Tony Blair pursue the levitra pills over the counter ‘Choice Agenda’ where, ‘As capacity expands, so choice will grow. Choice will fundamentally change the balance of power in the NHS.’1 In a consumerist society giving consumers more choice is seen as desirable.

However, choice is not a good in itself, giving people more levitra pills over the counter choice in certain situations can be problematic. I.e. Consumerism drives economic growth and this has a detrimental effect on the environment. And increasing the range of choices a patient is offered is often not the best way to improve the quality of healthcare provision.2 The assumptions behind the valuing of choice need careful unpacking and this Issue of the Journal of Medical Ethics includes papers that explore choice in a number of areas.This Issue's Editor’s choice is Tom Walker’s ‘The Value of Choice’,3 which puts forward a suggestion for the importance of the symbolic value of choice.

There are a number of ways of categorising the value of choice in healthcare. One account sees choice as valuable because it is by choosing that individuals make their life their own. Another account sees choice as valuable for instrumental reasons, people are generally, assuming they are sufficiently informed, the best judge of their own best interests. Walker argues for an additional third reason, the symbolic value of choice, originally proposed by Scanlon.

This sees choice as valuable because being given the option to choose, whether or not one takes it up, not the act of choosing is what makes choice valuable. Being offered the option to choose has a ‘communicative role’ in that it communicates that the person has standing and, for certain types of choice, being denied the opportunity to choose, ‘can be both demeaning and stigmatising.’ Walker states that denying someone the opportunity to choose in certain circumstances does not communicate anything untoward, and he goes to explore how we might determine when not allowing someone a choice would be demeaning. Here he stresses the importance of context in making this determination, it is not fixed by the features of a patient, but what being ‘allowed’ or ‘denied’ the opportunity to make a choice reveals about the healthcare professional’s view of the patient. €˜It communicates that they either see those patients as competent and equal members of society, or that they do not.’ Denying a patient the opportunity to choose an ineffective treatment, for example, does not communicate a negative judgement.

Walker says his account, ‘is intended to supplement existing accounts, not replace them. Because choice is valuable for more than one reason no single account can capture everything that matters.’The importance of pointing to the context of the choice is highlighted in Walker’s paper and it is only through careful examination of the context of that offering that we can determine if, in fact, this is an area where choice should be offered and to whom. Such an examination is carried out in Cameron Beattie’s paper,4 which considers the High Court review of service provision at the youth-focussed gender identity Tavistock Clinic. Beattie disagrees with the High Court’s view that it is ’highly unlikely’ that under-13s, and ’doubtful’ that 14–15 years old, can be competent to consent to puberty blocker therapy for gender dysphoria.

Beattie argues that having puberty blocker therapy is a choice that minors should be given the opportunity to make. In principle, children of that age could be competent to make the decision and that the decision is no more complex than other medical decisions that Gillick competence has conventionally been applied to. Children of this age fall into what Walker calls a ‘transitional’ group, ‘Of particular importance here is the extent to which societal features mean members of some groups find it particularly hard to be recognised as competent and equal members of society. That includes members of groups subject to discrimination….It also includes those who are in what we might call transitional groups such as teenagers struggling to be recognised as competent.’ In the case of denying puberty blockers, the symbolic value of choice is clear.The paper by Zeljka Buturovic5 examines the debate over young childless women requesting sterilisation.

There has been a discussion in the literature that critiques doctors’ hesitancy to accede to this type of request and Buturovic argues against these criticisms. The argument is that rather than a doctor’s refusal to sterilise a young childless woman or putting up obstacles to this being examples of, variously, inconsistency, paternalism, pronatalist bias and discrimination, it is understandable that doctors should be reluctant to follow this unusual request, and such hesitancy is of potential benefit to the young woman. This hesitancy can act as a filter for women who are not seriously committed to sterilisation. This, in essence, is the opposite argument to Beattie’s paper, that the barriers put up to prevent people exercising their choice in this case are warranted.

Young childless women should have their choice scrutinised and if necessary delayed so that it can be ascertained if the choice is a genuine one, and ‘to weed out (the) confused and uncommitted.’ Ultimately, that choice should be available for young childless woman, but it is a choice, given its long-term consequences and likely lack of reversibility, that should be carefully considered.These papers show that choice is a contextually based, complex and multi-facetted concept and approaches such as Walker’s, give us tools to think more carefully about the value of choice and what that means in particular situations. A consideration of choice is not complete without thinking about the effects of our choices on others, and this needs to be at the forefront of any ethical analysis. The ‘choice-agenda’ can often be a proxy for an individualistic conception of personal responsibility and a construction of the ‘good’ of the choice as being solely about that individual’s right to exercise a choice, rather than a more nuanced consideration of the wider, or even limited, effects of that choice on others. Although we have well-worn ways of thinking about harm – harm to others and liberty limiting principles6 – how the exercising of individual choice might harm others is often debatable and unclear, and political with a small and large P!.

For instance, in July 2021 Boris Johnson, the UK prime minister, announced that mask wearing would now be one of personal choice. The government would end the legal obligation to wear a face covering, ‘We will move away from legal restrictions and allow people to make their own informed decisions about how to manage the levitra.’ Johnson went on to say. €˜Guidance will suggest where you might choose to do so - especially when cases are rising and where you come into contact with people you don't usually meet in enclosed spaces, such as obviously crowded public transport.’7 This mandate for ‘freedom-day’ was criticised in a number of letters in high ranking medical journals,8 9 arguing, ‘The narrative of “caution, vigilance, and personal responsibility” is an abdication of the government’s fundamental duty to protect public health. €œPersonal responsibility” does not work in the face of an airborne, highly contagious infectious disease.

Infectious diseases are a matter of collective, rather than individual, responsibility.’8 In this case, someone’s personal choice to not wear a mask on public transport, where social distancing is impossible, conflicts with someone else’s choice to travel to work as safely as they can. As the critics of this policy and work in public health ethics notes, one person’s choice can have a significant detrimental effect on others, and in situations like this, such as this mask wearing example, where not allowing choice, that is maintaining the legally mandated requirement to wear a face mask (unless there are reasons for an exemption), is an ethically acceptable restriction on ‘personal choice.’ In Walker’s terminology disallowing this choice it is not demeaning or stigmatising, as it applies to everyone, and does not fail to recognise any particular person or group as equal members of society.Choice is often portrayed as a good thing like parenthood and apple pie and the use of choice by politicians to whip up support and bolster their political agendas, as shown by the examples of Blair and Johnson, shows the rhetorical power of the concept. But to really address in what circumstances choices should be offered, to whom and what type of choice, we need theoretical tools to help us understand and be attentive to the wider implications and the papers in this Issue help us to do that.Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants.IntroductionLarge-scale, international data sharing opens the door to the study of so-called ‘Big Data’, which holds great promise for improving patient-centred care. Big Data health research is envisioned to take precision medicine to the next level through increased understanding of disease aetiology and phenotypes, treatment effects, disease management and healthcare expenditure.1 However, lack of public trust is proven to be detrimental to the goals of data sharing.2 The case of care.data in the UK offers a blatant example of a data sharing initiative gone awry.

Criticism predominantly focused on limited public awareness and lack of clarity on the goals of the programme and ways to opt out.3 Citizens are becoming increasingly aware and critical of data privacy issues, and this warrants renewed investments to maintain public trust in data-intensive health research. Here, we use the term data-intensive health research to refer to a practice of grand-scale capture, (re)use and/or linkage of a wide variety of health-related data on individuals.Within the European Union (EU), the recently adopted General Data Protection Regulation (GDPR) (EU 2016/679) addresses some of the concerns the public may have with respect to privacy and data protection. One of the primary goals of the GDPR is to give individuals control over their personal data, most notably through consent.4 Other lawful grounds for the processing of personal data are listed, but it is unclear how these would exactly apply to scientific research. Legal norms remain open to interpretation and thus offer limited guidance to researchers.5 6 In Recital 33, the GDPR actually mentions that additional ethical standards are necessary for the processing of personal data for scientific research.

This indicates a recognised need for entities undertaking activities likely to incite public unease to go beyond compliance with legal requirements.7 Complementary ethical governance then becomes a prerequisite for securing public trust in data-intensive health research.A concept that could be of use in developing ethical governance is that of a ‘social license to operate’.7 The social license captures the notion of a mandate granted by society to certain occupational groups to determine for themselves what constitutes proper conduct, under the condition that such conduct is in line with society’s expectations. The term ‘social license’ was first used in the 1950s by American sociologist Everett Hughes to address relations between professional occupations and society.8 The concept has been used since to frame, for example, corporate social responsibility in the mining industry,9 governance of medical research in general8 and of data-intensive health research more specifically.7 10 As such, adequate ethical governance then becomes a precondition for obtaining a social license for data sharing activities.Key to an informed understanding of the social license is identifying the expectations society may hold with regard to sharing of and access to health data. Here, relevant societal actors are the subjects of Big Data health research, constituting both patients and the general public. Identification of patients’ and public views and attitudes allows for a better understanding of the elements of a socially sanctioned governance framework.

We know of the existence of research papers that have captured these views using quantitative or qualitative methods or a combination of both. So far, systematic reviews of the literature have limited their scope to citizens of specific countries,11 12 qualitative studies only13 or the sharing of genomic data.14 Therefore, we performed an up-to-date narrative review of both quantitative and qualitative studies to explore predominant patient and public views and attitudes towards data sharing for health research.MethodsWe searched the literature databases PubMed (MEDLINE), Embase, Scopus and Google Scholar in April 2019 for publications addressing patients’ and public views and attitudes towards the use of health data for research purposes. Synonyms of the following terms (connected by ‘AND’) were used to search titles and/or abstracts of indexed references. Patient or public.

Views. Data sharing. Research (See box 1 and online supplementary appendix 1). To merit inclusion, an article had to report results from an original research study (qualitative, quantitative or mixed methods) on attitudes of individuals regarding use of data for health research.

We restricted eligibility to records published in English and studies performed between 2009 and 2019. We chose 2009 as a lower limit because we assume that patients’ and public perspectives might have changed substantially with increasing awareness and use of digital (health) technologies. Systematic reviews and meta-analyses synthesising the empirical literature on this topic also qualified for review. Reports from stakeholder meet-ups and workshops were eligible as long as they included patients or the public as participants.

Since we were only interested in empirical evidence, expert opinion and publications merely advocating for the inclusion of patients’ and public views in Big Data health research were excluded. Studies that predominantly reported on views of other stakeholders—such as clinicians, researchers, policy makers or industry—were excluded. Articles reporting on conference proceedings, or views regarding (demographic) data collection in low or middle income countries or for public health and care/quality improvement were not considered relevant to this review. Despite our specific interest in data sharing within the European context, we broadened eligibility criteria to include studies performed in the USA, Canada, Australia and New Zealand.

Additional articles were identified through consultation with experts and review of references in the manuscript identified through the literature database searches. Views and attitudes of patients and the public were identified from selected references and reviewed by means of thematic content analysis.Supplemental materialBox 1 Key search terms(patient* OR public OR citizen*)AND(attitude* OR view* OR perspective* OR opinion* OR interview* OR qualitative* OR questionnaire* OR survey*)AND(“data sharing” OR “data access” OR “data transfer”)ANDResearchResultsStudy characteristicsSearches in PubMed (MEDLINE), Embase, Scopus and Google Scholar resulted in a total of 1153 non-unique records (see online supplementary appendix 1). We identified 27 papers for review, including 12 survey or questionnaire studies (quantitative), 8 interview or focus group studies (qualitative), 1 mixed methods study and 6 systematic reviews (see table 1). Most records were excluded because they were not relevant to our research question or because they did not report on findings from original (empirical) research studies.

