beauty
wellness

Kamagra gel online

Denis Clement kamagra gel online (Ghent, Belgium) who was the first chair, along with Pr. J. Linhart (Prague, Czechoslovakia).

Since its early days, this WG has had the particularity of bringing together not only cardiologists with expertise on peripheral vessels, but also specialists from neighbouring kamagra gel online fields such as internal medicine and angiology.Other pioneers such as Professors L. Urai, A. Strano and H.

Boccalon paved the way kamagra gel online of this working group, leading through the chairmanships of Professors Novo, Ciccone, Poredos, Balbarini, Lekakis, Cosentino, Vlachopoulos, and Marianne Brodmann to nowadays. In 2017, under the chairmanship of Marco De Carlo, we extended the scope of the working group by inviting specialists of the aorta to join us, and our working group has been renamed ‘Aorta &. Peripheral Vascular Diseases’ (A&PVDs).

The two main objectives kamagra gel online of this working group are. In 2018, the Working Group nucleus has been enriched by the presence of vascular surgeons who joined us after a fruitful collaboration for the writing of the 2017 ESC Guidelines of Peripheral Arterial Diseases (PAD), in collaboration with the European Society of Vascular Surgery (ESVS). Now, this Working Group is the unique place where physicians and researchers of different specialties throughout Europe can interact.In these last years, the number of members of this WG has almost doubled (Figure 1), reaching 600 adherents, underlining the WG’s dynamism and the regain of interest in peripheral vessels for many cardiologists, and the will for other specialists to join the ESC through this WG for collaborations.

Figure kamagra gel online 1WG A&PVD members evolution 2010–20.Figure 1WG A&PVD members evolution 2010–20.During the last years, the WG developed its network by extending partnerships with other bodies within the ESC, and with other neighbour societies around the vessels. To extend the collaboration between the ESC and the ESVS beyond the PAD guidelines, our WG and the ESVS elaborated a consensus document for the follow-up of patients revascularized for PADs, a first document addressing this important issue in Europe. We have also initiated a collaboration with the European Society of Vascular Medicine, by setting joint sessions in our respective meetings.Within the ESC, we have set several common projects (consensus documents, ESC webinars, and educational training programmes) with different bodies, summarized in Figure 2.

Figure 2WG A&PVD collaborations.Figure 2WG A&PVD collaborations.These collaborations enabled the production of a series of consensus documents summarized in Table 1.Among all, the most kamagra gel online salient collaboration has been with the WG on Thrombosis, because of major common grounds. Together, we successfully organized a 3-day educational training programme on antithrombotic strategies at the European Heart House in Nice. The collaboration has been extended with the writing of a consensus document on antithrombotic strategies in peripheral arterial diseases, to be finalized this year.

We also plan to merge our efforts for kamagra gel online a common congress. The next opus of Eurothrombosis congress will actually be Eurothrombosis &. Eurovessels.

Originally planned for October 2020, this congress will be held kamagra gel online in November 2021 in Lisbon, under the leadership of our two working groups. This will be the first ESC subspecialty congress involving our WG, highlighting the development of our activities.Among other upcoming events, we plan a new educational programme on Aortic Diseases, in collaboration with the WG on Cardiovascular Surgery, in 2021.Both for the congress and educational training programme, the WG facilitates participation for young trainees, proposing travel grants upon applications. All ESC members (and beyond), young or old, are wholeheartedly welcome!.

Conflict of interest kamagra gel online. None declared. Table 1Most recent publications involving the Working on Aorta and Peripheral Vascular Diseases The Role of Vascular Biomarkers for Primary and Secondary Prevention (in collaboration with the ARTERY society);Echovascular Imaging Assessment of Arterial Disease.

Complement to the ESC Guidelines (collaboration with the EACVI);Follow-up of patients after revascularization for Peripheral kamagra gel online Arterial Diseases (in collaboration with the European Society of Vascular Surgery);Diagnosis and management of deep vein thrombosis (in collaboration with WG on Pulmonary Circulation and Right Ventricular Function);Genetic counselling and testing in adults with congenital heart disease (collaboration with the WG on Grown-Up Congenital Heart Disease and the European Society on Human Genetics);The Role of Ventricular-Arterial Coupling in Cardiac Disease and Heart Failure. Assessment, Clinical Implications and Therapeutic Interventions (collaboration with the EACVI and the Heart Failure Association);Antithrombotic Therapy and Major Adverse Limb Events in Patients With Chronic Lower Extremity Arterial Disease. Systematic Review and Meta-Analysis (collaboration with WG on Cardiovascular Pharmacotherapy);Endothelial Function in Cardiovascular Precision Medicine (collaboration with WGs on Atherosclerosis and Vascular Biology, Coronary pathophysiology and microcirculation, and Thrombosis);… and the series The Year in Cardiology.

Aorta & kamagra gel online. Peripheral Circulation (2014–19) The Role of Vascular Biomarkers for Primary and Secondary Prevention (in collaboration with the ARTERY society);Echovascular Imaging Assessment of Arterial Disease. Complement to the ESC Guidelines (collaboration with the EACVI);Follow-up of patients after revascularization for Peripheral Arterial Diseases (in collaboration with the European Society of Vascular Surgery);Diagnosis and management of deep vein thrombosis (in collaboration with WG on Pulmonary Circulation and Right Ventricular Function);Genetic counselling and testing in adults with congenital heart disease (collaboration with the WG on Grown-Up Congenital Heart Disease and the European Society on Human Genetics);The Role of Ventricular-Arterial Coupling in Cardiac Disease and Heart Failure.

Assessment, Clinical Implications and Therapeutic Interventions kamagra gel online (collaboration with the EACVI and the Heart Failure Association);Antithrombotic Therapy and Major Adverse Limb Events in Patients With Chronic Lower Extremity Arterial Disease. Systematic Review and Meta-Analysis (collaboration with WG on Cardiovascular Pharmacotherapy);Endothelial Function in Cardiovascular Precision Medicine (collaboration with WGs on Atherosclerosis and Vascular Biology, Coronary pathophysiology and microcirculation, and Thrombosis);… and the series The Year in Cardiology. Aorta &.

Peripheral Circulation (2014–19) Table 1Most recent publications involving the Working on Aorta and Peripheral Vascular Diseases kamagra gel online The Role of Vascular Biomarkers for Primary and Secondary Prevention (in collaboration with the ARTERY society);Echovascular Imaging Assessment of Arterial Disease. Complement to the ESC Guidelines (collaboration with the EACVI);Follow-up of patients after revascularization for Peripheral Arterial Diseases (in collaboration with the European Society of Vascular Surgery);Diagnosis and management of deep vein thrombosis (in collaboration with WG on Pulmonary Circulation and Right Ventricular Function);Genetic counselling and testing in adults with congenital heart disease (collaboration with the WG on Grown-Up Congenital Heart Disease and the European Society on Human Genetics);The Role of Ventricular-Arterial Coupling in Cardiac Disease and Heart Failure. Assessment, Clinical Implications and Therapeutic Interventions (collaboration with the EACVI and the Heart Failure Association);Antithrombotic Therapy and Major Adverse Limb Events in Patients With Chronic Lower Extremity Arterial Disease.

Systematic Review and Meta-Analysis (collaboration with WG on Cardiovascular Pharmacotherapy);Endothelial Function in Cardiovascular Precision Medicine (collaboration with WGs on Atherosclerosis and Vascular Biology, Coronary pathophysiology and microcirculation, and Thrombosis);… and the series kamagra gel online The Year in Cardiology. Aorta &. Peripheral Circulation (2014–19) The Role of Vascular Biomarkers for Primary and Secondary Prevention (in collaboration with the ARTERY society);Echovascular Imaging Assessment of Arterial Disease.

Complement to the ESC Guidelines (collaboration with the EACVI);Follow-up of patients after revascularization for Peripheral Arterial Diseases (in collaboration with the European Society of Vascular Surgery);Diagnosis and management of deep vein thrombosis (in collaboration with WG on Pulmonary Circulation and Right Ventricular Function);Genetic counselling and testing in adults with congenital heart disease (collaboration kamagra gel online with the WG on Grown-Up Congenital Heart Disease and the European Society on Human Genetics);The Role of Ventricular-Arterial Coupling in Cardiac Disease and Heart Failure. Assessment, Clinical Implications and Therapeutic Interventions (collaboration with the EACVI and the Heart Failure Association);Antithrombotic Therapy and Major Adverse Limb Events in Patients With Chronic Lower Extremity Arterial Disease. Systematic Review and Meta-Analysis (collaboration with WG on Cardiovascular Pharmacotherapy);Endothelial Function in Cardiovascular Precision Medicine (collaboration with WGs on Atherosclerosis and Vascular Biology, Coronary pathophysiology and microcirculation, and Thrombosis);… and the series The Year in Cardiology.

Aorta & kamagra gel online. Peripheral Circulation (2014–19) Published on behalf of the European Society of Cardiology. All rights reserved.

Can you buy kamagra without a prescription

Kamagra
Tadalis sx
Brand cialis
Buy without prescription
Online Pharmacy
At cvs
Pharmacy
For womens
Memory problems
Stuffy or runny nose
Flushing
Best place to buy
In online pharmacy
In online pharmacy
Register first
Over the counter
RX pharmacy
Online Drugstore
Order online
Duration of action
Indian Pharmacy
Canadian Pharmacy
RX pharmacy
Does medicare pay
100mg 120 tablet $227.95
20mg 20 tablet $49.95
20mg 12 tablet $139.95
Brand
Diarrhea
Flu-like symptoms
Upset stomach

Today, the can you buy kamagra without a prescription U.S. Department of Health and Human Services (HHS) provided nearly $100 million to rural health clinics across the country to support outreach efforts to increase vaccinations in rural communities. The funds will go to more than 1,980 Rural Health Clinics (RHCs) who will use these resources to develop and implement additional treatment confidence and outreach efforts as many communities face the Delta variant and work to get more people vaccinated and protected can you buy kamagra without a prescription from erectile dysfunction treatment in medically underserved rural communities. The funding was made available by the American Rescue Plan and is being administered by the Health Resources and Services Administration (HRSA) through the Rural Health Clinic treatment Confidence (RHCVC) Program."Rural health clinics play a crucial role in supporting our national vaccination effort to defeat erectile dysfunction treatment," said HHS Secretary Xavier Becerra. "This funding will give trusted messengers in rural communities the tools they need to counsel patients on how erectile dysfunction treatments can help protect them can you buy kamagra without a prescription and their loved ones." RHCs are well positioned to disseminate information about how and where to get vaccinated at the local level, and coordinate with existing vaccination sites and public health partners to identify strategies to increase treatment confidence among key populations.

RHCs will also use this funding to improve health literacy, focusing on treatment safety and the benefits of broad vaccination for rural communities. These efforts will improve health care in rural areas by reinforcing key can you buy kamagra without a prescription messages about prevention and treatment of erectile dysfunction treatment and other infectious diseases. HRSA is making grant awards to RHCs based on the number of certified clinic sites they operate, providing approximately $49,500 per clinic site. RHCs are a special designation given to health care practices in underserved rural areas by the Centers for Medicare &. Medicaid Services to help ensure can you buy kamagra without a prescription access to care for rural residents.

"Rural Health Clinics are critical partners in addressing health equity gaps, including those related to vaccination," said HRSA Acting Administrator Diana Espinosa. "This funding will help can you buy kamagra without a prescription Rural Health Clinics address the barriers people in their communities face to getting vaccinated and build confidence in treatments through trusted resources for health care services and health information." HRSA also awarded a $750,000 cooperative agreement to the National Organization of State Offices of Rural Health to provide technical assistance to the RHCs participating in this Program. The National Organization of State Offices of Rural Health will work closely with the National Association of Rural Health Clinics, the technical assistance provider for the RHC erectile dysfunction treatment Testing and Mitigation Program. Collaboration between HRSA and these organizations ensures can you buy kamagra without a prescription RHCs will receive coordinated technical assistance to support their erectile dysfunction treatment response and improve health care in rural communities. To view a state-by-state breakdown of this funding visit.

Www.hrsa.gov/erectile dysfunction/rural-health-clinics/confidence/funding For more information about HRSA's rural programs, visit can you buy kamagra without a prescription. Https://www.hrsa.gov/rural-health/index.html To learn more about HRSA's Rural Health Clinic treatment Confidence Program, visit. Https://www.hrsa.gov/erectile dysfunction/rural-health-clinics/confidence.

Today, the kamagra gel online U.S generic kamagra cost. Department of Health and Human Services (HHS) provided nearly $100 million to rural health clinics across the country to support outreach efforts to increase vaccinations in rural communities. The funds will go to more than 1,980 Rural Health Clinics (RHCs) who will use these resources to develop and implement additional treatment confidence and outreach efforts as many communities face the Delta variant and work to get more people vaccinated and protected from erectile dysfunction treatment in medically underserved rural kamagra gel online communities. The funding was made available by the American Rescue Plan and is being administered by the Health Resources and Services Administration (HRSA) through the Rural Health Clinic treatment Confidence (RHCVC) Program."Rural health clinics play a crucial role in supporting our national vaccination effort to defeat erectile dysfunction treatment," said HHS Secretary Xavier Becerra.

"This funding will give trusted messengers in rural communities the tools they need to counsel patients on how erectile dysfunction treatments can help protect them and their loved ones." RHCs are well positioned to disseminate information about how and where to get vaccinated at the local level, and coordinate with existing vaccination sites and public health partners to identify strategies to increase treatment confidence kamagra gel online among key populations. RHCs will also use this funding to improve health literacy, focusing on treatment safety and the benefits of broad vaccination for rural communities. These efforts kamagra gel online will improve health care in rural areas by reinforcing key messages about prevention and treatment of erectile dysfunction treatment and other infectious diseases. HRSA is making grant awards to RHCs based on the number of certified clinic sites they operate, providing approximately $49,500 per clinic site.

RHCs are a special designation given to health care practices in underserved rural areas by the Centers for Medicare &. Medicaid Services to help kamagra gel online ensure access to care for rural residents. "Rural Health Clinics are critical partners in addressing health equity gaps, including those related to vaccination," said HRSA Acting Administrator Diana Espinosa. "This funding will help Rural Health Clinics address the barriers people in their communities face to getting kamagra gel online vaccinated and build confidence in treatments through trusted resources for health care services and health information." HRSA also awarded a $750,000 cooperative agreement to the National Organization of State Offices of Rural Health to provide technical assistance to the RHCs participating in this Program.

