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€‚For the buy carafate suspension podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This Focus Issue on heart failure (HF) provides novel clinically relevant information on sodium–glucose co-transporter-2 (SGLT2) inhibitors which, initially proposed for the treatment of type 2 diabetes mellitus (T2D), have been found to improve the outcome of HF with reduced ejection fraction (HFrEF) when administered on the top of drugs known to improve the outcome of HF and are recommended in current European Guidelines.1,2Acording to modelling estimates, when compared with no neurohormonal blockade, the use of a broad-based combination of disease-modifying drugs at target doses in patients with HF may reduce the risk of death by as much as 75%. It is surprising that in spite of this powerful therapeutic armamentarium, <1% of patients with chronic HF are currently receiving recommended drugs at doses that have been shown to prolong life.3 The issue opens with a Current Opinion article entitled ‘Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction. Implications for clinical practice’ by Milton Packer buy carafate suspension from the Baylor University Medical Center at Dallas in Texas, USA and colleagues.

The authors provide a perspective on the totality of evidence with SGLT2 inhibitors in patients with HFrEF.4 This paper is the first to issue a call for a major change in clinical practice based on the concordant results of DAPA-HF and EMPEROR-Reduced trials. The analyses and interpretations that are presented in this manuscript will undoubtedly generate considerable discussion and debate for a long time.Concern about hypotension often leads to withholding of beneficial therapy in patients with HFrEF. In a clinical research manuscript entitled ‘Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF)’ John McMurray from the Western Infirmary in Glasgow, UK and colleagues on behalf of the DAPA-HF Investigators and Committees evaluated the efficacy and safety of dapagliflozin according to baseline systolic blood pressure (SBP) in DAPA-HF trial.5 Key buy carafate suspension inclusion criteria were.

New York Heart Association (NYHA) class II–IV, left ventricular ejection fraction (LVEF) ≤40%, elevated N-terminal probrain natriuretic peptide (NT-proBNP) level, and SBP ≥95 mmHg. The primary outcome buy carafate suspension was a composite of worsening HF or cardiovascular death. The efficacy and safety of dapagliflozin was examined using SBP as both a categorical and a continuous variable.

The placebo-corrected reduction in SBP from baseline to 2 weeks with dapagliflozin was –2.54 mmHg. The benefit and buy carafate suspension safety of dapagliflozin were consistent across the range of SBP. Study drug discontinuation did not differ between dapagliflozin and placebo across the SBP categories examined.The authors conclude that dapagliflozin had a small effect on SBP in patients with HFrEF and was superior to placebo in improving outcomes, and well tolerated, across the range of SBP included in DAPA-HF.

The manuscript is accompanied by an Editorial by Francesco Cosentino from the University Hospital Solna in Stockholm, Sweden who comments that buy carafate suspension altogether, the results of the current post-hoc analysis demonstrating efficacy and safety of dapagliflozin regardless of SBP values might significantly contribute to foster the implementation of dapagliflozin use in HF clinical practice by dissipating any potential safety concern linked with its hypotensive effects.6In a clinical research article entitled ‘A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial’, Chim Lang from the University of Dundee in the UK and colleagues tested the hypothesis that dapagliflozin may regress left ventricular hypertrophy (LVH) in people with T2D.7 The authors randomly assigned 66 patients with T2D, LVH, and controlled blood pressure to receive dapagliflozin 10 mg once daily or placebo for 12 months. The primary endpoint was change in absolute left ventricular mass (LVM), assessed by cardiac magnetic resonance imaging (MRI).

In the intention-to-treat analysis, dapagliflozin significantly reduced LVM compared with placebo, with an buy carafate suspension absolute mean change of –2.82 g. Additional sensitivity analysis adjusting for baseline LVM, baseline blood pressure, weight, and SBP change showed the LVM change to remain statistically significant. Dapagliflozin significantly reduced pre-specified secondary endpoints including ambulatory 24-h SBP, nocturnal SBP, body buy carafate suspension weight, visceral adipose tissue, subcutaneous adipose tissue, insulin resistance, and high-sensitivity C-reactive protein.

Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial buy carafate suspension.

See pages 3421–3432).Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial buy carafate suspension.

See pages 3421–3432).Lang and colleagues conclude that dapagliflozin treatment significantly reduced LVM in patients with T2D and LVH. The regression of LVM suggests that dapagliflozin can initiate reverse remodelling and buy carafate suspension changes in left ventricular structure that may partly contribute to cardioprotective effects of dapagliflozin. This manuscript is accompanied by an Editorial by Francesco Paneni from the University of Zurich in Switzerland and colleagues.8 They note that the above-mentioned effects of SGLT2 inhibitors set the ground for a possible beneficial effect of these drugs in patients with HFpEF, where microvascular dysfunction, cardiomyocyte inflammation, and cardiometabolic alterations take centre stage.While several landmark studies have long established that implantable cardioverter-defibrillator (ICD) therapy improves survival for primary prevention of sudden cardiac death ,9 risk stratification parameters and methods for this purpose are clinically underused.

In a clinical research article entitled ‘Clinical effectiveness of primary prevention implantable cardioverter-defibrillators. Results of the EU-CERT-ICD controlled multicentre cohort study’ Markus Zabel from the Universitätsmedizin Göttingen in Germany and colleagues from the EU-CERT-ICD Study Investigators assessed the current clinical effectiveness of primary prevention by ICD therapy in a prospective investigator-initiated, controlled cohort study, conducted in 44 centres and 15 buy carafate suspension European countries. The study sought to assess current clinical effectiveness of primary prophylactic ICD implantation.10 The authors recruited 2327 patients with ischaemic or dilated cardiomyopathy and guideline indications for prophylactic ICD implantation.

The primary buy carafate suspension endpoint was all-cause mortality. Baseline and follow-up data from 2247 patients were analysable. 1516 patients with first ICD implantation (ICD group) and 731 patients without ICD serving as controls.

Multivariable models and propensity scoring buy carafate suspension for adjustment were used to compare the two groups for mortality. Adjusted mortality associated with ICD vs. Control was significantly lower (hazard buy carafate suspension ratio 0.731).

Subgroup analyses indicated no ICD benefit in diabetics or in those aged ≥75 years. Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and placebo at 6 months. Change in (A) buy carafate suspension left ventricular end-diastolic volume.

(B) left ventricular end-systolic volume. And (C) N-terminal pro b-type natriuretic peptide levels. At 6 months buy carafate suspension.

CDC, cardiosphere-derived cell. LVEDV, left ventricular end-diastolic volume buy carafate suspension. LVESV, left ventricular end-systolic volume.

NT-proBNP, N-terminal pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR) buy carafate suspension. A randomized, placebo-controlled, double-blinded trial.

See pages 3451--3458).Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and buy carafate suspension placebo at 6 months. Change in (A) left ventricular end-diastolic volume. (B) left ventricular end-systolic volume.

And (C) N-terminal pro b-type buy carafate suspension natriuretic peptide levels. At 6 months. CDC, cardiosphere-derived buy carafate suspension cell.

LVEDV, left ventricular end-diastolic volume. LVESV, left ventricular end-systolic volume. NT-proBNP, N-terminal pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, buy carafate suspension Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD.

Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial. See pages 3451--3458).The authors conclude that in contemporary ischaemic/dilated cardiomyopathy patients (LVEF ≤35%, narrow QRS), primary prophylactic ICD treatment was associated with a substantial reduction in mortality, although this improvement was not consistent buy carafate suspension across the whole population.

The manuscript is accompanied by an Editorial by N.A. Mark Estes III from the Heart and Vascular Institute UPMC in Pittsburgh, Pennsylvania, USA.11 buy carafate suspension The authors note that clinicians should be mindful of available risk stratification models and subgroup analyses from the EU-CERT-ICD and other studies. It follows that the process of shared decision-making should include careful consideration of the patient’s wishes and values, with an individualized assessment of potential benefit and risks of primary prevention of sudden death by ICD implantation.Cardiosphere-derived cells (CDCs) are cardiac progenitor cells which exhibit disease-modifying bioactivity in various models of cardiomyopathy and in previous clinical studies of acute myocardial infarction (MI), dilated cardiomyopathy, and Duchenne muscular dystrophy.12,13 In a clinical research article entitled ‘Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR).

