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Two years into the World Health Organization’s (WHO) ambitious effort to eliminate industrially produced trans fats from the global food supply, the Organization reports that 58 countries so far have introduced laws that will protect 3.2 billion people from the harmful substance by the end kamagra for sale online of 2021. But more than 100 countries still need to take actions to remove these harmful substances from their food supplies.Consumption of industrially produced trans fats are estimated to cause around 500,000 deaths per year due to coronary heart disease. €œIn a time when the whole world is fighting the kamagra for sale online COVID-19 pandemic, we must make every effort to protect people’s health.

That must include taking all steps possible to prevent noncommunicable diseases that can make them more susceptible to the coronavirus, and cause premature death,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. €œOur goal of eliminating trans fats by 2023 must not be delayed.” Fifteen kamagra for sale online countries account for approximately two thirds of the worldwide deaths linked to trans fat intake. Of these, four (Canada, Latvia, Slovenia, United States of America) have implemented WHO-recommended best-practice policies since 2017, either by setting mandatory limits for industrially produced trans fats to 2% of oils and fats in all foods or banning partially hydrogenated oils (PHO).But the remaining 11 countries (Azerbaijan, Bangladesh, Bhutan, Ecuador, Egypt, India, Iran, Mexico, Nepal, Pakistan, Republic of Korea) still need to take urgent action.

The report highlights two encouraging trends. First, when countries do act, they overwhelmingly kamagra for sale online adopt best-practice policies rather than less restrictive ones. New policy measures passed and/or introduced in the past year in Brazil, Turkey and Nigeria all meet WHO’s criteria for best-practice policies.

Countries, such as kamagra for sale online India, that have previously implemented less restrictive measures, are now updating policies to align with best practice. Second, regional regulations that set standards for multiple countries are becoming increasingly popular, emerging as a promising strategy for accelerating progress towards global elimination by 2023. In 2019, the European Union passed a best-practice policy, and all 35 countries that are part of the WHO American Region/Pan American Health Organization unanimously approved a regional plan of action to eliminate industrially produced trans fats by 2025.

Together, these kamagra for sale online two regional initiatives have the potential to protect an additional 1 billion people in more than 50 countries who were not previously protected by trans fat regulations. €œWith the global economic downturn, more than ever, countries are looking for best buys in public health,” said Dr Tom Frieden, President and CEO of Resolve to Save Lives. €œMaking food kamagra for sale online trans fat-free, saves lives and saves money, and, by preventing heart attacks, reduces the burden on health care facilities.” Despite the encouraging progress, important disparities persist in policy coverage by region and country income level.

Most policy actions to date, including those passed in 2019 and 2020, have been in higher-income countries and in the WHO Regions of the Americas and Europe. Best-practice policies have been adopted by seven upper-middle-income countries and 33 high-income countries. No low-income or lower-middle-income kamagra for sale online countries have yet done so.

Note to editors:Industrially produced trans fats are contained in hardened vegetable fats, such as margarine and ghee, and are often present in snack food, baked foods, and fried foods. Manufacturers often use them as they have a longer shelf life kamagra for sale online and are cheaper than other fats. But healthier alternatives can be used that do not affect taste or cost of food.WHO recommends that trans fat intake be limited to less than 1% of total energy intake, which translates to less than 2.2 g/day with a 2,000-calorie diet.

To achieve a world free of industrially produced trans fats by 2023, WHO recommends that countries. Develop and kamagra for sale online implement best-practice policies to set mandatory limits for industrially produced trans fats to 2% of oils and fats in all foods or to ban partially hydrogenated oils (PHO). Invest in monitoring mechanisms, e.g.

Lab capacity to kamagra for sale online measure and monitor trans fats in foods. And advocate for regional or sub-regional regulations to expand the benefits of trans fat policies.This report launches during 2020 Global Week for Action on Noncommunicable Diseases (NCDs) from 7 to 13 September. This year's theme is accountability to ensure that commitments made by governments, policy makers, industries, academia, and civil society become a reality.

Link to Report:https://apps.who.int/iris/bitstream/handle/10665/334170/9789240010178-eng.pdfAbout WHOThe World kamagra for sale online Health Organization provides global leadership in public health within the United Nations system. Founded in 1948, WHO works with 194 Member States, across six regions and from more than 150 offices, to promote health, keep the world safe and serve the vulnerable. Our goal for 2019-2023 is to ensure that a billion more people have universal health coverage, to protect a billion more people from health emergencies, and provide a further billion people with better health and wellbeing.For updates on COVID-19 and public health advice to protect yourself from coronavirus, visit www.who.int and follow WHO on Twitter, Facebook, Instagram, LinkedIn, TikTok, Pinterest, Snapchat, YouTubeAbout Resolve to Save LivesResolve to Save Lives, an initiative of the global kamagra for sale online health organization Vital Strategies, focuses on preventing deaths from cardiovascular disease and by preventing epidemics.

Resolve to Save Lives is funded by Bloomberg Philanthropies, the Bill &. Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded kamagra for sale online with support from the Chan Zuckerberg Foundation. It is led by Dr.

Tom Frieden, former director of the U.S. Centers for Disease Control and kamagra for sale online Prevention. To find out more, visit.

Https://www.resolvetosavelives.org or Twitter @ResolveTSL and @DrTomFriedenAbout Vital StrategiesVital Strategies is a global health organization that believes every person should be protected kamagra for sale online by a strong public health system. We work with governments and civil society in 73 countries to design and implement evidence-based strategies that tackle their most pressing public health problems. Our goal is to see governments adopt promising interventions at scale as rapidly as possible.

To find out more, please visit www.vitalstrategies.org or Twitter @VitalStrat.United Nations Secretary General António Guterres appeals for a quantum leap in funding for the ACT-Accelerator, a global solution to get the world moving, working and prospering againH.E kamagra for sale online. Cyril Ramaphosa, President of South Africa, and H.E. Erna Solberg, Prime Minister of Norway, co-chair the ACT-Acceleration Facilitation CouncilGlobal leaders – including over 30 heads of state and ministers – release statement of commitment to galvanizing support for the ACT-Accelerator and the need for the financial resources required to leave no one behindACT-Accelerator calculates that $35 billion is still required to give all countries the tools needed to end kamagra for sale online the pandemic as quickly as possible Today Dr Tedros Adhanom Ghebreyesus, WHO Director-General, and Dr Ursula von der Leyen, President of the European Commission, co-hosted the inaugural meeting of the Access to COVID-19 Tools (ACT) Accelerator Facilitation Council.

The meeting was co-chaired by H.E. Cyril Ramaphosa, President of South Africa and H.E. Erna Solberg, Prime Minister of Norway and included kamagra for sale online a keynote address from the UN Secretary-General António Guterres.The ACT-Accelerator is the proven, up-and-running, global collaboration accelerating the development, production, and equitable access to COVID-19 tests, treatments, and vaccines.

It was launched on 24 April 2020 by WHO with the European Commission, France and the Bill &. Melinda Gates Foundation and supported by the UN Secretary-General kamagra for sale online and multiple Heads of Government, it is already delivering substantial returns. Over 170 countries are engaged in the new COVID-19 Vaccine Facility and ten candidate vaccines are under evaluation, 9 of them in clinical trials, giving the largest and most diverse COVID-19 vaccine portfolio in the world.Investing in the ACT-Accelerator’s multilateral approach increases the chance of success for all countries by giving access to a greater number of tools more quickly, as well as sharing the costs, and mitigating the risks of, R&D.

A total of US$35 billion is still needed for the ACT-Accelerator to realise its goals of producing 2 billion vaccine doses, 245 million treatments and 500 million tests. Dr Tedros Adhanom Ghebreyesus, kamagra for sale online WHO Director-General, said. "Nearly 5 000 lives are lost each day due to COVID-19 and the global economy is expected to contract by trillions of dollars this year.

The case for investing to end the pandemic has kamagra for sale online never been stronger. The ACT-Accelerator is the best way to ensure equitable access to vaccines, diagnostics and therapeutics, but at present is facing a financing gap of US$35 billion. Fully financing the ACT-Accelerator would shorten the pandemic and pay back this investment rapidly as the global economy recovers".Ursula von der Leyen, President of the European Commission, said.

€œToday’s launch of the Facilitation Council brings us closer to our global kamagra for sale online goal. Access to coronavirus vaccines, tests and treatments for everyone who needs them, anywhere. The EU kamagra for sale online will use all its convening power to help keep the world united against coronavirus.

With the chairmanship of Norway and South Africa representing the global North and South, and the expertise of the WHO and our international partners, no country or region will be left behind in this fight.” UN Secretary-General António Guterres, said. €œWe now need US$35 billion more to go from set-up to scale kamagra for sale online and impact. There is a real urgency in these numbers.

Without an infusion of US$15 billion over the next 3 months, beginning immediately, we will lose the window of opportunity”.H.E. Cyril Ramaphosa, kamagra for sale online President of South Africa, said. "It is essential that humanity should have a sense that if and when a vaccine is developed, all countries, including my own continent, Africa, should benefit and not be left behind.

Humanity requires that a vaccine should be regarded as a public good to benefit all kamagra for sale online. We cannot achieve universal health coverage when a COVID-19 vaccine is available only to countries that are well-resourced”.President Paul Kagame of Rwanda noted. €œThis is certainly one of the most important initiatives underway in the world today and perhaps ever”.

He added “The difference between success and failure lies in building a robust public health infrastructure that can confront any health issue in kamagra for sale online a sustainable manner. Solid health systems combined with transformational partnerships such as this Accelerator are critical.”H.E Erna Solberg, Prime Minister of Norway said. €œThe ACT-Accelerator kamagra for sale online has already achieved impressive results.

The world has shown that it is able to come together at a time of crisis. Norway will work tirelessly to ensure that common interests are established and followed, and that all countries and actors are listened to, so that we can maximize our result together.”Today’s meeting was held at a crucial pivot point for the ACT-Accelerator as it reviewed an updated strategy and investment case for its scale-up phase. The document kamagra for sale online will be finalised by 17 September 2020 with publication soon after.

The UN Secretary-General has confirmed a high-level event will take place on 30 September 2020 at the forthcoming General Assembly.The role of the Council is to facilitate the work of the ACT-Accelerator through political leadership and advocacy for collective solutions in the global interest, and for the mobilization of additional resources.Membership of the Council is made up of representatives of the European Commission, World Health Organization, Bahrain, Brazil, Canada, China, France, Germany, India, Indonesia, Italy, Japan, Republic of Korea, Mexico, Nepal, Norway, Russia, Rwanda, Saudi Arabia, Singapore, South Africa. Spain, St Kitts and kamagra for sale online Nevis, Tuvala, United Kingdom, Uzbekistan and Vietnam. In addition the Council includes the Wellcome Trust, the World Economic Forum and the Bill &.