Ten studies reported on views of patients, 11 on views of the public/citizens and 6 studies combined views of patients, research participants and the public.View this table:Table 1 Study characteristicsWillingness to share data for health researchReviewed papers suggest widespread support for the sharing of data for health research.Four systematic reviews synthesising the views of patients and the public report that willingness for data to be linked and shared for research purposes is high11–14 and that people are generally open to and understand the benefits of data sharing.15Outpatients from a German university hospital who participated in a questionnaire study (n=503) expressed a strong willingness (93%) to give broad consent for secondary use of data,16 and 93% of a sample of UK citizens with Parkinson’s disease (n=306) were willing to share their data.17 Wide support for sharing of data internationally18 19 and in multicentre studies20 was reported among patient participants. Goodman et al found that most participants in a sample of US patients with cancer (n=228) were willing to have their data made available for ‘as many research studies as possible’.21 Regarding the use of anonymised healthcare data for research purposes, a qualitative study found UK rheumatology patients and patient representatives in support of data sharing (n=40).22Public respondents in survey studies recognised the benefits of storing electronic health information,23 and 78.8% (n=151) of surveyed Canadians felt positive about the use of routinely collected data for health research.24 The majority (55%) of a sample of older Swiss citizens (n=40) were in favour of placing genetic data at disposal for research.25 Focus group discussions convened in the UK showed that just over 50% of the members of the Citizens Council of The National Institute for Health and Care Excellence (NICE) said they would have no concerns about NICE using anonymised data derived from personal care records to evaluate treatments,26 and all participants in one qualitative study were keen to contribute to the National Healthcare Service (NHS)-related research.27Motivations to share dataPatients and public participants expressed similar reasons and motivations for their willingness to share data for health research, including contributing to advancements in healthcare, returning incurred benefits and the hope of future personal health benefits (tables 2–4).View this table:Table 2 Patients’ views and attitudes towards the sharing of health data for researchView this table:Table 3 Public views and attitudes towards the sharing of health data for researchView this table:Table 4 Patients’ and public views and attitudes towards the sharing of health data for researchIn the two systematic reviews that addressed this topic, sharing data for ‘the common good’ or ‘the greater good’ was identified as one of the most prevalent motivations.12 14For patients specifically, to help future patients or people with similar health problems was an important reason.14 16 One survey study conducted among German outpatients found that 72% listed returning their own benefits incurred from research as a driver for sharing clinical data.16 Patients with rare disease were also motivated by ‘great hope and trust’ in the development of international databases for health research.19 Among patients, support of research in general,16 the value attached to answering ‘important’ research questions,20 and a desire to contribute to advancements in medicine14 were prevalent reasons in favour of data sharing. Ultimately, the belief that data sharing could lead to improvements in health outcome and care was reported.20Only one original study research paper addressed public motivations. This study found that older citizens mentioned auistic reasons and the greater good in a series of interviews as reasons to share genetic data for research.25 In these interviews, citizens expressed no expectations of an immediate impact or beneficial return but ultimately wanted to help the next generation.Perceived benefits of data sharingPatients and the public perceive that data sharing could lead to better patient care through improved diagnosis and treatment options and more efficient use of resources.

Patients seem to also value the potential of (direct) personal health benefits.Two systematic reviews reported on perceived benefits of data sharing for health research purposes. Howe et al mentioned perceived benefits to research participants or the immediate community, benefits to the public and benefits to research and science.15 Shabani et al also listed accelerating research advancement and maximising the value of resources as perceived benefits.14Surveyed patients perceived that data sharing could help their doctor ‘make better decisions’ about their health (94%, n=3516)28 or result in an increased chance of receiving personalised health information (n=228).21In the original studies reviewed, advantages and potential benefits of data sharing were generally recognised by public and patient participants.22 29 Data sharing was believed to enable the study of long-term treatment effects and rare events, as well as the study of large numbers of people,24 to improve diagnosis25 and treatment quality,20 23 as well as to stimulate innovation30 and identify new treatment options.25 A cross-sectional online survey among patient and citizen groups in Italy (n=280) also identified the perception that data sharing could reduce waste in research.30Perceived risks of data sharingThe most significant risks of data sharing were perceived to results from breaches of confidentiality, commercial use and potential abuse of the data.Systematic reviews report on patients’ and public concerns about confidentiality in general,13 15 sometimes linked to the risk of reidentification,14 concerns about a party's competence in keeping data secure,12 and concerns that personal information could be mined from genomic data.14 A systematic review by Stockdale et al identified concerns among the public (UK and Ireland) about the motivation a party might have to use the data.14Patients in a UK qualitative study (n=40) perceived ‘detrimental’ consequences of data ‘falling into the wrong hands’, such as insurance companies.22 Respondents from the online patient community PatientsLikeMe were fearful of health data being ‘stolen by hackers’ (87%, n=3516).28Original research studies flagged data security and privacy as major public concerns.16 18 20 25 26 29–32 More specifically, many studies found that participants worried about who would have access to the data and about risk of misuses or abuses.13 15 18 25 27 33 A large pan-European survey among respondents from 27 EU member states revealed public concerns about different levels of access by third parties (48.9%–60.6%, n=20 882).23 Overall, reviewed papers suggest that patients and the public are concerned about the use of their data for commercial purposes.14 27 For example, the NICE Citizens Council expressed concerns about the potential for data to be sold to other organisations and used for profit and for purposes other than research.26 The Citizens Council also highlighted the need for transparency about how data are used and how it might be used in the future and for ensuring the research is conducted according to good scientific practice and that data are used to benefit society. Concerns about control and ownership of data were identified13 33 and about re-use of data for purposes that participants do not agree on.30 Fear of discrimination, stigmatisation, exploitation or other repercussions as a consequence of data being shared was widely cited by individuals.14 15 18Barriers to share dataStudies showed that patients and the public rarely mention barriers to data sharing in absolute terms. Rather, acceptance seemed to decrease if data sharing was financially motivated, and if people did not know how and with whom their data would be shared.First, individuals often opposed data sharing if it was motivated by financial gain or profit20 or if the data were shared with commercial/private companies.14 15 In one large pan-European survey (n=20 882), respondents were found to be strongly averse to health insurance companies and private sector pharmaceutical companies viewing their data.23 Second, lack of understanding and awareness around the use of data was viewed as a barrier to data sharing.15 22 Third, lack of transparency and controllability in releasing data were mentioned as factors compromising public trust in data sharing activities.14 22Factors affecting willingness to share dataA wide range of factors were identified from the literature that impacted individuals’ willingness to share data for health research, including geographical factors, age, individual-specific and research-specific characteristics.Geographical factorsMcCormack et al found that European patients’ expressions of trust and attitudes to risk were often affected by the regulatory and cultural practices in their home countries, as well as by the nature of the (rare) disease the patient participant had.18 Shah et al conducted a survey among patients in four Northern European countries (n=855) and found a significant association between country and attitudes towards sharing of deidentified data.34 Interestingly, Dutch respondents were less likely to support sharing of their deidentified data compared with UK citizens.AgeAmong a sample of surveyed patients with Parkinson’s disease (UK), a significant association was found between higher age and increased support for data sharing.17 According to a study based on semistructured interviews with older Swiss citizens, generational differences impacted willingness to share.25 With respect to public attitudes towards data sharing, findings of one systematic review suggest that males and older people are more likely to consent to sharing their medical data.27 A systematic review by Shabani et al suggests that patient and public participants with higher mean age are substantially less worried about privacy and confidentiality than other groups.14Individual-specific characteristicsA systematic review into patients’ and public perspectives on data sharing in the USA suggests that individuals from under-represented minorities are less willing to share data.11 A large multisite survey (n=13 000) among the US public found that willingness to share was associated with self-identified white race, higher educational attainment and lower religiosity.31 In another systematic review, race, gender, age, marital status and/or educational level all seemed to influence how people perceived sensitivity of genomic data and the sharing thereof.14 However, a UK study among patients with Parkinson’s disease found no clear relationship between data sharing and the number of years diagnosed, sex, medication class or health confidence.17Factors that clearly positively affected attitudes towards data sharing were perceptions of the (public) benefits and value of the research,13 20 fewer concerns and fewer information needs,31 and higher trust in and reputation of individuals or organisations conducting and/or overseeing data sharing.12–14 35 Conversely, willingness decreased with higher privacy and confidentiality concerns11 and higher distrust of the government as an oversight body for (genetic) research data.35Research-specific characteristicsPrivacy measures increased people’s willingness to share their data for health research, such as removal of social security numbers (90%, n=3516) and insurance ID (82%, n=3516), the sharing of only summary-level or aggregate data20 and deposition of data in a restricted access online database.29 Expressions of having control over what data are shared and with whom positively affected attitudes towards data sharing.34 In one study, being asked for consent for each study made participants (81%) feel ‘respected and involved’, and 74% agreed that they would feel that they ‘had control’.14 With respect to data sharing without prospective consent, participants became more accepting after being given information about the research processes and selection bias.27 Less support was observed for data sharing due to financial incentives25 and, more specifically, if data would be shared with private companies, such as insurance or pharmaceutical companies.11 25Conditions for sharingWidespread willingness to share data for health research very rarely led to participants’ unconditional support.

Studies showed agreement on the following conditions for responsible data sharing. Value, privacy, minimising risks, data security, transparency, control, information, trust, responsibility and accountability.ValueOne systematic review found that participants found it important that the research as a result of data sharing should be in the public’s interest and should reflect participants’ values.15 The NICE Citizens Council advocated for appropriate systems and good working practices to ensure a consistent approach to research planning, data capture and analysis.26Privacy, risks and data securityThe need to protect individuals’ privacy was considered paramount11 14 21 34 and participants often viewed deidentification of personal data as a top privacy measure.11 24 30 36 One survey among US patients with cancer found that only 20% (n=228) of participants found linkage of individuals with their deidentified data acceptable for return of individual health results and to support further research.21 Secured access to databases was considered an important measure to ensure data security in data sharing activities.30 34 A systematic review of participants’ attitudes towards data sharing showed that people established risk minimisation as another condition for data sharing.15 Findings by Mazor et al suggest that patients only support studies that offer value and minimise security risks.20Transparency and controlConditions regarding transparency were information about how data will be shared and with whom,14 35 the type of research that is to be performed, by whom the research will be performed,16 information on data sharing and monitoring policies and database governance,35 conditions framing access to data and data access agreements,24 28 30 and any partnerships with the pharmaceutical industry.19 More generally, participants expressed the desire to be involved in the data sharing process,35 to be notified when their data are (re)used and to be informed of the results of studies using their data.15 Spencer et al identified use of an electronic interface as a highly valued means to enable greater control over consent choices.22 When asked about the use of personal data for health research by the NHS, UK citizens were typically willing to accept models of consent other than the ones they would prefer.37 Acceptance of consent models with lower levels of individual control was found to be dependent on a number of factors, including adequate transparency, control over detrimental use and commercialisation, and the ability to object, particularly to any processing considered to be inappropriate or particularly sensitive.37Information and trustOne systematic review identified trust in the ability of the original institution to carry out the oversight tasks as a major condition for responsible data sharing.14 Appropriate education and information about data sharing was thought to include public campaigns to inform stakeholders about Big Data32 and information communicated at open days of research institutions (such as NICE) to ensure people understand what their data are being used for and to reassure them that personal data will not be passed on or sold to other organisations.26 The informed consent process for study participation was believed to include information about the fact that individuals’ data could potentially be shared,15 30 the objectives of data sharing and (biobank) research, the study’s data sharing plans,29 governance structure, logistics and accountability.33Responsibility and accountabilityParticipants often placed the responsibility for data sharing practices on the shoulders of researchers. Secondary use of data collected earlier for scientific research was viewed to require a data access committee that involves a researcher from the original research project, a clinician, patient representative and a participant in the original study.36 Researchers of the original study were required to monitor data used by other researchers.36 In terms of accountability, patient and public groups in Italy (n=280) placed high value on sanctions for misuse of data.30 Information on penalties or other consequences of a breach of protection or misuse was considered important by many.31 35DiscussionIn this study, we narratively reviewed 27 papers on patients’ and public views on and attitudes towards the use of health data for scientific research. Studies reported a widespread—though conditional—support for the linkage and sharing of data for health research.