A randomized, placebo-controlled, double-blinded trial’, Raj Makkar from the Cedars-Sinai Heart Institute in Los Angeles, California, USA and colleagues assessed the safety and efficacy of intracoronary administration of allogeneic CDCs in the multicentre, randomized, double-blind, placebo-controlled, intracoronary ALLogeneic Heart STem Cells to Achieve Myocardial Regeneration (ALLSTAR) trial.14 The authors enrolled patients 4 weeks to 12 months after MI, with LVEF ≤45% and left ventricular LV scar size ≥15% of LVM by MRI. A pre-specified interim analysis was performed when 6-month MRI buy carafate suspension data were available. The trial was subsequently stopped due to the low probability of detecting a significant treatment effect of CDCs based on the primary endpoint.

Patients were randomly allocated in a 2:1 ratio to receive CDCs or placebo in buy carafate suspension the infarct-related artery by the stop–flow technique. The primary safety endpoint was the occurrence, during 1-month post-intracoronary infusion, of acute myocarditis attributable to allogeneic CDCs, ventricular tachycardia- or ventricular fibrillation-related death, sudden unexpected death, or a major adverse cardiac event (death or hospitalization for HF or non-fatal MI). The primary efficacy endpoint was the relative percentage change in infarct size at 12 months post-infusion as assessed by contrast-enhanced cardiac MRI.

Makkar and colleagues randomly allocated 90 patients buy carafate suspension to the CDC group and 44 to the placebo group. The mean baseline LVEF was 40% and the mean scar size was 22% of the LVM. No primary safety endpoint events occurred buy carafate suspension.

There was no difference in the percentage change from baseline in scar size between CDC and placebo groups at 6 months. Compared with placebo, there were significant reductions in LV end-diastolic volume, LV end-systolic volume, and NT-proBNP at 6 months in CDC-treated patients.The authors conclude that intracoronary infusion of allogeneic CDCs in patients with post-MI left ventricular dysfunction was safe but did not reduce scar size relative to placebo at 6 months. The manuscript is accompanied by an Editorial by Francisco Fernandez-Aviles from the Hospital General Universitario Gregorio Marañón in Madrid, Spain and colleagues.15 The authors feel that various points need to be better addressed before proceeding again to clinical trials, if we want to move the field of cardiovascular regenerative and reparative medicine forward, for the sake of the cardiovascular buy carafate suspension health of millions of patients.Treatment of pathological cardiac remodelling and subsequent HF represents an unmet clinical need.

Long non-coding RNAs (lncRNAs) are emerging as crucial molecular orchestrators of disease processes including that of heart diseases.16,17 In a Basic Science article entitled ‘Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac hypertrophy’, Thomas Thum from the Hannover Medical School in Germany, and colleagues report on the powerful therapeutic potential of the conserved lncRNA H19 in the treatment of pathological cardiac hypertrophy.18 Pressure overload-induced left ventricular cardiac remodelling revealed an up-regulation of H19 in the early phase, but a strong sustained repression upon reaching the decompensated phase of HF. The translational potential of H19 was highlighted by its repression in a large animal (pig) model of LVH, in diseased human heart samples, in human stem cell-derived cardiomyocytes, and in human engineered heart tissue in response to afterload enhancement. Pressure overload-induced cardiac hypertrophy in H19 knockout mice was aggravated buy carafate suspension compared with wild-type mice.

In contrast, vector-based, cardiomyocyte-directed gene therapy using murine but also human H19 strongly attenuated HF even when cardiac hypertrophy was already established. Mechanistically, using microarray, gene set enrichment analyses, and chromatin immunoprecipitation-DNA sequencing, the authors identified a link between H19 buy carafate suspension and prohypertrophic nuclear factor of activated T cells (NFAT) signalling. H19 physically interacts with the polycomb repressive complex 2 to suppress H3K27 tri-methylation of the antihypertrophic Tescalcin locus which in turn leads to reduced NFAT expression and activity.Thum and colleagues conclude that H19 is highly conserved and down-regulated in failing hearts from mice, pigs, and humans.

H19 gene therapy prevents and reverses experimental pressure overload-induced HF. H19 acts as buy carafate suspension an antihypertrophic lncRNA and represents a promising therapeutic target to combat pathological cardiac remodelling. The manuscript is accompanied by an Editorial by Gianluigi Condorelli from the Humanitas University in Rozzano, Italy and colleagues.

The authors note that dysregulation of epigenetic mechanisms buy carafate suspension leading to aberrant loss of cardiomyocyte homeostasis is a critical point to consider in understanding the onset of cardiovascular pathologies. Thus exploiting lncRNAs as therapeutic agents in myocardial disease could pave the way for efficaciously combatting one of the greatest healthcare burdens worldwide.19With the advent of omics, an innovative inductive method has provided researchers with possible ways new to monitor health and disease. This approach incorporates data from studies of the genome, transcriptome, proteome, and metabolome to focus on the assessment of a varied range of biomolecules.20 In a clinical review article entitled ‘Omics phenotyping in heart failure.

The next frontier’ Antoni Bayes-Genis from the Cardiology Service, Hospital Universitari Germans Trias i Pujol in Badalona, Spain and colleagues provide a state-of-the-art review aiming to provide an up-to-date buy carafate suspension look at breakthrough omic technologies that are helping to unravel HF disease mechanisms and heterogeneity.21 Genomics, transcriptomics, proteomics, and metabolomics in HF are reviewed in depth. In addition, there is a thorough, expert discussion regarding the value of omics in identifying novel disease pathways, advancing understanding of disease mechanisms, differentiating HF phenotypes, yielding biomarkers for diagnosis or prognosis, or identifying new therapeutic targets in HF. The combination of multiple buy carafate suspension omics technologies may create a more comprehensive picture of the factors and pathophysiology involved in HF than achieved by either one alone, and provides a rich resource for predictive phenotype modelling.

However, the successful translation of omics tools as solutions to clinical HF requires that the observations are robust and reproducible, and can be validated across multiple independent populations to ensure confidence in clinical decision-making.This issue is also complemented by a Discussion Forum contribution. In a contribution entitled ‘Heart failure development in obesity. Mechanistic pathways’ Kristjan Karason from the Sahlgrenska University Hospital in Gothenburg, Sweden and colleagues provide a buy carafate suspension reply to a recent comment entitled ‘Incident heart failure risk after bariatric surgery.

The role of epicardial fat’.22,23The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Hugger, and Martin Meyer for help with compilation of this article. References1Docherty KF, Jhund PS, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, DeMets DL, Sabatine MS, Bengtsson O, Sjöstrand M, Langkilde AM, Desai AS, Diez M, Howlett JG, Katova T, Ljungman CEA, O’Meara E, Petrie MC, Schou M, Verma S, Vinh PN, Solomon SD, McMurray JJV. Effects of dapagliflozin in DAPA-HF according to background buy carafate suspension heart failure therapy.

Eur Heart J 2020;41:2379–2392.2Ponikowski P, Voors AA,, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure buy carafate suspension. The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC).

Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J buy carafate suspension 2016;37:2129–2200.3Packer M. Are the benefits of SGLT2 inhibitors in heart failure and a reduced ejection fraction influenced by background therapy?.

Expectations and realities of buy carafate suspension a new standard of care. Eur Heart J 2020;41:2393–2396.4Butler J, Zannad F, Filippatos G, Anker SD, Packer M. Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction.

Implications for clinical buy carafate suspension practice. Eur Heart J 2020;41:3398–3401.5Serenelli M, Böhm M, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P,, Sabatine MS, Solomon SD, DeMets DL, Bengtsson O, Sjöstrand M, Langkilde AM, Anand IS, Chiang CE, Chopra VK, de Boer RA, Diez M, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Verma S,, Docherty KF, Jhund PS, McMurray JJV. Effect of dapagliflozin buy carafate suspension according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF).

Eur Heart J 2020;41:3402–3418.6Savarese G, Cosentino F. The interaction between dapagliflozin and blood pressure in heart failure. New evidence dissipating buy carafate suspension concerns.

Eur Heart J 2020;41:3419–3420.7Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in buy carafate suspension people with type two diabetes. The DAPA-LVH trial.

Eur Heart J 2020;41:3421–3432.8Paneni F, Costantino S, Hamdani N. Regression of left ventricular hypertrophy with buy carafate suspension SGLT2 inhibitors. Eur Heart J 2020;41:3433–3436.9Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekvål TM, Spaulding C, Van Veldhuisen DJ.