Melinda Gates Foundation as well as the WHO Special Envoys for ACT-A, Civil Society representatives and industry representatives.Notes to Editors The Access to COVID-19 Tools ACT-Accelerator, is the proven, up-and-running global collaboration to accelerate the development, production, and equitable access to COVID-19 tests, treatments, and vaccines. It was set kamagra for sale online up in response to a call from G20 leaders in March and launched by the WHO, European Commission, France and The Bill &. Melinda Gates Foundation in April 2020.The ACT-Accelerator is not a decision-making body or a new organization, but works to speed up collaborative efforts among existing organizations to end the pandemic.

It is a framework for collaboration that has been designed to bring key players around the table with the goal of ending the pandemic as quickly kamagra for sale online as possible through the accelerated development, equitable allocation, and scaled up delivery of tests, treatments and vaccines, thereby protecting health systems and restoring societies and economies in the near term. It draws on the experience of leading global health organizations which are tackling the world’s toughest health challenges, and who, by working together, are able to unlock new and more ambitious results against COVID-19. Its members share a commitment to ensure all people have access to all the tools needed to defeat COVID-19 and to work with unprecedented levels of partnership to achieve it.

The ACT-Accelerator kamagra for sale online has four areas of work. Diagnostics, therapeutics, vaccines and the health system connector. Cross-cutting all kamagra for sale online of these is the workstream on Access &.

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A phase three global clinical trial led by the Murdoch Children's Research Institute (MCRI) has shown a new drug boosts bone growth in children born with achondroplasia, the most common type of dwarfism.The randomised, double-blind, placebo-controlled trial results, led by MCRI clinical geneticist Professor Ravi Savarirayan, have been published today in the medical journal, The Lancet.Achondroplasia is the most common cause of dwarfism and is caused by overactivity of the FGFR3 protein, which slows bone growth in children's limbs, spine, and the kamagra effekt base kamagra deutschland of their skull.The experimental drug, vosoritide, blocks the activity of FGFR3, potentially returning growth rates to normal. Previous MCRI-led trials have confirmed kamagra deutschland vosoritide was safe to give to young people with dwarfism. This new randomised controlled trial conclusively shows it is also effective increasing bone growth over one year of daily injections.Professor Savarirayan said, "This drug is like releasing the handbrake on a car, it lets you get up to full speed instead of having to drive with the brakes on."Achondroplasia is a genetic bone disorder affecting 250,000 people worldwide, or about one in every 25,000 children.

It is caused by a mutation in the FGFR3 gene that impairs bone growth and means that children grow around 4 cm kamagra deutschland per year, instead of the usual 6 to 7 cm. advertisement Current achondroplasia treatments, like surgery, only address the symptoms. In contrast, vosoritide is a precision therapy directly targeted at the molecular cause of the disease.BioMarin Pharmaceutical, who manufacturers the peptide drug and funded the trial, has applied to the US Food and Drug Administration to license vosoritide for its use in treating kamagra deutschland achondroplasia.

The European Medicines Agency validated the Company's application. Australian licensing kamagra deutschland is expected to follow sometime after a successful US application.For the trial, 121 children aged five to under 18 were enrolled, which was conducted at 24 hospitals in seven countries. In Melbourne, the trial was kamagra deutschland https://www.voiture-et-handicap.fr/kamagra-100mg-price-in-canada/ conducted at the Melbourne Children's Trial Centre.

The 60 children who received daily injections of vosoritide grew an average of 1.57 cm per year more than the children who received placebo, which brought them almost in line with their typically developing peers.Professor Savarirayan said, "We know that beyond the cold hard facts and figures around growth rates and bone biology, we have hope that a treatment can improve kids' health outcomes, social functioning and increase access to their environments. Anecdotally, our kamagra deutschland patients tell us they now are able to do more stuff like climbing trees, jumping rocks and being more independent generally, which is specific to their experiences."Dr Johnathon Day, Medical Director of Clinical Science at BioMarin Pharmaceutical Inc. Said, "Vosoritide is the first potential precision pharmacological therapy that addresses the underlying cause of achondroplasia and this randomized, double-blind, placebo-controlled Phase 3 study further adds to the scientific knowledge we've gained over many years from the clinical development program.

I'd like to personally thank and congratulate all of the kamagra deutschland investigators and I am especially grateful to all of the children and their families who have participated in these studies,"Paul Cohen and Elizabeth Ryan's daughter, Sarah, was born with achondroplasia. Sarah was one of the very first patients enrolled in the trial. Mr Cohen said, "During the trial we've seen Sarah grow up at the same kamagra deutschland rate as her friends.

She can now join in bike rides with her friends, and loves being allowed on our local waterslide."Although the trial did not significantly improve the children's proportions between their upper and lower bodies, the children will be followed until they achieve their final adult height to see how long the drug's effects last and whether they experience a growth spurt during puberty, as this doesn't normally happen in children with achondroplasia.Vosoritide is also being tested in children from birth to five years which may improve final height, body proportion and other age-related complications such as spinal cord compression, which can cause sudden death..

A phase three global clinical trial led by the Murdoch Children's Research Institute (MCRI) has shown a new drug boosts bone growth in kamagra for sale online children born with achondroplasia, the most common type of dwarfism.The randomised, double-blind, placebo-controlled trial results, led by MCRI clinical geneticist Professor Ravi Savarirayan, have been published today in the medical journal, The Lancet.Achondroplasia is the most common cause of dwarfism and is caused by overactivity of the FGFR3 protein, which slows bone growth in children's limbs, spine, and the base of their skull.The experimental drug, vosoritide, blocks the activity of FGFR3, potentially returning growth rates to normal. Previous MCRI-led trials have confirmed vosoritide kamagra for sale online was safe to give to young people with dwarfism. This new randomised controlled trial conclusively shows it is also effective increasing bone growth over one year of daily injections.Professor Savarirayan said, "This drug is like releasing the handbrake on a car, it lets you get up to full speed instead of having to drive with the brakes on."Achondroplasia is a genetic bone disorder affecting 250,000 people worldwide, or about one in every 25,000 children. It is caused by a mutation in the kamagra for sale online FGFR3 gene that impairs bone growth and means that children grow around 4 cm per year, instead of the usual 6 to 7 cm. advertisement Current achondroplasia treatments, like surgery, only address the symptoms.

In contrast, vosoritide is a precision therapy directly targeted at the kamagra for sale online molecular cause of the disease.BioMarin Pharmaceutical, who manufacturers the peptide drug and funded the trial, has applied to the US Food and Drug Administration to license vosoritide for its use in treating achondroplasia. The European Medicines Agency validated the Company's application. Australian licensing is expected to follow sometime after a kamagra for sale online successful US application.For the trial, 121 children aged five to under 18 were enrolled, which was conducted at 24 hospitals in seven countries. In Melbourne, the trial was conducted at the Melbourne Children's Trial kamagra for sale online Centre. The 60 children who received daily injections of vosoritide grew an average of 1.57 cm per year more than the children who received placebo, which brought them almost in line with their typically developing peers.Professor Savarirayan said, "We know that beyond the cold hard facts and figures around growth rates and bone biology, we have hope that a treatment can improve kids' health outcomes, social functioning and increase access to their environments.

Anecdotally, our patients tell us they now are able to do more stuff like climbing trees, jumping rocks kamagra for sale online and being more independent generally, which is specific to their experiences."Dr Johnathon Day, Medical Director of Clinical Science at BioMarin Pharmaceutical Inc. Said, "Vosoritide is the first potential precision pharmacological therapy that addresses the underlying cause of achondroplasia and this randomized, double-blind, placebo-controlled Phase 3 study further adds to the scientific knowledge we've gained over many years from the clinical development program. I'd like to personally thank and congratulate all kamagra for sale online of the investigators and I am especially grateful to all of the children and their families who have participated in these studies,"Paul Cohen and Elizabeth Ryan's daughter, Sarah, was born with achondroplasia. Sarah was one of the very first patients enrolled in the trial. Mr Cohen said, "During kamagra for sale online the trial we've seen Sarah grow up at the same rate as her friends.

She can now join in bike rides with her friends, and loves being allowed on our local waterslide."Although the trial did not significantly improve the children's proportions between their upper and lower bodies, the children will be followed until they achieve their final adult height to see how long the drug's effects last and whether they experience a growth spurt during puberty, as this doesn't normally happen in children with achondroplasia.Vosoritide is also being tested in children from birth to five years which may improve final height, body proportion and other age-related complications such as spinal cord compression, which can cause sudden death..

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One of the priority actions in the New Zealand kamagra bestellen betrouwbaar Healthy Ageing Strategy (2016) was to improve models of care for Home and Community Support Services (HCSS) in response to the multiple and kamagra 24 hour delivery growing demands on HCSS. The National Framework for HCSS provides guidance for district health boards for future commissioning, developing, delivering and evaluating HCSS to improve national consistency and quality of care. The National Framework for HCSS was developed in collaboration with key stakeholders in the HCSS sector, including older people and their kamagra bestellen betrouwbaar whānau. It includes. a vision and principles to guide service design core (essential) components of services that could be expected anywhere in the country a draft outcomes framework describing the outcomes sought from HCSS at individual, population and system levels.

The National Framework kamagra bestellen betrouwbaar for HCSS covers DHB-funded services for. people aged 65 years and over who have an assessed need in response to an interRAI assessment and meet criteria for funding people considered to be alike in age and interest – for example, Pacific peoples and Māori, aged over 55 years, and others aged over 60 years, with age-related disabilities older people receiving HCSS who require increased support following an acute health episode who have required hospitalisation HCSS that may continue concurrently with short-term Accident Compensation Corporation (ACC) services. Three additional initiatives are linked with developing the National Framework to help achieve consistency in service commissioning, provision and resource allocation. First, a National kamagra bestellen betrouwbaar Service Specification for HCSS. This service specification will become the nationally mandated specification describing in detail the services and service approaches required of DHBs and providers.

This National Service Specification will be implemented by July 2022, in line with DHB service commissioning timetables. This approach aims to achieve the best balance between national consistency kamagra bestellen betrouwbaar and flexibility for DHBs in meeting the needs of their populations. Second, a nationally consistent case-mix methodology will be developed for all DHBs to use as a way of improving targeting of resources according to need. Some DHBs are already applying case-mix methods to resource allocation or use. However, different kamagra bestellen betrouwbaar versions of the methodology are being used, resulting in some inconsistency in resource allocation and lack of transparency across DHBs.

This indicates the need for a single, nationally consistent case-mix method which will also be implemented across all DHBs by July 2022. Third, a nationally consistent outcomes and measurement framework will be developed for use in HCSS and is expected to be completed by July 2021.The Historical mortality web tool presents mortality data (numbers and age-standardised rates) by sex for certain causes of death from 1948 to 2016. Mortality data by sex, age group and ethnicity (Māori and kamagra bestellen betrouwbaar non-Māori) best kamagra site is presented from 1996 to 2016.The web tool enables you to explore trends over time using interactive graphs and tables. Filtered results and the full data set can be downloaded from within the web tool. The causes of death included are.