The only outlier seems to be the finding that just over half (n=25) of the NICE Citizens Council answered ‘no’ to the question whether they had any concerns if NICE used anonymised data to fill in the gaps if NICE was not getting enough evidence in ‘the usual ways’.26 However, we hasten to point out that the question about willingness to share is different from the question whether people have concerns or not. In addition, after a 2-day discussion meeting Council members were perhaps more sensitised to the potential concerns regarding data sharing. Therefore, we suggest that the way and context within which questions are phrased may influence the answers people give.Overall, people expressed similar motivations to share their data, perceived similar benefits (despite some variation between patients and citizens), yet at the same time displayed a range of concerns, predominantly relating to confidentiality and data security, awareness about access and control, and potential harms resulting from these risks. Both patient and public participants conveyed that certain factors would increase or reduce their willingness to have their data shared.

For example, the presence of privacy-protecting measures (eg, data deidentification and the use of secured databases) seemed to increase willingness to share, as well as transparency and information about data sharing processes and responsibilities. The identified views and attitudes appeared to come together in the conditions stipulated by participants. Value, privacy and confidentiality, minimising risks, data security, transparency, control, information, trust, responsibility and accountability.In our Introduction, we mentioned that identifying patients’ and public views and attitudes allows for a better understanding of the elements of a socially sanctioned governance framework. In other words, what work should our governance framework be doing in order to obtain a social license?.

This review urges researchers and institutions to address people’s diverse concerns and to make an effort to meet the conditions identified. Without these conditions, institutions lack trustworthiness, which is vital for the proceedings of medicine and biomedical science. As such, a social license is not a ‘nice to have’ but a ‘need to have’. Our results also confirm that patients and the public indeed care about more than legal compliance alone, and wish to be engaged through information, transparency and control.

This work supports the findings of a recent systematic review into ethical principles of data sharing as specified in various international ethical guidelines and literature.38 What this body of research implies is considerable diversity of values and beliefs both between and within countries.The goal of this narrative review was to identify the most internationally dominant, aggregated patient and public views about the broad topic of data sharing for health research. We deliberately opted for the methodology of a narrative review rather than a systematic review. Most narrative reviews deal with a broad range of issues to a given topic rather than addressing a particular topic in depth.39 This means narrative reviews may be most useful for obtaining a broad perspective on a topic, and that they often are less useful in generating quantitative answers to specific clinical questions. However, because narrative reviews do not require specification of the search and selection strategy and the way of critically appraising literature can be variable, the connection between evidence generated by narrative reviews and (clinical) recommendations is less rigorous and risk of bias exists.

This is something to take into account in this study. A risk of bias assessment was not possible due to the heterogeneity of the findings. We acknowledge that our methodological choices may have affected the discriminative power or granularity of our findings. For example, there is a difference between sharing of routinely collected health data versus secondary use of health data collected for research purposes.

And we can only make loose assumptions about potential differences between patient and public views.In addition, we should mention that this work is centred around studies conducted in Western countries as the whole Big Data space and literature is dominated by Western countries, higher socioeconomic status and Caucasians. However, most of the disease burden globally and within countries is most probably not represented in the ‘Big Data’ and so we have to stress the lack of generalisability to large parts of the world.Nevertheless, we believe our findings point towards essential elements of a governance framework for data sharing for health research purposes. If we are to conclude that the identified conditions ought to act as the pillars of a governance framework, the next step is to identify how these conditions could be practically operationalised. For example, if people value information, transparency and control, what type of consent is most likely to valorise these conditions?.

And what policy for returning research results would be desirable?. Once we know what to value, we can start thinking about the ways to acknowledge that value. A new challenge arising here, however, is what to do when people hold different or even conflicting values or preferences. Discrete choice experiments could help to test people’s preferences regarding specific topics, such as preferred modes of informed consent.

Apart from empirical work, conceptual analysis is needed to clarify how public trust, trustworthiness of institutions and accountability are interconnected.ConclusionThis narrative review suggests widespread—though conditional—support among patients and the public for data sharing for health research. Despite the fact that participants recognise actual or potential benefits of health research, they report a number of significant concerns and related conditions. We believe identified conditions (eg, social value, data security, transparency and accountability) ought to be operationalised in a value-based governance framework that incorporates the diverse patient and public values, needs and interests, and which reflects the way these same conditions are met, to strengthen the social license for Big Data health research.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsWe thank Susanne Løgstrup (European Heart Network) and Evert-Ben van Veen (Medlaw) for their valuable feedback during various stages in drafting the manuscript..

Choice is 10mg levitra online probably one of the most often official site discussed areas in bioethics, alongside the related concepts of informed consent and autonomy. It is generally, prima facie, portrayed as a good 10mg levitra online thing. In healthcare, the 2000s saw 10mg levitra online the UK Prime Minister Tony Blair pursue the ‘Choice Agenda’ where, ‘As capacity expands, so choice will grow.

Choice will fundamentally change the balance of power in the NHS.’1 In a consumerist society giving consumers more choice is seen as desirable. However, choice 10mg levitra online is not a good in itself, giving people more choice in certain situations can be problematic. I.e.

Consumerism drives economic growth and this has a detrimental effect on the environment. And increasing the range of choices a patient is offered is often not the best way to improve the quality of healthcare provision.2 The assumptions behind the valuing of choice need careful unpacking and this Issue of the Journal of Medical Ethics includes papers that explore choice in a number of areas.This Issue's Editor’s choice is Tom Walker’s ‘The Value of Choice’,3 which puts forward a suggestion for the importance of the symbolic value of choice. There are a number of ways of categorising the value of choice in healthcare.

One account sees choice as valuable because it is by choosing that individuals make their life their own. Another account sees choice as valuable for instrumental reasons, people are generally, assuming they are sufficiently informed, the best judge of their own best interests. Walker argues for an additional third reason, the symbolic value of choice, originally proposed by Scanlon.

This sees choice as valuable because being given the option to choose, whether or not one takes it up, not the act of choosing is what makes choice valuable. Being offered the option to choose has a ‘communicative role’ in that it communicates that the person has standing and, for certain types of choice, being denied the opportunity to choose, ‘can be both demeaning and stigmatising.’ Walker states that denying someone the opportunity to choose in certain circumstances does not communicate anything untoward, and he goes to explore how we might determine when not allowing someone a choice would be demeaning. Here he stresses the importance of context in making this determination, it is not fixed by the features of a patient, but what being ‘allowed’ or ‘denied’ the opportunity to make a choice reveals about the healthcare professional’s view of the patient.

€˜It communicates that they either see those patients as competent and equal members of society, or that they do not.’ Denying a patient the opportunity to choose an ineffective treatment, for example, does not communicate a negative judgement. Walker says his account, ‘is intended to supplement existing accounts, not replace them. Because choice is valuable for more than one reason no single account can capture everything that matters.’The importance of pointing to the context of the choice is highlighted in Walker’s paper and it is only through careful examination of the context of that offering that we can determine if, in fact, this is an area where choice should be offered and to whom.

Such an examination is carried out in Cameron Beattie’s paper,4 which considers the High Court review of service provision at the youth-focussed gender identity Tavistock Clinic. Beattie disagrees with the High Court’s view that it is ’highly unlikely’ that under-13s, and ’doubtful’ that 14–15 years old, can be competent to consent to puberty blocker therapy for gender dysphoria. Beattie argues that having puberty blocker therapy is a choice that minors should be given the opportunity to make.

In principle, children of that age could be competent to make the decision and that the decision is no more complex than other medical decisions that Gillick competence has conventionally been applied to. Children of this age fall into what Walker calls a ‘transitional’ group, ‘Of particular importance here is the extent to which societal features mean members of some groups find it particularly hard to be recognised as competent and equal members of society. That includes members of groups subject to discrimination….It also includes those who are in what we might call transitional groups such as teenagers struggling to be recognised as competent.’ In the case of denying puberty blockers, the symbolic value of choice is clear.The paper by Zeljka Buturovic5 examines the debate over young childless women requesting sterilisation.

There has been a discussion in the literature that critiques doctors’ hesitancy to accede to this type of request and Buturovic argues against these criticisms. The argument is that rather than a doctor’s refusal to sterilise a young childless woman or putting up obstacles to this being examples of, variously, inconsistency, paternalism, pronatalist bias and discrimination, it is understandable that doctors should be reluctant to follow this unusual request, and such hesitancy is of potential benefit to the young woman. This hesitancy can act as a filter for women who are not seriously committed to sterilisation.

This, in essence, is the opposite argument to Beattie’s paper, that the barriers put up to prevent people exercising their choice in this case are warranted. Young childless women should have their choice scrutinised and if necessary delayed so that it can be ascertained if the choice is a genuine one, and ‘to weed out (the) confused and uncommitted.’ Ultimately, that choice should be available for young childless woman, but it is a choice, given its long-term consequences and likely lack of reversibility, that should be carefully considered.These papers show that choice is a contextually based, complex and multi-facetted concept and approaches such as Walker’s, give us tools to think more carefully about the value of choice and what that means in particular situations. A consideration of choice is not complete without thinking about the effects of our choices on others, and this needs to be at the forefront of any ethical analysis.

The ‘choice-agenda’ can often be a proxy for an individualistic conception of personal responsibility and a construction of the ‘good’ of the choice as being solely about that individual’s right to exercise a choice, rather than a more nuanced consideration of the wider, or even limited, effects of that choice on others. Although we have well-worn ways of thinking about harm – harm to others and liberty limiting principles6 – how the exercising of individual choice might harm others is often debatable and unclear, and political with a small and large P!. For instance, in July 2021 Boris Johnson, the UK prime minister, announced that mask wearing would now be one of personal choice.