The National Organization of State Offices of Rural Health will work closely with the National Association of Rural Health Clinics, the technical assistance provider for the RHC erectile dysfunction treatment Testing and Mitigation Program. Collaboration between HRSA and these organizations kamagra gel online ensures RHCs will receive coordinated technical assistance to support their erectile dysfunction treatment response and improve health care in rural communities. To view a state-by-state breakdown of this funding visit. Www.hrsa.gov/erectile dysfunction/rural-health-clinics/confidence/funding For kamagra gel online more information about HRSA's rural programs, visit.

Https://www.hrsa.gov/rural-health/index.html To learn more about HRSA's Rural Health Clinic treatment Confidence Program, visit. Https://www.hrsa.gov/erectile dysfunction/rural-health-clinics/confidence.

What may interact with Kamagra?

Do not take Kamagra with any of the following:

  • cisapride
  • methscopolamine nitrate
  • nitrates like amyl nitrite, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin
  • nitroprusside
  • other sildenafil products (Caverta, Silagra, Eriacta, etc.)

Kamagra may also interact with the following:

  • certain drugs for high blood pressure
  • certain drugs for the treatment of HIV or AIDS
  • certain drugs used for fungal or yeast s, like fluconazole, itraconazole, ketoconazole, and voriconazole
  • cimetidine
  • erythromycin
  • rifampin

This list may not describe all possible interactions. Give your health care providers a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

Kamagra best buy

In this issue of BMJ Quality and Safety, Jorro-Barón and colleagues1 report the findings of a stepped-wedge cluster randomised trial (SW-CRT) to evaluate the implementation of the I-PASS handover system among six paediatric intensive care units (PICUs) at five Argentinian hospitals between July 2018 and May kamagra best buy 2019. According to kamagra best buy the authors, prior to the intervention there were complaints that handovers were ‘…lengthy, disorganized, …participants experienced problems with interruptions, distractions, and … senior professionals had problems accepting dissent’.Adverse events were assessed by two independent reviewers using the Global Assessment of Pediatric Patient Safety instrument. Study results demonstrated significantly improved handover compliance in the intervention group, validating Kirkpatrick Level 3 (behavioural change)2 effectiveness of the training initiative.

Notably, however, on the primary outcome there were kamagra best buy no differences between control and intervention groups regarding preventable adverse events per 1000 days of hospitalisation (control 60.4 (37.5–97.4) vs intervention 60.4 (33.2–109.9), p=0.998, risk ratio. 1.0 (0.74–1.34)). Regarding balancing measures, there was no observed difference in the ‘full-shift’ handover duration (control 35.7 min (29.6–41.8) kamagra best buy.

Intervention 34.7 min (26.5–42.1), p=0.490), although more time was spent on individual patient handovers in the intervention period (7.29 min (5.77–8.81). Control 5.96 kamagra best buy min (4.69–7.23). P=0.001).

From the provider perspective, preintervention and postintervention Agency for Healthcare Research and Quality (AHRQ) safety culture surveys did not show significant differences in their responses to communication-focused questions before and after the intervention.Thus, consistent with all previous studies, I-PASS was implemented successfully and handover quality improved. However, is the lack of association of I-PASS implementation with clinical outcomes and adverse events in this study a concern?. To answer this question, it is necessary to review the origins of I-PASS more than a decade ago and its continually expanding evidence base.Healthcare has a handover problemHandovers are among the most vulnerable reoccurring processes in healthcare.

In the AHRQ safety culture survey,3 the handovers and transitions of care domain is consistently among the lowest scoring, and handover and communication issues are among the most common cause of Joint Commission Sentinel Events and the subject of Joint Commission Sentinel Event Alert Issue 58.4 A study by CRICO Strategies found that communication issues were a factor in 30% of 23 658 malpractice claims filed from 2009 to 2013, accounting for $1.7 billion in incurred losses.5 The importance of handovers and care transitions for trainees is specifically discussed in a Clinical Learning Environment Review Issue Brief published by the Accreditation Council for Graduate Medical Education (ACGME),6 and Section VI.E.3 (Transitions of Care) of the ACGME Common Program Requirements (Residency) addresses the requirement for residents to be taught and to use structured handovers.7Both the numbers of handovers and handover-related problems have increased in contemporary practice because of greater patient complexity and the expanding number and types of providers involved in a typical patient’s care. Further, in teaching institutions, resident work-hour restrictions have resulted in the need for complex coverage schemes. Off-hours care is often provided by ‘cross-covering’, ‘float’ or ‘moonlighting’ practitioners who are responsible for numerous unfamiliar patients during their shifts, thus imposing an even greater need for effective handovers.

The net effect of all these changes may be inconsistent, fragmented care resulting from suboptimal handovers from one provider, service or hospital to another, with resulting medical errors (often of omission) and adverse events.Structured, standardised handoversThese serious vulnerabilities have led to pleas for more consistent, structured and standardised handovers.8–11 In addition to their use in routine shift-to-shift provider sign-off, these may be of particular value in the high-risk transfers of critically ill patients, such as from operating rooms to postoperative care units and ICUs12–16. Admissions to a surgery unit17. Management of trauma patients18–20.

ICU to general ward transfers21 22. Night and weekend coverage of large services, many of whose patients are unfamiliar to the physician receiving the handover23–28. And end-of-rotation resident transitions.29–31Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes.32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites.

A basic, common framework that could be customised to individual use cases would clearly be preferable.The I-PASS systemResponding to these concerns, the I-PASS Study Group was initiated in 2009 and the I-PASS Institute in 2016. Although numerous other systems are available, since its pilot studies a decade ago,34 35 I-PASS has emerged as the dominant system in healthcare for structured, standardised handovers. This system is specifically designed for healthcare applications.

It is based on adult educational principles and simple to use. It has been extensively validated in the peer-reviewed literature encompassing studies at multiple institutions in the USA and internationally34–40. And extensive training materials are available to assist programmes in implementation.39 41–45 Ideally, this system is implemented hospital-wide, which addresses the issue of cross-unit and cross-service transfers.I-PASS includes five major elements regarded as important for every handover—illness severity, patient summary, action list, situation awareness/contingency planning and synthesis by receiver.

The first three of these elements are often included in non-structured handovers, although not necessarily in a specific sequence or format. The last two I-PASS elements—situational awareness/contingency planning and synthesis—have not historically been included in typical handover practice. The former assures that any anticipated problems are conveyed from the handover giver to the incoming provider and that appropriate responses to these issues are discussed.

Synthesis is closed-loop communication, with brief read-back of the handover information by the receiver to assure their accurate comprehension, followed by an opportunity for questions and discussion. This read-back of mission-critical communications is standard operating practice in other high-reliability settings such as aviation, the military and nuclear power. It is essential to establishing a shared mental model of the current state and any potential concerns.

However, other than in I-PASS, it is quite uncommon in healthcare, with the potential exception of confirming verbal or telephonic orders.I-PASS validationIn an initial study of I-PASS handover implementation by residents on two general inpatient paediatric units at Boston Children’s Hospital,34 written handovers were more comprehensive and had fewer omissions of key data, and mean time spent on verbal handover sessions did not change significantly (32.3 min vs 33.2 min). Medical errors and adverse events were ascertained prospectively by research nurse reviewers and independent physician investigators. Following I-PASS implementation, preventable adverse events decreased from 3.3 (95% CI 1.7 to 4.8) to 1.5 (95% CI 0.51 to 2.4) per 100 admissions (p=0.04), and medical error rates decreased significantly from 33.8 per 100 admissions (95% CI 27.3 to 40.3) to 18.3 per 100 admissions (95% CI 14.7 to 21.9.

P<0.001). A commentary by Horwitz46 noted that this was ‘…by far the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations and is the first to demonstrate an associated significant decrease in medical errors on a large scale’, while also noting limitations including its uncontrolled, ‘before and after’ design, confounding by secular changes, Hawthorne effects and inability to blind the nurses collecting adverse event data.The more expansive, landmark I-PASS study was conducted by Starmer and colleagues37 among nine paediatric hospitals and 10 740 patient admissions between January 2011 and May 2013. Handover quality was evaluated, and medical errors and adverse events were ascertained by active surveillance, including on-site nurse review of medical records, orders, formal incident reports, nursing reports and daily medical error reports from residents.

Independent physician investigators classified occurrences as adverse events, near misses or exclusions, and they subclassified adverse events as preventable or non-preventable. Results revealed a 23% reduction in medical errors from the preintervention to the postintervention period (24.5 vs 18.8 per 100 admissions, p<0.001) and a 30% reduction in preventable adverse events (4.7 vs 3.3 events per 100 admissions, p<0.001). Inclusion of prespecified elements in written and verbal handovers increased significantly, and there was no significant change in handover time per patient (2.4 vs 2.5 min.

P=0.55).Subsequent investigations in other institutions have replicated many of the findings of the original I-PASS studies, with higher postintervention inclusion rates of critical handover elements. Fewer mistakes or omissions. Greater provider satisfaction with handover organisation and information conveyed.

Unchanged or shorter handoff times. And decreased handover interruptions (probably reflecting greater attention to the importance of the handover process).36 40 47–50 In a mentored implementation study conducted in 2015–2016 among 16 hospitals (five community hospitals, 11 academic centres and multiple specialties), handover quality improved, and there was a provider-reported 27% reduction in adverse events.38 Among nurses at Boston Children’s Hospital, I-PASS implementation was associated with significant decreases in handover-related care failures.40In recognition of its achievements in improving healthcare quality, the I-PASS Study Group was awarded the 2016 John M Eisenberg Award for Patient Safety and Quality by the National Quality Forum and the Joint Commission.The challenge of linking handovers to clinical outcomes and eventsAlthough investigations from many centres, including the report of Jorro-Barrón and colleagues,1 have now confirmed that I-PASS can be readily assimilated and used by clinicians, most of these have either not rigorously assessed adverse events, medical errors and other clinical outcomes (Kirkpatrick Level 4 evaluation) or have failed to demonstrate significant postintervention improvements in these clinical outcomes. Why is this, and should current or potential I-PASS users be concerned?.

With regard to the first question, there are practical considerations that complicate the rigorous study of clinical outcome improvements associated with I-PASS (or any other handover system). Notwithstanding the importance of effective communications, these are only one of many provider processes and hospital systems, not to mention the overall hospital quality and safety culture, that impact a patient’s clinical outcome. In most hospitals, a diverse portfolio of quality and safety improvement initiatives are always being conducted.

Disentangling and isolating the effects of any one specific intervention, such as I-PASS handovers, is challenging if not impossible. At a minimum, it requires real-time, prospective monitoring by trained nurse or physician reviewers as in the original I-PASS studies, a research design which realistically is unlikely to be reproduced. Ideally, the study design would also include blinding of the study period (control or intervention) and blinding of observers, the former of which is virtually impossible for this type of intervention.Further, if other provider processes and hospital systems are functioning at a high level, they may partially offset the impact of suboptimal communications and make it even more challenging to demonstrate significant improvements.

The current study of Jorro-Barón and colleagues,1 which uses PICUs as the unit of analysis, illustrates this concept. PICUs are typically among the most compulsive, detail-oriented units in any hospital, even if they may have nominally ‘non-standardized’ handovers.Study design. The SW-CRTIn an attempt to address the limitations of some previous studies, Parent and colleagues51 studied eight medical and surgical ICUs across two academic tertiary teaching hospitals using an SW-CRT design.

Clinician self-assessment of having been inadequately prepared for their shift because of a poor-quality handoff decreased from 35 of 343 handoffs (10.2%) in the control arm to 53 of 740 handoffs (7.2%) postintervention (OR 0.19. 95% CI 0.03 to 0.74. P=0.03).

€˜Last-minute’, early morning order writing decreased, and handover duration increased but not significantly (+5.5 min. 95% CI 0.34 to 9.39. P=0.30).

As in the current study of Jorro-Barón and colleagues,1 who also employed an SW-CRT, there were no associated changes in clinical outcomes such as ICU length of stay, duration of mechanical ventilation or necessity for reintubation. The authors comment that given high baseline quality of care in these ICUs, it was not surprising that there were no changes in outcomes.An SW-CRT is generally considered a rigorous study design as it includes cluster randomisation. However, though novel and increasingly popular, this approach is complex and may sometimes add confusion rather than clarity.52–57 Its major appeal is that all clusters will at some point, in a random and sequential fashion, transition from control to intervention condition.

For an intervention that is perceived by participants as having more potential for good than harm, this may enhance cluster recruitment. It may also make it possible to conduct a randomised study in scenarios where pragmatic considerations, such as the inability to conduct interventions simultaneously across numerous clusters, may make a parallel randomised study (or any study) infeasible.However, as acknowledged even by its proponents, the added practical and statistical complexity of SW-CRTs often makes them more challenging to properly implement, and compared with traditional parallel cluster randomised trials they may be more prone to biases.53–57 A Consolidated Standards of Reporting Trials extension has been specifically developed in response to these concerns.55 Unique design and analytical considerations include the number of clusters, sequences and periods. Clusters per sequence.

And cluster-period sizes.55 56 Concerns include recruitment and selection biases. Proper accounting for secular trends in outcomes (ie, because of the sequential rather than simultaneous nature of the SW-CRT design, observations from the intervention condition occur on average at a later calendar time, so that the intervention effect may be confounded by an underlying time trend). Accounting for repeated measures on participants and clusters in sample size calculations and analyses (ie, data are not independent).

Possible time-varying treatment effects. And the potential for within-cluster contamination of observations obtained under the control or intervention condition.52–56Regarding contamination, a secular trend may be responsible if, for example, institutional activities focused on improving patient outcomes include a general emphasis on communications. There might also be more direct contamination of the intervention among clusters waiting to be crossed over, as described in the context of the Matching Michigan programme.58 Participating in a trial and awareness of being observed may change the behaviour of participants.

For example, in the handover intervention of Jorro-Barón and colleagues,1 some providers in a control condition cluster may, because they are aware of the interest in handovers, begin to implement more standardised practices before the formal shift to the intervention condition. This potentially dilutes any subsequent impact of the intervention by virtue of what could be considered either a Hawthorne effect or a local secular trend, in either case leading to generally better handovers in the preintervention period. Some SW-CRTs include a transition period without any observations to allow for sufficient time to implement the intervention,53 59 thereby creating more contrast.