2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European buy carafate suspension Society of Cardiology (ESC). Endorsed by.

Association for European Paediatric and Congenital buy carafate suspension Cardiology (AEPC). Eur Heart J 2015;36:2793–2867.10Zabel M, Willems R, Lubinski A, Bauer A, Brugada J, Conen D, Flevari P, Hasenfuß G, Svetlosak M, Huikuri HV, Malik M, Pavlović N, Schmidt G, Sritharan R, Schlögl S, Szavits-Nossan J, Traykov V, Tuinenburg AE, Willich SN, Harden M, Friede T, Svendsen JH, Sticherling C, Merkely B. Clinical effectiveness of primary prevention implantable cardioverter-defibrillators.

Results of the EU-CERT-ICD controlled multicentre cohort buy carafate suspension study. Eur Heart J 2020;41:3437–3447.11Estes MNA, Saba S. Primary prevention of sudden buy carafate suspension death with the implantable cardioverter defibrillator.

Bridging the evidence gap. Eur Heart J 2020;41:3448–3450.12Aminzadeh MA, Tseliou E, Sun B, Cheng K, Malliaras K, Makkar RR, Marbán E. Therapeutic efficacy buy carafate suspension of cardiosphere-derived cells in a transgenic mouse model of non-ischaemic dilated cardiomyopathy.

Eur Heart J 2015;36:751–762.13Fadini GP, Mehta A, Dhindsa DS, Bonora BM, Sreejit G, Nagareddy P, Quyyumi AA. Circulating stem cells and cardiovascular buy carafate suspension outcomes. From basic science to the clinic.

Eur Heart J 2020. Doi:10.1093/eurheartj/ehz923.14Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty buy carafate suspension T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR).

A randomized, placebo-controlled, double-blinded trial. Eur Heart J 2020;41:3451–3458.15Sanz-Ruiz buy carafate suspension R, Fernández-Avilés F. Cardiovascular regenerative and reparative medicine.

Is myocardial infarction the buy carafate suspension model?. Eur Heart J 2020;41:3459–3461.16Ounzain S, Micheletti R, Beckmann T, Schroen B, Alexanian M, Pezzuto I, Crippa S, Nemir M, Sarre A, Johnson R, Dauvillier J, Burdet F, Ibberson M, Guigó R, Xenarios I, Heymans S, Pedrazzini T. Genome-wide profiling of the cardiac transcriptome after myocardial infarction identifies novel heart-specific long non-coding RNAs.

Eur Heart buy carafate suspension J 2015;36:353–368.17Lüscher TF. Novel molecular mechanisms of vascular disease. Non-coding RNAs, buy carafate suspension inflammation, and radiation.

Eur Heart J. 2020;40:2467–2470.18Viereck J, Bührke A, Foinquinos A, Chatterjee S, Kleeberger JA, Xiao K, Janssen-Peters H, Batkai S, Ramanujam D, Kraft T, Cebotari S, Gueler F, Beyer AM, Schmitz J, Bräsen JH, Schmitto JD, Gyöngyösi M, Löser A, Hirt MN, Eschenhagen T, Engelhardt S, Bär C, Thum T. Targeting muscle-enriched long buy carafate suspension non-coding RNA H19 reverses pathological cardiac hypertrophy.

Eur Heart J 2020;41:3462–3474.19Pagiatakis C, Hall IF, Condorelli G. Long non-coding RNA buy carafate suspension H19. A new avenue for RNA therapeutics in cardiac hypertrophy?.

Eur Heart J 2020;41:3475–3476.20Hoogeveen RM, Pereira JPB, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw KT, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular buy carafate suspension risk prediction using targeted plasma proteomics in primary prevention. Eur Heart J 2020;ehaa648.

21Bayes-Genis A, Liu PP, Lanfear DE, de Boer RA, González A, Thum T, Emdin M, Januzzi JL. Omics phenotyping buy carafate suspension in heart failure. The next frontier.

Eur Heart buy carafate suspension J 2020;41:3477–3484.22Karason K, Jamaly S. Heart failure development in obesity. Mechanistic pathways.

Eur Heart J 2020;41:3485.23van Woerden G, van Veldhuisen buy carafate suspension SL, Rienstra M. Incident heart failure risk after bariatric surgery. The role buy carafate suspension of epicardial fat.

Eur Heart J 2020;41:1775. Published on behalf of the European Society of Cardiology. All rights buy carafate suspension reserved.

© The Author(s) 2020. For permissions, buy carafate suspension please email. Journals.permissions@oup.com.Case presentationA 32-year-old cardiology resident was scheduled to round on the COVID-19 wards at a large, government teaching hospital in Bahrain.

To cover the increasing workload, the hospital required additional medical personnel to provide care for the numerous COVID-19 patients that were being seen. Prior to examining COVID-19-positive patients, she donned buy carafate suspension appropriate personal protective equipment (PPE)—a gown, gloves, N95 mask, and face shield. As part of her physical exam, she was obliged to auscultate her patients with a stethoscope, listening for cardiopulmonary abnormalities that can be comorbid with severe COVID-19 infection.

Thus, she was required to unzip her gown and keep her stethoscope either in her ears or around her neck. She used buy carafate suspension a standard-length Littman Cardiology™ stethoscope, requiring her to be in close proximity to the patient (i.e. Lean over to the patient’s level).One day after her rounds, she developed a sore throat.

She subsequently was tested positive for COVID-19 via polymerase chain reaction buy carafate suspension (PCR). The resident cardiologist remembered one patient that she had examined where she suspected the transmission occurred. She recalls examining a patient who was COVID-19 positive.

Prior to the patient’s intubation buy carafate suspension she applied her own stethoscope directly to the patient’s chest to perform auscultation. The resident was perspiring and beginning to feel exhausted from her prior rounding and was breathing heavily as she unzipped her gown to place the stethoscope back within. The resident believes that COVID-19 viral particles which were transmitted to the stethoscope became aerosolized and inhaled buy carafate suspension as she brought the stethoscope close to her mouth while tucking it back into her gown.

The resident recovered, re-tested negative for COVID-19, and has now returned to her normal duties.The COVID-19 pandemic has called into question the triple-faceted role of the stethoscope. A diagnostic tool, symbol of patient–provider connection, and possible vector for infectious disease (Figure 1). A recent article in the American Journal of Medicine discusses developments in each arm of this triple buy carafate suspension role with reference to COVID-19, arguing that developments in stethoscope diagnostic technology, a need to bolster clinical skills, and developments in stethoscope hygiene methods will perpetuate both its relevance and safety.

This argument was made in light of those who believe the stethoscope will become obsolete with the development of more advanced technologies, as well as its potential to transmit disease.1 It is clear that a contaminated stethoscope might pose a danger to patients and providers, and can be a potential vector for the transmission of COVID-19, as illustrated in the case above. Thus, providers should seek to educate themselves on stethoscope contamination, assess the current methods of hygiene, and innovate accordingly rather than buy carafate suspension cast the stethoscope aside. Figure 1The three-faceted role of the stethoscope.

The stethoscope lies at the intersection of three roles in medicine. Diagnostic tool buy carafate suspension. Connection between provider and patients.

And a potential vector for infectious disease. As increased buy carafate suspension infection control vigilance has placed the stethoscope in a position of contention. Each facet of the stethoscope must be weighed in consideration of medicines’s cherished symbol.Figure 1The three-faceted role of the stethoscope.

The stethoscope lies at the intersection buy carafate suspension of three roles in medicine. Diagnostic tool. Connection between provider and patients.

And a buy carafate suspension potential vector for infectious disease. As increased infection control vigilance has placed the stethoscope in a position of contention. Each facet of the stethoscope must be weighed in consideration of medicines’s cherished symbol.Studies have demonstrated that stethoscopes can harbour similar levels and types of microbes to those on one’s hand.2 Thus, it is no surprise that the stethoscope has been christened as the physician’s ‘third hand’, with reference both to its potential for pathogen transmission buy carafate suspension and its integral role in patient–provider connection.

Despite this, no clear guidelines exist for performing stethoscope hygiene. The Centers for Disease Control (CDC) classifies the stethoscope as a ‘non-critical’ medical device (i.e. Only in contact with intact skin, not with bodily fluids), and recommends cleaning between buy carafate suspension as often as after contact with each patient to once weekly using an alcohol or bleach-based disinfectant.3 It has been demonstrated that viruses, including COVID-19,4 are capable of surviving on skin and other surfaces for an extended period of time.5 Thus, current guidelines may not adequately reflect the risk that stethoscope contamination poses.COVID-19 has fostered an era of increased infection control vigilance, and thus the benefits of the stethoscope must be rationally weighed against the risks.