All cancer Ischaemic heart disease Cerebrovascular disease Chronic lower respiratory diseases Other forms of heart disease Influenza and Pneumonia Diabetes mellitus Motor vehicle accidents Intentional self-harm Assault All kamagra bestellen betrouwbaar deaths. The full data set presented in the web tool is available for you to download in text file format. A technical document accompanies the web tool. This document contains information about the data source and analytical methods used to produce summary kamagra bestellen betrouwbaar data, and a data dictionary for variables used in the web tool. About the data used in this edition Data from 1948 to 1995 presented in these tables was sourced from publications in the Ministry of Health Mortality data and stats series.

Data from 1996 to 2016 was extracted from the New Zealand Mortality Collection records on 07 June 2019. At the time kamagra bestellen betrouwbaar of extraction, there were 606,450 deaths registered from 1996 to 2016. Included in this data were 641 deaths provisionally coded awaiting coroners’ findings and 41 deaths awaiting coroners’ findings with no known cause. Ethnic breakdowns of mortality data are only shown from 1996 onwards because there was a significant change in the way ethnicity was defined, and in the way ethnicity data was collected in 1995. For more information please refer to the Ministry of Health report, Mortality and kamagra bestellen betrouwbaar Demographic Data 1996.

Disclaimer In this edition, data for causes of death was extracted and recalculated for the years 1996–2016 to reflect ongoing updates to data in the New Zealand Mortality Collection (for example, following the release of coroners’ findings) and the revision of population estimates and projections following each census. For this reason there may be small changes to some numbers and rates from those presented in previous publications and tables. We have quality checked the collection, extraction, and reporting of kamagra bestellen betrouwbaar the data presented here. However errors can occur. Contact the Ministry of Health if you have any concerns regarding any of the data or analyses presented here, at data-enquires@health.govt.nz.

One of the priority actions in the New Zealand Healthy Ageing Strategy (2016) was to improve models of care for kamagra for sale online Home and Community Support who can buy kamagra Services (HCSS) in response to the multiple and growing demands on HCSS. The National Framework for HCSS provides guidance for district health boards for future commissioning, developing, delivering and evaluating HCSS to improve national consistency and quality of care. The National Framework for HCSS was developed kamagra for sale online in collaboration with key stakeholders in the HCSS sector, including older people and their whānau. It includes. a vision and principles to guide service design core (essential) components of services that could be expected anywhere in the country a draft outcomes framework describing the outcomes sought from HCSS at individual, population and system levels.

The National Framework for kamagra for sale online HCSS covers DHB-funded services for. people aged 65 years and over who have an assessed need in response to an interRAI assessment and meet criteria for funding people considered to be alike in age and interest – for example, Pacific peoples and Māori, aged over 55 years, and others aged over 60 years, with age-related disabilities older people receiving HCSS who require increased support following an acute health episode who have required hospitalisation HCSS that may continue concurrently with short-term Accident Compensation Corporation (ACC) services. Three additional initiatives are linked with developing the National Framework to help achieve consistency in service commissioning, provision and resource allocation. First, a National kamagra for sale online Service Specification for HCSS. This service specification will become the nationally mandated specification describing in detail the services and service approaches required of DHBs and providers.

This National Service Specification will be implemented by July 2022, in line with DHB service commissioning timetables. This approach aims kamagra for sale online to achieve the best balance between national consistency and flexibility for DHBs in meeting the needs of their populations. Second, a nationally consistent case-mix methodology will be developed for all DHBs to use as a way of improving targeting of resources according to need. Some DHBs are already applying case-mix methods to resource allocation or use. However, different versions of the methodology are being used, resulting in some inconsistency in resource allocation kamagra for sale online and lack of transparency across DHBs.

This indicates the need for a single, nationally consistent case-mix method which will also be implemented across all DHBs by July 2022. Third, a nationally consistent outcomes and measurement framework will be developed for use in HCSS and is expected to be completed by July 2021.The Historical mortality web tool presents mortality data (numbers and age-standardised rates) by sex for certain causes of death from 1948 to 2016. Mortality data by sex, age group and ethnicity (Māori and non-Māori) is presented from 1996 kamagra for sale online to 2016.The web tool enables https://www.voiture-et-handicap.fr/buy-kamagra-oral-jelly-online-australia/ you to explore trends over time using interactive graphs and tables. Filtered results and the full data set can be downloaded from within the web tool. The causes of death included are.

All cancer Ischaemic heart disease Cerebrovascular disease Chronic lower respiratory diseases Other forms of heart disease Influenza kamagra for sale online and Pneumonia Diabetes mellitus Motor vehicle accidents Intentional self-harm Assault All deaths. The full data set presented in the web tool is available for you to download in text file format. A technical document accompanies the web tool. This document contains information about the data source and analytical methods used to produce summary data, and a data dictionary for variables used in the kamagra for sale online web tool. About the data used in this edition Data from 1948 to 1995 presented in these tables was sourced from publications in the Ministry of Health Mortality data and stats series.

Data from 1996 to 2016 was extracted from the New Zealand Mortality Collection records on 07 June 2019. At the kamagra for sale online time of extraction, there were 606,450 deaths registered from 1996 to 2016. Included in this data were 641 deaths provisionally coded awaiting coroners’ findings and 41 deaths awaiting coroners’ findings with no known cause. Ethnic breakdowns of mortality data are only shown from 1996 onwards because there was a significant change in the way ethnicity was defined, and in the way ethnicity data was collected in 1995. For more information please refer to the Ministry of Health report, Mortality and Demographic Data 1996 kamagra for sale online.

Disclaimer In this edition, data for causes of death was extracted and recalculated for the years 1996–2016 to reflect ongoing updates to data in the New Zealand Mortality Collection (for example, following the release of coroners’ findings) and the revision of population estimates and projections following each census. For this reason there may be small changes to some numbers and rates from those presented in previous publications and tables. We have quality checked the collection, extraction, and reporting of kamagra for sale online the data presented here. However errors can occur. Contact the Ministry of Health if you have any concerns regarding any of the data or analyses presented here, at data-enquires@health.govt.nz.

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What you really need to do is increase your activity level outside of work and incorporate some regular exercises that combat the negative effects of sitting. These exercises can include core strengthening, stretching of the hips and chest and exercises to reverse your forward posture. If you are experiencing kamagra pills australia pain related to sitting for long periods of time, a physical therapist can help you identify a more targeted exercise program.

Physical Therapist Kyle Stevenson, D.P.T., sees patients at MidMichigan’s Rehabilitation Services location in Greater Midland North-End Fitness Center. He has a special interest in sports medicine, and enjoys kamagra pills australia working with athletes of all ages. He has completed specialized coursework and training for the throwing athletes.

New patients are welcome with a physician referral by kamagra pills australia calling (989) 832-5913. Those who would like more information about MidMichigan’s Rehabilitation Services may visit www.midmichigan.org/rehabilitation.W-sitting is a normal developmental position that babies usually discover when they sit back straight from their hands and knees. Their legs will then form a “W.” Often, babies also transition back to a single hip, toward a side sitting position.

When a baby varies his or her sitting kamagra pills australia position, W-sitting is rarely a problem. However, when a baby sits back straight to a W-sit consistently, they don’t get the opportunity to elongate and activate lateral trunk muscles to develop their core muscles. W-sitting is a very stable position that children find useful, however, it allows them to play without developing kamagra pills australia muscle that provide the ability for kids to reach out to their sides or rotate across their midline, leading to underdevelopment of lower trunk muscles, which stabilize the pelvis.

When a child uses this position as their preference without the normal variety in movements, it can affect development. They may kamagra pills australia demonstrate an in-toeing gait, core weakness or balance difficulties. The hips are positioned in extreme internal rotation, placing stress on the hips and the knee joints.

This can lead to hip and knee orthopedic issues as the child develops. So, what can you kamagra pills australia do to prevent any development issues?. Encourage your child to alternate sitting positions, such as side sitting (alternating sides), ring sitting, or, with older children, sitting in a chair or on a ball.

This might be challenging initially, but once your child gets kamagra pills australia used to it, they may just need reminders. If it’s difficult for your child to sit in alternate positions or they begin to show other developmental concerns, a referral to a physical therapist may be helpful to facilitate trunk muscle development. Eileen McMahon, M.S.P.T., is a physical therapist at MidMichigan Health..

Over the last few years, there have been many articles detailing how bad kamagra for sale online sitting can be for the body. You may have even seen the phrase, “Sitting is the new smoking.” But how bad is sitting down, really?. As a physical therapist, I see many people who come into my office and sheepishly kamagra for sale online admit that they sit all day long for their jobs. As our reliance on technology for our jobs increases, this becomes more and more of the norm for society. Personally, I think sitting has gotten a bad rap, and what we kamagra for sale online really need to do is look at our lack of physical activity overall.

When we sit every day for our job, it can have a negative impact on the body, but an overall lack of physical activity is much more concerning than sitting itself. When we sit, our bodies adapt to that position. There are several things that occur, such as a tightening of the hamstrings kamagra for sale online and a forward head and rounded shoulder posture. We don’t use our core muscles when we sit, because our body is supported, so there can be a weakening of those muscles as well. Our body kamagra for sale online gets used to not having to use these muscle groups.

Then, when you do try to get out and be active, or work in the yard, you might be more susceptible to injury or pain because your body isn’t used to that kind of stress. In short, you don’t need to quit your day job to pursue a career kamagra for sale online that involves standing all day. What you really need to do is increase your activity level outside of work and incorporate some regular exercises that combat the negative effects of sitting. These exercises can include core strengthening, stretching of the hips and chest and exercises to reverse your forward posture. If you are experiencing pain related to sitting for long periods kamagra for sale online of time, a physical therapist can help you identify a more targeted exercise program.

Physical Therapist Kyle Stevenson, D.P.T., sees patients at MidMichigan’s Rehabilitation Services location in Greater Midland North-End Fitness Center. He has kamagra for sale online a special interest in sports medicine, and enjoys working with athletes of all ages. He has completed specialized coursework and training for the throwing athletes. New patients are welcome kamagra for sale online with a physician referral by calling (989) 832-5913. Those who would like more information about MidMichigan’s Rehabilitation Services may visit www.midmichigan.org/rehabilitation.W-sitting is a normal developmental position that babies usually discover when they sit back straight from their hands and knees.

Their legs will then form a “W.” Often, babies also transition back to a single hip, toward a side sitting position. When a baby varies his or her sitting position, W-sitting is rarely a kamagra for sale online problem. However, when a baby sits back straight to a W-sit consistently, they don’t get the opportunity to elongate and activate lateral trunk muscles to develop their core muscles. W-sitting is a very stable position kamagra for sale online that children find useful, however, it allows them to play without developing muscle that provide the ability for kids to reach out to their sides or rotate across their midline, leading to underdevelopment of lower trunk muscles, which stabilize the pelvis. When a child uses this position as their preference without the normal variety in movements, it can affect development.

They may demonstrate kamagra for sale online an in-toeing gait, core weakness or balance difficulties. The hips are positioned in extreme internal rotation, placing stress on the hips and the knee joints. This can lead to hip and knee orthopedic issues as the child develops. So, what can you do to prevent any development issues?. Encourage your child to alternate sitting positions, such as side sitting (alternating sides), ring sitting, or, with older children, sitting in a chair or on a ball.