Finally, because of sometimes prolonged PICU length of stay and regularly scheduled resident rotations on and off a unit or service, some patients and providers might overlap the transition from control to intervention state and contribute observations to both, while others will be limited to one or the other. This possibility is not clearly defined by the authors of the current study, but seems unlikely to have had a major statistical effect.Do we need more evidence?. From an implementation science perspective, handovers are a deeply flawed healthcare process with the demonstrated potential to harm patients.

A new tool—I-PASS—has been developed which can be easily and economically taught and subsequently applied by virtually any provider, and many resources are available to assist in implementation.45 It has few, if any, unintended negative consequences to patients or providers and has been associated in at least two extensive and well-conducted (although non-randomised) trials with dramatic reductions in medical errors and adverse events. Notably, these were conducted at a time when there was much less emphasis on and awareness of handover systems, including I-PASS. Thus, there was much greater separation between control and intervention states than would be possible today.Returning to the question posed at the beginning of this commentary, is the inability to demonstrate a favourable impact on clinical outcomes in studies other than those of the developers34 35 a reason to question the value of I-PASS?.

For the reasons discussed above, I think not. In his classic 2008 article,60 ‘The Science of Improvement’, Dr Don Berwick recounts the transformational development of sophisticated statistical analyses in healthcare, of which the randomised clinical trial is the paradigm. While in many instances randomised controlled trials have been invaluable in scientifically affirming or rejecting the utility of specific treatments or interventions, their limitations are more obvious in interventions involving complex social and behavioural change.

Berwick illustrates this challenge with the example of hospital rapid response teams, whose benefit was challenged by the results of a large cluster randomised trial. His comments regarding that conflict are equally applicable to the current challenge of demonstrating the impact of standardised handovers on clinical outcomes:These critics refused to accept as evidence the large, positive, accumulating experience of many hospitals that were adapting rapid response for their own use, such as children’s hospitals. How can accumulating local reports of effectiveness of improvement interventions, such as rapid response systems, be reconciled with contrary findings from formal trials with their own varying imperfections?.

The reasons for this apparent gap between science and experience lie deep in epistemology. The introduction of rapid response systems in hospitals is a complex, multicomponent intervention—essentially a process of social change. The effectiveness of these systems is sensitive to an array of influences.

Leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.Having personally observed the value of I-PASS, as well as the devastating consequences of inadequate handovers, I vote with Dr Berwick.

The evidence for effectiveness is overwhelming and the need for action is urgent—all that is lacking is the will to implement.Ethics statementsPatient consent for publicationNot required.Palliative care is associated with improved patient-centred and caregiver-centred outcomes, higher-quality end-of-life care, and decreased healthcare use among patients with serious illness.1–3 The Centre to Advance Palliative Care has established a set of recommended clinical criteria (or ‘triggers’), including a projected survival of less than 1 year,4 to help clinicians identify patients likely to benefit from palliative care. Nevertheless, referrals often occur within the last 3 months of life5 due in part to clinician overestimation of prognosis.6 A growing number of automated predictive models leverage vast data in the electronic medical record (EMR) to accurately predict short-term mortality risk in real time and can be paired with systems to prompt clinicians to refer to palliative care.7–12 These models hold great promise to overcome the many clinician-level and system-level barriers to improving access to timely palliative care. First, mortality risk prediction algorithms have been shown to outperform clinician prognostic assessment, and clinician–machine collaboration may even outperform both.13 Second, algorithm-based ‘nudges’ that systematically provide prognostic information could address many cognitive biases, including status quo bias and optimism bias,14 15 that make clinicians less apt to identify patients who may benefit from palliative care.

Indeed, such models have been shown to improve the frequency of palliative care delivery and patient outcomes in the hospital and clinic settings.9 16 17 With that said, successful implementation of automated prognostic models into routine clinical care at scale requires clinician and patient engagement and support.In this issue of BMJ Quality &. Safety, Saunders and colleagues report on the acceptability of using the EMR-based Modified Hospitalised-Patient One-Year Mortality Risk (mHOMR) score to alert clinicians to individual patients with a >21% risk of dying within 12 months. The goal of the clinician notification of an elevated risk score was to prompt clinicians to consider palliative care referral.18 In a previously reported feasibility study among 400 hospitalised patients, use of the mHOMR alert was associated with increased rates of goals of care discussions and palliative care consultation in comparison to the preimplementation baseline (34% vs 18%, respectively).19 In the present study, the authors conducted qualitative interviews pre-mHOMR and post-mHOMR implementation among 64 stakeholders, including patients identified at high risk by the mHOMR algorithm, their caregivers, staff and physicians.

Thirty-five (55%) participants agreed that the mHOMR tool was acceptable. 14 (22%) were unsure or did not agree. And 15 (23%) did not respond.

Participants identified many potential benefits of the programme, citing the advantages of an automated approach to facilitate and justify clinical decision making. Participants also acknowledged possible barriers, particularly ‘situational challenges’ such as the content, timing and mechanism of provider notification. Additional logistical concerns included alert fatigue, potential redundancy, uncertainty regarding next steps and a worry that certain therapeutic options could be withheld from flagged patients.

The authors concluded that clinicians and patients found the automated prognostic trigger to be an acceptable addition to usual clinical care.Saunders et al’s work adds to our understanding of critical perceptions regarding end users’ acceptability of automated prognostic triggers in routine clinical care. The findings from this study align with prior evidence suggesting that clinicians recognise the value of automated, algorithm-based approaches to improve serious illness care. For example, in a qualitative study of clinicians by Hallen et al, prognostic models confirmed clinicians’ gestalt and served as a tool to help communicate prognosis to patients.20 Clinicians described prognostic models as a tool to facilitate interclinician disagreements, mitigate medicolegal risk, and overcome the tendency to ignore or overestimate prognosis.20 Clinicians also reported that EMR-generated lists of high-risk patients improved their ability to identify potential palliative care beneficiaries in a mixed-methods study by Mason et al.21 In a single-centre pilot study, we similarly found that most clinicians believed that using an EMR-based prognostic model to encourage inpatient palliative care consultation was acceptable.9 However, in the Saunders et al study, as in prior similar work, clinicians highlighted the importance of delivering notifications without causing excess provider workload, redundancy or alert fatigue.16 18 21 Clinicians also raised concerns regarding the accuracy of the prognostic information and the potential for negative effects on patients due to common misperceptions about palliative care being equivalent to hospice.18 20 21 Ultimately, Saunders et al’s work complements and builds on existing literature, demonstrating a general perception that integration of automated prognostic models into routine clinical care could be beneficial and acceptable.Important gaps remain in this literature which were not addressed by the Saunders et al study.

For example, there is a need to capture more diverse clinician and patient perspectives, and there was no information provided about the sociodemographic or clinical characteristics of the study participants. Additionally, important themes found in prior studies were not identified in this study. For example, two prior studies of clinicians’ perspectives on automated prognostic triggers for palliative care revealed concerns that prognosis alone may not be a sufficient surrogate indicator of actual palliative care need, or may inadvertently engender clinician overconfidence in an individual patient’s prognosis.9 21 The brevity of the interviews in Saunders et al’s study (mean.

12 min) could suggest all relevant themes may not have emerged in the data analysis. Additionally, while the inclusion of patient and caregiver perceptions is an important addition, limited information is provided about their perspectives and whether certain themes differed among the stakeholders. In the study from Mason et al, themes unique to patients and caregivers were identified, such as hesitancy due to a lack of understanding of palliative care, a preference to ‘focus on the present’, and a worry that a clinician would not have the time to adequately address advanced care planning or palliative care during their visit.21 Healthcare systems should therefore be prepared to consider their unique workflows, patients and staff prior to implementing one of these programmes.Achieving stakeholder acceptability prior to widespread implementation is essential.

An intervention should ideally undergo multiple cycles of optimisation with ongoing appraisal of patient and clinician perspectives prior to wide-scale implementation.22 23 Additionally, it is unclear whether clinicians’ acceptability of the intervention in one setting will generalise to other inpatient health settings. For instance, Saunders et al found that some providers were leery about the use of mHOMR due the need to balance the patient’s acute needs that brought them to the hospital with their long-term priorities that may be better served in the outpatient setting.18 Clinical workflows, patient acuity and patient–provider relationships are markedly different between the inpatient and outpatient settings, suggesting Saunders et al’s findings cannot be extrapolated to outpatient care. This is particularly relevant as many ‘off-the-shelf’ prognostic algorithms are now commercially available that, while accurate, may not be as familiar or acceptable to clinicians as a homegrown model.

Therefore, while Saunders et al’s work is a great addition to the field, additional assessments are needed across different healthcare environments and varying clinical and demographic cohorts to demonstrate that this approach is acceptable in other health settings. It is likely that multiple implementation strategies will be needed to successfully adapt automated prognostic models across a range of clinical settings.Thoughtful consideration of the many forces that alter clinical decision making will also be critical for downstream success of these interventions. Suboptimal clinical decision making is often a result of systemic biases, such as status quo and optimism bias, which result in clinician resistance to change current practice and a belief that their patients are less prone to negative outcomes.14 15 Intentional application of targeted behavioural economics principles will help ensure that the use of prognostic triggers to improve palliative care effectively changes clinical behaviour.24 For example, using an ‘opt-out’ approach for palliative care referral may make the optimal choice the path of least resistance, increasing uptake among clinicians.16 These approaches will need to be balanced against rising clinician alert fatigue25 and resource constraints.Given the implementation challenges that accompany an intervention using prognostic triggers, hybrid effectiveness trials that test both clinical effectiveness and implementation outcomes offer one strategy to advance the integration of automated prognostic models.26 Implementation outcomes are typically based on a framework which provides a systematic way to develop, manage and evaluate interventions.

For example, Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) is a framework that measures the impact of a programme based on five factors. Reach, effectiveness, adoption, implementation and maintenance.27 Due to their pragmatic approach, hybrid trials frequently include heterogenous samples and clinical settings that optimise external validity and generalisability.26 28 They can be designed to primarily test the effects of a clinical interventions while observing and gathering information on implementation outcomes (type I), for equal evaluation of both the clinical intervention and implementation strategies (type II), or to primarily assess implementation outcomes while collecting effectiveness data (type III).26 29 For example, Beidas et al used a type I hybrid effectiveness–implementation trial design to test the effectiveness of an exercise intervention for breast cancer. This study not only evaluated the effectiveness of the intervention but also identified multiple significant implementation barriers such as cost, referral logistics and patient selection challenges which informed their subsequent dissemination efforts.30 Prospective, randomised, hybrid effectiveness–implementation designs focusing on other key implementation outcomes are a logical and necessary next step in advancing the field.

In total, the work by Saunders et al demonstrates the potential acceptability of an automated prognostic model to improve the timeliness of palliative care, setting the stage for further work to optimise and implement these programmes into real-world clinical care.Ethics statementsPatient consent for publicationNot required..

In this issue of BMJ Quality and Safety, Jorro-Barón and kamagra gel online colleagues1 report the findings of a stepped-wedge cluster randomised trial (SW-CRT) to evaluate the implementation of the I-PASS handover system among six paediatric intensive care units (PICUs) at five Argentinian hospitals between July 2018 and May 2019. According to kamagra gel online the authors, prior to the intervention there were complaints that handovers were ‘…lengthy, disorganized, …participants experienced problems with interruptions, distractions, and … senior professionals had problems accepting dissent’.Adverse events were assessed by two independent reviewers using the Global Assessment of Pediatric Patient Safety instrument. Study results demonstrated significantly improved handover compliance in the intervention group, validating Kirkpatrick Level 3 (behavioural change)2 effectiveness of the training initiative. Notably, however, on the primary outcome there were no differences between control and intervention groups regarding preventable adverse events per 1000 days of hospitalisation (control kamagra gel online 60.4 (37.5–97.4) vs intervention 60.4 (33.2–109.9), p=0.998, risk ratio. 1.0 (0.74–1.34)).

Regarding balancing measures, there was no observed difference in the ‘full-shift’ handover duration (control 35.7 kamagra gel online min (29.6–41.8). Intervention 34.7 min (26.5–42.1), p=0.490), although more time was spent on individual patient handovers in the intervention period (7.29 min (5.77–8.81). Control 5.96 kamagra gel online min (4.69–7.23). P=0.001). From the provider perspective, preintervention and postintervention Agency for Healthcare Research and Quality (AHRQ) safety culture surveys did not show significant differences in their responses to communication-focused questions before and after the intervention.Thus, consistent with all previous studies, I-PASS was implemented successfully and handover quality improved.

However, is the lack of association of I-PASS implementation with clinical outcomes and adverse events in this study a concern?. To answer this question, it is necessary to review the origins of I-PASS more than a decade ago and its continually expanding evidence base.Healthcare has a handover problemHandovers are among the most vulnerable reoccurring processes in healthcare. In the AHRQ safety culture survey,3 the handovers and transitions of care domain is consistently among the lowest scoring, and handover and communication issues are among the most common cause of Joint Commission Sentinel Events and the subject of Joint Commission Sentinel Event Alert Issue 58.4 A study by CRICO Strategies found that communication issues were a factor in 30% of 23 658 malpractice claims filed from 2009 to 2013, accounting for $1.7 billion in incurred losses.5 The importance of handovers and care transitions for trainees is specifically discussed in a Clinical Learning Environment Review Issue Brief published by the Accreditation Council for Graduate Medical Education (ACGME),6 and Section VI.E.3 (Transitions of Care) of the ACGME Common Program Requirements (Residency) addresses the requirement for residents to be taught and to use structured handovers.7Both the numbers of handovers and handover-related problems have increased in contemporary practice because of greater patient complexity and the expanding number and types of providers involved in a typical patient’s care. Further, in teaching institutions, resident work-hour restrictions have resulted in the need for complex coverage schemes. Off-hours care is often provided by ‘cross-covering’, ‘float’ or ‘moonlighting’ practitioners who are responsible for numerous unfamiliar patients during their shifts, thus imposing an even greater need for effective handovers.