The government would end the legal obligation to wear a face covering, ‘We will move away from legal restrictions and allow people to make their own informed decisions about how to manage the levitra.’ Johnson went on to say. €˜Guidance will suggest where you might choose to do so - especially when cases are rising and where you come into contact with people you don't usually meet in enclosed spaces, such as obviously crowded public transport.’7 This mandate for ‘freedom-day’ was criticised in a number of letters in high ranking medical journals,8 9 arguing, ‘The narrative of “caution, vigilance, and personal responsibility” is an abdication of the government’s fundamental duty to protect public health. €œPersonal responsibility” does not work in the face of an airborne, highly contagious infectious disease.

Infectious diseases are a matter of collective, rather than individual, responsibility.’8 In this case, someone’s personal choice to not wear a mask on public transport, where social distancing is impossible, conflicts with someone else’s choice to travel to work as safely as they can. As the critics of this policy and work in public health ethics notes, one person’s choice can have a significant detrimental effect on others, and in situations like this, such as this mask wearing example, where not allowing choice, that is maintaining the legally mandated requirement to wear a face mask (unless there are reasons for an exemption), is an ethically acceptable restriction on ‘personal choice.’ In Walker’s terminology disallowing this choice it is not demeaning or stigmatising, as it applies to everyone, and does not fail to recognise any particular person or group as equal members of society.Choice is often portrayed as a good thing like parenthood and apple pie and the use of choice by politicians to whip up support and bolster their political agendas, as shown by the examples of Blair and Johnson, shows the rhetorical power of the concept. But to really address in what circumstances choices should be offered, to whom and what type of choice, we need theoretical tools to help us understand and be attentive to the wider implications and the papers in this Issue help us to do that.Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants.IntroductionLarge-scale, international data sharing opens the door to the study of so-called ‘Big Data’, which holds great promise for improving patient-centred care.

Big Data health research is envisioned to take precision medicine to the next level through increased understanding of disease aetiology and phenotypes, treatment effects, disease management and healthcare expenditure.1 However, lack of public trust is proven to be detrimental to the goals of data sharing.2 The case of care.data in the UK offers a blatant example of a data sharing initiative gone awry. Criticism predominantly focused on limited public awareness and lack of clarity on the goals of the programme and ways to opt out.3 Citizens are becoming increasingly aware and critical of data privacy issues, and this warrants renewed investments to maintain public trust in data-intensive health research. Here, we use the term data-intensive health research to refer to a practice of grand-scale capture, (re)use and/or linkage of a wide variety of health-related data on individuals.Within the European Union (EU), the recently adopted General Data Protection Regulation (GDPR) (EU 2016/679) addresses some of the concerns the public may have with respect to privacy and data protection.

One of the primary goals of the GDPR is to give individuals control over their personal data, most notably through consent.4 Other lawful grounds for the processing of personal data are listed, but it is unclear how these would exactly apply to scientific research. Legal norms remain open to interpretation and thus offer limited guidance to researchers.5 6 In Recital 33, the GDPR actually mentions that additional ethical standards are necessary for the processing of personal data for scientific research. This indicates a recognised need for entities undertaking activities likely to incite public unease to go beyond compliance with legal requirements.7 Complementary ethical governance then becomes a prerequisite for securing public trust in data-intensive health research.A concept that could be of use in developing ethical governance is that of a ‘social license to operate’.7 The social license captures the notion of a mandate granted by society to certain occupational groups to determine for themselves what constitutes proper conduct, under the condition that such conduct is in line with society’s expectations.

The term ‘social license’ was first used in the 1950s by American sociologist Everett Hughes to address relations between professional occupations and society.8 The concept has been used since to frame, for example, corporate social responsibility in the mining industry,9 governance of medical research in general8 and of data-intensive health research more specifically.7 10 As such, adequate ethical governance then becomes a precondition for obtaining a social license for data sharing activities.Key to an informed understanding of the social license is identifying the expectations society may hold with regard to sharing of and access to health data. Here, relevant societal actors are the subjects of Big Data health research, constituting both patients and the general public. Identification of patients’ and public views and attitudes allows for a better understanding of the elements of a socially sanctioned governance framework.

We know of the existence of research papers that have captured these views using quantitative or qualitative methods or a combination of both. So far, systematic reviews of the literature have limited their scope to citizens of specific countries,11 12 qualitative studies only13 or the sharing of genomic data.14 Therefore, we performed an up-to-date narrative review of both quantitative and qualitative studies to explore predominant patient and public views and attitudes towards data sharing for health research.MethodsWe searched the literature databases PubMed (MEDLINE), Embase, Scopus and Google Scholar in April 2019 for publications addressing patients’ and public views and attitudes towards the use of health data for research purposes. Synonyms of the following terms (connected by ‘AND’) were used to search titles and/or abstracts of indexed references.

Research (See box 1 and online supplementary appendix 1). To merit inclusion, an article had to report results from an original research study (qualitative, quantitative or mixed methods) on attitudes of individuals regarding use of data for health research. We restricted eligibility to records published in English and studies performed between 2009 and 2019.

We chose 2009 as a lower limit because we assume that patients’ and public perspectives might have changed substantially with increasing awareness and use of digital (health) technologies. Systematic reviews and meta-analyses synthesising the empirical literature on this topic also qualified for review. Reports from stakeholder meet-ups and workshops were eligible as long as they included patients or the public as participants.

Since we were only interested in empirical evidence, expert opinion and publications merely advocating for the inclusion of patients’ and public views in Big Data health research were excluded. Studies that predominantly reported on views of other stakeholders—such as clinicians, researchers, policy makers or industry—were excluded. Articles reporting on conference proceedings, or views regarding (demographic) data collection in low or middle income countries or for public health and care/quality improvement were not considered relevant to this review.

Despite our specific interest in data sharing within the European context, we broadened eligibility criteria to include studies performed in the USA, Canada, Australia and New Zealand. Additional articles were identified through consultation with experts and review of references in the manuscript identified through the literature database searches. Views and attitudes of patients and the public were identified from selected references and reviewed by means of thematic content analysis.Supplemental materialBox 1 Key search terms(patient* OR public OR citizen*)AND(attitude* OR view* OR perspective* OR opinion* OR interview* OR qualitative* OR questionnaire* OR survey*)AND(“data sharing” OR “data access” OR “data transfer”)ANDResearchResultsStudy characteristicsSearches in PubMed (MEDLINE), Embase, Scopus and Google Scholar resulted in a total of 1153 non-unique records (see online supplementary appendix 1).

We identified 27 papers for review, including 12 survey or questionnaire studies (quantitative), 8 interview or focus group studies (qualitative), 1 mixed methods study and 6 systematic reviews (see table 1). Most records were excluded because they were not relevant to our research question or because they did not report on findings from original (empirical) research studies. Ten studies reported on views of patients, 11 on views of the public/citizens and 6 studies combined views of patients, research participants and the public.View this table:Table 1 Study characteristicsWillingness to share data for health researchReviewed papers suggest widespread support for the sharing of data for health research.Four systematic reviews synthesising the views of patients and the public report that willingness for data to be linked and shared for research purposes is high11–14 and that people are generally open to and understand the benefits of data sharing.15Outpatients from a German university hospital who participated in a questionnaire study (n=503) expressed a strong willingness (93%) to give broad consent for secondary use of data,16 and 93% of a sample of UK citizens with Parkinson’s disease (n=306) were willing to share their data.17 Wide support for sharing of data internationally18 19 and in multicentre studies20 was reported among patient participants.

Goodman et al found that most participants in a sample of US patients with cancer (n=228) were willing to have their data made available for ‘as many research studies as possible’.21 Regarding the use of anonymised healthcare data for research purposes, a qualitative study found UK rheumatology patients and patient representatives in support of data sharing (n=40).22Public respondents in survey studies recognised the benefits of storing electronic health information,23 and 78.8% (n=151) of surveyed Canadians felt positive about the use of routinely collected data for health research.24 The majority (55%) of a sample of older Swiss citizens (n=40) were in favour of placing genetic data at disposal for research.25 Focus group discussions convened in the UK showed that just over 50% of the members of the Citizens Council of The National Institute for Health and Care Excellence (NICE) said they would have no concerns about NICE using anonymised data derived from personal care records to evaluate treatments,26 and all participants in one qualitative study were keen to contribute to the National Healthcare Service (NHS)-related research.27Motivations to share dataPatients and public participants expressed similar reasons and motivations for their willingness to share data for health research, including contributing to advancements in healthcare, returning incurred benefits and the hope of future personal health benefits (tables 2–4).View this table:Table 2 Patients’ views and attitudes towards the sharing of health data for researchView this table:Table 3 Public views and attitudes towards the sharing of health data for researchView this table:Table 4 Patients’ and public views and attitudes towards the sharing of health data for researchIn the two systematic reviews that addressed this topic, sharing data for ‘the common good’ or ‘the greater good’ was identified as one of the most prevalent motivations.12 14For patients specifically, to help future patients or people with similar health problems was an important reason.14 16 One survey study conducted among German outpatients found that 72% listed returning their own benefits incurred from research as a driver for sharing clinical data.16 Patients with rare disease were also motivated by ‘great hope and trust’ in the development of international databases for health research.19 Among patients, support of research in general,16 the value attached to answering ‘important’ research questions,20 and a desire to contribute to advancements in medicine14 were prevalent reasons in favour of data sharing. Ultimately, the belief that data sharing could lead to improvements in health outcome and care was reported.20Only one original study research paper addressed public motivations. This study found that older citizens mentioned auistic reasons and the greater good in a series of interviews as reasons to share genetic data for research.25 In these interviews, citizens expressed no expectations of an immediate impact or beneficial return but ultimately wanted to help the next generation.Perceived benefits of data sharingPatients and the public perceive that data sharing could lead to better patient care through improved diagnosis and treatment options and more efficient use of resources.

Patients seem to also value the potential of (direct) personal health benefits.Two systematic reviews reported on perceived benefits of data sharing for health research purposes. Howe et al mentioned perceived benefits to research participants or the immediate community, benefits to the public and benefits to research and science.15 Shabani et al also listed accelerating research advancement and maximising the value of resources as perceived benefits.14Surveyed patients perceived that data sharing could help their doctor ‘make better decisions’ about their health (94%, n=3516)28 or result in an increased chance of receiving personalised health information (n=228).21In the original studies reviewed, advantages and potential benefits of data sharing were generally recognised by public and patient participants.22 29 Data sharing was believed to enable the study of long-term treatment effects and rare events, as well as the study of large numbers of people,24 to improve diagnosis25 and treatment quality,20 23 as well as to stimulate innovation30 and identify new treatment options.25 A cross-sectional online survey among patient and citizen groups in Italy (n=280) also identified the perception that data sharing could reduce waste in research.30Perceived risks of data sharingThe most significant risks of data sharing were perceived to results from breaches of confidentiality, commercial use and potential abuse of the data.Systematic reviews report on patients’ and public concerns about confidentiality in general,13 15 sometimes linked to the risk of reidentification,14 concerns about a party's competence in keeping data secure,12 and concerns that personal information could be mined from genomic data.14 A systematic review by Stockdale et al identified concerns among the public (UK and Ireland) about the motivation a party might have to use the data.14Patients in a UK qualitative study (n=40) perceived ‘detrimental’ consequences of data ‘falling into the wrong hands’, such as insurance companies.22 Respondents from the online patient community PatientsLikeMe were fearful of health data being ‘stolen by hackers’ (87%, n=3516).28Original research studies flagged data security and privacy as major public concerns.16 18 20 25 26 29–32 More specifically, many studies found that participants worried about who would have access to the data and about risk of misuses or abuses.13 15 18 25 27 33 A large pan-European survey among respondents from 27 EU member states revealed public concerns about different levels of access by third parties (48.9%–60.6%, n=20 882).23 Overall, reviewed papers suggest that patients and the public are concerned about the use of their data for commercial purposes.14 27 For example, the NICE Citizens Council expressed concerns about the potential for data to be sold to other organisations and used for profit and for purposes other than research.26 The Citizens Council also highlighted the need for transparency about how data are used and how it might be used in the future and for ensuring the research is conducted according to good scientific practice and that data are used to benefit society. Concerns about control and ownership of data were identified13 33 and about re-use of data for purposes that participants do not agree on.30 Fear of discrimination, stigmatisation, exploitation or other repercussions as a consequence of data being shared was widely cited by individuals.14 15 18Barriers to share dataStudies showed that patients and the public rarely mention barriers to data sharing in absolute terms.