This might be challenging initially, but once your child gets used to it, they may just need reminders. If it’s difficult for your child to sit in alternate positions or they begin to show other developmental concerns, a referral to a physical therapist may be helpful to facilitate trunk muscle development. Eileen McMahon, M.S.P.T., is a physical therapist at MidMichigan Health..

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Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee on Child and Adolescent cheap kamagra pills HealthExecutive kamagra 100mg Board Member, Texas Pediatric SocietyDoctors are community leaders. This role has become even more important during the COVID-19 pandemic. As patients navigate our new reality, they are looking to us to determine what is safe, how to protect kamagra 100mg their families, and the future of their health care. As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net.

The U.S. Census helps determine funding for those resources, and that is why it kamagra 100mg is of the upmost importance that each and every Texan, no matter address, immigration status, or age, respond to the 2020 U.S. Census. The deadline has been cut short one month and now closes Sept kamagra 100mg.

30.COVID-19 has only increased the importance of completing the census to help our local communities and economies recover. The novel coronavirus has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more. Schools also have been stretched thin, with teachers kamagra 100mg scrambling to teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago.

Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the pandemic’s fallout. Therefore, it is vital that all Texans be counted.The federal dollars Texas receives generally depends on kamagra 100mg our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example. Federal funds kamagra 100mg pay for 60% of the state’s program, which provides health coverage for two out of five Texas children, one in three individuals with disabilities, and 53% of all births.

The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars. If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, kamagra 100mg but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census.

Texas also uses this federal funding to study and respond to maternal kamagra 100mg mortality and perinatal depression.Food and housing As unemployment rises and families struggle financially, many live with uncertainty as to where they will find their next meal. Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the pandemic continues. The Central Texas Food Bank saw a 206% rise in clients in kamagra 100mg March.

Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census. Funding for local housing programs also is calculated via the census. An accurate count kamagra 100mg will help ensure that people who lose their homes during this economic crisis have better hope of finding shelter while our communities recover. Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by coronavirus, more parents are taking on roles as breadwinner, parent, teacher, and caretaker.

This stress highlights the desperate need kamagra 100mg for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families. The good news is you still have time to complete the census. Visit 2020census.gov to take kamagra 100mg it.

It takes less than five minutes to complete. Then talk to your family, neighbors, and kamagra 100mg colleagues about doing the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the pandemic. Thank you for helping Texas heal and for supporting these essential safety net programs.(L to R).

UTHSA medical students Swetha Maddipudi, Brittany Hansen, Charles Wang, Carson Cortino, faculty advisor Kaparaboyna Kumar, MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz, kamagra 100mg and Frank Jung pose with the TMA Be Wise Immunize banner. Photo courtesy by Ryan WealtherRyan WealtherMedical Student, UT Health San Antonio Long School of MedicineStudent Member, Texas Medical AssociationEditor’s Note. August is National Immunization Awareness Month. This article is part of a Me&My Doctor series highlighting kamagra 100mg and promoting the use of vaccinations.“Can the flu shot give you the flu?.

€â€œIs it dangerous for pregnant women to get a flu shot?. €â€œCan vaccines cause autism? kamagra 100mg. €These were questions women at Alpha Home, a residential substance abuse rehabilitation center in San Antonio, asked my fellow medical students and me during a flu vaccine discussion. It is easy to see why these questions were asked, as vaccine misinformation is common today.UTHSA medical student Frank Jing (left) gets a vaccine fromKaparaboyna Kumar, MD, (right).Photo courtesy of Ryan Wealther“No” is the answer to all the questions.

These were exactly the types of myths we kamagra 100mg set out to dispel at our vaccination drive.UT Health San Antonio Long School of Medicine medical students (under the supervision of Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the vaccine drive at Alpha Home with the support of TMA’s Be Wise – Immunize℠ program, a public health initiative that aims to increase vaccinations and vaccine awareness through shot clinics and education. Our program consisted of a vaccination drive and an interactive, educational presentation that addressed influenza, common flu shot questions, and general vaccine myths. The Alpha Home residents could ask us questions during the program.We were interested to see if our educational program could answer Alpha Home residents’ questions about vaccinations and allay their hesitations about getting a flu vaccination kamagra 100mg. To gauge this, we created a brief survey.(Before I discuss the results of the survey, I should define vaccine hesitancy.

Vaccine hesitancy is a concept defined by the World Health Organization. It relates to when patients do not vaccinate despite having access to vaccines kamagra 100mg. Vaccine hesitancy is a problem because it prevents individuals from receiving their vaccinations. That makes them more susceptible to getting sick from vaccine-preventable diseases.)We surveyed the residents’ opinions about vaccinations before and after our educational program.

While opinions about shots improved kamagra 100mg with each survey question, we saw the most significant attitude change reflected in answers to the questions “I am concerned that vaccinations might not be safe,” and “How likely are you to receive a flu shot today?. € We had informed the residents and improved their understanding and acceptance of immunizations.Post-survey results show more residents at the Alpha Home shifted to more positive attitudes about vaccines, after learning more about their effectiveness by trusted members of the medical community. Graph by kamagra 100mg Ryan WealtherWhy is this important?. First, our findings confirm what we already knew.

Education by a trusted member of the medical community can effect change. In fact, it is widely known that physician recommendation of vaccination is one of the most critical kamagra 100mg factors affecting whether patients receive an influenza vaccination. Perhaps some added proof to this is that a few of the Alpha Home residents were calling me “Dr. Truth” by the end of the evening.Second, our findings add to our understanding kamagra 100mg of adult vaccine hesitancy.

This is significant because most of what we know about vaccine hesitancy is limited to parental attitudes toward their children’s vaccinations. Some parents question shots for their children, and many of the most deadly diseases we vaccinate against are given in childhood, including polio, tetanus, measles, and whooping cough shots. However, adults need kamagra 100mg some vaccinations as well, like the yearly influenza vaccine. After taking part in the UTHSA educational program, more residents at the Alpha Home shared more willingness to receive the flu vaccine.

Graph by Ryan WealtherAnother reason improving attitudes is important is that receiving a flu shot is even more timely during the COVID-19 pandemic because it decreases illnesses and conserves health care resources. Thousands of people each year are hospitalized from kamagra 100mg the flu, and with hospitals filling up with coronavirus patients, we could avoid adding dangerously ill flu patients to the mix. Lastly, these findings are important because once a COVID-19 vaccination becomes available, more people might be willing to receive it if their overall attitude toward immunizations is positive. Though the COVID-19 vaccine is still in kamagra 100mg development, it is not immune to vaccine hesitancy.

Recent polls have indicated up to one-third of Americans would not receive a COVID-19 vaccine even if it were accessible and affordable. Work is already being done to try to raise awareness and acceptance. In addition, misinformation about kamagra 100mg the COVID vaccine is circulating widely. (Someone recently asked me if the COVID vaccine will implant a microchip in people, and I have seen the same myth circulating on social media.

It will not.) This myth, however, illustrates the need for health care professionals to answer patients’ questions and to assuage their concerns.Vaccines work best when many people in a community receive them, and vaccine hesitancy can diminish vaccination rates, leaving people who can't get certain vaccines susceptible kamagra 100mg to these vaccine-preventable diseases. For example, babies under 6 months of age should not receive a flu shot, so high community vaccination rates protect these babies from getting sick with the flu. Our educational program at Alpha Home is just one example of how health care professionals can increase awareness and acceptance of shots. As the COVID-19 pandemic progresses, we need kamagra 100mg to ensure children and adults receive their vaccinations as recommended by their physician and the Centers for Disease Control and Prevention.

I encourage readers who have questions about the vaccinations they or their child may need to talk with their physician. As health care professionals, we’re more than happy to answer your questions..

Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee on Child and Adolescent HealthExecutive Board https://www.voiture-et-handicap.fr/kamagra-online-purchase/ Member, Texas Pediatric SocietyDoctors kamagra for sale online are community leaders. This role has become even more important during the COVID-19 pandemic. As patients navigate our new reality, they are looking to us to determine what kamagra for sale online is safe, how to protect their families, and the future of their health care.

As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net. The U.S. Census helps kamagra for sale online determine funding for those resources, and that is why it is of the upmost importance that each and every Texan, no matter address, immigration status, or age, respond to the 2020 U.S.

Census. The deadline has kamagra for sale online been cut short one month and now closes Sept. 30.COVID-19 has only increased the importance of completing the census to help our local communities and economies recover.

The novel coronavirus has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more. Schools also have been stretched thin, with teachers kamagra for sale online scrambling to teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago.

Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the pandemic’s fallout. Therefore, it is vital that all kamagra for sale online Texans be counted.The federal dollars Texas receives generally depends on our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example.

Federal funds pay for 60% of the state’s program, which kamagra for sale online provides health coverage for two out of five Texas children, one in three individuals with disabilities, and 53% of all births. The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars.

If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is kamagra for sale online key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census. Texas also uses this federal funding to study and respond to maternal mortality and perinatal depression.Food and housing As unemployment kamagra for sale online rises and families struggle financially, many live with uncertainty as to where they will find their next meal.

Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the pandemic continues. The Central Texas Food Bank saw a 206% rise in clients kamagra for sale online in March.

Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census. Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their homes during this economic crisis have better hope of finding shelter while our kamagra for sale online communities recover.

Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by coronavirus, more parents are taking on roles as breadwinner, parent, teacher, and caretaker. This stress highlights kamagra for sale online the desperate need for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families.

The good news is you still have time to complete the census. Visit 2020census.gov to take kamagra for sale online it. It takes less than five minutes to complete.

Then talk to your family, neighbors, and kamagra for sale online colleagues about doing the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the pandemic. Thank you for helping Texas heal and for supporting these essential safety net programs.(L to R).

UTHSA medical students Swetha Maddipudi, Brittany Hansen, Charles kamagra for sale online Wang, Carson Cortino, faculty advisor Kaparaboyna Kumar, MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz, and Frank Jung pose with the TMA Be Wise Immunize banner. Photo courtesy by Ryan WealtherRyan WealtherMedical Student, UT Health San Antonio Long School of MedicineStudent Member, Texas Medical AssociationEditor’s Note. August is National Immunization Awareness Month.

This article is part of a Me&My Doctor series highlighting kamagra for sale online and promoting the use of vaccinations.“Can the flu shot give you the news flu?. €â€œIs it dangerous for pregnant women to get a flu shot?. €â€œCan vaccines cause autism? kamagra for sale online.

€These were questions women at Alpha Home, a residential substance abuse rehabilitation center in San Antonio, asked my fellow medical students and me during a flu vaccine discussion. It is easy to see why these questions were asked, as vaccine misinformation is common today.UTHSA medical student Frank Jing (left) gets a vaccine fromKaparaboyna Kumar, MD, (right).Photo courtesy of Ryan Wealther“No” is the answer to all the questions. These were exactly the types of myths we set out to dispel at our vaccination drive.UT Health San Antonio Long School of Medicine medical students (under the supervision of Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the vaccine drive at Alpha Home with the support of TMA’s kamagra for sale online Be Wise – Immunize℠ program, a public health initiative that aims to increase vaccinations and vaccine awareness through shot clinics and education.