The net effect of all these changes may be inconsistent, fragmented care resulting from suboptimal handovers from one provider, service or hospital to another, with resulting medical errors (often of omission) and adverse events.Structured, standardised handoversThese serious vulnerabilities have led to pleas for more consistent, structured and standardised handovers.8–11 In addition to their use in routine shift-to-shift provider sign-off, these may be of particular value in the high-risk transfers of critically ill patients, such as from operating rooms to postoperative care units and ICUs12–16. Admissions to a surgery unit17. Management of trauma patients18–20. ICU to general ward transfers21 22. Night and weekend coverage of large services, many of whose patients are unfamiliar to the physician receiving the handover23–28.

And end-of-rotation resident transitions.29–31Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes.32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites. A basic, common framework that could be customised to individual use cases would clearly be preferable.The I-PASS systemResponding to these concerns, the I-PASS Study Group was initiated in 2009 and the I-PASS Institute in 2016. Although numerous other systems are available, since its pilot studies a decade ago,34 35 I-PASS has emerged as the dominant system in healthcare for structured, standardised handovers. This system is specifically designed for healthcare applications. It is based on adult educational principles and simple to use.

It has been extensively validated in the peer-reviewed literature encompassing studies at multiple institutions in the USA and internationally34–40. And extensive training materials are available to assist programmes in implementation.39 41–45 Ideally, this system is implemented hospital-wide, which addresses the issue of cross-unit and cross-service transfers.I-PASS includes five major elements regarded as important for every handover—illness severity, patient summary, action list, situation awareness/contingency planning and synthesis by receiver. The first three of these elements are often included in non-structured handovers, although not necessarily in a specific sequence or format. The last two I-PASS elements—situational awareness/contingency planning and synthesis—have not historically been included in typical handover practice. The former assures that any anticipated problems are conveyed from the handover giver to the incoming provider and that appropriate responses to these issues are discussed.

Synthesis is closed-loop communication, with brief read-back of the handover information by the receiver to assure their accurate comprehension, followed by an opportunity for questions and discussion. This read-back of mission-critical communications is standard operating practice in other high-reliability settings such as aviation, the military and nuclear power. It is essential to establishing a shared mental model of the current state and any potential concerns. However, other than in I-PASS, it is quite uncommon in healthcare, with the potential exception of confirming verbal or telephonic orders.I-PASS validationIn an initial study of I-PASS handover implementation by residents on two general inpatient paediatric units at Boston Children’s Hospital,34 written handovers were more comprehensive and had fewer omissions of key data, and mean time spent on verbal handover sessions did not change significantly (32.3 min vs 33.2 min). Medical errors and adverse events were ascertained prospectively by research nurse reviewers and independent physician investigators.

Following I-PASS implementation, preventable adverse events decreased from 3.3 (95% CI 1.7 to 4.8) to 1.5 (95% CI 0.51 to 2.4) per 100 admissions (p=0.04), and medical error rates decreased significantly from 33.8 per 100 admissions (95% CI 27.3 to 40.3) to 18.3 per 100 admissions (95% CI 14.7 to 21.9. P<0.001). A commentary by Horwitz46 noted that this was ‘…by far the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations and is the first to demonstrate an associated significant decrease in medical errors on a large scale’, while also noting limitations including its uncontrolled, ‘before and after’ design, confounding by secular changes, Hawthorne effects and inability to blind the nurses collecting adverse event data.The more expansive, landmark I-PASS study was conducted by Starmer and colleagues37 among nine paediatric hospitals and 10 740 patient admissions between January 2011 and May 2013. Handover quality was evaluated, and medical errors and adverse events were ascertained by active surveillance, including on-site nurse review of medical records, orders, formal incident reports, nursing reports and daily medical error reports from residents. Independent physician investigators classified occurrences as adverse events, near misses or exclusions, and they subclassified adverse events as preventable or non-preventable.

Results revealed a 23% reduction in medical errors from the preintervention to the postintervention period (24.5 vs 18.8 per 100 admissions, p<0.001) and a 30% reduction in preventable adverse events (4.7 vs 3.3 events per 100 admissions, p<0.001). Inclusion of prespecified elements in written and verbal handovers increased significantly, and there was no significant change in handover time per patient (2.4 vs 2.5 min. P=0.55).Subsequent investigations in other institutions have replicated many of the findings of the original I-PASS studies, with higher postintervention inclusion rates of critical handover elements. Fewer mistakes or omissions. Greater provider satisfaction with handover organisation and information conveyed.

Unchanged or shorter handoff times. And decreased handover interruptions (probably reflecting greater attention to the importance of the handover process).36 40 47–50 In a mentored implementation study conducted in 2015–2016 among 16 hospitals (five community hospitals, 11 academic centres and multiple specialties), handover quality improved, and there was a provider-reported 27% reduction in adverse events.38 Among nurses at Boston Children’s Hospital, I-PASS implementation was associated with significant decreases in handover-related care failures.40In recognition of its achievements in improving healthcare quality, the I-PASS Study Group was awarded the 2016 John M Eisenberg Award for Patient Safety and Quality by the National Quality Forum and the Joint Commission.The challenge of linking handovers to clinical outcomes and eventsAlthough investigations from many centres, including the report of Jorro-Barrón and colleagues,1 have now confirmed that I-PASS can be readily assimilated and used by clinicians, most of these have either not rigorously assessed adverse events, medical errors and other clinical outcomes (Kirkpatrick Level 4 evaluation) or have failed to demonstrate significant postintervention improvements in these clinical outcomes. Why is this, and should current or potential I-PASS users be concerned?. With regard to the first question, there are practical considerations that complicate the rigorous study of clinical outcome improvements associated with I-PASS (or any other handover system). Notwithstanding the importance of effective communications, these are only one of many provider processes and hospital systems, not to mention the overall hospital quality and safety culture, that impact a patient’s clinical outcome.

In most hospitals, a diverse portfolio of quality and safety improvement initiatives are always being conducted. Disentangling and isolating the effects of any one specific intervention, such as I-PASS handovers, is challenging if not impossible. At a minimum, it requires real-time, prospective monitoring by trained nurse or physician reviewers as in the original I-PASS studies, a research design which realistically is unlikely to be reproduced. Ideally, the study design would also include blinding of the study period (control or intervention) and blinding of observers, the former of which is virtually impossible for this type of intervention.Further, if other provider processes and hospital systems are functioning at a high level, they may partially offset the impact of suboptimal communications and make it even more challenging to demonstrate significant improvements. The current study of Jorro-Barón and colleagues,1 which uses PICUs as the unit of analysis, illustrates this concept.

PICUs are typically among the most compulsive, detail-oriented units in any hospital, even if they may have nominally ‘non-standardized’ handovers.Study design. The SW-CRTIn an attempt to address the limitations of some previous studies, Parent and colleagues51 studied eight medical and surgical ICUs across two academic tertiary teaching hospitals using an SW-CRT design. Clinician self-assessment of having been inadequately prepared for their shift because of a poor-quality handoff decreased from 35 of 343 handoffs (10.2%) in the control arm to 53 of 740 handoffs (7.2%) postintervention (OR 0.19. 95% CI 0.03 to 0.74. P=0.03).

€˜Last-minute’, early morning order writing decreased, and handover duration increased but not significantly (+5.5 min. 95% CI 0.34 to 9.39. P=0.30). As in the current study of Jorro-Barón and colleagues,1 who also employed an SW-CRT, there were no associated changes in clinical outcomes such as ICU length of stay, duration of mechanical ventilation or necessity for reintubation. The authors comment that given high baseline quality of care in these ICUs, it was not surprising that there were no changes in outcomes.An SW-CRT is generally considered a rigorous study design as it includes cluster randomisation.

However, though novel and increasingly popular, this approach is complex and may sometimes add confusion rather than clarity.52–57 Its major appeal is that all clusters will at some point, in a random and sequential fashion, transition from control to intervention condition. For an intervention that is perceived by participants as having more potential for good than harm, this may enhance cluster recruitment. It may also make it possible to conduct a randomised study in scenarios where pragmatic considerations, such as the inability to conduct interventions simultaneously across numerous clusters, may make a parallel randomised study (or any study) infeasible.However, as acknowledged even by its proponents, the added practical and statistical complexity of SW-CRTs often makes them more challenging to properly implement, and compared with traditional parallel cluster randomised trials they may be more prone to biases.53–57 A Consolidated Standards of Reporting Trials extension has been specifically developed in response to these concerns.55 Unique design and analytical considerations include the number of clusters, sequences and periods. Clusters per sequence. And cluster-period sizes.55 56 Concerns include recruitment and selection biases.

Proper accounting for secular trends in outcomes (ie, because of the sequential rather than simultaneous nature of the SW-CRT design, observations from the intervention condition occur on average at a later calendar time, so that the intervention effect may be confounded by an underlying time trend). Accounting for repeated measures on participants and clusters in sample size calculations and analyses (ie, data are not independent). Possible time-varying treatment effects. And the potential for within-cluster contamination of observations obtained under the control or intervention condition.52–56Regarding contamination, a secular trend may be responsible if, for example, institutional activities focused on improving patient outcomes include a general emphasis on communications. There might also be more direct contamination of the intervention among clusters waiting to be crossed over, as described in the context of the Matching Michigan programme.58 Participating in a trial and awareness of being observed may change the behaviour of participants.

For example, in the handover intervention of Jorro-Barón and colleagues,1 some providers in a control condition cluster may, because they are aware of the interest in handovers, begin to implement more standardised practices before the formal shift to the intervention condition. This potentially dilutes any subsequent impact of the intervention by virtue of what could be considered either a Hawthorne effect or a local secular trend, in either case leading to generally better handovers in the preintervention period. Some SW-CRTs include a transition period without any observations to allow for sufficient time to implement the intervention,53 59 thereby creating more contrast. Finally, because of sometimes prolonged PICU length of stay and regularly scheduled resident rotations on and off a unit or service, some patients and providers might overlap the transition from control to intervention state and contribute observations to both, while others will be limited to one or the other. This possibility is not clearly defined by the authors of the current study, but seems unlikely to have had a major statistical effect.Do we need more evidence?.

From an implementation science perspective, handovers are a deeply flawed healthcare process with the demonstrated potential to harm patients. A new tool—I-PASS—has been developed which can be easily and economically taught and subsequently applied by virtually any provider, and many resources are available to assist in implementation.45 It has few, if any, unintended negative consequences to patients or providers and has been associated in at least two extensive and well-conducted (although non-randomised) trials with dramatic reductions in medical errors and adverse events. Notably, these were conducted at a time when there was much less emphasis on and awareness of handover systems, including I-PASS. Thus, there was much greater separation between control and intervention states than would be possible today.Returning to the question posed at the beginning of this commentary, is the inability to demonstrate a favourable impact on clinical outcomes in studies other than those of the developers34 35 a reason to question the value of I-PASS?. For the reasons discussed above, I think not.

In his classic 2008 article,60 ‘The Science of Improvement’, Dr Don Berwick recounts the transformational development of sophisticated statistical analyses in healthcare, of which the randomised clinical trial is the paradigm. While in many instances randomised controlled trials have been invaluable in scientifically affirming or rejecting the utility of specific treatments or interventions, their limitations are more obvious in interventions involving complex social and behavioural change. Berwick illustrates this challenge with the example of hospital rapid response teams, whose benefit was challenged by the results of a large cluster randomised trial. His comments regarding that conflict are equally applicable to the current challenge of demonstrating the impact of standardised handovers on clinical outcomes:These critics refused to accept as evidence the large, positive, accumulating experience of many hospitals that were adapting rapid response for their own use, such as children’s hospitals. How can accumulating local reports of effectiveness of improvement interventions, such as rapid response systems, be reconciled with contrary findings from formal trials with their own varying imperfections?.

The reasons for this apparent gap between science and experience lie deep in epistemology. The introduction of rapid response systems in hospitals is a complex, multicomponent intervention—essentially a process of social change. The effectiveness of these systems is sensitive to an array of influences. Leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn.

Critics who use it as a truth standard in this context are incorrect.Having personally observed the value of I-PASS, as well as the devastating consequences of inadequate handovers, I vote with Dr Berwick. The evidence for effectiveness is overwhelming and the need for action is urgent—all that is lacking is the will to implement.Ethics statementsPatient consent for publicationNot required.Palliative care is associated with improved patient-centred and caregiver-centred outcomes, higher-quality end-of-life care, and decreased healthcare use among patients with serious illness.1–3 The Centre to Advance Palliative Care has established a set of recommended clinical criteria (or ‘triggers’), including a projected survival of less than 1 year,4 to help clinicians identify patients likely to benefit from palliative care. Nevertheless, referrals often occur within the last 3 months of life5 due in part to clinician overestimation of prognosis.6 A growing number of automated predictive models leverage vast data in the electronic medical record (EMR) to accurately predict short-term mortality risk in real time and can be paired with systems to prompt clinicians to refer to palliative care.7–12 These models hold great promise to overcome the many clinician-level and system-level barriers to improving access to timely palliative care. First, mortality risk prediction algorithms have been shown to outperform clinician prognostic assessment, and clinician–machine collaboration may even outperform both.13 Second, algorithm-based ‘nudges’ that systematically provide prognostic information could address many cognitive biases, including status quo bias and optimism bias,14 15 that make clinicians less apt to identify patients who may benefit from palliative care. Indeed, such models have been shown to improve the frequency of palliative care delivery and patient outcomes in the hospital and clinic settings.9 16 17 With that said, successful implementation of automated prognostic models into routine clinical care at scale requires clinician and patient engagement and support.In this issue of BMJ Quality &.

Safety, Saunders and colleagues report on the acceptability of using the EMR-based Modified Hospitalised-Patient One-Year Mortality Risk (mHOMR) score to alert clinicians to individual patients with a >21% risk of dying within 12 months. The goal of the clinician notification of an elevated risk score was to prompt clinicians to consider palliative care referral.18 In a previously reported feasibility study among 400 hospitalised patients, use of the mHOMR alert was associated with increased rates of goals of care discussions and palliative care consultation in comparison to the preimplementation baseline (34% vs 18%, respectively).19 In the present study, the authors conducted qualitative interviews pre-mHOMR and post-mHOMR implementation among 64 stakeholders, including patients identified at high risk by the mHOMR algorithm, their caregivers, staff and physicians. Thirty-five (55%) participants agreed that the mHOMR tool was acceptable. 14 (22%) were unsure or did not agree. And 15 (23%) did not respond.