Rather, acceptance seemed to decrease if data sharing was financially motivated, and if people did not know how and with whom their data would be shared.First, individuals often opposed data sharing if it was motivated by financial gain or profit20 or if the data were shared with commercial/private companies.14 15 In one large pan-European survey (n=20 882), respondents were found to be strongly averse to health insurance companies and private sector pharmaceutical companies viewing their data.23 Second, lack of understanding and awareness around the use of data was viewed as a barrier to data sharing.15 22 Third, lack of transparency and controllability in releasing data were mentioned as factors compromising public trust in data sharing activities.14 22Factors affecting willingness to share dataA wide range of factors were identified from the literature that impacted individuals’ willingness to share data for health research, including geographical factors, age, individual-specific and research-specific characteristics.Geographical factorsMcCormack et al found that European patients’ expressions of trust and attitudes to risk were often affected by the regulatory and cultural practices in their home countries, as well as by the nature of the (rare) disease the patient participant had.18 Shah et al conducted a survey among patients in four Northern European countries (n=855) and found a significant association between country and attitudes towards sharing of deidentified data.34 Interestingly, Dutch respondents were less likely to support sharing of their deidentified data compared with UK citizens.AgeAmong a sample of surveyed patients with Parkinson’s disease (UK), a significant association was found between higher age and increased support for data sharing.17 According to a study based on semistructured interviews with older Swiss citizens, generational differences impacted willingness to share.25 With respect to public attitudes towards data sharing, findings of one systematic review suggest that males and older people are more likely to consent to sharing their medical data.27 A systematic review by Shabani et al suggests that patient and public participants with higher mean age are substantially less worried about privacy and confidentiality than other groups.14Individual-specific characteristicsA systematic review into patients’ and public perspectives on data sharing in the USA suggests that individuals from under-represented minorities are less willing to share data.11 A large multisite survey (n=13 000) among the US public found that willingness to share was associated with self-identified white race, higher educational attainment and lower religiosity.31 In another systematic review, race, gender, age, marital status and/or educational level all seemed to influence how people perceived sensitivity of genomic data and the sharing thereof.14 However, a UK study among patients with Parkinson’s disease found no clear relationship between data sharing and the number of years diagnosed, sex, medication class or health confidence.17Factors that clearly positively affected attitudes towards data sharing were perceptions of the (public) benefits and value of the research,13 20 fewer concerns and fewer information needs,31 and higher trust in and reputation of individuals or organisations conducting and/or overseeing data sharing.12–14 35 Conversely, willingness decreased with higher privacy and confidentiality concerns11 and higher distrust of the government as an oversight body for (genetic) research data.35Research-specific characteristicsPrivacy measures increased people’s willingness to share their data for health research, such as removal of social security numbers (90%, n=3516) and insurance ID (82%, n=3516), the sharing of only summary-level or aggregate data20 and deposition of data in a restricted access online database.29 Expressions of having control over what data are shared and with whom positively affected attitudes towards data sharing.34 In one study, being asked for consent for each study made participants (81%) feel ‘respected and involved’, and 74% agreed that they would feel that they ‘had control’.14 With respect to data sharing without prospective consent, participants became more accepting after being given information about the research processes and selection bias.27 Less support was observed for data sharing due to financial incentives25 and, more specifically, if data would be shared with private companies, such as insurance or pharmaceutical companies.11 25Conditions for sharingWidespread willingness to share data for health research very rarely led to participants’ unconditional support. Studies showed agreement on the following conditions for responsible data sharing. Value, privacy, minimising risks, data security, transparency, control, information, trust, responsibility and accountability.ValueOne systematic review found that participants found it important that the research as a result of data sharing should be in the public’s interest and should reflect participants’ values.15 The NICE Citizens Council advocated for appropriate systems and good working practices to ensure a consistent approach to research planning, data capture and analysis.26Privacy, risks and data securityThe need to protect individuals’ privacy was considered paramount11 14 21 34 and participants often viewed deidentification of personal data as a top privacy measure.11 24 30 36 One survey among US patients with cancer found that only 20% (n=228) of participants found linkage of individuals with their deidentified data acceptable for return of individual health results and to support further research.21 Secured access to databases was considered an important measure to ensure data security in data sharing activities.30 34 A systematic review of participants’ attitudes towards data sharing showed that people established risk minimisation as another condition for data sharing.15 Findings by Mazor et al suggest that patients only support studies that offer value and minimise security risks.20Transparency and controlConditions regarding transparency were information about how data will be shared and with whom,14 35 the type of research that is to be performed, by whom the research will be performed,16 information on data sharing and monitoring policies and database governance,35 conditions framing access to data and data access agreements,24 28 30 and any partnerships with the pharmaceutical industry.19 More generally, participants expressed the desire to be involved in the data sharing process,35 to be notified when their data are (re)used and to be informed of the results of studies using their data.15 Spencer et al identified use of an electronic interface as a highly valued means to enable greater control over consent choices.22 When asked about the use of personal data for health research by the NHS, UK citizens were typically willing to accept models of consent other than the ones they would prefer.37 Acceptance of consent models with lower levels of individual control was found to be dependent on a number of factors, including adequate transparency, control over detrimental use and commercialisation, and the ability to object, particularly to any processing considered to be inappropriate or particularly sensitive.37Information and trustOne systematic review identified trust in the ability of the original institution to carry out the oversight tasks as a major condition for responsible data sharing.14 Appropriate education and information about data sharing was thought to include public campaigns to inform stakeholders about Big Data32 and information communicated at open days of research institutions (such as NICE) to ensure people understand what their data are being used for and to reassure them that personal data will not be passed on or sold to other organisations.26 The informed consent process for study participation was believed to include information about the fact that individuals’ data could potentially be shared,15 30 the objectives of data sharing and (biobank) research, the study’s data sharing plans,29 governance structure, logistics and accountability.33Responsibility and accountabilityParticipants often placed the responsibility for data sharing practices on the shoulders of researchers.

Secondary use of data collected earlier for scientific research was viewed to require a data access committee that involves a researcher from the original research project, a clinician, patient representative and a participant in the original study.36 Researchers of the original study were required to monitor data used by other researchers.36 In terms of accountability, patient and public groups in Italy (n=280) placed high value on sanctions for misuse of data.30 Information on penalties or other consequences of a breach of protection or misuse was considered important by many.31 35DiscussionIn this study, we narratively reviewed 27 papers on patients’ and public views on and attitudes towards the use of health data for scientific research. Studies reported a widespread—though conditional—support for the linkage and sharing of data for health research. The only outlier seems to be the finding that just over half (n=25) of the NICE Citizens Council answered ‘no’ to the question whether they had any concerns if NICE used anonymised data to fill in the gaps if NICE was not getting enough evidence in ‘the usual ways’.26 However, we hasten to point out that the question about willingness to share is different from the question whether people have concerns or not.

In addition, after a 2-day discussion meeting Council members were perhaps more sensitised to the potential concerns regarding data sharing. Therefore, we suggest that the way and context within which questions are phrased may influence the answers people give.Overall, people expressed similar motivations to share their data, perceived similar benefits (despite some variation between patients and citizens), yet at the same time displayed a range of concerns, predominantly relating to confidentiality and data security, awareness about access and control, and potential harms resulting from these risks. Both patient and public participants conveyed that certain factors would increase or reduce their willingness to have their data shared.

For example, the presence of privacy-protecting measures (eg, data deidentification and the use of secured databases) seemed to increase willingness to share, as well as transparency and information about data sharing processes and responsibilities. The identified views and attitudes appeared to come together in the conditions stipulated by participants. Value, privacy and confidentiality, minimising risks, data security, transparency, control, information, trust, responsibility and accountability.In our Introduction, we mentioned that identifying patients’ and public views and attitudes allows for a better understanding of the elements of a socially sanctioned governance framework.

In other words, what work should our governance framework be doing in order to obtain a social license?. This review urges researchers and institutions to address people’s diverse concerns and to make an effort to meet the conditions identified. Without these conditions, institutions lack trustworthiness, which is vital for the proceedings of medicine and biomedical science.

As such, a social license is not a ‘nice to have’ but a ‘need to have’. Our results also confirm that patients and the public indeed care about more than legal compliance alone, and wish to be engaged through information, transparency and control. This work supports the findings of a recent systematic review into ethical principles of data sharing as specified in various international ethical guidelines and literature.38 What this body of research implies is considerable diversity of values and beliefs both between and within countries.The goal of this narrative review was to identify the most internationally dominant, aggregated patient and public views about the broad topic of data sharing for health research.

We deliberately opted for the methodology of a narrative review rather than a systematic review. Most narrative reviews deal with a broad range of issues to a given topic rather than addressing a particular topic in depth.39 This means narrative reviews may be most useful for obtaining a broad perspective on a topic, and that they often are less useful in generating quantitative answers to specific clinical questions. However, because narrative reviews do not require specification of the search and selection strategy and the way of critically appraising literature can be variable, the connection between evidence generated by narrative reviews and (clinical) recommendations is less rigorous and risk of bias exists.

This is something to take into account in this study. A risk of bias assessment was not possible due to the heterogeneity of the findings. We acknowledge that our methodological choices may have affected the discriminative power or granularity of our findings.

For example, there is a difference between sharing of routinely collected health data versus secondary use of health data collected for research purposes. And we can only make loose assumptions about potential differences between patient and public views.In addition, we should mention that this work is centred around studies conducted in Western countries as the whole Big Data space and literature is dominated by Western countries, higher socioeconomic status and Caucasians. However, most of the disease burden globally and within countries is most probably not represented in the ‘Big Data’ and so we have to stress the lack of generalisability to large parts of the world.Nevertheless, we believe our findings point towards essential elements of a governance framework for data sharing for health research purposes.

If we are to conclude that the identified conditions ought to act as the pillars of a governance framework, the next step is to identify how these conditions could be practically operationalised. For example, if people value information, transparency and control, what type of consent is most likely to valorise these conditions?. And what policy for returning research results would be desirable?.

Once we know what to value, we can start thinking about the ways to acknowledge that value. A new challenge arising here, however, is what to do when people hold different or even conflicting values or preferences. Discrete choice experiments could help to test people’s preferences regarding specific topics, such as preferred modes of informed consent.