Our program consisted of a vaccination drive and an interactive, educational presentation that addressed influenza, common flu shot questions, and general vaccine myths. The Alpha Home residents could ask us questions during the program.We were interested to see if our educational program could answer Alpha Home residents’ questions about vaccinations and allay their hesitations about getting a flu vaccination kamagra for sale online. To gauge this, we created a brief survey.(Before I discuss the results of the survey, I should define vaccine hesitancy.

Vaccine hesitancy is a concept defined by the World Health Organization. It relates to when patients do not vaccinate despite having access kamagra for sale online to vaccines. Vaccine hesitancy is a problem because it prevents individuals from receiving their vaccinations.

That makes them more susceptible to getting sick from vaccine-preventable diseases.)We surveyed the residents’ opinions about vaccinations before and after our educational program. While opinions about shots improved kamagra for sale online with each survey question, we saw the most significant attitude change reflected in answers to the questions “I am concerned that vaccinations might not be safe,” and “How likely are you to receive a flu shot today?. € We had informed the residents and improved their understanding and acceptance of immunizations.Post-survey results show more residents at the Alpha Home shifted to more positive attitudes about vaccines, after learning more about their effectiveness by trusted members of the medical community.

Graph by Ryan WealtherWhy is this kamagra for sale online important?. First, our findings confirm what we already knew. Education by a trusted member of the medical community can effect change.

In fact, it is widely known that physician kamagra for sale online recommendation of vaccination is one of the most critical factors affecting whether patients receive an influenza vaccination. Perhaps some added proof to this is that a few of the Alpha Home residents were calling me “Dr. Truth” by the end of the evening.Second, our findings add to our understanding of adult vaccine hesitancy kamagra for sale online.

This is significant because most of what we know about vaccine hesitancy is limited to parental attitudes toward their children’s vaccinations. Some parents question shots for their children, and many of the most deadly diseases we vaccinate against are given in childhood, including polio, tetanus, measles, and whooping cough shots. However, adults need some kamagra for sale online vaccinations as well, like the yearly influenza vaccine.

After taking part in the UTHSA educational program, more residents at the Alpha Home shared more willingness to receive the flu vaccine. Graph by Ryan WealtherAnother reason improving attitudes is important is that receiving a flu shot is even more timely during the COVID-19 pandemic because it decreases illnesses and conserves health care resources. Thousands of people each year are hospitalized from the flu, kamagra for sale online and with hospitals filling up with coronavirus patients, we could avoid adding dangerously ill flu patients to the mix.

Lastly, these findings are important because once a COVID-19 vaccination becomes available, more people might be willing to receive it if their overall attitude toward immunizations is positive. Though the COVID-19 vaccine is still in development, it is not immune to vaccine kamagra for sale online hesitancy. Recent polls have indicated up to one-third of Americans would not receive a COVID-19 vaccine even if it were accessible and affordable.

Work is already being done to try to raise awareness and acceptance. In addition, kamagra for sale online misinformation about the COVID vaccine is circulating widely. (Someone recently asked me if the COVID vaccine will implant a microchip in people, and I have seen the same myth circulating on social media.

It will not.) This myth, however, illustrates the need for health care professionals to answer patients’ questions and to assuage their concerns.Vaccines work best when many people in a community kamagra for sale online receive them, and vaccine hesitancy can diminish vaccination rates, leaving people who can't get certain vaccines susceptible to these vaccine-preventable diseases. For example, babies under 6 months of age should not receive a flu shot, so high community vaccination rates protect these babies from getting sick with the flu. Our educational program at Alpha Home is just one example of how health care professionals can increase awareness and acceptance of shots.

As the COVID-19 pandemic progresses, we need to kamagra for sale online ensure children and adults receive their vaccinations as recommended by their physician and the Centers for Disease Control and Prevention. I encourage readers who have questions about the vaccinations they or their child may need to talk with their physician. As health care professionals, we’re more than happy to answer your questions..

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We live kamagra gold 100 in kamagra sildenafil citrate 100mg unprecedented times. But what makes them without parallel is not the current pandemic crisis nor the continued problems facing minorities in our institutions. Rather, it’s that kamagra gold 100 for the first time, the problems of accessibility, rights and freedoms are now invading privileged spaces.

There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals. For many, the world is not suddenly on kamagra gold 100 fire. It has long been burning.The present pandemic lays bare systemic prejudice against the most vulnerable among us.

We at Medical Humanities, with our focus on global health and social justice, welcome discussion about how the crisis has disproportionately affected racial and fiscal minorities, those from the disabled community, those who are LGBTQA+ and other vulnerable groups. What we focus on here, now, can lead to greater accessibility and equity in the future.In this expanded issue, we offer some of the incredible work being done across the field of medical humanities kamagra gold 100 prior to the COVID-19 crisis, and we are already reviewing articles on the role of health humanities during the pandemic. The process of academic publishing tends not to lend itself to immediacy, however, and the challenges of pandemic means greater pressure on everyone, from the authors to the reviewers and readers.To remedy this, we at Medical Humanities have been increasing the work on our blog platform, a place where content can be quickly updated, and where conversations can occur among readers and writers.

We openly invite submissions concerning the virus, as well as topics relevant to kamagra gold 100 our wider CFP (call for posts/papers) this year on social justice and health, to both blog and journal. We will do our best to expedite. Finally, we have also been addressing social justice and access in our podcast, where we interviewed disability activist Alice Wong and most recently Dr Oni Blackstock, primary care physician and HIV specialist in New York.

We hope to have kamagra gold 100 many more on these critical subjects.We wish all of you good health and safety and know that many of you are yet on the front lines. Thank you for being part of the community of Medical Humanities.IntroductionMinecraft is a computer game with no specific goals to accomplish. The gameworld consists of three-dimensional kamagra gold 100 (3D) cubes and objects which the player (Steve) can mine and build into infinitely complex (and logically impossible) structures.

Steve sometimes encounters other characters (‘mobs’), such as animals and hostile creatures. He can ‘spawn’ and destroy them. While it looks like a harmless game of logical construction, it conveys some worryingly delusive ideas about the real world kamagra gold 100.

The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification in mental health has had various forms throughout history. Mack and kamagra gold 100 colleagues set out a history of psychiatric classification beginning in 2600 BC with Egyptian references to melancholia and hysteria. Through the Ancient Greeks with Hippocrates’ phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease.

Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some common trends such as the labels ‘melancholia’ and ‘hysteria’ which kamagra gold 100 have survived millennia, the label ‘depression’ is relatively new. The earliest usage noted by Snaith is from 1899.

€˜in simple pathological depression…the patient exhibits a growing indifference to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of kamagra gold 100 subtypes would emerge. This did not happen until the middle of the 20th century. With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate.

In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical quarrels around categorisation of mental kamagra gold 100 disorders. DSM I and DSM II have been described as products of an American Psychiatric Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories. €˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the kamagra gold 100 mental health establishment as a therapeutic state.

Zimbardo, who described psychiatric care as a controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’. Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other cultures.8 Considering these limitations, kamagra gold 100 some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science.

In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are opposing stances in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility. The nominalism–realism debate is illustrated using as metaphor three different stances a cricket umpire might take on calling kamagra gold 100 strikes and balls. The discussion sets out two of these as extreme views.

€˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who is characterised kamagra gold 100 as holding particularly extreme views, is named as an archetypal solipsist. There is implied to be a degree of arrogance associated with this view in the illustrative example in which the umpire states ‘there are no balls and there are no strikes until I call them’.

Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than kamagra gold 100 to focus on its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’. The natural conclusion the reader is invited to reach is that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’. Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’.

The prototypical kamagra gold 100 approach is again put forward as a clinically useful middle ground. Illustrations are drawn from natural science. €˜a triangle and a kamagra gold 100 square are never the same’, inciting the reader to consider science as value-free.

The prototypical approach emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification. Doing so is more kamagra gold 100 like playing Minecraft than cricket.

The National Institute for Health and Care Excellence (NICE) guideline for depression is taken as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, specifically subcategories of persistent forms of depression. As well as serving a clinical purpose, diagnosis in medicine is a kamagra gold 100 way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service. The consequences for recipients of healthcare are therefore significant.

Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression. €˜further-line’ treatment of depression (equivalent to TRD), CD and ‘depression with co-morbidities’ kamagra gold 100. The latter is subdivided into treatments for ‘complex depression’ and ‘psychotic depression’.

These categories and subcategories introduce an unfortunate sense of kamagra gold 100 certainty as though these labels represent real things. An analysis follows of how these definitions play out in terms of grouping of randomised controlled trials in the NICE evidence review. Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years.

Dysthymia and double depression (MDD kamagra gold 100 superimposed on dysthymia) were included. If 75% of the trial population met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point. If 80% of the trial participants met these criteria, it was reviewed in the TRD category.13 Complex depression was defined as ‘depression kamagra gold 100 co-existing with personality disorder’.

To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there is a potential problem with attempting to categorise trial populations into just one of these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information. The analysis below will illustrate this using examples from within the NICE review.Cataloguing kamagra gold 100 complexity in trial populationsWithin the category of further-line treatments (TRD), 64 trials were reviewed.

Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’. In drilling down by way kamagra gold 100 of illustration, this analysis considers the 51 trials in the augmentation strategy evidence review. Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs.

Fonagy 2015 and Kocsis 200915). About half of the trials (23/51) did not report the mean duration of episode, meaning kamagra gold 100 that it is not possible to know what percentage of participants also met the criteria for CD. Of trials that did report episode duration, 17 reported a mean duration longer than 24 months.

While the standard deviations varied in size or were unreported, the mean indicates a good likelihood that a significant proportion of kamagra gold 100 the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE. For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations. Only 14 of 51 trials report employment data.

Of those that do, unemployment ranges from 12% to 56% kamagra gold 100 across trial samples. None of the trials report trauma history. About half of the trials (26/51) excluded people who were considered a kamagra gold 100 suicide risk.

The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity. Of these, 18 did not exclude any diagnoses, while 12 excluded some (but not all) disorders. The most common diagnoses excluded were kamagra gold 100 psychotic disorders, substance or alcohol abuse, and bipolar disorder (excluded in 26, 25 and 23 trials, respectively).

Only 7 of 51 trials clearly stated that all axis 1 diagnoses were excluded. This leaves only 13 studies providing any kamagra gold 100 data about comorbidity. Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD.

Many stated PD as an exclusion criterion but without defining a threshold for exclusion. For example, PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’ kamagra gold 100. Some excluded certain PDs (such as antisocial or borderline) and not others but without reporting the prevalence of those not excluded.

In the five trials where prevalence was clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of kamagra gold 100 the sample (Town 201715). Two studies reported the mean number of PDs. 2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The majority of trials (43/51) did not report the prevalence of physical illness.

Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be interpreted in different ways kamagra gold 100. For example, illness could be excluded if it was ‘unstable’, ‘serious’, ‘significant’, ‘relevant’, or would ‘contraindicate’ or ‘impact’ the medication. Of the eight trials reporting information about physical health, kamagra gold 100 there was a wide variation.

Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used scales of physical health. Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more kamagra gold 100 severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners.

NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials which use more than one of these measures reveals problems in the algorithm. Of the 51 trials, there are 6 instances in which the study population falls into NICE’s more severe category according to one measure and into the less severe category according to another kamagra gold 100. In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715).

The other two trials were designated more severe (Barbee 2011, Dunner 200715). Only 17 of 51 trials kamagra gold 100 reported two or more depression scale measures, leaving much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?. A key philosophical error in science is to confuse an absence of knowledge with knowledge of absence.

It is likely that some of the study populations kamagra gold 100 deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity. Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm). The information may be non-existent as it was not collected.

It may be somewhere kamagra gold 100 in the publication pipeline. Or it may be sitting in a database with a research team that has run out of funds for supplementary analyses. Wherever those data are or are not, their absence from published articles does not define kamagra gold 100 the phenomenology of depression for the patients who took part.

As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial also meets the guideline criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published cut-off scores). NICE categorised kamagra gold 100 this population as less severe TRD, not CD and not complex.Notes1.

Avram H. Mack et kamagra gold 100 al. (1994), “A Brief History of Psychiatric Classification.

From the Ancients to DSM-IV,” Psychiatric Clinics 17, no. 3. 515–9.2.

R. P. Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no.

3. 387.3. Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &.

Gerald N. Grob (1991), “Origins of DSM-I. A Study in Appearance and Reality,” The American Journal of Psychiatry.

421–31.5. Wilson M. Compton and Samuel B.

Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no. 4. 198–9.6.

Gerald L. Klerman (1984), “A Debate on DSM-III. The Advantages of DSM-III,” The American Journal of Psychiatry.

539–42.7. Thomas E. Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist.

Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no. 4. 189–204.9.

Sami Timimi (2014), “No More Psychiatric Labels. Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no. 3.

208–15.10. Allen Frances et al. (1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy.

A Forum for Bioethics and Philosophy of Medicine 19, no. 3. 207–18.11.

Andrea Jobst et al. (2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33. 20.12.

National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management. Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13.

Ibid., 351–62.14. Ibid., 597.15. Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used.

See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16. National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management.

Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17. National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18. Peter Fonagy et al.

(2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression. The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no. 3.

312–21.19. American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults. Draft.20.

Jacqui Thornton (2018), “Depression in Adults. Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361. K2681..

We live kamagra for sale online kamagra effekt in unprecedented times. But what makes them without parallel is not the current pandemic crisis nor the continued problems facing minorities in our institutions. Rather, it’s that for the first time, the problems of accessibility, rights and freedoms are now invading kamagra for sale online privileged spaces. There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals.

For many, the world is kamagra for sale online not suddenly on fire. It has long been burning.The present pandemic lays bare systemic prejudice against the most vulnerable among us. We at Medical Humanities, with our focus on global health and social justice, welcome discussion about how the crisis has disproportionately affected racial and fiscal minorities, those from the disabled community, those who are LGBTQA+ and other vulnerable groups. What we kamagra for sale online focus on here, now, can lead to greater accessibility and equity in the future.In this expanded issue, we offer some of the incredible work being done across the field of medical humanities prior to the COVID-19 crisis, and we are already reviewing articles on the role of health humanities during the pandemic.

The process of academic publishing tends not to lend itself to immediacy, however, and the challenges of pandemic means greater pressure on everyone, from the authors to the reviewers and readers.To remedy this, we at Medical Humanities have been increasing the work on our blog platform, a place where content can be quickly updated, and where conversations can occur among readers and writers. We openly invite submissions concerning the virus, as well as topics kamagra for sale online relevant to our wider CFP (call for posts/papers) this year on social justice and health, to both blog and journal. We will do our best to expedite. Finally, we have also been addressing social justice and access in our podcast, where we interviewed disability activist Alice Wong and most recently Dr Oni Blackstock, primary care physician and HIV specialist in New York.

We hope to have many more on these critical subjects.We wish all of you good health and safety and know that many kamagra for sale online of you are yet on the front lines. Thank you for being part of the community of Medical Humanities.IntroductionMinecraft is a computer game with no specific goals to accomplish. The gameworld consists of kamagra for sale online three-dimensional (3D) cubes and objects which the player (Steve) can mine and build into infinitely complex (and logically impossible) structures. Steve sometimes encounters other characters (‘mobs’), such as animals and hostile creatures.

He can ‘spawn’ and destroy them. While it looks like a kamagra for sale online harmless game of logical construction, it conveys some worryingly delusive ideas about the real world. The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification in mental health has had various forms throughout history. Mack and colleagues set out a history of psychiatric classification beginning in kamagra for sale online 2600 BC with Egyptian references to melancholia and hysteria.

Through the Ancient Greeks with Hippocrates’ phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease. Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some common trends kamagra for sale online such as the labels ‘melancholia’ and ‘hysteria’ which have survived millennia, the label ‘depression’ is relatively new. The earliest usage noted by Snaith is from 1899.

€˜in simple pathological depression…the patient exhibits a growing indifference kamagra for sale online to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge. This did not happen until the middle of the 20th century. With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate. In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds kamagra for sale online for professional disputes and philosophical quarrels around categorisation of mental disorders.

DSM I and DSM II have been described as products of an American Psychiatric Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories. €˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in kamagra for sale online the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state. Zimbardo, who described psychiatric care as a controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’.

Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in kamagra for sale online philosophy of science. In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are opposing stances in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility. The nominalism–realism kamagra for sale online debate is illustrated using as metaphor three different stances a cricket umpire might take on calling strikes and balls. The discussion sets out two of these as extreme views.

€˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who is characterised as holding particularly extreme views, kamagra for sale online is named as an archetypal solipsist. There is implied to be a degree of arrogance associated with this view in the illustrative example in which the umpire states ‘there are no balls and there are no strikes until I call them’. Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances kamagra for sale online provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than to focus on its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’.

The natural conclusion the reader is invited to reach is that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’. Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’. The prototypical kamagra for sale online approach is again put forward as a clinically useful middle ground. Illustrations are drawn from natural science.

€˜a triangle and a square are never the same’, inciting the reader to consider science kamagra for sale online as value-free. The prototypical approach emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification. Doing so kamagra for sale online is more like playing Minecraft than cricket.

The National Institute for Health and Care Excellence (NICE) guideline for depression is taken as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, specifically subcategories of persistent forms of depression. As well as serving a clinical purpose, diagnosis in medicine kamagra for sale online is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service. The consequences for recipients of healthcare are therefore significant. Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression.

€˜further-line’ treatment of depression (equivalent to TRD), CD and ‘depression with kamagra for sale online co-morbidities’. The latter is subdivided into treatments for ‘complex depression’ and ‘psychotic depression’. These categories and subcategories introduce an unfortunate sense of certainty as kamagra for sale online though these labels represent real things. An analysis follows of how these definitions play out in terms of grouping of randomised controlled trials in the NICE evidence review.

Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years. Dysthymia and double depression (MDD superimposed on dysthymia) were kamagra for sale online included. If 75% of the trial population met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point. If 80% of the trial participants met these criteria, it was reviewed in the kamagra for sale online TRD category.13 Complex depression was defined as ‘depression co-existing with personality disorder’.

To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there is a potential problem with attempting to categorise trial populations into just one of these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information. The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the category of further-line treatments kamagra for sale online (TRD), 64 trials were reviewed. Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’.

In drilling down by way of illustration, this analysis considers the 51 trials in kamagra for sale online the augmentation strategy evidence review. Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs. Fonagy 2015 and Kocsis 200915). About half of the trials (23/51) did not report the mean duration of episode, meaning that it kamagra for sale online is not possible to know what percentage of participants also met the criteria for CD.

Of trials that did report episode duration, 17 reported a mean duration longer than 24 months. While the standard deviations varied in size or were unreported, the mean indicates a kamagra for sale online good likelihood that a significant proportion of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE. For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations. Only 14 of 51 trials report employment data.

Of those that do, unemployment ranges from 12% to 56% across kamagra for sale online trial samples. None of the trials report trauma history. About half of the trials (26/51) excluded kamagra for sale online people who were considered a suicide risk. The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity.

Of these, 18 did not exclude any diagnoses, while 12 excluded some (but not all) disorders. The most common diagnoses excluded were psychotic disorders, substance or alcohol kamagra for sale online abuse, and bipolar disorder (excluded in 26, 25 and 23 trials, respectively). Only 7 of 51 trials clearly stated that all axis 1 diagnoses were excluded. This leaves only 13 studies providing any data kamagra for sale online about comorbidity.

Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD. Many stated PD as an exclusion criterion but without defining a threshold for exclusion. For example, PD could be excluded kamagra for sale online if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’. Some excluded certain PDs (such as antisocial or borderline) and not others but without reporting the prevalence of those not excluded.

In the five trials where prevalence was kamagra for sale online clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample (Town 201715). Two studies reported the mean number of PDs. 2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The majority of trials (43/51) did not report the prevalence of physical illness. Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be kamagra for sale online interpreted in different ways.

For example, illness could be excluded if it was ‘unstable’, ‘serious’, ‘significant’, ‘relevant’, or would ‘contraindicate’ or ‘impact’ the medication. Of the eight trials reporting information about physical health, there kamagra for sale online was a wide variation. Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used scales of physical health.

Two indicating mild problems kamagra for sale online (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners. NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials which use more than one of these measures reveals problems in the algorithm. Of the 51 trials, there are 6 instances in which the study kamagra for sale online population falls into NICE’s more severe category according to one measure and into the less severe category according to another. In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715).

The other two trials were designated more severe (Barbee 2011, Dunner 200715). Only 17 kamagra for sale online of 51 trials reported two or more depression scale measures, leaving much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?. A key philosophical error in science is to confuse an absence of knowledge with knowledge of absence. It is likely that some of kamagra for sale online the study populations deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity.

Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm). The information may be non-existent as it was not collected. It may be somewhere in the publication kamagra for sale online pipeline. Or it may be sitting in a database with a research team that has run out of funds for supplementary analyses.

Wherever those data kamagra for sale online are or are not, their absence from published articles does not define the phenomenology of depression for the patients who took part. As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial also meets the guideline criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published cut-off scores). NICE categorised kamagra for sale online this population as less severe TRD, not CD and not complex.Notes1.

Avram H. Mack et al kamagra for sale online. (1994), “A Brief History of Psychiatric Classification. From the Ancients to DSM-IV,” Psychiatric Clinics 17, no.

Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no. 3. 387.3. Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &.

Grob (1991), “Origins of DSM-I. A Study in Appearance and Reality,” The American Journal of Psychiatry. 421–31.5. Wilson M.

Compton and Samuel B. Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no. 4. 198–9.6.

Gerald L. Klerman (1984), “A Debate on DSM-III. The Advantages of DSM-III,” The American Journal of Psychiatry. 539–42.7.