Participants identified many potential benefits of the programme, citing the advantages of an automated approach to facilitate and justify clinical decision making. Participants also acknowledged possible barriers, particularly ‘situational challenges’ such as the content, timing and mechanism of provider notification. Additional logistical concerns included alert fatigue, potential redundancy, uncertainty regarding next steps and a worry that certain therapeutic options could be withheld from flagged patients. The authors concluded that clinicians and patients found the automated prognostic trigger to be an acceptable addition to usual clinical care.Saunders et al’s work adds to our understanding of critical perceptions regarding end users’ acceptability of automated prognostic triggers in routine clinical care. The findings from this study align with prior evidence suggesting that clinicians recognise the value of automated, algorithm-based approaches to improve serious illness care.

For example, in a qualitative study of clinicians by Hallen et al, prognostic models confirmed clinicians’ gestalt and served as a tool to help communicate prognosis to patients.20 Clinicians described prognostic models as a tool to facilitate interclinician disagreements, mitigate medicolegal risk, and overcome the tendency to ignore or overestimate prognosis.20 Clinicians also reported that EMR-generated lists of high-risk patients improved their ability to identify potential palliative care beneficiaries in a mixed-methods study by Mason et al.21 In a single-centre pilot study, we similarly found that most clinicians believed that using an EMR-based prognostic model to encourage inpatient palliative care consultation was acceptable.9 However, in the Saunders et al study, as in prior similar work, clinicians highlighted the importance of delivering notifications without causing excess provider workload, redundancy or alert fatigue.16 18 21 Clinicians also raised concerns regarding the accuracy of the prognostic information and the potential for negative effects on patients due to common misperceptions about palliative care being equivalent to hospice.18 20 21 Ultimately, Saunders et al’s work complements and builds on existing literature, demonstrating a general perception that integration of automated prognostic models into routine clinical care could be beneficial and acceptable.Important gaps remain in this literature which were not addressed by the Saunders et al study. For example, there is a need to capture more diverse clinician and patient perspectives, and there was no information provided about the sociodemographic or clinical characteristics of the study participants. Additionally, important themes found in prior studies were not identified in this study. For example, two prior studies of clinicians’ perspectives on automated prognostic triggers for palliative care revealed concerns that prognosis alone may not be a sufficient surrogate indicator of actual palliative care need, or may inadvertently engender clinician overconfidence in an individual patient’s prognosis.9 21 The brevity of the interviews in Saunders et al’s study (mean. 12 min) could suggest all relevant themes may not have emerged in the data analysis.

Additionally, while the inclusion of patient and caregiver perceptions is an important addition, limited information is provided about their perspectives and whether certain themes differed among the stakeholders. In the study from Mason et al, themes unique to patients and caregivers were identified, such as hesitancy due to a lack of understanding of palliative care, a preference to ‘focus on the present’, and a worry that a clinician would not have the time to adequately address advanced care planning or palliative care during their visit.21 Healthcare systems should therefore be prepared to consider their unique workflows, patients and staff prior to implementing one of these programmes.Achieving stakeholder acceptability prior to widespread implementation is essential. An intervention should ideally undergo multiple cycles of optimisation with ongoing appraisal of patient and clinician perspectives prior to wide-scale implementation.22 23 Additionally, it is unclear whether clinicians’ acceptability of the intervention in one setting will generalise to other inpatient health settings. For instance, Saunders et al found that some providers were leery about the use of mHOMR due the need to balance the patient’s acute needs that brought them to the hospital with their long-term priorities that may be better served in the outpatient setting.18 Clinical workflows, patient acuity and patient–provider relationships are markedly different between the inpatient and outpatient settings, suggesting Saunders et al’s findings cannot be extrapolated to outpatient care. This is particularly relevant as many ‘off-the-shelf’ prognostic algorithms are now commercially available that, while accurate, may not be as familiar or acceptable to clinicians as a homegrown model.

Therefore, while Saunders et al’s work is a great addition to the field, additional assessments are needed across different healthcare environments and varying clinical and demographic cohorts to demonstrate that this approach is acceptable in other health settings. It is likely that multiple implementation strategies will be needed to successfully adapt automated prognostic models across a range of clinical settings.Thoughtful consideration of the many forces that alter clinical decision making will also be critical for downstream success of these interventions. Suboptimal clinical decision making is often a result of systemic biases, such as status quo and optimism bias, which result in clinician resistance to change current practice and a belief that their patients are less prone to negative outcomes.14 15 Intentional application of targeted behavioural economics principles will help ensure that the use of prognostic triggers to improve palliative care effectively changes clinical behaviour.24 For example, using an ‘opt-out’ approach for palliative care referral may make the optimal choice the path of least resistance, increasing uptake among clinicians.16 These approaches will need to be balanced against rising clinician alert fatigue25 and resource constraints.Given the implementation challenges that accompany an intervention using prognostic triggers, hybrid effectiveness trials that test both clinical effectiveness and implementation outcomes offer one strategy to advance the integration of automated prognostic models.26 Implementation outcomes are typically based on a framework which provides a systematic way to develop, manage and evaluate interventions. For example, Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) is a framework that measures the impact of a programme based on five factors. Reach, effectiveness, adoption, implementation and maintenance.27 Due to their pragmatic approach, hybrid trials frequently include heterogenous samples and clinical settings that optimise external validity and generalisability.26 28 They can be designed to primarily test the effects of a clinical interventions while observing and gathering information on implementation outcomes (type I), for equal evaluation of both the clinical intervention and implementation strategies (type II), or to primarily assess implementation outcomes while collecting effectiveness data (type III).26 29 For example, Beidas et al used a type I hybrid effectiveness–implementation trial design to test the effectiveness of an exercise intervention for breast cancer.

This study not only evaluated the effectiveness of the intervention but also identified multiple significant implementation barriers such as cost, referral logistics and patient selection challenges which informed their subsequent dissemination efforts.30 Prospective, randomised, hybrid effectiveness–implementation designs focusing on other key implementation outcomes are a logical and necessary next step in advancing the field. In total, the work by Saunders et al demonstrates the potential acceptability of an automated prognostic model to improve the timeliness of palliative care, setting the stage for further work to optimise and implement these programmes into real-world clinical care.Ethics statementsPatient consent for publicationNot required..

Cheap kamagra uk paypal

A fourth wave of the opioid epidemic is coming, a cheap kamagra uk paypal national expert on drug use and policy said during a virtual panel discussion this week hosted by the Berkshire County, Massachusetts, District Attorney’s Office and the Berkshire Opioid Addiction Prevention Collaborative.Dr. Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco (UCSF) School of Medicine, said the next wave in the country’s opioid health emergency will focus on stimulants like methamphetamine and cocaine, and drug combinations where stimulants are used in conjunction with opioids.“The use of methamphetamines is back and it’s back cheap kamagra uk paypal big time,” said Ciccarone, whose most recent research has focused on heroin use.Previously, officials had said there were three waves of the opioid epidemic – the first being prescription pills, the second being heroin, and the third being synthetic drugs, like fentanyl.Now, Ciccarone said, what federal law enforcement and medical experts are seeing is an increase in the use of stimulants, especially methamphetamines.The increase in deaths due to stimulants may be attributed to a number of causes. The increase in supply, both imported and domestically produced, as well as the increase of the drugs’ potency.“Meth’s purity and potency has gone up to historical levels,” he said.

€œAs of 2018, we’ve reached unseen heights of 97 cheap kamagra uk paypal percent potency and 97 percent purity. In a prohibitionist world, we should not be seeing such high quality. This is almost pharmaceutical quality.”Additionally, law enforcement and public health experts like Ciccarone are seeing an increase in the co-use cheap kamagra uk paypal of stimulants with opioids, he said.

Speedballs, cocaine mixed with heroin, and goofballs, methamphetamines used with heroin or fentanyl, are becoming more common from the Midwest into Appalachia and up through New England, he said.Federal law enforcement officials are recommending local communities prepare for the oncoming rise in illegal drugs coming into their communities.“Some people will use them both at the same time, but some may use them in some combination regularly,” he said. €œThey may use meth in the morning to go to work, and use heroin at night to come down.”The co-use, he said, was an organic response to the fentanyl overdose epidemic.“Some of the things that we heard … is that cheap kamagra uk paypal meth is popularly construed as helping to decrease heroin and fentanyl use. Helping with heroin withdraw symptoms and helping with heroin overdoses,” he said.

€œWe debated this for many years that people were using stimulants to reverse overdoses – we’re cheap kamagra uk paypal hearing it again.”“Supply is up, purity is up, price is down,” he said. €œWe know from economics that when drug patterns go in that direction, use is going up.”Ciccarone said that there should not be deaths because of stimulants, but that heroin/fentanyl is the deadly element in the equation.His recommendations to communities were not to panic, but to lower the stigma surrounding drug use in order to affect change. Additionally, he said, policies should focus cheap kamagra uk paypal on reduction.

supply reduction, demand reduction and harm reduction. But not focus on only one single drug.Additionally, he said that by addressing issues within communities and by healing communities cheap kamagra uk paypal socially, economically and spiritually, communities can begin to reduce demand.“We’ve got to fix the cracks in our society, because drugs fall into the cracks,” he said.Shutterstock U.S. Rep.

Annie Kuster (D-NH) recently held two virtual roundtables addressing how erectile dysfunction treatment has affected New Hampshire’s healthcare industry.“The health and economic crisis cheap kamagra uk paypal caused by erectile dysfunction treatment has created significant challenges for Granite State healthcare, mental health, and substance use treatment providers — at the same time, we are seeing increases in substance abuse and mental illness across New Hampshire,” Kuster said. €œFrom the transition to telehealth care and cancellations of elective procedures to a cheap kamagra uk paypal lack of personal protective equipment and increasing health needs of our communities – providers have overcome a multitude of obstacles due to erectile dysfunction treatment in recent months. I was glad to hear from these hard-working Granite Staters, whose insights will continue to guide my work in Congress as we respond to this kamagra.

I’m committed to ensuring that communities across New Hampshire can safely access the care and treatment they deserve.”The cheap kamagra uk paypal first roundtable addressed substance-use disorder (SUD) and mental health.The second virtual roundtable was an opportunity for health care providers to speak about their workplace challenges during the kamagra. Kuster is the founder and co-chairwoman of the Bipartisan Opioid Task Force, which held a virtual discussion in June on the opioid crisis and the kamagra.Shutterstock Opioid prescription rates for outpatient knee surgery vary nationwide, according to a study recently published in BMJ Open. €œWe found massive levels of variation in the proportion of patients who are prescribed opioids between states, even after adjusting for cheap kamagra uk paypal nuances of the procedure and differences in patient characteristics,” said Dr.

M. Kit Delgado, the study’s senior author and an assistant professor of Emergency Medicine cheap kamagra uk paypal and Epidemiology in the Perelman School of Medicine at the University of Pennsylvania. €œWe’ve also seen that the average number of pills prescribed was extremely high for outpatient procedures of this type, particularly for patients who had not been taking opioids prior to surgery.”Researchers examined insurance claims for nearly 100,000 patients who had arthroscopic knee surgery between 2015 and 2019 and had not used any opioid prescriptions in the six months before the surgery.Within three days of a procedure, 72 percent of patients filled an opioid prescription.

High prescription rates were found cheap kamagra uk paypal in the Midwest and the Rocky Mountain regions. The coasts had lower rates.Nationwide, the average prescription strength was equivalent to 250 milligrams of morphine over five days. This is the threshold for increased risk of opioid overdose death, cheap kamagra uk paypal according to the Centers for Disease Control and Prevention.Shutterstock U.S.

Secretary of Labor Eugene Scalia awarded nearly $20 million to four states significantly impacted by the opioid crisis, the Department of Labor announced Thursday. The Florida Department of Economic Opportunity, the Maryland Department of Labor, the Ohio Department of Job and Family Services, and the Wisconsin Department cheap kamagra uk paypal of Workforce Development were awarded the money as part of the DOL’s “Support to Communities. Fostering Opioid Recovery through Workforce Development” created after the passage of the SUPPORT for Patients and Communities Act of 2018.

The money will be cheap kamagra uk paypal used to retrain workers in areas with high rates of substance use disorders. At a press conference in Piketon, Ohio, Scalia said the DOL had awarded cheap kamagra uk paypal Ohio’s Department of Job and Family Services $5 million to help communities in southern Ohio combat the opioid crisis in that area. €œToday’s funding represents this Administration’s continued commitment to serving those most in need,” said Assistant Secretary for Employment and Training John Pallasch.

€œThe U.S cheap kamagra uk paypal. Department of Labor is taking a strong stand to support individuals and communities impacted by the crisis.”Grantees will use the funds to collaborate with community partners, such as employers, local workforce development boards, treatment and recovery centers, law enforcement officials, faith-based community organizations, and others, to address the economic effects of substance misuse, opioid use, addiction, and overdose.Shutterstock CVS Health has completed the installation of time-delayed safe technology at all 446 Massachusetts locations as part of its initiatives aimed at reducing the misuse and diversion of prescription medications in Massachusetts, the company announced Thursday. The safes are intended to prevent robberies of controlled substance medications, such as oxycodone and hydrocodone, by electronically delaying the time it takes for pharmacy cheap kamagra uk paypal employees to open the safe where those drugs are stored.The company also announced that it had added 50 new medication disposal units in select stores throughout Massachusetts.

Those units join 106 secure disposal units previously installed at CVS locations across the state and another 43 units previously donated to Massachusetts law enforcement agencies. The company plans cheap kamagra uk paypal to install another six units in stores by the year’s end. €œWhile our nation and our company focus on erectile dysfunction treatment, testing, and other measures to prevent community transmission of the kamagra, the misuse of prescription drugs remains an ongoing challenge in Massachusetts and elsewhere that warrants our continued attention,” said John Hering, Region Director for CVS Health.

€œThese steps to reduce the theft and diversion of opioid medications bring added security to our stores and more disposal options cheap kamagra uk paypal for our communities.”In 2015, CVS implemented time-delayed safe technology in CVS pharmacies across Indianapolis in response to the high volume of pharmacy robberies in that city. The company saw a 70 percent decline in pharmacy robberies in stores where the time-delayed safes were installed. Since then, the company has installed 4,760 time-delayed safes in 15 states and the District of Columbia and has seen a 50 percent decline in pharmacy robberies cheap kamagra uk paypal in those areas.