Apart from empirical work, conceptual analysis is needed to clarify how public trust, trustworthiness of institutions and accountability are interconnected.ConclusionThis narrative review suggests widespread—though conditional—support among patients and the public for data sharing for health research. Despite the fact that participants recognise actual or potential benefits of health research, they report a number of significant concerns and related conditions. We believe identified conditions (eg, social value, data security, transparency and accountability) ought to be operationalised in a value-based governance framework that incorporates the diverse patient and public values, needs and interests, and which reflects the way these same conditions are met, to strengthen the social license for Big Data health research.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsWe thank Susanne Løgstrup (European Heart Network) and Evert-Ben van Veen (Medlaw) for their valuable feedback during various stages in drafting the manuscript..

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Latest erectile dysfunction News THURSDAY, Aug buy generic levitra from canada online. 12, 2021 (HealthDay News) erectile dysfunction treatment vaccination will be required for all U.S. Health and Human Services (HHS) employees who deal with patients, HHS Secretary Xavier Becerra announced Thursday buy generic levitra from canada online.

The order will affect more than 25,000 clinicians, researchers, contractors, trainees and volunteers within the U.S. National Institutes of Health, the Indian Health Service, and the U.S. Public Health Service Commissioned Corps, the buy generic levitra from canada online Associated Press reported.

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A growing number of private and public employers in the United States -- such as Google, United Airlines and the state of California -- are requiring workers to get vaccinated due to surging case numbers driven by the highly contagious Delta variant. Last month, the U.S. Department of Veterans Affairs said its health care workers must get vaccinated, and the Pentagon recently announced that all service members will be required to get vaccinated, buy generic levitra from canada online to maintain military readiness, the AP reported.

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Associated Press Robert Preidt and Robin Foster Copyright © 2021 HealthDay. All rights reserved.Latest Alzheimer's News By Amy Norton HealthDay ReporterTHURSDAY, buy generic levitra from canada online Aug. 12, 2021 (HealthDay News) Older adults who take certain diabetes drugs may see a slower decline in their memory and thinking skills, a new study suggests.

Researchers in South Korea found that among older people who'd been having memory issues, those using diabetes drugs called DDP-4 inhibitors typically showed a slower progression in those symptoms over the next few years. That was compared with both diabetes-free older adults and those buy generic levitra from canada online taking other diabetes medications. People on DDP-4 inhibitors also showed smaller amounts of the "plaques" that build up in the brains of people with Alzheimer's disease.

Experts cautioned that the findings do not prove the drugs can prevent or delay dementia. To do that, researchers would need buy generic levitra from canada online to conduct clinical trials that directly test the medications, said Dr. Howard Fillit, chief science officer for the nonprofit Alzheimer's Drug Discovery Foundation in New York City.

But, he said, the study adds to evidence that certain existing medications -- including some for diabetes or high blood pressure -- could be "repurposed" for protecting the aging brain. In fact, buy generic levitra from canada online other diabetes medications, such as metformin and GLP-1 agonists, are already being studied for slowing down declines in memory and thinking skills. There has been less research, Fillit said, into DDP-4 inhibitors -- which include oral medications like sitagliptin (Januvia), linagliptin (Tradjenta), saxagliptin (Onglyza) and alogliptin (Nesina).

They share a similarity with GLP-1 agonists, in that they act on the same "pathway" in buy generic levitra from canada online the body. Fillit explained that DDP-4 inhibitors work by boosting blood levels of GLP-1, a gut hormone that stimulates insulin release. Insulin is a hormone that regulates blood sugar.

People with diabetes are resistant buy generic levitra from canada online to insulin, which results in chronically high blood sugar levels. Some studies have found that people with Alzheimer's also have problems with insulin resistance -- and researchers have speculated that may contribute to the brain degeneration seen in the disease. But Fillit said that diabetes medications might have effects beyond improving insulin resistance.

Animal research has suggested DDP-4 inhibitors buy generic levitra from canada online can reduce brain inflammation and protect brain cells from Alzheimer's-like injury. For the current study, researchers led by Dr. Phil Hyu Lee of Yonsei University College of Medicine in Seoul reviewed the cases of 282 patients who had come to their clinic with complaints about their memory and thinking abilities.

Brain scans had shown all had evidence of amyloid -- the protein that makes up Alzheimer's-related buy generic levitra from canada online plaques. Of those patients, half had diabetes. 70 were taking a DDP-4 inhibitor, and 71 were using other diabetes drugs, most often metformin and sulfonylureas.

On average, the researchers found, patients on DDP-4 inhibitors had less amyloid buildup than either the buy generic levitra from canada online diabetes-free patients or those on other diabetes medications. And over the next few years, they also showed a slower decline on tests of memory and thinking. The findings were published online Aug.

11 in the journal buy generic levitra from canada online Neurology. Maria Carrillo, chief science officer for the Alzheimer's Association, stressed that the study cannot prove DDP-4 inhibitors slow down the dementia process. SLIDESHOW The Stages of Dementia.

Alzheimer's Disease and Aging Brains See Slideshow buy generic levitra from canada online One of the study's limitations, she noted, is that patients' amyloid levels were only measured at the start. So it's not clear whether those on DDP-4 inhibitors had a slower accumulation of brain plaques over time. It's well known, Carrillo said, that people with diabetes have a higher risk of developing Alzheimer's buy generic levitra from canada online than those without diabetes -- though the reasons are not fully clear, she added.

Insulin resistance, as well as high blood sugar, may partly explain it, according to the Alzheimer's Association. Carrillo noted that this study did not look at patients' long-term blood sugar control -- and whether that had any role in their rates of decline over time. "There is some rationale for looking buy generic levitra from canada online at these diabetes drugs in people with Alzheimer's," Carrillo said.

But like Fillit, she said only randomized clinical trials -- where patients are randomly assigned to take a DDP-4 inhibitor or not -- can prove whether there are benefits. One question for future studies, Fillit said, is whether DDP-4 inhibitors can slow mental decline in people without diabetes, or only those with the disease. Because Alzheimer's is so complex, buy generic levitra from canada online Fillit said it is likely that medication combinations -- aimed at different mechanisms behind the disease -- will prove most effective at treating or preventing the disease.

Both of the nonprofits encourage people to eat a healthy diet, exercise, avoid smoking and engage in mentally stimulating activities to help keep their bodies and minds in good shape as they age. More information The Alzheimer's Drug Discovery Foundation has more on protecting brain health. SOURCES.

Maria Carrillo, PhD, chief science officer, Alzheimer's Association, Chicago. Howard Fillit, MD, chief science officer, Alzheimer's Drug Discovery Foundation, New York City. Neurology, online, Aug.

11, 2021 Copyright © 2021 HealthDay. All rights reserved. From Healthy Resources Featured Centers Health Solutions From Our SponsorsLatest erectile dysfunction News By Dennis Thompson HealthDay ReporterFRIDAY, Aug.

13, 2021 Masks are making an unwanted comeback in many parts of the United States, after new data showing that fully vaccinated people with "breakthrough" erectile dysfunction s carry enough levitra in their bodies to pose a potential risk to the unvaccinated. But these breakthrough s — which have become slightly more common with the highly transmissible Delta variant — pose little to no threat to most vaccinated folks who are unlucky enough to get them, infectious disease experts stressed. Nearly all breakthrough erectile dysfunction treatment cases occurring in the United States are symptom-free or mild illnesses that can be treated at home, if they require treatment at all, said Dr.

Amesh Adalja, a senior scholar with the Johns Hopkins Center for Health Security, in Baltimore. "The fact that the breakthrough s are mild is evidence not of the treatment's failing, but of the treatment succeeding, because treatments aren't force fields or bug zappers," Adalja said. "They are meant to minimize the symptoms that could occur with a breakthrough ." Instead, vaccinated folks are being asked to mask up to protect the unvaccinated, as well as themselves, so that enough hospital beds remain available for everyone.

The average number of people hospitalized daily for erectile dysfunction treatment during the last week of July alone outpaced the total number of vaccinated people who have ever been hospitalized for a breakthrough , the U.S. Centers for Disease Control and Prevention noted. The CDC estimates that 7,707 people per day, on average, were hospitalized with erectile dysfunction treatment s from July 28 through Aug.

3, 2021. By comparison, all hospitalizations from breakthrough erectile dysfunction treatment s that have been reported to the CDC from the beginning of the U.S. Vaccination program through Aug.

2 amount to just 7,101. There also have been 1,507 deaths reported from breakthrough s among the vaccinated -- just 0.6% of the nearly 241,100 total erectile dysfunction treatment deaths that have occurred so far in 2021, CDC data show. The erectile dysfunction treatments now available in the United States were not designed to completely prevent , Adalja explained.

Rather, they were intended to prevent severe illness that could land someone in the hospital or kill them. Essentially taming a tiger of an down into a kitten. A growing pile of data suggests that the treatments are, in fact, working as intended.

Fully immunized people account for less than 5% of hospitalizations and less than 6% of deaths from erectile dysfunction treatment, according to a New York Times analysis of data from 40 states. NBC News reports 125,682 breakthrough cases in 38 states, represent less than 0.08% of the 164.2 million-plus people who have been fully vaccinated since the start of the year, or about one in every 1,300. The whole goal of vaccination was to make erectile dysfunction treatment into just another seasonal bug, Adalja said.

That's how it's working out for those who've gotten the full jab. "What we've always tried to do with erectile dysfunction treatment is make it a more manageable respiratory levitra, like ones we deal with day in and day out," Adalja said. "That's what the treatment is accomplishing.

Breakthrough s are going to be something we hear about and see. I think virtually everybody's going to get a breakthrough at some point," he added. "The fact is, when you get those breakthrough s it's going to be mild because of the treatments, and that's all we've ever asked of the treatments," Adalja concluded.

In fact, some experts suggest a mild breakthrough case could actually be helpful, further boosting and improving your immunity against erectile dysfunction treatment. The illness, though blunted by the treatment, provides the immune system a chance to learn more about the erectile dysfunction and strengthen its defenses. The reason the CDC changed its tune in July and urged people to start wearing masks indoors again, at least in high-transmission areas, had nothing to do with the threat of breakthrough s to vaccinated people.

Instead, the agency was responding to new data suggesting that people with breakthrough s could carry viral loads as high as those of infected people with erectile dysfunction treatment. Thanks to the treatment, these people most often suffer only mild illness if any at all, despite the large amount of levitra in their bodies. But those large viral loads make it more likely that they could spread erectile dysfunction treatment to unvaccinated people in their midst — and those unprotected folks are at greater risk of hospitalization and death from the highly infectious Delta variant.

Vaccinated people who are resentful about having to don masks again to protect their unvaccinated neighbors should consider it something of an insurance policy for their own access to health care, said Dr. Preeti Malani, an infectious disease professor and chief health officer for the University of Michigan. "Something that gets lost in all this is when your health care system is overwhelmed by erectile dysfunction treatment cases, if you fall and break your leg or if you develop appendicitis or you have some other issue that requires care, it becomes more complicated to receive that care," Malani pointed out.

She said she's concerned about breakthrough s in some vulnerable groups, mainly seniors or folks with conditions that compromise their immune system. "We are seeing more people hospitalized who have breakthrough [s], but these have tended to be individuals who were older. I saw someone who was 108, a couple of weeks ago.