In the vignette posed here, the cardiology resident felt the need to use her stethoscope to assess the COVID-19 patients on her round. Her likely buy carafate suspension rationale was the utility it provides in assessing the variety of cardiopulmonary abnormalities that can manifest during a COVID-19 infection. One of the most common manifestations of COVID-19 infection is multifocal pneumonia, often occurring prior to acute respiratory distress and need for mechanical ventilation.6 While pneumonia is diagnosed most definitively using imaging modalities (CT and X-ray) and laboratory testing, resource-limited scenarios might necessitate the usage of a stethoscope to listen for pulmonary indications (coarse breath sounds).

Furthermore, there is growing evidence that cardiovascular disease is highly comorbid with COVID-19 infection, leading to worse outcomes. The most common cardiovascular comorbidities among hospitalized COVID-19 patients are hypertension, coronary buy carafate suspension artery disease, and diabetes mellitus.7,8 In addition, recent reports have implicated COVID-19 in causing myocardial injury and left ventricular systolic dysfunction.9 Considering the sequelae of COVID-19 cardiopulmonary manifestations, auscultation using a stethoscope can be highly warranted. Therefore, emphasis must be placed on ensuring that the stethoscope can be used safely.Assessments of stethoscope hygiene practices have widely demonstrated deficits in adherence and method.

Direct observational studies have demonstrated stethoscope hygiene rates using recommended methods (wiping with alcohol, bleach, hydrogen peroxide, etc.) between 11.3% and 24%, with unconventional practices also being reported such as placing a glove over the stethoscope prior to auscultation or washing it with water/hand towel in a sink.10,11 Such findings imply that while stethoscope hygiene practices are deficient, providers who are cognizant of stethoscope contamination are struggling to find an effective form of hygiene that does not impede workflow—a proverbial ‘cry for help.’ With regard to current methods of stethoscope hygiene, providers cite lack of access to cleaning supplies, forgetfulness, or a lack of time as reasons for not performing stethoscope hygiene.12Healthcare guidelines advise against using personal stethoscopes in contact precaution settings in order to limit the potential for cross-contamination. Rather, single-patient disposable buy carafate suspension stethoscopes are often used for such patients. However, the audio quality of single-patient stethoscopes is quite poor,13 and it has been demonstrated that these stethoscopes can be contaminated with pathogens that can potentially be transmitted to providers, who must share this stethoscope.14 Proper cleaning of these stethoscopes between usage may not occur in high-workflow environments, such as the intensive care unit (ICU).

Thus, a more feasible and effective modality of stethoscope hygiene is warranted.A ray of hope for stethoscope hygiene is buy carafate suspension technological innovation. Among the solutions presented in recent years have been a UV-LED case for the stethoscope diaphragm,1, stethoscopes made from antimicrobial copper alloys,16 and disposable stethoscope diaphragm covers.17 The challenge imposed by the first two innovations is a lack of complete microbial disinfection. Given that it is unknown what viral dose threshold corresponds to COVID-19 pathogenesis, current infection control standards might necessitate a method that ensures zero transmission.

Stethoscope diaphragm covers alone can provide an aseptic contact surface during auscultation,17 but one is likely to encounter the same impediments stated for conventional stethoscope cleaning.12 A company based in San Diego, USA (AseptiScope Inc., San Diego, CA, USA) has attempted to overcome this issue by developing a touch-free diaphragm barrier dispenser.1 A recent article buy carafate suspension discussed the role of stethoscope contamination during COVID-19, stating that a specific barrier for the stethoscope is needed to prevent stethoscope contamination and subsequent transmission to patients and providers.18 A touch-free stethoscope diaphragm dispenser might be a feasible solution for this need.In the era of COVID-19, the stethoscope carries both profound utility as well as risk to patients if effective hygiene practices are not implemented. Thus, providers need to exercise caution when auscultating patients with COVID-19 given the risk for cross-contamination. However, rather than casting aside the stethoscope due to this risk, safety should be bolstered through education, hygiene buy carafate suspension practice, and consideration of innovative solutions.Conflict of interest.

A.S.M. Is a co-founder and the Chief Clinical Officer for AseptiScope Inc. (San Diego, CA, buy carafate suspension USA).

None of the other authors have conflicts to disclose. ReferencesReferences are available as supplementary material at buy carafate suspension European Heart Journal online. Published on behalf of the European Society of Cardiology.

All rights reserved. © The Author(s) 2020 buy carafate suspension. For permissions, please email.

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John Rawls begins a Theory of Justice with the observation that 'Justice is carafate and constipation the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override'1 (p.3). The COVID-19 pandemic has resulted in lock-downs, the restriction of liberties, debate about the right to refuse medical treatment and many other changes to the everyday behaviour of persons carafate and constipation. The justice issues it raises are diverse, profound and will demand our attention for some time. How we can respect the Rawlsian commitment carafate and constipation to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to COVID-19 triage situations. Their argument seems to highlight instances of what is called the McNamara fallacy.

US Secretary of Defense Robert McNamara used enemy body counts as a measure carafate and constipation of military success during the Vietnam war. So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so they draw a distinction between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew between carafate and constipation the different forms of procedural fairness. While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p. 85) there is carafate and constipation little prospect of that.

As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for COVID-19 is no exception. Instead, we should carafate and constipation work toward a transparent and fair process, what Rawls would describe as imperfect procedural justice (p. 85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85).

Their proposal is to triage patients into three broad categories. High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about COVID-19 triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for COVID-19 can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for COVID-19. They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for COVID-19 that means looking beyond access to ICU.

Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for COVID-19 in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to COVID-19 should broadened to include all the services a system might provide.Brown et al argue in favour of COVID-19 immunity passports and the following summarises one of the key arguments in their article.7COVID-19 immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from COVID-19 should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues. Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to COVID-19, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding. Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the virus.

Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the pandemic.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles. They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about COVID-19. These include that information about COVID-19 is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests.

They observe that COVID-19 has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for COVID-19 and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means. They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other. These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The COVID-19 pandemic is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs COVID-19 spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly.

In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access. However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with COVID-19 who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020. Central to these disucssions were two assumptions.

First, that ICU admission was a valuable but scarce resource in the pandemic context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU. In this paper we explain how scarcity and value were conflated in the early ICU COVID-19 triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question. Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a pandemic, such as masks or vaccines.

ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient. People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe COVID-19 pandemic generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission.

The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups. The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups. This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the pandemic with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are prognostically relevant in COVID-19 infection. Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears.

Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it. Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases. Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with COVID-19 are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the pandemic, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate. This has the potential to compromise important decisions with regard to care for patients with COVID-19.The emerging reality of ICUIn general, the majority of patients who are ventilated for COVID-19 in ICU will die. Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation.

Emerging data show case fatality rates of 50%–88% for ventilated patients with COVID-19. In China11 and Italy about half of those with COVID-19 who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in COVID-19 needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired infections such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage. Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-pandemic) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of COVID-19, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with COVID-19 begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with COVID-19 admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds. First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits.

For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups. In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with COVID-19, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with COVID-19 in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care.

This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas. Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the COVID-19 pandemic response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to COVID-19 in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate infection preventon and control training when dealing with patients with COVID-19 or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation. Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from COVID-19. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with COVID-19 (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people).

There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat COVID-19 with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist COVID-19 communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the pandemic.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team. Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources. These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the pandemic context.

See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during COVID-19Despite the sometimes overwhelming pressure of the pandemic, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for SARS-CoV-2 are quarantined in health facilities until they receive two consecutive negative tests. Patients may be isolated in hospital for several weeks. To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity.

However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During COVID-19 the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers. Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear. An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of COVID-19, given the unprecedented nature and scale of the pandemic and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis.

This suggests the need for COVID-19-specific ACPs. Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with COVID-19 is challenging and complex. Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients.

But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients. And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature. Equity can be addressed more robustly if pandemic responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with COVID-19.

Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the pandemic will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in infections but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the COVID-19 Chronicles strip..