The company said it would add an additional 1,000 in-store medication disposal units to the 2,500 units it currently has in CVS pharmacies nationwide. The units allow customers to drop unused prescriptions into a safe place for their disposal cheap kamagra uk paypal to prevent those drugs from being misused. CVS stores that do not offer medication disposal units offer all customers filling opioid prescriptions for the first time with DisposeRX packets that effectively and efficiently breakdown unused drugs into a biodegradable gel for safe disposal in the trash at home..

A fourth wave of the opioid epidemic is coming, a national expert on drug use and policy said during a virtual panel discussion this week hosted by the Berkshire County, Massachusetts, District Attorney’s Office and kamagra gel online the Berkshire Opioid Addiction Prevention Collaborative.Dr. Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco (UCSF) School of Medicine, said the next wave in the country’s opioid health emergency will focus on stimulants like methamphetamine and cocaine, and drug combinations where stimulants are used in conjunction with opioids.“The use of methamphetamines is back and it’s back big time,” said Ciccarone, whose most recent research has focused on heroin use.Previously, officials had said there were three waves of the opioid epidemic – the first being prescription pills, the second being heroin, and the third being synthetic drugs, like fentanyl.Now, Ciccarone said, what federal law enforcement and medical experts are seeing is an increase in the use of stimulants, especially methamphetamines.The increase in deaths due to stimulants kamagra gel online may be attributed to a number of causes. The increase in supply, both imported and domestically produced, as well as the increase of the drugs’ potency.“Meth’s purity and potency has gone up to historical levels,” he said. €œAs of 2018, we’ve reached unseen heights of 97 percent potency and kamagra gel online 97 percent purity.

In a prohibitionist world, we should not be seeing such high quality. This is almost pharmaceutical quality.”Additionally, law enforcement and public health experts like Ciccarone are seeing kamagra gel online an increase in the co-use of stimulants with opioids, he said. Speedballs, cocaine mixed with heroin, and goofballs, methamphetamines used with heroin or fentanyl, are becoming more common from the Midwest into Appalachia and up through New England, he said.Federal law enforcement officials are recommending local communities prepare for the oncoming rise in illegal drugs coming into their communities.“Some people will use them both at the same time, but some may use them in some combination regularly,” he said. €œThey may use meth in the morning to go to work, and use heroin at night to come down.”The co-use, he said, was an organic response to the fentanyl overdose epidemic.“Some of the things that we heard … is that meth is popularly construed as kamagra gel online helping to decrease heroin and fentanyl use.

Helping with heroin withdraw symptoms and helping with heroin overdoses,” he said. €œWe debated this for kamagra gel online many years that people were using stimulants to reverse overdoses – we’re hearing it again.”“Supply is up, purity is up, price is down,” he said. €œWe know from economics that when drug patterns go in that direction, use is going up.”Ciccarone said that there should not be deaths because of stimulants, but that heroin/fentanyl is the deadly element in the equation.His recommendations to communities were not to panic, but to lower the stigma surrounding drug use in order to affect change. Additionally, he said, policies should focus on kamagra gel online reduction.

supply reduction, demand reduction and harm reduction. But not focus on only one single drug.Additionally, he said that by addressing issues kamagra gel online within communities and by healing communities socially, economically and spiritually, communities can begin to reduce demand.“We’ve got to fix the cracks in our society, because drugs fall into the cracks,” he said.Shutterstock U.S. Rep. Annie Kuster (D-NH) recently held two virtual roundtables addressing how erectile dysfunction treatment has affected New Hampshire’s healthcare industry.“The health and economic crisis caused by erectile dysfunction treatment has created significant challenges for Granite State healthcare, mental health, and substance use treatment providers — at the same kamagra gel online time, we are seeing increases in substance abuse and mental illness across New Hampshire,” Kuster said.

€œFrom the transition to telehealth care and cancellations of elective procedures to a lack of personal protective equipment and increasing health kamagra gel online needs of our communities – providers have overcome a multitude of obstacles due to erectile dysfunction treatment in recent months. I was glad to hear from these hard-working Granite Staters, whose insights will continue to guide my work in Congress as we respond to this kamagra. I’m committed to ensuring that communities kamagra gel online across New Hampshire can safely access the care and treatment they deserve.”The first roundtable addressed substance-use disorder (SUD) and mental health.The second virtual roundtable was an opportunity for health care providers to speak about their workplace challenges during the kamagra. Kuster is the founder and co-chairwoman of the Bipartisan Opioid Task Force, which held a virtual discussion in June on the opioid crisis and the kamagra.Shutterstock Opioid prescription rates for outpatient knee surgery vary nationwide, according to a study recently published in BMJ Open.

€œWe found massive levels of variation in the proportion of patients who are prescribed opioids between states, even after adjusting for nuances of the procedure and differences in patient characteristics,” said Dr kamagra gel online. M. Kit Delgado, the study’s senior author and an assistant professor of Emergency Medicine and Epidemiology in the Perelman School of Medicine at the University of kamagra gel online Pennsylvania. €œWe’ve also seen that the average number of pills prescribed was extremely high for outpatient procedures of this type, particularly for patients who had not been taking opioids prior to surgery.”Researchers examined insurance claims for nearly 100,000 patients who had arthroscopic knee surgery between 2015 and 2019 and had not used any opioid prescriptions in the six months before the surgery.Within three days of a procedure, 72 percent of patients filled an opioid prescription.

High prescription rates were found kamagra gel online in the Midwest and the Rocky Mountain regions. The coasts had lower rates.Nationwide, the average prescription strength was equivalent to 250 milligrams of morphine over five days. This is the threshold for increased kamagra gel online risk of opioid overdose death, according to the Centers for Disease Control and Prevention.Shutterstock U.S. Secretary of Labor Eugene Scalia awarded nearly $20 million to four states significantly impacted by the opioid crisis, the Department of Labor announced Thursday.

The Florida Department of Economic Opportunity, the Maryland Department of Labor, the Ohio Department kamagra gel online of Job and Family Services, and the Wisconsin Department of Workforce Development were awarded the money as part of the DOL’s “Support to Communities. Fostering Opioid Recovery through Workforce Development” created after the passage of the SUPPORT for Patients and Communities Act of 2018. The money will be used to retrain workers in areas with high kamagra gel online rates of substance use disorders. At a press conference in Piketon, Ohio, Scalia said the DOL had awarded Ohio’s Department of Job and Family Services $5 million to help communities in southern Ohio combat the opioid crisis kamagra gel online in that area.

€œToday’s funding represents this Administration’s continued commitment to serving those most in need,” said Assistant Secretary for Employment and Training John Pallasch. €œThe U.S kamagra gel online. Department of Labor is taking a strong stand to support individuals and communities impacted by the crisis.”Grantees will use the funds to collaborate with community partners, such as employers, local workforce development boards, treatment and recovery centers, law enforcement officials, faith-based community organizations, and others, to address the economic effects of substance misuse, opioid use, addiction, and overdose.Shutterstock CVS Health has completed the installation of time-delayed safe technology at all 446 Massachusetts locations as part of its initiatives aimed at reducing the misuse and diversion of prescription medications in Massachusetts, the company announced Thursday. The safes are intended to prevent robberies of controlled substance medications, such as oxycodone and hydrocodone, by electronically delaying the time it takes for pharmacy employees to open the safe where those drugs are stored.The company also announced that it had added 50 new medication disposal units kamagra gel online in select stores throughout Massachusetts.

Those units join 106 secure disposal units previously installed at CVS locations across the state and another 43 units previously donated to Massachusetts law enforcement agencies. The company plans to install another six units in stores by kamagra gel online the year’s end. €œWhile our nation and our company focus on erectile dysfunction treatment, testing, and other measures to prevent community transmission of the kamagra, the misuse of prescription drugs remains an ongoing challenge in Massachusetts and elsewhere that warrants our continued attention,” said John Hering, Region Director for CVS Health. €œThese steps to reduce the theft and diversion of opioid medications bring added security to our stores and more disposal options for our communities.”In 2015, CVS implemented time-delayed safe technology in CVS pharmacies across Indianapolis in response to the high volume of pharmacy robberies in that city.

The company saw a 70 percent decline in pharmacy robberies in stores where the time-delayed safes were installed. Since then, the company has installed 4,760 time-delayed safes in 15 states and the District of Columbia and has seen a 50 percent decline in pharmacy robberies in those areas. The company said it would add an additional 1,000 in-store medication disposal units to the 2,500 units it currently has in CVS pharmacies nationwide. The units allow customers to drop unused prescriptions into a safe place for their disposal to prevent those drugs from being misused.

CVS stores that do not offer medication disposal units offer all customers filling opioid prescriptions for the first time with DisposeRX packets that effectively and efficiently breakdown unused drugs into a biodegradable gel for safe disposal in the trash at home..

Buy kamagra tablets online

Latest erectile dysfunction buy kamagra tablets online News Cipro online without prescription FRIDAY, Sept. 4, 2020 (Healthday News) -- Rumors suggesting that erectile dysfunction treatment deaths in the United States are much lower than reported are due to people misinterpreting standard death certificate language, a Centers for Disease Control and Prevention official says.Social media conspiracy theories claiming that only a small percentage of buy kamagra tablets online people reported to have died from erectile dysfunction treatment actually died from the disease have cited death certificates that list other underlying causes, CNN reported.But that doesn't mean the patients did not die from erectile dysfunction treatment, said Bob Anderson, chief of mortality statistics at the CDC."In 94% of deaths with erectile dysfunction treatment, other conditions are listed in addition to erectile dysfunction treatment. These causes may include chronic conditions like diabetes or hypertension," Anderson explained in a statement, CNN reported. "In 6% of the death certificates that list erectile dysfunction treatment, only one cause or condition is listed," he buy kamagra tablets online noted."The underlying cause of death is the condition that began the chain of events that ultimately led to the person's death. In 92% of all deaths that mention erectile dysfunction treatment, erectile dysfunction treatment is listed as the underlying cause of death."As of Aug.

22, CDC data show that 161,392 death certificates listed erectile dysfunction treatment as a cause of death buy kamagra tablets online. As of Sept. 2, there had been more than 185,000 deaths from erectile dysfunction treatment in the U.S., according to Johns Hopkins University, which uses buy kamagra tablets online independent data, CNN reported.Other top U.S. Health officials have said that erectile dysfunction treatment death data are accurate.Copyright © 2019 HealthDay. All rights reserved.Latest buy kamagra tablets online Cancer News By Alan MozesHealthDay ReporterFRIDAY, Sept.

4, 2020Millions of people color their own hair, even though some of the chemicals in permanent hair dyes are considered possible carcinogens.So, is home hair coloring safe?. According to a buy kamagra tablets online new study, the answer is a qualified yes.After tracking cancer risk among more than 117,000 U.S. Women for 36 years, the investigators found that personal use of permanent hair dyes was not associated with any increase in the risk of developing bladder, brain, colon, kidney, lung, blood or immune system cancer. Nor were these dyes linked buy kamagra tablets online to an uptick in most skin or breast cancers."We observed no positive association between personal permanent hair dye use and risk of most cancers or cancer-related mortality," said study lead author Dr. Yin Zhang, a research fellow in medicine with Brigham and Women's Hospital, Harvard Medical School and the Dana-Farber Cancer Institute, in Boston.But permanent dye use was linked to a slightly increased risk for basal cell carcinoma (skin cancer), ovarian cancer and some forms of breast cancer.In addition, an increased risk for Hodgkin lymphoma was observed, but only among women whose hair was naturally dark.

The research team said it remained unclear as to why, but speculated that it could be buy kamagra tablets online that darker dyes have higher concentrations of problematic chemicals.The findings were published online Sept. 2 in the BMJ.The study team noted that somewhere between 50% and 80% of American and European women aged 40 and up color their hair. One in 10 men do the same.According to the American Cancer buy kamagra tablets online Society (ACS), hair dyes are regulated as cosmetics by the U.S. Food and Drug Administration. But the FDA places much of the safety burden on manufacturers.Permanent dyes account for roughly 80% of all dyes used in the United States and Europe, the study buy kamagra tablets online noted, and an even higher percentage in Asia.Why?.

Because "if you use permanent hair dyes, the color changes will last until the hair is replaced by new growth, which will be much longer than that of semi-permanent dyes, [which] last for five to 10 washings, or temporary dyes, [which last] one to two washings," Zhang said.The problem?. Permanent hair dyes are "the most aggressive" type on the market, said Zhang, and the kind "that has posed the greatest potential concern about cancer risk."According to the ACS, the concern centers on the ingredients in hair dyes, such as aromatic amines, phenols and hydrogen peroxide.Prior investigations have turned up signs of trouble, with some (though not all ingredients) finding a link buy kamagra tablets online between dye use and blood cancers and breast cancer.Still, the ACS points out that research looking into any association between such dyes and cancer risk have had mixed results. And studying hair dyes can be a moving target, as different dyes contain different ingredients, and the composition of those ingredients may change over time.For example, ACS experts noted that studies conducted in the 1970s found that some types of aromatic amines appeared to cause cancer in animal studies. As a result, some dye manufacturers have dropped amines from their dye recipes.The latest study focused buy kamagra tablets online on U.S. Women who were enrolled in the ongoing Nurses' Health Study.

All were cancer-free at the study's start, and all reported if they had ever used a permanent hair dye.Zhang's team concluded that using the dye did not appear to significantly raise the risk for most buy kamagra tablets online cancers. But investigators stressed that they did not definitively establish that such dyes do or do not raise cancer risk, given that their work was purely observational."Current evidence regarding the carcinogenic potential of personal use of permanent hair dyes are not conclusive," Zhang said, adding that "further investigations are needed."So, what should women do?. The ACS says, "There is no specific medical advice for current or former hair dye users."But Zhang suggested that consumers carefully follow directions -- such as buy kamagra tablets online "using gloves, keeping track of time, [and] rinsing the scalp thoroughly with water after use" -- to reduce any potential risk.Copyright © 2020 HealthDay. All rights reserved buy kamagra tablets online. QUESTION An average adult has about ________ square feet of skin.