The people being hospitalized tend to be individuals who have more underlying health conditions," Malani said. "For healthy people, overwhelmingly [breakthrough s] are something that is an inconvenience and doesn't have long-lasting effects," she added. Still, until vaccination rates approach herd immunity, erectile dysfunction treatment surges in specific regions will continue to strain hospital resources and make prevention strategies like masking necessary, Malani said.

"Vaccination still is the only way out of this, but now what is clear is that more people need to be vaccinated," Malani said of the Delta surge. "At this point, what I'm recommending to my friends and family is in indoor crowded public spaces, wear a mask. It's not a big deal." More information The U.S.

Centers for Disease Control and Prevention has more about erectile dysfunction treatment vaccination. SOURCES. Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore.

Preeti Malani, MD, infectious disease professor and chief health officer, University of Michigan Copyright © 2021 HealthDay. All rights reserved..

Latest erectile dysfunction 10mg levitra online News THURSDAY, Aug Source. 12, 2021 (HealthDay News) erectile dysfunction treatment vaccination will be required for all U.S. Health and Human Services (HHS) employees who deal with patients, HHS 10mg levitra online Secretary Xavier Becerra announced Thursday. The order will affect more than 25,000 clinicians, researchers, contractors, trainees and volunteers within the U.S.

National Institutes of Health, the Indian Health Service, and the U.S. Public Health Service Commissioned Corps, 10mg levitra online the Associated Press reported. "Requiring our HHS health care workforce to get vaccinated will protect our federal workers, as well as the patients and people they serve," Becerra said in a statement. HHS employs more than 80,000 people.

Those not covered by new mandate 10mg levitra online are subject to a White House policy that compels federal workers and contractors to provide their vaccination status and requires those who aren't vaccinated to get regular erectile dysfunction treatment testing and places certain workplace restrictions on them, the AP reported. A growing number of private and public employers in the United States -- such as Google, United Airlines and the state of California -- are requiring workers to get vaccinated due to surging case numbers driven by the highly contagious Delta variant. Last month, the U.S. Department of Veterans Affairs said its health care workers must get vaccinated, and the Pentagon recently announced that all service members will be required to get vaccinated, to 10mg levitra online maintain military readiness, the AP reported.

While vaccination is nearly universal among doctors, the same isn't true for all health care workers. Nursing homes and hospitals rely on support staff for tasks ranging from clerical duties to transporting patients, and their vaccination rates often mirror the surrounding communities. Despite widespread availability of free treatments, only about half of 10mg levitra online the U.S. Population is fully vaccinated, data from the U.S.

Centers for Disease Control and Prevention shows. New erectile dysfunction treatment 10mg levitra online cases have surged past 100,000 a day, a level not seen since the deadly wave of the fall and winter gained momentum last November, the AP reported. More information Visit the U.S. Centers for 10mg levitra online Disease Control and Prevention for more on erectile dysfunction treatments.

SOURCE. Associated Press Robert Preidt and Robin Foster Copyright © 2021 HealthDay. All rights reserved.Latest Alzheimer's News By Amy 10mg levitra online Norton HealthDay ReporterTHURSDAY, Aug. 12, 2021 (HealthDay News) Older adults who take certain diabetes drugs may see a slower decline in their memory and thinking skills, a new study suggests.

Researchers in South Korea found that among older people who'd been having memory issues, those using diabetes drugs called DDP-4 inhibitors typically showed a slower progression in those symptoms over the next few years. That was compared with both diabetes-free older adults 10mg levitra online and those taking other diabetes medications. People on DDP-4 inhibitors also showed smaller amounts of the "plaques" that build up in the brains of people with Alzheimer's disease. Experts cautioned that the findings do not prove the drugs can prevent or delay dementia.

To do that, researchers would need to conduct 10mg levitra online clinical trials that directly test the medications, said Dr. Howard Fillit, chief science officer for the nonprofit Alzheimer's Drug Discovery Foundation in New York City. But, he said, the study adds to evidence that certain existing medications -- including some for diabetes or high blood pressure -- could be "repurposed" for protecting the aging brain. In fact, 10mg levitra online other diabetes medications, such as metformin and GLP-1 agonists, are already being studied for slowing down declines in memory and thinking skills.

There has been less research, Fillit said, into DDP-4 inhibitors -- which include oral medications like sitagliptin (Januvia), linagliptin (Tradjenta), saxagliptin (Onglyza) and alogliptin (Nesina). They share a similarity with GLP-1 agonists, in that they act on the 10mg levitra online same "pathway" in the body. Fillit explained that DDP-4 inhibitors work by boosting blood levels of GLP-1, a gut hormone that stimulates insulin release. Insulin is a hormone that regulates blood sugar.

People with diabetes are resistant to insulin, which results in chronically high blood sugar levels 10mg levitra online. Some studies have found that people with Alzheimer's also have problems with insulin resistance -- and researchers have speculated that may contribute to the brain degeneration seen in the disease. But Fillit said that diabetes medications might have effects beyond improving insulin resistance. Animal research has suggested DDP-4 inhibitors can reduce brain inflammation and protect brain cells from 10mg levitra online Alzheimer's-like injury.

For the current study, researchers led by Dr. Phil Hyu Lee of Yonsei University College of Medicine in Seoul reviewed the cases of 282 patients who had come to their clinic with complaints about their memory and thinking abilities. Brain scans had shown all had 10mg levitra online evidence of amyloid -- the protein that makes up Alzheimer's-related plaques. Of those patients, half had diabetes.

70 were taking a DDP-4 inhibitor, and 71 were using other diabetes drugs, most often metformin and sulfonylureas. On average, the researchers found, patients on DDP-4 inhibitors had less amyloid 10mg levitra online buildup than either the diabetes-free patients or those on other diabetes medications. And over the next few years, they also showed a slower decline on tests of memory and thinking. The findings were published online Aug.

11 in the journal Neurology 10mg levitra online. Maria Carrillo, chief science officer for the Alzheimer's Association, stressed that the study cannot prove DDP-4 inhibitors slow down the dementia process. SLIDESHOW The Stages of Dementia. Alzheimer's Disease and Aging Brains See Slideshow One of the 10mg levitra online study's limitations, she noted, is that patients' amyloid levels were only measured at the start.

So it's not clear whether those on DDP-4 inhibitors had a slower accumulation of brain plaques over time. It's well known, Carrillo said, that people with diabetes have a higher risk of developing Alzheimer's than those without diabetes -- though the reasons are not 10mg levitra online fully clear, she added. Insulin resistance, as well as high blood sugar, may partly explain it, according to the Alzheimer's Association. Carrillo noted that this study did not look at patients' long-term blood sugar control -- and whether that had any role in their rates of decline over time.

"There is some rationale for looking at these diabetes drugs in people with 10mg levitra online Alzheimer's," Carrillo said. But like Fillit, she said only randomized clinical trials -- where patients are randomly assigned to take a DDP-4 inhibitor or not -- can prove whether there are benefits. One question for future studies, Fillit said, is whether DDP-4 inhibitors can slow mental decline in people without diabetes, or only those with the disease. Because Alzheimer's is so complex, Fillit said it is likely that medication combinations -- aimed 10mg levitra online at different mechanisms behind the disease -- will prove most effective at treating or preventing the disease.

Both of the nonprofits encourage people to eat a healthy diet, exercise, avoid smoking and engage in mentally stimulating activities to help keep their bodies and minds in good shape as they age. More information The Alzheimer's Drug Discovery Foundation has more on protecting brain health. SOURCES. Maria Carrillo, PhD, chief science officer, Alzheimer's Association, Chicago.

Howard Fillit, MD, chief science officer, Alzheimer's Drug Discovery Foundation, New York City. Neurology, online, Aug. 11, 2021 Copyright © 2021 HealthDay. All rights reserved.

From Healthy Resources Featured Centers Health Solutions From Our SponsorsLatest erectile dysfunction News By Dennis Thompson HealthDay ReporterFRIDAY, Aug. 13, 2021 Masks are making an unwanted comeback in many parts of the United States, after new data showing that fully vaccinated people with "breakthrough" erectile dysfunction s carry enough levitra in their bodies to pose a potential risk to the unvaccinated. But these breakthrough s — which have become slightly more common with the highly transmissible Delta variant — pose little to no threat to most vaccinated folks who are unlucky enough to get them, infectious disease experts stressed. Nearly all breakthrough erectile dysfunction treatment cases occurring in the United States are symptom-free or mild illnesses that can be treated at home, if they require treatment at all, said Dr.

Amesh Adalja, a senior scholar with the Johns Hopkins Center for Health Security, in Baltimore. "The fact that the breakthrough s are mild is evidence not of the treatment's failing, but of the treatment succeeding, because treatments aren't force fields or bug zappers," Adalja said. "They are meant to minimize the symptoms that could occur with a breakthrough ." Instead, vaccinated folks are being asked to mask up to protect the unvaccinated, as well as themselves, so that enough hospital beds remain available for everyone. The average number of people hospitalized daily for erectile dysfunction treatment during the last week of July alone outpaced the total number of vaccinated people who have ever been hospitalized for a breakthrough , the U.S.

Centers for Disease Control and Prevention noted. The CDC estimates that 7,707 people per day, on average, were hospitalized with erectile dysfunction treatment s from July 28 through Aug. 3, 2021. By comparison, all hospitalizations from breakthrough erectile dysfunction treatment s that have been reported to the CDC from the beginning of the U.S.

Vaccination program through Aug. 2 amount to just 7,101. There also have been 1,507 deaths reported from breakthrough s among the vaccinated -- just 0.6% of the nearly 241,100 total erectile dysfunction treatment deaths that have occurred so far in 2021, CDC data show. The erectile dysfunction treatments now available in the United States were not designed to completely prevent , Adalja explained.

Rather, they were intended to prevent severe illness that could land someone in the hospital or kill them. Essentially taming a tiger of an down into a kitten. A growing pile of data suggests that the treatments are, in fact, working as intended. Fully immunized people account for less than 5% of hospitalizations and less than 6% of deaths from erectile dysfunction treatment, according to a New York Times analysis of data from 40 states.

NBC News reports 125,682 breakthrough cases in 38 states, represent less than 0.08% of the 164.2 million-plus people who have been fully vaccinated since the start of the year, or about one in every 1,300. The whole goal of vaccination was to make erectile dysfunction treatment into just another seasonal bug, Adalja said. That's how it's working out for those who've gotten the full jab. "What we've always tried to do with erectile dysfunction treatment is make it a more manageable respiratory levitra, like ones we deal with day in and day out," Adalja said.

"That's what the treatment is accomplishing. Breakthrough s are going to be something we hear about and see. I think virtually everybody's going to get a breakthrough at some point," he added. "The fact is, when you get those breakthrough s it's going to be mild because of the treatments, and that's all we've ever asked of the treatments," Adalja concluded.

In fact, some experts suggest a mild breakthrough case could actually be helpful, further boosting and improving your immunity against erectile dysfunction treatment. The illness, though blunted by the treatment, provides the immune system a chance to learn more about the erectile dysfunction and strengthen its defenses. The reason the CDC changed its tune in July and urged people to start wearing masks indoors again, at least in high-transmission areas, had nothing to do with the threat of breakthrough s to vaccinated people. Instead, the agency was responding to new data suggesting that people with breakthrough s could carry viral loads as high as those of infected people with erectile dysfunction treatment.