John Rawls begins a Theory of Justice with the observation that 'Justice is the first virtue of social institutions, buy carafate suspension as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot override'1 (p.3). The COVID-19 pandemic has resulted in lock-downs, the restriction of liberties, debate about the right to refuse medical treatment buy carafate suspension and many other changes to the everyday behaviour of persons. The justice issues it raises are diverse, profound and will demand our attention for some time.

How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and COVID-19 is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al buy carafate suspension add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to COVID-19 triage situations. Their argument seems to highlight instances of what is called the McNamara fallacy. US Secretary of Defense Robert McNamara used buy carafate suspension enemy body counts as a measure of military success during the Vietnam war.

So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so they draw a distinction between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew buy carafate suspension between the different forms of procedural fairness. While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p.

85) there is little buy carafate suspension prospect of that. As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for COVID-19 is no exception. Instead, we should work toward a transparent and buy carafate suspension fair process, what Rawls would describe as imperfect procedural justice (p.

85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85).

Their proposal is to triage patients into three broad categories. High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about COVID-19 triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for COVID-19 can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for COVID-19.

They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for COVID-19 that means looking beyond access to ICU. Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for COVID-19 in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to COVID-19 should broadened to include all the services a system might provide.Brown et al argue in favour of COVID-19 immunity passports and the following summarises one of the key arguments in their article.7COVID-19 immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from COVID-19 should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues.

Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to COVID-19, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding.

Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the virus. Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the pandemic.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles.

They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about COVID-19. These include that information about COVID-19 is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests.

They observe that COVID-19 has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for COVID-19 and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means. They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other.

These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The COVID-19 pandemic is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs COVID-19 spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly. In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access.

However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with COVID-19 who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020.

Central to these disucssions were two assumptions. First, that ICU admission was a valuable but scarce resource in the pandemic context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU.

In this paper we explain how scarcity and value were conflated in the early ICU COVID-19 triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question. Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a pandemic, such as masks or vaccines.

ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient.

People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe COVID-19 pandemic generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission. The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups.

The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups. This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the pandemic with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are prognostically relevant in COVID-19 infection.

Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears. Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it. Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases.

Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with COVID-19 are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the pandemic, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate.

This has the potential to compromise important decisions with regard to care for patients with COVID-19.The emerging reality of ICUIn general, the majority of patients who are ventilated for COVID-19 in ICU will die. Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation. Emerging data show case fatality rates of 50%–88% for ventilated patients with COVID-19.

In China11 and Italy about half of those with COVID-19 who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in COVID-19 needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired infections such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage. Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-pandemic) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of COVID-19, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with COVID-19 begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with COVID-19 admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds.

First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits. For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups.

In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with COVID-19, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with COVID-19 in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care.

This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas. Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the COVID-19 pandemic response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to COVID-19 in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate infection preventon and control training when dealing with patients with COVID-19 or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation.

Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from COVID-19. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with COVID-19 (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people). There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat COVID-19 with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist COVID-19 communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the pandemic.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team.

Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources.

These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the pandemic context. See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during COVID-19Despite the sometimes overwhelming pressure of the pandemic, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for SARS-CoV-2 are quarantined in health facilities until they receive two consecutive negative tests.

Patients may be isolated in hospital for several weeks. To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity.

However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During COVID-19 the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers. Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear.

An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of COVID-19, given the unprecedented nature and scale of the pandemic and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis. This suggests the need for COVID-19-specific ACPs.

Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with COVID-19 is challenging and complex.

Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients. But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients.

And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature. Equity can be addressed more robustly if pandemic responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with COVID-19.

Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the pandemic will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in infections but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the COVID-19 Chronicles strip..

What should my health care professional know before I take Carafate?

They need to know if you have any of these conditions:

  • kidney disease
  • an unusual or allergic reaction to sucralfate, other medicines, foods, dyes, or preservatives
  • pregnant or trying to get pregnant
  • breast-feeding

Does carafate need to be refrigerated

September 11, 2020 Ottawa, does carafate need to be refrigerated ON Health Canada Today, the Honourable Patty Hajdu issued the following statement. Yesterday’s Supreme Court of British Columbia’s decision in Cambie, which dismissed the constitutional challenge to provisions of British Columbia’s Medicare Protection Act and upheld the ban on patient charges and private insurance, validates our belief that all Canadians deserve universally accessible health care. Access to medically necessary services should does carafate need to be refrigerated be uniformly available to all, based on need rather than ability or willingness to pay. Patient charges—whether they take the form of charges at the point of service or payment for private insurance—undermine equity. The Government of Canada fully welcomes the Court’s does carafate need to be refrigerated decision and commends the Government of British Columbia for its successful defence of universally accessible health care.

This decision validates Canada’s single-payer public health care system and the fundamental principle that access to medically necessary health services should be based on health need and not on the ability or willingness to pay. We believe that these values are more important than ever as we continue to respond to the unprecedented challenges presented by the COVID-19 outbreak, and the Government of does carafate need to be refrigerated Canada will continue to defend universally accessible health care for all Canadians. The Honourable Patty Hajdu, P.C., M.P.Funding will redirect people who use drugs from the criminal justice system August 26, 2020 - Peterborough, Ontario - Health Canada Problematic substance use has devastating impacts on people, families and communities across Canada. Tragically, the COVID-19 outbreak has worsened the situation for many Canadians struggling with substance use. The Government of Canada continues to address this serious public health issue does carafate need to be refrigerated by focusing on increasing access to quality treatment and harm reduction services nationwide.

Today, on behalf of the Honourable Patty Hajdu, Minister of Health, the Honourable Maryam Monsef, Minister for Women and Gender Equality and Rural Economic Development, announced more than $1.9 million in funding over the next three years to the Peterborough Police Service. Through this funding, people who use drugs and experience mental health issues will be connected to newly-created does carafate need to be refrigerated community-based outreach and support services. As part of this project, the Peterborough Police Service is working with local partners to create a community-based outreach team to increase the capacity for front-line community services to help people at risk who are referred by police. With the help of this new team, people who use drugs or experience mental health issues will be redirected from the criminal justice system to harm reduction, peer support, health and social services. Additionally, this initiative will increase access to culturally appropriate services for Indigenous Peoples, LGBTQ2+ populations, youth, women, and those living with HIV through partnerships with other organizations such as Nogojiwanong Friendship Centre and Peterborough AIDS Research Network.

The Government of Canada is committed to working with partners, peer workers, people with lived and living experience and other stakeholders to ensure Canadians receive the support they need to reduce the harms related to substance use..

September 11, 2020 Ottawa, ON Health Canada Today, buy carafate suspension the Honourable Patty Hajdu issued the following statement. Yesterday’s Supreme Court of British Columbia’s decision in Cambie, which dismissed the constitutional challenge to provisions of British Columbia’s Medicare Protection Act and upheld the ban on patient charges and private insurance, validates our belief that all Canadians deserve universally accessible health care. Access to medically necessary services should be uniformly available buy carafate suspension to all, based on need rather than ability or willingness to pay.

Patient charges—whether they take the form of charges at the point of service or payment for private insurance—undermine equity. The Government of Canada fully welcomes the Court’s decision and commends the Government of British Columbia buy carafate suspension for its successful defence of universally accessible health care. This decision validates Canada’s single-payer public health care system and the fundamental principle that access to medically necessary health services should be based on health need and not on the ability or willingness to pay.

We believe that these values are more important than ever as we continue to respond to the unprecedented challenges presented by the COVID-19 outbreak, and the Government of buy carafate suspension Canada will continue to defend universally accessible health care for all Canadians. The Honourable Patty Hajdu, P.C., M.P.Funding will redirect people who use drugs from the criminal justice system August 26, 2020 - Peterborough, Ontario - Health Canada Problematic substance use has devastating impacts on people, families and communities across Canada. Tragically, the COVID-19 outbreak has worsened the situation for many Canadians struggling with substance use.

The Government of buy carafate suspension Canada continues to address this serious public health issue by focusing on increasing access to quality treatment and harm reduction services nationwide. Today, on behalf of the Honourable Patty Hajdu, Minister of Health, the Honourable Maryam Monsef, Minister for Women and Gender Equality and Rural Economic Development, announced more than $1.9 million in funding over the next three years to the Peterborough Police Service. Through this funding, people who use drugs and experience mental health issues will be connected to newly-created community-based outreach and support services.