See Answer buy kamagra tablets online References SOURCES. Yin Zhang, MD, research fellow, medicine, Brigham and Women's Hospital, Harvard Medical School, and Dana-Farber Cancer Institute, Boston. American Cancer Society buy kamagra tablets online. BMJ.Latest Prevention &. Wellness News By Steven ReinbergHealthDay ReporterTHURSDAY, buy kamagra tablets online Sept.

3, 2020 (HealthDay News)You tested positive for erectile dysfunction treatment and dutifully quarantined yourself for two weeks to avoid infecting others. Now, you're feeling better and buy kamagra tablets online you think you pose no risk to friends or family, right?. Not necessarily, claims a new study that shows it takes roughly a month to completely clear the erectile dysfunction from your body. To be safe, erectile dysfunction treatment patients should be retested after four weeks or more to be certain the kamagra isn't still active, Italian researchers say.Whether you are still infectious during the month after you are diagnosed is a roll of buy kamagra tablets online the dice. The test used in the study, an RT-PCR nasal swab, had a 20% false-negative rate.

That means one in five results that are negative for erectile dysfunction treatment are wrong and patients can still sicken others."The timing of retesting people with erectile dysfunction treatment in isolation is relevant for the identification of the best protocol of follow-up," said lead researcher buy kamagra tablets online Dr. Francesco Venturelli, from the epidemiology unit at Azienda Unita Sanitaria Locale--IRCCS in di Reggio Emilia."Nevertheless, the results of this study clearly highlight the importance of producing evidence on the duration of erectile dysfunction infectivity to avoid unnecessary isolation without increasing the risk of viral spread from clinically recovered people," he added.For the study, the researchers tracked nearly 4,500 people who had erectile dysfunction treatment between Feb. 26 and buy kamagra tablets online April 22, 2020, in the Reggio Emilia province in Italy.Among these patients, nearly 1,260 cleared the kamagra and more than 400 died. It took an average of 31 days for someone to clear the kamagra after the first positive test.Each patient was tested an average of three times. 15 days buy kamagra tablets online after the first positive test.

14 days after the second. And nine days after the third.The investigators found buy kamagra tablets online that about 61% of the patients cleared the kamagra. But there was a false-negative rate of slightly under one-quarter of the tests.The average time to clearance was 30 days after the first positive test and 36 days after symptoms began. With increasing age and severity of the , it took slightly longer to clear the , the researchers noted."In countries in which the testing strategy for the follow-up of buy kamagra tablets online people with erectile dysfunction treatment requires at least one negative test to end isolation, this evidence supports the assessment of the most efficient and safe retesting timing -- namely 30 days after disease onset," Venturelli said.The report was published online Sept. 3 in the BMJ Open.Dr.

Marc Siegel, a professor of medicine at NYU Langone Medical Center in buy kamagra tablets online New York City, agreed that retesting is needed to be sure that the kamagra is no longer present."The advice to patients is to get tested again a month after your initial test," he said. "What's new here is the finding that the speed of viral clearance doesn't happen in a day, but in 30 days."Siegel said that when a blood test for erectile dysfunction treatment is perfected, it would be the best option to use to reduce the possibility of false-negative results.The one caveat to retesting, he said, is that it shouldn't take tests away from people who need one to diagnose erectile dysfunction treatment. With tests still in short supply, massive retesting may have to wait until new buy kamagra tablets online antigen tests are widely available, he noted.Copyright © 2020 HealthDay. All rights reserved. SLIDESHOW Health buy kamagra tablets online Screening Tests Every Woman Needs See Slideshow References SOURCES.

Francesco Venturelli, MD, epidemiology unit, Azienda Unita Sanitaria Locale--IRCCS di buy kamagra tablets online Reggio Emilia, Italy. Marc Siegel, MD, professor, medicine, NYU Langone Medical Center, New York City. BMJ Open, buy kamagra tablets online Sept. 3, 2020, onlineLatest Diabetes News By Serena GordonHealthDay ReporterFRIDAY, Sept. 4, 2020A erectile dysfunction treatment can cause a lot of serious, sometimes lingering health problems, like lung damage, buy kamagra tablets online kidney damage and ongoing heart issues.

Lately, research has suggested it may also cause the sudden onset of insulin-dependent diabetes.A new report details the case of a 19-year-old German with asymptomatic erectile dysfunction treatment who ended up hospitalized with a new case of insulin-dependent diabetes.Five to seven weeks before his diabetes developed, the young man's parents developed erectile dysfunction treatment symptoms after an Austrian ski trip. Eventually, the entire family was tested buy kamagra tablets online. Both parents tested positive for erectile dysfunction treatment antibodies, as did the 19-year-old, indicating all had been infected with the erectile dysfunction. However, the son had never had symptoms of the .When the 19-year-old was admitted to the hospital, he was exhausted, had buy kamagra tablets online lost more than 26 pounds in a few weeks, was urinating frequently and had left-sided flank pain. His blood sugar level was over 550 milligrams per deciliter (mg/dL) -- a normal level is less than 140 mg/dL on a random blood test.Doctors suspected he had type 1 diabetes.

He tested positive for a genetic variant that is rarely associated with type buy kamagra tablets online 1 diabetes, but not genetic variants commonly present in type 1. He also didn't have antibodies that people with type 1 diabetes usually have at diagnosis.New type of diabetes?. This left the buy kamagra tablets online experts puzzled. Was this type 1 or type 2 diabetes or some new type of diabetes?. If it isn't type 1 diabetes, might this buy kamagra tablets online sudden onset diabetes go away on its own?.

And finally, they couldn't be sure that the erectile dysfunction treatment caused the diabetes. It's possible it was buy kamagra tablets online a preexisting condition that hadn't yet been diagnosed.Still, the authors of the study, led by Dr. Matthias Laudes of University Medical Centre Schleswig-Holstein in Kiel, Germany, believe they have a plausible explanation for how erectile dysfunction treatment s could lead to a new and sudden diabetes diagnosis. Their report buy kamagra tablets online is in the Sept. 2 Nature Metabolism.Beta cells in the pancreas contain a significant number of so-called ACE2 receptors.

These receptors are believed to be where the spike protein from the erectile dysfunction buy kamagra tablets online attaches to cells. Beta cells produce insulin, a hormone that helps usher the sugar from foods into the body's cells for fuel. The authors buy kamagra tablets online theorized that a erectile dysfunction , which affects the ACE2 receptors, might also damage beta cells in the pancreas.This process is similar to what's believed to occur in type 1 diabetes. The immune system mistakenly turns on healthy cells (autoimmune attack) after a viral and damages or destroys beta cells, possibly causing type 1 diabetes. Someone with buy kamagra tablets online type 1 diabetes has little to no insulin.

Classic type 1 diabetes requires lifelong insulin injections or delivery of insulin via an insulin pump.Dr. Caroline Messer, an endocrinologist at Lenox Hill Hospital in New York City, said she's heard there's buy kamagra tablets online been an uptick in autoimmune diabetes since the kamagra started.She said the authors' suggestion that beta cells may be destroyed in erectile dysfunction treatment s makes sense."This could account for the uptick in antibody negative type 1 diabetes," she said. "It is important for practitioners to be aware of the possibility of insulin-dependent diabetes approximately four weeks after in spite of negative [type 1 diabetes] antibodies."Sanjoy Dutta, vice president of research for JDRF (formerly the Juvenile Diabetes Research Foundation), said, "I don't think this is type 1 or type 2 diabetes. I think it should be called new onset or sudden onset insulin-dependent diabetes."Tracking these casesDutta said there have been enough of these cases in erectile dysfunction treatment patients that a registry has been created to keep track buy kamagra tablets online of their frequency. It includes more than 150 clinical centers throughout the world.He said people with sudden onset diabetes also seem to have significant insulin resistance and need very high doses buy kamagra tablets online of intravenous insulin.

Insulin resistance is more common in type 2 diabetes.He has also read of diabetes cases that have reversed -- no longer requiring insulin, which does not happen with type 1 diabetes. SLIDESHOW Diabetes buy kamagra tablets online. What Raises and Lowers Your Blood Sugar Level?. See Slideshow "We need buy kamagra tablets online to know the mechanism behind these cases, and until we get more evidence, we should stay open-minded. We don't know if it's beta cell destruction.

It's too soon for this to buy kamagra tablets online be boxed in as type 1 diabetes," Dutta noted.A new study from the University of Florida may put a damper on the German authors' theory. They looked at the pancreases of 36 deceased people without erectile dysfunction treatment, and didn't find ACE2 in their beta cells.Their finding "does not provide support to the notion that you're going to develop diabetes because the erectile dysfunction goes in and destroys an individual's insulin-producing cells," senior author Mark Atkinson, director of the UF Diabetes Institute, said in a university news release.The UF study was just published as a preprint on the website bioRxiv.org. Preprint websites let scientists distribute research buy kamagra tablets online quickly. However, information on them has not been peer-reviewed and should be considered preliminary.Dutta said whatever the mechanism might be, the general public and health care providers should be alert for symptoms of diabetes after a erectile dysfunction treatment . These include buy kamagra tablets online extreme fatigue, dry mouth, extreme thirst, frequent urination and unexplained weight loss.Copyright © 2020 HealthDay.

All rights reserved. From Diabetes Resources Featured Centers buy kamagra tablets online Health Solutions From Our Sponsors References SOURCES. Caroline Messer, M.D., endocrinologist, Lenox Hill Hospital, New York City. Sanjoy Dutta, Ph.D., vice president, buy kamagra tablets online research, JDRF. Nature Metabolism, Sept.

2, 2020 buy kamagra tablets online. University of Florida Health, news release, Sept. 2, 2020.Latest Infectious Disease buy kamagra tablets online News THURSDAY, Sept. 3, 2020 (HealthDay News)When the erectile dysfunction kamagra first spread across the United States this spring, most erectile dysfunction treatment patients in Michigan were prescribed unneeded antibiotics, a new study indicates.Antibiotics don't work against kamagraes, including the new erectile dysfunction, and overuse of antibiotics can contribute to antibiotic resistance worldwide.For the study, researchers analyzed data from more than 1,700 patients with suspected erectile dysfunction treatment who were admitted to 38 Michigan hospitals in March and April, when the state was one of the kamagra hotspots in the country.More than half of the patients were given antibiotics soon after arrival in case they had a bacterial in addition to the erectile dysfunction. But tests showed that 96.5% of those patients only had erectile dysfunction treatment.The 3.5% of patients who had a bacterial as well as the new erectile dysfunction were more likely to die, according to the study published online recently in the journal Clinical Infectious Diseases.Faster testing and understanding of risk factors could help doctors identify patients with both types of s and spare other erectile dysfunction treatment patients the risks buy kamagra tablets online associated with the overuse of antibiotics, the researchers said.The use of antibiotics varied widely between hospitals, the investigators found.

In some, only one-fourth of patients received them within two days of admission, while nearly all patients received antibiotics in other hospitals.As erectile dysfunction treatment test turnaround time shortened, the use of antibiotics fell, but was still too high, according to study author Dr. Valerie Vaughn, a hospitalist physician who helped launch Michigan Medicine's erectile dysfunction treatment intensive care units."For every patient who eventually tested positive for both erectile dysfunction [the kamagra that causes erectile dysfunction treatment] and a co-occurring bacterial that was present on their arrival, 20 other patients received antibiotics but turned out not to need them," Vaughn said in a university news release."These data show the crucial importance of early and appropriate testing, with rapid turnaround, to ensure appropriate use of antibiotics and reduce unneeded harm," Vaughn added.-- Robert PreidtCopyright © 2020 HealthDay. All rights reserved. QUESTION About how much does an adult human brain weigh?. See Answer References SOURCE.

Michigan Medicine/University of Michigan, news release, Aug. 21, 2020.

Latest erectile dysfunction News FRIDAY, https://seifenkiste.nato-leipzig.de/cipro-online-without-prescription/ Sept kamagra gel online. 4, 2020 (Healthday News) -- Rumors suggesting that erectile dysfunction treatment deaths in the United States are much lower than reported are due to people misinterpreting standard death certificate language, a Centers for Disease Control and Prevention official says.Social media conspiracy theories claiming that only a small percentage of people reported to kamagra gel online have died from erectile dysfunction treatment actually died from the disease have cited death certificates that list other underlying causes, CNN reported.But that doesn't mean the patients did not die from erectile dysfunction treatment, said Bob Anderson, chief of mortality statistics at the CDC."In 94% of deaths with erectile dysfunction treatment, other conditions are listed in addition to erectile dysfunction treatment. These causes may include chronic conditions like diabetes or hypertension," Anderson explained in a statement, CNN reported. "In 6% of the death certificates that kamagra gel online list erectile dysfunction treatment, only one cause or condition is listed," he noted."The underlying cause of death is the condition that began the chain of events that ultimately led to the person's death. In 92% of all deaths that mention erectile dysfunction treatment, erectile dysfunction treatment is listed as the underlying cause of death."As of Aug.

22, CDC data show that 161,392 death certificates listed erectile dysfunction treatment as a kamagra gel online cause of death. As of Sept. 2, there had been more than 185,000 deaths from kamagra gel online erectile dysfunction treatment in the U.S., according to Johns Hopkins University, which uses independent data, CNN reported.Other top U.S. Health officials have said that erectile dysfunction treatment death data are accurate.Copyright © 2019 HealthDay. All rights reserved.Latest Cancer News By kamagra gel online Alan MozesHealthDay ReporterFRIDAY, Sept.

4, 2020Millions of people color their own hair, even though some of the chemicals in permanent hair dyes are considered possible carcinogens.So, is home hair coloring safe?. According to a kamagra gel online new study, the answer is a qualified yes.After tracking cancer risk among more than 117,000 U.S. Women for 36 years, the investigators found that personal use of permanent hair dyes was not associated with any increase in the risk of developing bladder, brain, colon, kidney, lung, blood or immune system cancer. Nor were these dyes linked to an uptick in most skin or breast cancers."We observed no positive association between personal permanent hair dye use and risk of most cancers or cancer-related mortality," kamagra gel online said study lead author Dr. Yin Zhang, a research fellow in medicine with Brigham and Women's Hospital, Harvard Medical School and the Dana-Farber Cancer Institute, in Boston.But permanent dye use was linked to a slightly increased risk for basal cell carcinoma (skin cancer), ovarian cancer and some forms of breast cancer.In addition, an increased risk for Hodgkin lymphoma was observed, but only among women whose hair was naturally dark.