Thanks to the treatment, these people most often suffer only mild illness if any at all, despite the large amount of levitra in their bodies. But those large viral loads make it more likely that they could spread erectile dysfunction treatment to unvaccinated people in their midst — and those unprotected folks are at greater risk of hospitalization and death from the highly infectious Delta variant. Vaccinated people who are resentful about having to don masks again to protect their unvaccinated neighbors should consider it something of an insurance policy for their own access to health care, said Dr. Preeti Malani, an infectious disease professor and chief health officer for the University of Michigan.

"Something that gets lost in all this is when your health care system is overwhelmed by erectile dysfunction treatment cases, if you fall and break your leg or if you develop appendicitis or you have some other issue that requires care, it becomes more complicated to receive that care," Malani pointed out. She said she's concerned about breakthrough s in some vulnerable groups, mainly seniors or folks with conditions that compromise their immune system. "We are seeing more people hospitalized who have breakthrough [s], but these have tended to be individuals who were older. I saw someone who was 108, a couple of weeks ago.

The people being hospitalized tend to be individuals who have more underlying health conditions," Malani said. "For healthy people, overwhelmingly [breakthrough s] are something that is an inconvenience and doesn't have long-lasting effects," she added. Still, until vaccination rates approach herd immunity, erectile dysfunction treatment surges in specific regions will continue to strain hospital resources and make prevention strategies like masking necessary, Malani said. "Vaccination still is the only way out of this, but now what is clear is that more people need to be vaccinated," Malani said of the Delta surge.

"At this point, what I'm recommending to my friends and family is in indoor crowded public spaces, wear a mask. It's not a big deal." More information The U.S. Centers for Disease Control and Prevention has more about erectile dysfunction treatment vaccination. SOURCES.

Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore. Preeti Malani, MD, infectious disease professor and chief health officer, University of Michigan Copyright © 2021 HealthDay. All rights reserved..

Katie levitre

Funding Will katie levitre Help Communities, Hospitals, Health Clinics Respond to the levitra and Support Local Efforts to Increase treatment Confidence and Uptake in Rural CommunitiesToday, thanks to the American Rescue Plan, the U.S. Department of Health and Human Services (HHS) is announcing the availability of nearly $1 billion to strengthen erectile dysfunction treatment response efforts and increase vaccinations in rural communities. As part of the Biden Administration's commitment to expanding access to treatments and ensuring equity in the erectile dysfunction treatment response, the Health Resources and Services Administration, a part of HHS, will increase the number of treatments sent to rural communities, expand testing and other erectile dysfunction treatment prevention services, and work to increase treatment confidence by empowering trusted local voices with additional funding for outreach efforts in katie levitre underserved communities.

"Rural health providers are vital to ensure equity in erectile dysfunction treatment testing, vaccinations and in making sure rural residents have the information about treatment safety, especially for populations who are at an increased risk for erectile dysfunction treatment or severe illness due to systemic health and social inequities and geographic isolation," said HHS Secretary Xavier Becerra. "Support to katie levitre Rural Health Clinics and small rural hospitals for erectile dysfunction treatment testing, strengthening treatment allocation and confidence, and treatment outreach will help rural residents make informed health decisions about erectile dysfunction treatment to protect themselves and their communities." HRSA's Rural Health Clinic erectile dysfunction treatment Testing and Mitigation Program will provide $460 million to more than 4,600 rural health clinics (RHCs) across the country. RHCs will use the funds to maintain and increase erectile dysfunction treatment testing, expand access to testing for rural residents, and broaden efforts to mitigate the spread of the levitra in ways tailored to their local communities.

RHCs are a special certification given katie levitre to health care practices in underserved rural areas by the Centers for Medicare and Medicaid Services (CMS) to help ensure access to care for rural residents. HRSA will provide up to $100,000 per RHC-certified clinic site and will issue the funds this summer. To further support erectile dysfunction treatment testing in rural areas, HRSA will provide $398 million to existing grantees of the Small Rural Hospital Improvement Program (SHIP) to work with approximately 1,730 small rural hospitals – those with fewer than 50 beds – and Critical Access Hospitals on erectile dysfunction treatment testing and mitigation.

SHIP state grantees will use the funding to support all eligible rural hospitals, up katie levitre to $230,000 per hospital, and will issue the funds later in the year. "Addressing the health care challenges rural areas face requires a targeted approach that's tailored to the needs of local communities," said HRSA Acting Administrator Diana Espinosa. "This critical katie levitre funding strengthens our ability to deliver on President Biden's commitment to ensure that the nation's underserved communities and those who are disproportionately affected by erectile dysfunction treatment get the help they need." HRSA will also support RHCs to increase the availability of erectile dysfunction treatments in rural communities and expand outreach to build treatment confidence.

Working in partnership with the Centers for Disease Control and Prevention (CDC), HRSA is inviting Medicare-certified RHCs to join the new Rural Health Clinic erectile dysfunction treatment Distribution (RHCVD) Program to directly receive treatments from the Biden Administration. HRSA and CDC will continue to enroll interested RHCs to receive erectile dysfunction treatments, the allocation for which is katie levitre separate from jurisdictions' weekly allocations. In addition, through the Rural Health Clinic treatment Confidence (RHCVC) Program, HRSA will make nearly $100 million available in grants to eligible RHCs nationwide to address health equity gaps by offering support and resources to medically underserved rural communities where erectile dysfunction treatment uptake lags in comparison to more populated areas.

HRSA will fund all eligible RHCs that apply. The RHCVC Program is katie levitre the first targeted RHC grant since the passage of the Rural Health Clinic Service Act in 1977. RHCs will be able to use the funds to increase treatment confidence, improve health care in rural areas, and reinforce key messages about prevention and treatment of erectile dysfunction treatment and other infectious diseases.

Implementation efforts in rural communities katie levitre will include disseminating information to rural residents about how and where to get vaccinated, and coordinating with existing vaccination sites and public health partners to identify strategies to increase treatment confidence among key populations. RHCs may also use funding to promote vaccination and bolster patient literacy in rural areas on the benefits of broad vaccination and treatment safety in support of continued efforts to return to a more normal lifestyle. For more information about HRSA's rural programs, visit the Federal Office of katie levitre Rural Health Policy website.

Https://www.hrsa.gov/rural-health/index.html To learn more about HRSA's allocation to Rural Health Clinics for erectile dysfunction treatment testing visit. Https://www.hrsa.gov/rural-health/erectile dysfunction/rural-health-clinics-erectile dysfunction treatment-testing-fy20-awards To learn more about the Small Rural Hospital Improvement Program (SHIP), visit https://www.hrsa.gov/rural-health/rural-hospitals..

Funding Will Help Communities, Hospitals, Health Clinics Respond to the levitra and Support 10mg levitra online Local Efforts to Increase treatment Confidence and Uptake in Rural moved here CommunitiesToday, thanks to the American Rescue Plan, the U.S. Department of Health and Human Services (HHS) is announcing the availability of nearly $1 billion to strengthen erectile dysfunction treatment response efforts and increase vaccinations in rural communities. As part of the Biden Administration's commitment to expanding access to treatments and ensuring equity in the erectile dysfunction treatment response, the Health Resources and Services Administration, a part of HHS, will increase the number 10mg levitra online of treatments sent to rural communities, expand testing and other erectile dysfunction treatment prevention services, and work to increase treatment confidence by empowering trusted local voices with additional funding for outreach efforts in underserved communities. "Rural health providers are vital to ensure equity in erectile dysfunction treatment testing, vaccinations and in making sure rural residents have the information about treatment safety, especially for populations who are at an increased risk for erectile dysfunction treatment or severe illness due to systemic health and social inequities and geographic isolation," said HHS Secretary Xavier Becerra.

"Support to Rural Health Clinics and small rural hospitals for erectile dysfunction treatment testing, strengthening treatment allocation and confidence, and treatment outreach will help rural residents make informed health decisions about erectile dysfunction treatment to protect themselves and their communities." HRSA's Rural Health Clinic 10mg levitra online erectile dysfunction treatment Testing and Mitigation Program will provide $460 million to more than 4,600 rural health clinics (RHCs) across the country. RHCs will use the funds to maintain and increase erectile dysfunction treatment testing, expand access to testing for rural residents, and broaden efforts to mitigate the spread of the levitra in ways tailored to their local communities. RHCs are a special certification given to health care practices in underserved rural areas by the Centers for Medicare and Medicaid Services (CMS) to help ensure access to care for rural residents 10mg levitra online. HRSA will provide up to $100,000 per RHC-certified clinic site and will issue the funds this summer.

To further support erectile dysfunction treatment testing in rural areas, HRSA will provide $398 million to existing grantees of the Small Rural Hospital Improvement Program (SHIP) to work with approximately 1,730 small rural hospitals – those with fewer than 50 beds – and Critical Access Hospitals on erectile dysfunction treatment testing and mitigation. SHIP state grantees will use the funding to support all eligible rural 10mg levitra online hospitals, up to $230,000 per hospital, and will issue the funds later in the year. "Addressing the health care challenges rural areas face requires a targeted approach that's tailored to the needs of local communities," said HRSA Acting Administrator Diana Espinosa. "This critical funding strengthens our ability to deliver on President Biden's commitment to ensure that the nation's underserved communities and those who are disproportionately affected by erectile dysfunction treatment get the help they need." HRSA will also support RHCs to increase the availability of erectile dysfunction treatments in rural communities and 10mg levitra online expand outreach to build treatment confidence.

Working in partnership with the Centers for Disease Control and Prevention (CDC), HRSA is inviting Medicare-certified RHCs to join the new Rural Health Clinic erectile dysfunction treatment Distribution (RHCVD) Program to directly receive treatments from the Biden Administration. HRSA and CDC will continue to enroll interested RHCs to receive erectile dysfunction treatments, the allocation for which is 10mg levitra online separate from jurisdictions' weekly allocations. In addition, through the Rural Health Clinic treatment Confidence (RHCVC) Program, HRSA will make nearly $100 million available in grants to eligible RHCs nationwide to address health equity gaps by offering support and resources to medically underserved rural communities where erectile dysfunction treatment uptake lags in comparison to more populated areas. HRSA will fund all eligible RHCs that apply.

The RHCVC Program is the first targeted RHC grant since the passage of 10mg levitra online the Rural Health Clinic Service Act in 1977. RHCs will be able to use the funds to increase treatment confidence, improve health care in rural areas, and reinforce key messages about prevention and treatment of erectile dysfunction treatment and other infectious diseases. Implementation efforts in rural communities will include disseminating information to rural residents about how and where to get vaccinated, and coordinating with existing vaccination sites and public health 10mg levitra online partners to identify strategies to increase treatment confidence among key populations. RHCs may also use funding to promote vaccination and bolster patient literacy in rural areas on the benefits of broad vaccination and treatment safety in support of continued efforts to return to a more normal lifestyle.

For more information about HRSA's rural programs, visit 10mg levitra online the Federal Office of Rural Health Policy website. Https://www.hrsa.gov/rural-health/index.html To learn more about HRSA's allocation to Rural Health Clinics for erectile dysfunction treatment testing visit. Https://www.hrsa.gov/rural-health/erectile dysfunction/rural-health-clinics-erectile dysfunction treatment-testing-fy20-awards To learn more about the Small Rural Hospital Improvement Program (SHIP), visit https://www.hrsa.gov/rural-health/rural-hospitals..

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