As part of this project, the Peterborough Police Service is working with local partners to create a community-based outreach team to increase the capacity for front-line community services to help people at risk who are referred by police. With the help of this new team, people who use drugs or experience mental health issues will be redirected from the criminal justice system to harm reduction, peer support, health and social services. Additionally, this initiative will increase access to culturally appropriate services for Indigenous Peoples, LGBTQ2+ populations, youth, women, and those living with HIV through partnerships with other organizations such as Nogojiwanong Friendship Centre and Peterborough AIDS Research Network.

The Government of Canada is committed to working with partners, peer workers, people with lived and living experience and other stakeholders to ensure Canadians receive the support they need to reduce the harms related to substance use..

Carafate and diarrhea

Rheumatic feverIs there any disease group more ’deserving’ of a place at the neglected tropical disease table than carafate and diarrhea the post streptococcal illnesses, glomerulonephritis and rheumatic fever?. These dropped off the radar of most high income countries in the second half of the 20th century but have continued to smoulder, largely unchecked, in low and middle income countries (LMICs). The burden is carafate and diarrhea frightening. 300 000 incident cases per year and 30 million prevalent cases, the damage from chronic carditis resulting, in so many, in heart failure and stroke.There are a number of approaches. Primary prevention (vaccination) remains a work in progress.

Secondary prevention (prompt treatment) is largely dependent on diagnosis which depends on a positive throat swab or serological evidence carafate and diarrhea in the form of the ASOT and ADB titres and this is where the complexities begin. Tertiary prevention, early diagnosis of heart disease by echo screening and prophylaxis has promise but is gestational. The range of population norms depends on exposure and threshold levels in one country might not be applicable elsewhere inevitably resulting in false positive and false negative carafate and diarrhea results. Okello et al establishes a range of ASOT levels in urban Uganda and shows much higher mean titres than other comparable populations. Joshua Osowicki and Andrew Steer discuss the implications of these findings in the context of a multipronged approach to rheumatic fever during the wait for the long yearned-for group A streptococcal vaccine.

See pages 825 and 813Febrile neutropaeniaOncological treatment is carafate and diarrhea prolonged and draining for both a child and their family. A major contributor to the fatigue is the need for recurrent admissions for chemotherapy induced febrile neutropenia (FN). Though evidence carafate and diarrhea of benefit is scanty to non-existent, it is traditional to keep children in hospital on IV antibiotic treatment for several days irrespective of culture results and clinical appearance. Sereveratne and colleagues assess the safety of a more flexible approach in a tertiary oncology centre, allowing discharge at 48 hours, even if culture positive as long as ‘wellness’ and social criteria were metIn total, 179 episodes of FN were reviewed from 47 patients. In 70% (125/179) of episodes, patients were discharged safely once 48 hours microbiology results were available, with only 5.6% (7/125) resulting in readmission in the 48 hours following discharge.

There were carafate and diarrhea no deaths from sepsis. This approach won’t work for all episodes of febrile neutropenia, but, probably applies to the majority and the differences to quality of life if adopted widely are hard to overstate. See page 881Infectious disease mortalityTrends in carafate and diarrhea infectious disease mirror changes in vaccination programmes, society and the environment, diagnostics and microbiological epidemiology. Ferreras-Antolin examines Public Health England data over two eras, 2003 to 2005 and 2013 to 2015. In the latter period, there were 5088 death registrations recorded in children aged 28 days to <15 years in England and Wales (17.6 deaths/100 000 children annually) and, in the first 6897 (23.9/100 000).

The incidence rate ratio (IRR) of 0.74 (95% CI 0.71 to 0.77) fell significantly and the stories behind carafate and diarrhea these data are revealing. There is little doubt that PCV vaccination has played a role though, in this series, it is too early to assess the contribution of the (2015 launched) meningococcal B programme. The raw data also mask the rise of (the still non-vaccine preventable) invasive group A streptococcal disease (one of the arguments for varicella vaccination) and the future role for Group B streptococcal immunisation. Influenza deaths were rare and, despite a carafate and diarrhea reduction between the eras was not a major explanator. See page 857Fibre and constipationOne of the more entrenched tenets of child nutrition folklore is that of the association between fibre and constipation.

In a re-analysis of data from the latest carafate and diarrhea NICE review, information from the ALSPAC cohort (in which stool consistency pre-weaning was established) and monozygotic twin studies, Tappin persuasively argues (through triangulation analysis) that fibre is the result of and confounded by parental response to hard stool and is neither a cause of constipation or a treatment. Laxation (as advocated) should be the first line and used early to prevent the all too familiar chronic issues with undertreatment. Soiling. Loss of carafate and diarrhea self esteem. Poor mood and loss of appetite.

See page 864Drowning and autismDrowning is a major carafate and diarrhea cause of global child mortality, particularly in low and middle income country settings. Interventions such as fencing off access and swimming lessons have partially ameliorated the risk, but progress has been slow and awareness probably still the single best form of prophylaxis. Autistic children represent a high risk group due to their inherent communication and behavioural issues. Peden assesses the association between autism and drowning carafate and diarrhea in Australia from coronial certificates between 2002 and 2018. Of the 667 cases of drowning among 0–19 year olds (with known history), 27 (4%) had an ASD diagnosis, relative risk 2.85 (95% CI 0.61 to 13.24).

Children and adolescents with ASD were significantly more likely to drown when compared carafate and diarrhea with those without ASD. If aged 5–9 years (44.4% of ASD cases. 13.3% of non ASD cases). In a carafate and diarrhea lake or dam (25.9% vs 10.0%) and during winter (37.0% vs 13.1%). These sobering figures are likely to be an underestimate as the diagnosis of ASD is often not made until the age of 5 years, past the highest drowning risk preschool group.

Rheumatic feverIs buy carafate suspension there any disease group more ’deserving’ of a place at the neglected tropical disease table than the post streptococcal illnesses, glomerulonephritis and rheumatic fever?. These dropped off the radar of most high income countries in the second half of the 20th century but have continued to smoulder, largely unchecked, in low and middle income countries (LMICs). The burden is frightening buy carafate suspension. 300 000 incident cases per year and 30 million prevalent cases, the damage from chronic carditis resulting, in so many, in heart failure and stroke.There are a number of approaches. Primary prevention (vaccination) remains a work in progress.

Secondary prevention (prompt treatment) is largely dependent on diagnosis which depends on a positive throat swab or serological evidence in the buy carafate suspension form of the ASOT and ADB titres and this is where the complexities begin. Tertiary prevention, early diagnosis of heart disease by echo screening and prophylaxis has promise but is gestational. The range of population norms depends on exposure and threshold levels in one country might not be applicable buy carafate suspension elsewhere inevitably resulting in false positive and false negative results. Okello et al establishes a range of ASOT levels in urban Uganda and shows much higher mean titres than other comparable populations. Joshua Osowicki and Andrew Steer discuss the implications of these findings in the context of a multipronged approach to rheumatic fever during the wait for the long yearned-for group A streptococcal vaccine.

See pages 825 and 813Febrile neutropaeniaOncological buy carafate suspension treatment is prolonged and draining for both a child and their family. A major contributor to the fatigue is the need for recurrent admissions for chemotherapy induced febrile neutropenia (FN). Though evidence of benefit is scanty to non-existent, it is traditional to keep children in hospital on buy carafate suspension IV antibiotic treatment for several days irrespective of culture results and clinical appearance. Sereveratne and colleagues assess the safety of a more flexible approach in a tertiary oncology centre, allowing discharge at 48 hours, even if culture positive as long as ‘wellness’ and social criteria were metIn total, 179 episodes of FN were reviewed from 47 patients. In 70% (125/179) of episodes, patients were discharged safely once 48 hours microbiology results were available, with only 5.6% (7/125) resulting in readmission in the 48 hours following discharge.

There were no deaths from buy carafate suspension sepsis. This approach won’t work for all episodes of febrile neutropenia, but, probably applies to the majority and the differences to quality of life if adopted widely are hard to overstate. See page 881Infectious disease mortalityTrends in infectious disease mirror changes in vaccination programmes, buy carafate suspension society and the environment, diagnostics and microbiological epidemiology. Ferreras-Antolin examines Public Health England data over two eras, 2003 to 2005 and 2013 to 2015. In the latter period, there were 5088 death registrations recorded in children aged 28 days to <15 years in England and Wales (17.6 deaths/100 000 children annually) and, in the first 6897 (23.9/100 000).