Thomas E. Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist. 513–5.8. Daniel F.

Hartner and Kari L. Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no. 4. 189–204.9.

Sami Timimi (2014), “No More Psychiatric Labels. Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no. 3. 208–15.10.

Allen Frances et al. (1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy. A Forum for Bioethics and Philosophy of Medicine 19, no. 3.

207–18.11. Andrea Jobst et al. (2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33. 20.12.

National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management. Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13. Ibid., 351–62.14.

Ibid., 597.15. Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used. See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16. National Institute for Health and Care Excellence (2018), Depression in Adults.

Treatment and Management. Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17. National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18. Peter Fonagy et al.

(2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression. The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no. 3. 312–21.19.

American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults. Draft.20. Jacqui Thornton (2018), “Depression in Adults. Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361.

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Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee on Child and Adolescent HealthExecutive kamagra oral jelly benefits Board Member, Texas Pediatric SocietyDoctors are community leaders. This role has become even more important during the COVID-19 pandemic. As patients navigate our new reality, they are looking to us to determine what is safe, how to kamagra oral jelly benefits protect their families, and the future of their health care. As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net. The U.S.

Census helps determine funding for those resources, and that is why it is of the upmost importance that each and every Texan, no matter address, immigration status, or age, respond kamagra oral jelly benefits to the 2020 U.S. Census. The deadline has been cut short one month and kamagra oral jelly benefits now closes Sept. 30.COVID-19 has only increased the importance of completing the census to help our local communities and economies recover. The novel coronavirus has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more.

Schools also have been stretched thin, with teachers scrambling to kamagra oral jelly benefits teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago. Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the pandemic’s fallout. Therefore, it is kamagra oral jelly benefits vital that all Texans be counted.The federal dollars Texas receives generally depends on our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example.

Federal funds pay for 60% of the state’s program, which provides health kamagra oral jelly benefits coverage for two out of five Texas children, one in three individuals with disabilities, and 53% of all births. The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars. If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, kamagra oral jelly benefits but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census.

Texas also uses this federal funding to study and respond to maternal mortality and perinatal depression.Food kamagra oral jelly benefits and housing As unemployment rises and families struggle financially, many live with uncertainty as to where they will find their next meal. Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the pandemic continues. The Central Texas Food Bank kamagra oral jelly benefits saw a 206% rise in clients in March. Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census.

Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their homes kamagra oral jelly benefits during this economic crisis have better hope of finding shelter while our communities recover. Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by coronavirus, more parents are taking on roles as breadwinner, parent, teacher, and caretaker. This stress highlights the desperate kamagra oral jelly benefits need for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families.

The good news is you still have time to complete the census. Visit 2020census.gov kamagra oral jelly benefits to take it. It takes less than five minutes to complete. Then talk to your family, neighbors, and colleagues about doing the same kamagra oral jelly benefits. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the pandemic.

Thank you for helping Texas heal and for supporting these essential safety net programs.(L to R). UTHSA medical students Swetha Maddipudi, Brittany Hansen, Charles Wang, Carson Cortino, faculty kamagra oral jelly benefits advisor Kaparaboyna Kumar, MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz, and Frank Jung pose with the TMA Be Wise Immunize banner. Photo courtesy by Ryan WealtherRyan WealtherMedical Student, UT Health San Antonio Long School of MedicineStudent Member, Texas Medical AssociationEditor’s Note. August is National Immunization Awareness Month. This article is part of a Me&My Doctor series highlighting and promoting the use kamagra oral jelly benefits of vaccinations.“Can the flu shot give you the flu?.

€â€œIs it dangerous for pregnant women to get a flu shot?. €â€œCan vaccines cause kamagra oral jelly benefits autism?. €These were questions women at Alpha Home, a residential substance abuse rehabilitation center in San Antonio, asked my fellow medical students and me during a flu vaccine discussion. It is easy to see why these questions were asked, as vaccine misinformation is common today.UTHSA medical student Frank Jing (left) gets a vaccine fromKaparaboyna Kumar, MD, (right).Photo courtesy of Ryan Wealther“No” is the answer to all the questions. These were exactly the types of myths we set out to dispel at our vaccination drive.UT Health San Antonio Long School of Medicine kamagra oral jelly benefits medical students (under the supervision of Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the vaccine drive at Alpha Home with the support of TMA’s Be Wise – Immunize℠ program, a public health initiative that aims to increase vaccinations and vaccine awareness through shot clinics and education.

Our program consisted of a vaccination drive and an interactive, educational presentation that addressed influenza, common flu shot questions, and general vaccine myths. The Alpha Home residents could ask us questions during the program.We were interested to see if our educational program could answer Alpha Home residents’ questions about vaccinations and kamagra oral jelly benefits allay their hesitations about getting a flu vaccination. To gauge this, we created a brief survey.(Before I discuss the results of the survey, I should define vaccine hesitancy. Vaccine hesitancy is a concept defined by the World Health Organization. It relates to when patients kamagra oral jelly benefits do not vaccinate despite having access to vaccines.

Vaccine hesitancy is a problem because it prevents individuals from receiving their vaccinations. That makes them more susceptible to getting sick from vaccine-preventable diseases.)We surveyed the residents’ opinions about vaccinations before and after our educational program. While opinions about shots improved with each survey question, we saw the most significant attitude change reflected in answers to the questions “I kamagra oral jelly benefits am concerned that vaccinations might not be safe,” and “How likely are you to receive a flu shot today?. € We had informed the residents and improved their understanding and acceptance of immunizations.Post-survey results show more residents at the Alpha Home shifted to more positive attitudes about vaccines, after learning more about their effectiveness by trusted members of the medical community. Graph by Ryan WealtherWhy is kamagra oral jelly benefits this important?.

First, our findings confirm what we already knew. Education by a trusted member of the medical community can effect change. In fact, it is widely known that physician recommendation of vaccination kamagra oral jelly benefits is one of the most critical factors affecting whether patients receive an influenza vaccination. Perhaps some added proof to this is that a few of the Alpha Home residents were calling me “Dr. Truth” by the kamagra oral jelly benefits end of the evening.Second, our findings add to our understanding of adult vaccine hesitancy.

This is significant because most of what we know about vaccine hesitancy is limited to parental attitudes toward their children’s vaccinations. Some parents question shots for their children, and many of the most deadly diseases we vaccinate against are given in childhood, including polio, tetanus, measles, and whooping cough shots. However, adults need some vaccinations as well, like the kamagra oral jelly benefits yearly influenza vaccine. After taking part in the UTHSA educational program, more residents at the Alpha Home shared more willingness to receive the flu vaccine. Graph by Ryan WealtherAnother reason improving attitudes is important is that receiving a flu shot is even more timely during the COVID-19 pandemic because it decreases illnesses and conserves health care resources.

Thousands of people each year are hospitalized from the flu, and with hospitals filling up with coronavirus patients, we could avoid kamagra oral jelly benefits adding dangerously ill flu patients to the mix. Lastly, these findings are important because once a COVID-19 vaccination becomes available, more people might be willing to receive it if their overall attitude toward immunizations is positive. Though the COVID-19 vaccine is still in development, it is not immune kamagra oral jelly benefits to vaccine hesitancy. Recent polls have indicated up to one-third of Americans would not receive a COVID-19 vaccine even if it were accessible and affordable. Work is already being done to try to raise awareness and acceptance.

In addition, misinformation about the COVID kamagra oral jelly benefits vaccine is circulating widely. (Someone recently asked me if the COVID vaccine will implant a microchip in people, and I have seen the same myth circulating on social media. It will not.) This myth, however, illustrates the need for health care professionals to answer patients’ questions and to assuage their concerns.Vaccines work best when many people in a community receive them, and vaccine hesitancy can diminish vaccination rates, leaving kamagra oral jelly benefits people who can't get certain vaccines susceptible to these vaccine-preventable diseases. For example, babies under 6 months of age should not receive a flu shot, so high community vaccination rates protect these babies from getting sick with the flu. Our educational program at Alpha Home is just one example of how health care professionals can increase awareness and acceptance of shots.

As the COVID-19 pandemic progresses, we need to ensure children and adults receive their kamagra oral jelly benefits vaccinations as recommended by their physician and the Centers for Disease Control and Prevention. I encourage readers who have questions about the vaccinations they or their child may need to talk with their physician. As health care professionals, we’re more than happy to answer your questions..

Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee on Child check my source and Adolescent kamagra for sale online HealthExecutive Board Member, Texas Pediatric SocietyDoctors are community leaders. This role has become even more important during the COVID-19 pandemic. As patients navigate our new reality, they are looking to us to kamagra for sale online determine what is safe, how to protect their families, and the future of their health care. As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net.

The U.S. Census helps determine funding for those resources, and that is why it is of the upmost importance that each and every Texan, no matter address, immigration kamagra for sale online status, or age, respond to the 2020 U.S. Census. The deadline kamagra for sale online has been cut short one month and now closes Sept.

30.COVID-19 has only increased the importance of completing the census to help our local communities and economies recover. The novel coronavirus has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more. Schools also have been stretched thin, with teachers scrambling to teach kamagra for sale online students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago.

Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the pandemic’s fallout. Therefore, it is vital that kamagra for sale online all Texans be counted.The federal dollars Texas receives generally depends on our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example. Federal funds pay for 60% of the state’s program, which provides health coverage for two out of five Texas children, one in three individuals kamagra for sale online with disabilities, and 53% of all births.

The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars. If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, kamagra for sale online any of which are potentially detrimental.The census data also is key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census.

Texas also uses this federal funding to study and respond to maternal mortality and perinatal depression.Food kamagra for sale online and housing As unemployment rises and families struggle financially, many live with uncertainty as to where they will find their next meal. Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the pandemic continues. The Central Texas Food Bank saw a 206% rise in clients in kamagra for sale online March.

Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census. Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their kamagra for sale online homes during this economic crisis have better hope of finding shelter while our communities recover. Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by coronavirus, more parents are taking on roles as breadwinner, parent, teacher, and caretaker.

This stress highlights the desperate kamagra for sale online need for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families. The good news is you still have time to complete the census. Visit 2020census.gov to take it kamagra for sale online.

It takes less than five minutes to complete. Then talk to your family, neighbors, kamagra for sale online and colleagues about doing the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the pandemic. Thank you for helping Texas heal and for supporting these essential safety net programs.(L to R).

UTHSA medical students Swetha Maddipudi, Brittany Hansen, Charles Wang, Carson Cortino, faculty advisor Kaparaboyna Kumar, MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz, and Frank Jung pose with the TMA Be Wise Immunize banner kamagra for sale online. Photo courtesy by Ryan WealtherRyan WealtherMedical Student, UT Health San Antonio Long School of MedicineStudent Member, Texas Medical AssociationEditor’s Note. August is National Immunization Awareness Month. This article is part of a Me&My Doctor series kamagra for sale online highlighting and promoting the use of vaccinations.“Can the flu shot give you the flu?.