The research kamagra gel online team said it remained unclear as to why, but speculated that it could be that darker dyes have higher concentrations of problematic chemicals.The findings were published online Sept. 2 in the BMJ.The study team noted that somewhere between 50% and 80% of American and European women aged 40 and up color their hair. One in 10 men do the same.According to the American Cancer Society (ACS), hair dyes are regulated as kamagra gel online cosmetics by the U.S. Food and Drug Administration. But the FDA places much of the safety burden on manufacturers.Permanent dyes account for roughly 80% of all dyes used in the kamagra gel online United States and Europe, the study noted, and an even higher percentage in Asia.Why?.

Because "if you use permanent hair dyes, the color changes will last until the hair is replaced by new growth, which will be much longer than that of semi-permanent dyes, [which] last for five to 10 washings, or temporary dyes, [which last] one to two washings," Zhang said.The problem?. Permanent kamagra gel online hair dyes are "the most aggressive" type on the market, said Zhang, and the kind "that has posed the greatest potential concern about cancer risk."According to the ACS, the concern centers on the ingredients in hair dyes, such as aromatic amines, phenols and hydrogen peroxide.Prior investigations have turned up signs of trouble, with some (though not all ingredients) finding a link between dye use and blood cancers and breast cancer.Still, the ACS points out that research looking into any association between such dyes and cancer risk have had mixed results. And studying hair dyes can be a moving target, as different dyes contain different ingredients, and the composition of those ingredients may change over time.For example, ACS experts noted that studies conducted in the 1970s found that some types of aromatic amines appeared to cause cancer in animal studies. As a result, some dye manufacturers have dropped amines from their dye kamagra gel online recipes.The latest study focused on U.S. Women who were enrolled in the ongoing Nurses' Health Study.

All were cancer-free at the study's start, and all reported if they had ever used kamagra gel online a permanent hair dye.Zhang's team concluded that using the dye did not appear to significantly raise the risk for most cancers. But investigators stressed that they did not definitively establish that such dyes do or do not raise cancer risk, given that their work was purely observational."Current evidence regarding the carcinogenic potential of personal use of permanent hair dyes are not conclusive," Zhang said, adding that "further investigations are needed."So, what should women do?. The ACS says, "There is no specific medical advice for current or former hair dye users."But Zhang suggested that consumers carefully follow directions -- kamagra gel online such as "using gloves, keeping track of time, [and] rinsing the scalp thoroughly with water after use" -- to reduce any potential risk.Copyright © 2020 HealthDay. All rights kamagra gel online reserved. QUESTION An average adult has about ________ square feet of skin.

See Answer kamagra gel online References SOURCES. Yin Zhang, MD, research fellow, medicine, Brigham and Women's Hospital, Harvard Medical School, and Dana-Farber Cancer Institute, Boston. American Cancer kamagra gel online Society. BMJ.Latest Prevention &. Wellness News By Steven ReinbergHealthDay ReporterTHURSDAY, kamagra gel online Sept.

3, 2020 (HealthDay News)You tested positive for erectile dysfunction treatment and dutifully quarantined yourself for two weeks to avoid infecting others. Now, you're feeling better and you think you pose no risk to friends kamagra gel online or family, right?. Not necessarily, claims a new study that shows it takes roughly a month to completely clear the erectile dysfunction from your body. To be kamagra gel online safe, erectile dysfunction treatment patients should be retested after four weeks or more to be certain the kamagra isn't still active, Italian researchers say.Whether you are still infectious during the month after you are diagnosed is a roll of the dice. The test used in the study, an RT-PCR nasal swab, had a 20% false-negative rate.

That means one in five results that are negative for erectile dysfunction treatment are wrong and patients can still sicken others."The timing of retesting people with erectile dysfunction treatment in isolation is relevant for the identification of the best protocol of follow-up," said lead kamagra gel online researcher Dr. Francesco Venturelli, from the epidemiology unit at Azienda Unita Sanitaria Locale--IRCCS in di Reggio Emilia."Nevertheless, the results of this study clearly highlight the importance of producing evidence on the duration of erectile dysfunction infectivity to avoid unnecessary isolation without increasing the risk of viral spread from clinically recovered people," he added.For the study, the researchers tracked nearly 4,500 people who had erectile dysfunction treatment between Feb. 26 and April 22, 2020, in the Reggio Emilia province kamagra gel online in Italy.Among these patients, nearly 1,260 cleared the kamagra and more than 400 died. It took an average of 31 days for someone to clear the kamagra after the first positive test.Each patient was tested an average of three times. 15 days after the first positive test kamagra gel online.

14 days after the second. And nine days after the third.The investigators found that about kamagra gel online 61% of the patients cleared the kamagra. But there was a false-negative rate of slightly under one-quarter of the tests.The average time to clearance was 30 days after the first positive test and 36 days after symptoms began. With increasing age and severity of the , it took slightly longer to clear the , the researchers noted."In countries in which the testing strategy for the follow-up of people with erectile dysfunction treatment requires at least one negative test to end isolation, this evidence supports the assessment of the most efficient and safe retesting timing -- namely 30 days after disease onset," kamagra gel online Venturelli said.The report was published online Sept. 3 in the BMJ Open.Dr.

Marc Siegel, a professor of medicine at NYU Langone Medical Center in New York City, agreed that retesting is needed to be sure that the kamagra is no longer kamagra gel online present."The advice to patients is to get tested again a month after your initial test," he said. "What's new here is the finding that the speed of viral clearance doesn't happen in a day, but in 30 days."Siegel said that when a blood test for erectile dysfunction treatment is perfected, it would be the best option to use to reduce the possibility of false-negative results.The one caveat to retesting, he said, is that it shouldn't take tests away from people who need one to diagnose erectile dysfunction treatment. With tests still in short supply, massive retesting may have to wait until new kamagra gel online antigen tests are widely available, he noted.Copyright © 2020 HealthDay. All rights reserved. SLIDESHOW Health Screening Tests Every Woman kamagra gel online Needs See Slideshow References SOURCES.

Francesco Venturelli, kamagra gel online MD, epidemiology unit, Azienda Unita Sanitaria Locale--IRCCS di Reggio Emilia, Italy. Marc Siegel, MD, professor, medicine, NYU Langone Medical Center, New York City. BMJ Open, Sept kamagra gel online. 3, 2020, onlineLatest Diabetes News By Serena GordonHealthDay ReporterFRIDAY, Sept. 4, 2020A erectile dysfunction treatment can cause a lot of serious, sometimes lingering health problems, like lung damage, kidney damage and ongoing kamagra gel online heart issues.

Lately, research has suggested it may also cause the sudden onset of insulin-dependent diabetes.A new report details the case of a 19-year-old German with asymptomatic erectile dysfunction treatment who ended up hospitalized with a new case of insulin-dependent diabetes.Five to seven weeks before his diabetes developed, the young man's parents developed erectile dysfunction treatment symptoms after an Austrian ski trip. Eventually, the entire kamagra gel online family was tested. Both parents tested positive for erectile dysfunction treatment antibodies, as did the 19-year-old, indicating all had been infected with the erectile dysfunction. However, the son had never had symptoms of kamagra gel online the .When the 19-year-old was admitted to the hospital, he was exhausted, had lost more than 26 pounds in a few weeks, was urinating frequently and had left-sided flank pain. His blood sugar level was over 550 milligrams per deciliter (mg/dL) -- a normal level is less than 140 mg/dL on a random blood test.Doctors suspected he had type 1 diabetes.

He tested positive for a genetic variant that is rarely associated with type 1 diabetes, but not genetic variants kamagra gel online commonly present in type 1. He also didn't have antibodies that people with type 1 diabetes usually have at diagnosis.New type of diabetes?. This left kamagra gel online the experts puzzled. Was this type 1 or type 2 diabetes or some new type of diabetes?. If it isn't type 1 diabetes, might this sudden onset kamagra gel online diabetes go away on its own?.

And finally, they couldn't be sure that the erectile dysfunction treatment caused the diabetes. It's possible it was a preexisting condition that hadn't yet been diagnosed.Still, the authors of the kamagra gel online study, led by Dr. Matthias Laudes of University Medical Centre Schleswig-Holstein in Kiel, Germany, believe they have a plausible explanation for how erectile dysfunction treatment s could lead to a new and sudden diabetes diagnosis. Their report is in kamagra gel online the Sept. 2 Nature Metabolism.Beta cells in the pancreas contain a significant number of so-called ACE2 receptors.

These receptors are believed to be where kamagra gel online the spike protein from the erectile dysfunction attaches to cells. Beta cells produce insulin, a hormone that helps usher the sugar from foods into the body's cells for fuel. The authors theorized that a erectile dysfunction , which affects the ACE2 receptors, might also damage beta cells in the pancreas.This process is similar to what's believed to occur in type kamagra gel online 1 diabetes. The immune system mistakenly turns on healthy cells (autoimmune attack) after a viral and damages or destroys beta cells, possibly causing type 1 diabetes. Someone with kamagra gel online type 1 diabetes has little to no insulin.

Classic type 1 diabetes requires lifelong insulin injections or delivery of insulin via an insulin pump.Dr. Caroline Messer, an endocrinologist at Lenox Hill Hospital in New York City, said she's heard there's been an uptick in autoimmune diabetes since the kamagra started.She said the authors' suggestion that beta cells may be destroyed in erectile dysfunction treatment s makes sense."This could account kamagra gel online for the uptick in antibody negative type 1 diabetes," she said. "It is important for practitioners to be aware of the possibility of insulin-dependent diabetes approximately four weeks after in spite of negative [type 1 diabetes] antibodies."Sanjoy Dutta, vice president of research for JDRF (formerly the Juvenile Diabetes Research Foundation), said, "I don't think this is type 1 or type 2 diabetes. I think it should be called new kamagra gel online onset or sudden onset insulin-dependent diabetes."Tracking these casesDutta said there have been enough of these cases in erectile dysfunction treatment patients that a registry has been created to keep track of their frequency. It includes more than 150 clinical centers throughout the world.He said kamagra gel online people with sudden onset diabetes also seem to have significant insulin resistance and need very high doses of intravenous insulin.

Insulin resistance is more common in type 2 diabetes.He has also read of diabetes cases that have reversed -- no longer requiring insulin, which does not happen with type 1 diabetes. SLIDESHOW kamagra gel online Diabetes. What Raises and Lowers Your Blood Sugar Level?. See Slideshow "We need to know the mechanism behind kamagra gel online these cases, and until we get more evidence, we should stay open-minded. We don't know if it's beta cell destruction.

It's too soon for this to be boxed in as type 1 diabetes," Dutta noted.A new study from the University of Florida may put a damper on the German authors' theory kamagra gel online. They looked at the pancreases of 36 deceased people without erectile dysfunction treatment, and didn't find ACE2 in their beta cells.Their finding "does not provide support to the notion that you're going to develop diabetes because the erectile dysfunction goes in and destroys an individual's insulin-producing cells," senior author Mark Atkinson, director of the UF Diabetes Institute, said in a university news release.The UF study was just published as a preprint on the website bioRxiv.org. Preprint websites let scientists distribute research kamagra gel online quickly. However, information on them has not been peer-reviewed and should be considered preliminary.Dutta said whatever the mechanism might be, the general public and health care providers should be alert for symptoms of diabetes after a erectile dysfunction treatment . These include extreme fatigue, dry mouth, extreme thirst, kamagra gel online frequent urination and unexplained weight loss.Copyright © 2020 HealthDay.

All rights reserved. From Diabetes Resources Featured kamagra gel online Centers Health Solutions From Our Sponsors References SOURCES. Caroline Messer, M.D., endocrinologist, Lenox Hill Hospital, New York City. Sanjoy Dutta, Ph.D., vice president, research, kamagra gel online JDRF. Nature Metabolism, Sept.

2, 2020. University of Florida Health, news release, Sept. 2, 2020.Latest Infectious Disease News THURSDAY, Sept. 3, 2020 (HealthDay News)When the erectile dysfunction kamagra first spread across the United States this spring, most erectile dysfunction treatment patients in Michigan were prescribed unneeded antibiotics, a new study indicates.Antibiotics don't work against kamagraes, including the new erectile dysfunction, and overuse of antibiotics can contribute to antibiotic resistance worldwide.For the study, researchers analyzed data from more than 1,700 patients with suspected erectile dysfunction treatment who were admitted to 38 Michigan hospitals in March and April, when the state was one of the kamagra hotspots in the country.More than half of the patients were given antibiotics soon after arrival in case they had a bacterial in addition to the erectile dysfunction. But tests showed that 96.5% of those patients only had erectile dysfunction treatment.The 3.5% of patients who had a bacterial as well as the new erectile dysfunction were more likely to die, according to the study published online recently in the journal Clinical Infectious Diseases.Faster testing and understanding of risk factors could help doctors identify patients with both types of s and spare other erectile dysfunction treatment patients the risks associated with the overuse of antibiotics, the researchers said.The use of antibiotics varied widely between hospitals, the investigators found.

In some, only one-fourth of patients received them within two days of admission, while nearly all patients received antibiotics in other hospitals.As erectile dysfunction treatment test turnaround time shortened, the use of antibiotics fell, but was still too high, according to study author Dr. Valerie Vaughn, a hospitalist physician who helped launch Michigan Medicine's erectile dysfunction treatment intensive care units."For every patient who eventually tested positive for both erectile dysfunction [the kamagra that causes erectile dysfunction treatment] and a co-occurring bacterial that was present on their arrival, 20 other patients received antibiotics but turned out not to need them," Vaughn said in a university news release."These data show the crucial importance of early and appropriate testing, with rapid turnaround, to ensure appropriate use of antibiotics and reduce unneeded harm," Vaughn added.-- Robert PreidtCopyright © 2020 HealthDay. All rights reserved. QUESTION About how much does an adult human brain weigh?. See Answer References SOURCE.

Michigan Medicine/University of Michigan, news release, Aug. 21, 2020.

, so I made a batch of organic hemp infused iced tea & I’ve been starting my days that way. This tea is from @standarddose my new favorite online shop. They have curated an incredible selection of clean and organic products that benefit your skin both internally and externally. I’ve rounded up a few of my favorites in my stories (included the best damn natural deodorant I’ve ever tried). Anyone else on the iced tea kick? #sponsored">