The incidence rate ratio (IRR) of 0.74 (95% CI buy carafate suspension 0.71 to 0.77) fell significantly and the stories behind these data are revealing. There is little doubt that PCV vaccination has played a role though, in this series, it is too early to assess the contribution of the (2015 launched) meningococcal B programme. The raw data also mask the rise of (the still non-vaccine preventable) invasive group A streptococcal disease (one of the arguments for varicella vaccination) and the future role for Group B streptococcal immunisation. Influenza deaths buy carafate suspension were rare and, despite a reduction between the eras was not a major explanator. See page 857Fibre and constipationOne of the more entrenched tenets of child nutrition folklore is that of the association between fibre and constipation.

In a re-analysis of data from the latest NICE review, information from the ALSPAC cohort (in which stool consistency pre-weaning was established) and monozygotic twin studies, Tappin persuasively argues (through triangulation analysis) that fibre is the result of and confounded buy carafate suspension by parental response to hard stool and is neither a cause of constipation or a treatment. Laxation (as advocated) should be the first line and used early to prevent the all too familiar chronic issues with undertreatment. Soiling. Loss of buy carafate suspension self esteem. Poor mood and loss of appetite.

See page 864Drowning and autismDrowning is a major cause of buy carafate suspension global child mortality, particularly in low and middle income country settings. Interventions such as fencing off access and swimming lessons have partially ameliorated the risk, but progress has been slow and awareness probably still the single best form of prophylaxis. Autistic children represent a high risk group due to their inherent communication and behavioural issues. Peden assesses the buy carafate suspension association between autism and drowning in Australia from coronial certificates between 2002 and 2018. Of the 667 cases of drowning among 0–19 year olds (with known history), 27 (4%) had an ASD diagnosis, relative risk 2.85 (95% CI 0.61 to 13.24).

Children and adolescents buy carafate suspension with ASD were significantly more likely to drown when compared with those without ASD. If aged 5–9 years (44.4% of ASD cases. 13.3% of non ASD cases). In a lake or dam (25.9% vs 10.0%) buy carafate suspension and during winter (37.0% vs 13.1%). These sobering figures are likely to be an underestimate as the diagnosis of ASD is often not made until the age of 5 years, past the highest drowning risk preschool group.

Why is carafate liquid so expensive

Besides providing healthcare to millions, Medicaid helps recipients make healthier food choices according to UConn research published in the why is carafate liquid so expensive journal Health Economics. UConn Professor of Agricultural why is carafate liquid so expensive and Resource Economics, Rigoberto Lopez, Rebecca Boehm now an economist with the Union of Concerned Scientists, and Xi He now a post-doctoral researcher at the Iowa State were interested in investigating the impact of Medicaid on food choices.Medicaid is beneficial to recipients in a multitude of ways, by reducing emergency room visits, increasing access to preventive healthcare, while reducing out-of-pocket medical costs and debt, for instance. The program is highly politicized and is met with criticism and assumptions that it is too costly, yet research has shown the program actually saves states money.He, Lopez, and Boehm were interested in looking at other potential benefits of the program and also hoped to bridge some gaps in the literature says He,"There are many studies about the impact of Medicaid on mental health or on health spending but few studies have looked at how Medicaid affects food choices."He explains that by virtue of spending less on healthcare, new Medicaid recipients would have more room in their budget for food and therefore may spend more money on the same unhealthy foods and beverages they have always purchased.

On the other hand, with more access to healthcare and health education through contact with why is carafate liquid so expensive providers, the researchers surmised that purchasing patterns could improve, says He.To see if this was the case, the researchers looked at purchases of beverages such as carbonated soft drinks, juice, milk and other non-alcoholic beverages before and after the expansion of Medicaid and compared purchases in states that did and did not expand the program under the Affordable Care Act. In a way, the states that did not expand Medicaid why is carafate liquid so expensive were the control group for their study. They also compared purchase preferences for sugar content of these beverages.

advertisement "We found that households in expansion states significantly why is carafate liquid so expensive increased their purchase of diet soda and bottled water, but there was no change in purchase of regular soda. But overall, these results indicate that Medicaid expansion, in states that did expand, shifted people's purchases to products with less sugar," says He.Access to healthcare has wide-ranging positive effects on the lives and habits of recipients. The added benefit of knowledge resulting from access to healthcare is not a policy mechanism that is usually discussed says Boehm,"With so many people working to help people eat healthier and to reduce obesity in the US, I why is carafate liquid so expensive don't hear a lot of talk about how the provision of healthcare through this income effect we proposed in this study can help people eat and drink healthier."Lopez says programs like Medicaid are often unfairly attacked and those attacks are done so without the numbers and data, therefore it is vital that research like this reaches decision makers."Besides the obvious benefit of subsidized healthcare, there is an additional spillover of the program in promoting a healthy diet by reducing one of the three evils of the American diet -- sugar -- which is bad in all respects from calories to cancer to obesity.

The program contributes not just to cover the treatment of patients but also in a more preventive why is carafate liquid so expensive way," says Lopez.The researchers add that now with the pandemic, prevention and access to healthcare is more vital than ever. This is especially true for those with pre-existing conditions and conditions that put people at an increased risk for corona virus, such as obesity.Continued research on the implications of programs such as Medicaid are needed, says Lopez, who says policy decisions need to be made based on research, not politics."It's important to see if we spend this money on Medicaid, we're getting some of it back even if it's indirect," says Boehm. "Policy makers need why is carafate liquid so expensive to have this information.

Not all states expanded Medicaid under the ACA, so if we have these results saying we see diet quality benefits that may help push other states to join the expansion..

Besides providing healthcare to millions, Medicaid helps recipients make healthier food choices according to buy carafate suspension UConn research published in the journal Health Economics. UConn Professor of Agricultural and Resource Economics, Rigoberto Lopez, Rebecca Boehm now an economist with the Union of Concerned Scientists, and Xi He now a post-doctoral researcher at the Iowa State were interested in investigating the impact of Medicaid on food choices.Medicaid is beneficial to recipients in a multitude of ways, by reducing emergency room visits, increasing access to preventive healthcare, while reducing out-of-pocket medical costs and buy carafate suspension debt, for instance. The program is highly politicized and is met with criticism and assumptions that it is too costly, yet research has shown the program actually saves states money.He, Lopez, and Boehm were interested in looking at other potential benefits of the program and also hoped to bridge some gaps in the literature says He,"There are many studies about the impact of Medicaid on mental health or on health spending but few studies have looked at how Medicaid affects food choices."He explains that by virtue of spending less on healthcare, new Medicaid recipients would have more room in their budget for food and therefore may spend more money on the same unhealthy foods and beverages they have always purchased. On the other hand, with more access to healthcare and health education through contact with providers, the researchers surmised that purchasing patterns could improve, says He.To see if this was the case, the researchers looked at purchases of beverages such as carbonated soft drinks, juice, milk and buy carafate suspension other non-alcoholic beverages before and after the expansion of Medicaid and compared purchases in states that did and did not expand the program under the Affordable Care Act. In a way, the states that did not expand Medicaid were the control group for buy carafate suspension their study.

They also compared purchase preferences for sugar content of these beverages. advertisement "We buy carafate suspension found that households in expansion states significantly increased their purchase of diet soda and bottled water, but there was no change in purchase of regular soda. But overall, these results indicate that Medicaid expansion, in states that did expand, shifted people's purchases to products with less sugar," says He.Access to healthcare has wide-ranging positive effects on the lives and habits of recipients. The added benefit of knowledge buy carafate suspension resulting from access to healthcare is not a policy mechanism that is usually discussed says Boehm,"With so many people working to help people eat healthier and to reduce obesity in the US, I don't hear a lot of talk about how the provision of healthcare through this income effect we proposed in this study can help people eat and drink healthier."Lopez says programs like Medicaid are often unfairly attacked and those attacks are done so without the numbers and data, therefore it is vital that research like this reaches decision makers."Besides the obvious benefit of subsidized healthcare, there is an additional spillover of the program in promoting a healthy diet by reducing one of the three evils of the American diet -- sugar -- which is bad in all respects from calories to cancer to obesity. The program contributes not just to cover the treatment of patients but also in buy carafate suspension a more preventive way," says Lopez.The researchers add that now with the pandemic, prevention and access to healthcare is more vital than ever.

This is especially true for those with pre-existing conditions and conditions that put people at an increased risk for corona virus, such as obesity.Continued research on the implications of programs such as Medicaid are needed, says Lopez, who says policy decisions need to be made based on research, not politics."It's important to see if we spend this money on Medicaid, we're getting some of it back even if it's indirect," says Boehm. "Policy makers need to have this information. Not all states expanded Medicaid under the ACA, so if we have these results saying we see diet quality benefits that may help push other states to join the expansion..

Carafate vs gaviscon

During the initial phase of COVID-19 lockdown, rates of loneliness among people in the UK were high and were associated with a number of social and health factors, according to a new study published this week in the open-access carafate vs gaviscon journal PLOS ONE by Jenny Groarke of Queen's University Belfast, UK, and colleagues.Loneliness is a significant public health issue and is associated with worse physical and mental health as well as increased mortality risk. Systematic review findings recommend that interventions addressing loneliness should focus on individuals who are socially isolated. However, researchers have lacked a comprehensive understanding of how vulnerability to loneliness might carafate vs gaviscon be different in the context of a pandemic.In the new study, researchers used an online survey to collect data about UK adults during the initial phase of COVID-19 lockdown in the country, from March 23 to April 24, 2020. 1,964 eligible participants responded to the survey, answering questions about loneliness, sociodemographic factors, health, and their status in relation to COVID-19. Participants were aged 18 to 87 years old (average 37.11), were mostly white (92.7%), female (70.4%), not religious (57.5%) and the majority were employed (71.9%).The overall prevalence of loneliness, defined as having carafate vs gaviscon a high score on the loneliness scale (ie., a score of 7 or higher out of 9), was over a quarter of respondents.

26.6%. In the week carafate vs gaviscon prior to completing the survey, 49% to 70% of respondents reported feeling isolated, left out or lacking companionship. Risk factors for loneliness were being in a younger age group (aOR. 4.67 -- 5.31), being separated carafate vs gaviscon or divorced (OR. 2.29), meeting clinical criteria for depression (OR.

1.74), greater emotion carafate vs gaviscon regulation difficulties (OR. 1.04), and poor-quality sleep due to the COVID-19 crisis (OR. 1.30). Higher levels of social support (OR. 0.92), being married/co-habiting (OR.

0.35) and living with a greater number of adults (OR. 0.87) were protective factors.The authors hope that these findings can inform support strategies and help to target those most vulnerable to loneliness during the pandemic.Groarke adds. "We found that rates of loneliness during the early stages of the UK lockdown were high. Our results suggest that supports and interventions to reduce loneliness should prioritise young people, those with mental health symptoms, and people who are socially isolated. Supports aimed at improving emotion regulation, sleep quality and increasing social support could reduce the impact of physical distancing regulations on mental health outcomes." Story Source.

Materials provided by PLOS. Note. Content may be edited for style and length..

During the initial phase of COVID-19 lockdown, rates of loneliness among people in the UK were high and were associated with a number of social and health factors, according to a new study published this week in the open-access journal PLOS ONE by Jenny Groarke of Queen's University Belfast, buy carafate suspension UK, and colleagues.Loneliness is a significant public health issue and is associated with worse physical and mental health as well as increased mortality risk. Systematic review findings recommend that interventions addressing loneliness should focus on individuals who are socially isolated. However, researchers have lacked a comprehensive understanding of how vulnerability to loneliness might be different in the context of a pandemic.In the buy carafate suspension new study, researchers used an online survey to collect data about UK adults during the initial phase of COVID-19 lockdown in the country, from March 23 to April 24, 2020. 1,964 eligible participants responded to the survey, answering questions about loneliness, sociodemographic factors, health, and their status in relation to COVID-19. Participants were aged 18 to 87 years old (average 37.11), were mostly white (92.7%), female (70.4%), buy carafate suspension not religious (57.5%) and the majority were employed (71.9%).The overall prevalence of loneliness, defined as having a high score on the loneliness scale (ie., a score of 7 or higher out of 9), was over a quarter of respondents.

26.6%. In the week prior to completing the survey, 49% to 70% of respondents reported feeling isolated, left buy carafate suspension out or lacking companionship. Risk factors for loneliness were being in a younger age group (aOR. 4.67 -- buy carafate suspension 5.31), being separated or divorced (OR. 2.29), meeting clinical criteria for depression (OR.

1.74), greater buy carafate suspension emotion regulation difficulties (OR. 1.04), and poor-quality sleep due to the COVID-19 crisis (OR. 1.30). Higher levels of social support (OR. 0.92), being married/co-habiting (OR.

0.35) and living with a greater number of adults (OR. 0.87) were protective factors.The authors hope that these findings can inform support strategies and help to target those most vulnerable to loneliness during the pandemic.Groarke adds. "We found that rates of loneliness during the early stages of the UK lockdown were high. Our results suggest that supports and interventions to reduce loneliness should prioritise young people, those with mental health symptoms, and people who are socially isolated. Supports aimed at improving emotion regulation, sleep quality and increasing social support could reduce the impact of physical distancing regulations on mental health outcomes." Story Source.

Materials provided by PLOS. Note. Content may be edited for style and length..

Sucralfate vs carafate

€‹Regional and rural patients sucralfate vs carafate now have access to 24-hour critical care under a $21.7 million telestroke service being rolled out across NSW.Patients at Port Macquarie and Coffs Harbour hospitals are the first to benefit from the NSW Telestroke Service, based at Sydney’s Prince of Wales Hospital. Health Minister Brad Hazzard said the revolutionary service will expand to up to 23 sites over the next three years. €œThe NSW Telestroke Service will remove geographical barriers and improve outcomes for thousands of regional sucralfate vs carafate and rural stroke patients every year, giving them a much greater chance of surviving and leading a normal life,” Mr Hazzard said. €œPeople in regional and rural areas have a far greater risk of hospitalisation from stroke and this vital service will provide them with immediate, life-saving diagnosis and treatment from the state’s leading clinicians.” In 2018-19, 13,651 people were hospitalised for a stroke in NSW. Of those, 32 per cent were from regional, rural or sucralfate vs carafate remote areas.

A successful pilot project in the Hunter New England, Central Coast and Mid North Coast local health districts since 2017 has already helped 1200 patients. The Stroke Foundation’s Chief Executive Officer Sharon McGowan welcomed the launch of the statewide sucralfate vs carafate service, jointly funded by the State and Federal governments. €œWhen a stroke strikes, it kills up to 1.9 million brain cells per minute. This service will have an enormous impact by providing time-critical, best-practice sucralfate vs carafate treatment that saves lives and reduces lifelong disability,” Ms McGowan said. Prince of Wales Hospital’s Director of Clinical Neuroscience Professor Ken Butcher said.

€œThe service links expert stroke clinicians with local emergency physicians to quickly determine the best possible treatment plan for a patient.” ​.

€‹Regional and rural patients now have access to 24-hour critical care under a $21.7 million telestroke service being rolled out across NSW.Patients at Port Macquarie and Coffs Harbour hospitals are the first to benefit from the NSW Telestroke buy carafate suspension Service, based at Sydney’s Prince of Wales Hospital. Health Minister Brad Hazzard said the revolutionary service will expand to up to 23 sites over the next three years. €œThe NSW Telestroke Service will remove geographical barriers and improve outcomes for thousands of regional and rural stroke patients every year, giving them a much greater chance of surviving buy carafate suspension and leading a normal life,” Mr Hazzard said. €œPeople in regional and rural areas have a far greater risk of hospitalisation from stroke and this vital service will provide them with immediate, life-saving diagnosis and treatment from the state’s leading clinicians.” In 2018-19, 13,651 people were hospitalised for a stroke in NSW.

Of those, buy carafate suspension 32 per cent were from regional, rural or remote areas. A successful pilot project in the Hunter New England, Central Coast and Mid North Coast local health districts since 2017 has already helped 1200 patients. The Stroke Foundation’s Chief Executive Officer Sharon McGowan welcomed the launch of the statewide buy carafate suspension service, jointly funded by the State and Federal governments. €œWhen a stroke strikes, it kills up to 1.9 million brain cells per minute.

This service will have an enormous impact by providing time-critical, best-practice treatment that buy carafate suspension saves lives and reduces lifelong disability,” Ms McGowan said. Prince of Wales Hospital’s Director of Clinical Neuroscience Professor Ken Butcher said. €œThe service links expert stroke clinicians with local emergency physicians to quickly determine the best possible treatment plan for a patient.” ​.

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