€â€œIs it dangerous for pregnant women to get a flu shot?. €â€œCan vaccines cause autism? kamagra for sale online. €These were questions women at Alpha Home, a residential substance abuse rehabilitation center in San Antonio, asked my fellow medical students and me during a flu vaccine discussion. It is easy to see why these questions were asked, as vaccine misinformation is common today.UTHSA medical student Frank Jing (left) gets a vaccine fromKaparaboyna Kumar, MD, (right).Photo courtesy of Ryan Wealther“No” is the answer to all the questions.

These were exactly the types of myths we set out to dispel at our vaccination drive.UT Health San Antonio Long School of Medicine medical students (under the supervision of Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the vaccine drive at Alpha Home with the support of TMA’s kamagra for sale online Be Wise – Immunize℠ program, a public health initiative that aims to increase vaccinations and vaccine awareness through shot clinics and education. Our program consisted of a vaccination drive and an interactive, educational presentation that addressed influenza, common flu shot questions, and general vaccine myths. The Alpha Home residents could ask us questions during the program.We were interested to see if our educational program could answer Alpha Home residents’ questions about vaccinations and allay their hesitations about getting kamagra for sale online a flu vaccination. To gauge this, we created a brief survey.(Before I discuss the results of the survey, I should define vaccine hesitancy.

Vaccine hesitancy is a concept defined by the World Health Organization. It relates to when patients do not vaccinate despite having kamagra for sale online access to vaccines. Vaccine hesitancy is a problem because it prevents individuals from receiving their vaccinations. That makes them more susceptible to getting sick from vaccine-preventable diseases.)We surveyed the residents’ opinions about vaccinations before and after our educational program.

While opinions about shots improved with each survey question, we saw the most significant attitude change reflected in answers to the questions “I am concerned that vaccinations might not be safe,” and kamagra for sale online “How likely are you to receive a flu shot today?. € We had informed the residents and improved their understanding and acceptance of immunizations.Post-survey results show more residents at the Alpha Home shifted to more positive attitudes about vaccines, after learning more about their effectiveness by trusted members of the medical community. Graph by Ryan WealtherWhy kamagra for sale online is this important?. First, our findings confirm what we already knew.

Education by a trusted member of the medical community can effect change. In fact, it is widely kamagra for sale online known that physician recommendation of vaccination is one of the most critical factors affecting whether patients receive an influenza vaccination. Perhaps some added proof to this is that a few of the Alpha Home residents were calling me “Dr. Truth” by the end of the evening.Second, our findings add to kamagra for sale online our understanding of adult vaccine hesitancy.

This is significant because most of what we know about vaccine hesitancy is limited to parental attitudes toward their children’s vaccinations. Some parents question shots for their children, and many of the most deadly diseases we vaccinate against are given in childhood, including polio, tetanus, measles, and whooping cough shots. However, adults kamagra for sale online need some vaccinations as well, like the yearly influenza vaccine. After taking part in the UTHSA educational program, more residents at the Alpha Home shared more willingness to receive the flu vaccine.

Graph by Ryan WealtherAnother reason improving attitudes is important is that receiving a flu shot is even more timely during the COVID-19 pandemic because it decreases illnesses and conserves health care resources. Thousands of people kamagra for sale online each year are hospitalized from the flu, and with hospitals filling up with coronavirus patients, we could avoid adding dangerously ill flu patients to the mix. Lastly, these findings are important because once a COVID-19 vaccination becomes available, more people might be willing to receive it if their overall attitude toward immunizations is positive. Though the COVID-19 vaccine is still in development, it is not immune to kamagra for sale online vaccine hesitancy.

Recent polls have indicated up to one-third of Americans would not receive a COVID-19 vaccine even if it were accessible and affordable. Work is already being done to try to raise awareness and acceptance. In addition, misinformation about the COVID vaccine is circulating kamagra for sale online widely. (Someone recently asked me if the COVID vaccine will implant a microchip in people, and I have seen the same myth circulating on social media.

It will not.) This myth, however, illustrates the kamagra for sale online need for health care professionals to answer patients’ questions and to assuage their concerns.Vaccines work best when many people in a community receive them, and vaccine hesitancy can diminish vaccination rates, leaving people who can't get certain vaccines susceptible to these vaccine-preventable diseases. For example, babies under 6 months of age should not receive a flu shot, so high community vaccination rates protect these babies from getting sick with the flu. Our educational program at Alpha Home is just one example of how health care professionals can increase awareness and acceptance of shots. As the COVID-19 pandemic progresses, we need to ensure kamagra for sale online children and adults receive their vaccinations as recommended by their physician and the Centers for Disease Control and Prevention.

I encourage readers who have questions about the vaccinations they or their child may need to talk with their physician. As health care professionals, we’re more than happy to answer your questions..

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A strict permit system is kamagra review blogs in place for all flights arriving in NSW from Victoria and passengers undergo comprehensive police and health checks kamagra tablets side effects upon arrival. Health Minister Brad Hazzard said all flights are met by NSW Health staff and police officers to ensure anyone entering NSW complies with the current health orders. “There are only limited reasons anyone from Victoria should kamagra tablets side effects be entering NSW and people have been turned back despite being allowed on the plane in Melbourne,” Mr Hazzard said. €œVictorian residents are not permitted into NSW at all unless they are needed for specific purposes and even then have to apply for and get a permit.

€œWe are constantly reviewing the situation in Victoria and will adjust the health orders as necessary to protect the people of NSW.” Anyone who flies into NSW from Victoria must either be a NSW resident or have a relevant permit kamagra tablets side effects that allows entry into NSW – that can include:defence officialsdoctors and nursescritical workers in energy, mining and constructionchild protection workersdisability workers.All travellers are provided with a pack of two masks and hand sanitiser by the airlines. Upon arrival into NSW all passengers from Victoria are. given masks if they left them on the planetemperature checkedasked relevant questions about their health. And their kamagra tablets side effects permit is checked to ensure it complies with the strict permit system.Anyone without a valid permit is referred to NSW Police and taken to the Special Health Accommodation to complete 14 days of quarantine.

Strict instructions and rules are in place for those going into ‘Home Isolation’ including. Recommended they be collected in a private car by family or friendsnot to use public transport to get hometo only sit in the back seat of a car with the windows open and air conditioning not on recirculationtold kamagra tablets side effects to wear their face masks and observe hand hygiene recommendations, andcalled to make sure they arrive home.NSW Health is provided the contact details of everyone who enters NSW from Victoria. NSW Police is conducting regular compliance checks for people told to go into ‘Home Isolation’ as well as responding to reports from the community in relation to suspected breaches. Over kamagra tablets side effects the weekend, NSW Police visited almost 600 homes to check that those that were meant to be self-isolating were doing so.

In addition to that, over the same period NSW Police received 374 calls to Crime Stoppers reporting suspected breaches of the health orders, the majority of which were for people suspected of not following self-isolation rules. ​Seven cutting-edge NSW research projects have been awarded almost $15 million in NSW Government grants to improve the health of people with spinal who can buy kamagra cord injuries (SCI).Treasurer Dominic Perrottet and Minister for Health and Medical Research Brad Hazzard today announced the grants at the opening of the Neuroscience Research Australia (NeuRA) Spinal Cord Injury Research Centre at Randwick where three of the projects will be carried out. €œThe investment of close to $15 million over four years was a centrepiece of our last Budget and it’s exciting to see the range of research projects now underway,” Mr kamagra tablets side effects Perrottet said. €œThis is about improving the health and wellbeing of people with spinal cord injuries, and these projects could help people not just in NSW but right around the world.” Minister Hazzard said every one of the innovative projects holds tremendous promise to improve treatment for people living with spinal cord injuries, giving back muscle function, sense of touch and other abilities that most of us take for granted.

€œA spinal injury brings very substantial life challenges, but advances kamagra tablets side effects in research now mean survivors can have a better quality of life – and even the hope of a cure,” Mr Hazzard said. €œThese projects have great scope, from investigating ways to restore touch sensation through immersive virtual reality through to using electrical stimulation to improve breathing for people affected by the most severe form of paralysis.” The following grant recipients will conduct their research at the new NeuRA centre. Associate Professor Sylvia Gustin, The University kamagra tablets side effects of NSW, Neuroscience Research Australia – received $2.5 million for her research project on using virtual reality training to restore touch sensation. Professor Jane Butler – Neuroscience Research Australia, The University of NSW, received $1.5 million to develop a treatment to restore voluntary function after spinal cord injury.

And Dr Euan McCaughey, Neuroscience Research Australia, The University of NSW, received $2.4 million for his research into using muscle stimulation to improve respiratory function for people with tetraplegia. The projects have been awarded through the NSW Government’s Spinal Cord Injury Research Grants program, launched in November 2019, with guidance kamagra tablets side effects from an advisory committee of spinal cord injury experts. NeuRA CEO, Professor Peter Schofield, said the range and scope of the funded research projects held exciting promise for health related outcomes. €œNeuroscience Research Australia is at the forefront of spinal cord injury research in kamagra tablets side effects Australia.

Our new Spinal Cord Injury Research Centre and these research projects will dramatically improve Australia’s understanding of how to best treat people with these life-long injuries,” Professor Schofield said. €œNeuRA thanks the NSW Government for funding the Spinal Cord Injury Research Grants Program, and SpinalCure Australia for its tireless efforts in campaigning for more research funding to improve the quality of life for people with a spinal cord injury.” Information on grant recipients and their research projects is available on the OHMR Funded Research Directory​​.​​​.

A strict permit best site system is in place for all flights arriving in NSW from Victoria and passengers undergo comprehensive kamagra for sale online police and health checks upon arrival. Health Minister Brad Hazzard said all flights are met by NSW Health staff and police officers to ensure anyone entering NSW complies with the current health orders. “There are only limited reasons anyone from Victoria should be entering NSW and people have been turned back kamagra for sale online despite being allowed on the plane in Melbourne,” Mr Hazzard said. €œVictorian residents are not permitted into NSW at all unless they are needed for specific purposes and even then have to apply for and get a permit. €œWe are constantly reviewing the situation in Victoria and will adjust the health orders as necessary to protect the people of NSW.” Anyone who flies into NSW from Victoria must either be a NSW resident or have a relevant permit that allows entry into NSW – that can include:defence officialsdoctors and nursescritical workers in energy, mining and constructionchild protection workersdisability workers.All travellers are provided with a pack of two masks kamagra for sale online and hand sanitiser by the airlines.

Upon arrival into NSW all passengers from Victoria are. given masks if they left them on the planetemperature checkedasked relevant questions about their health. And their permit is checked to ensure it complies with the strict permit system.Anyone without a valid permit is kamagra for sale online referred to NSW Police and taken to the Special Health Accommodation to complete 14 days of quarantine. Strict instructions and rules are in place for those going into ‘Home Isolation’ including. Recommended they be collected in a private car by family or friendsnot to use public transport to get hometo only sit in the back seat of a car with the windows open and air conditioning not on recirculationtold to wear their face masks and observe hand hygiene recommendations, andcalled to make sure they arrive home.NSW Health is provided the kamagra for sale online contact details of everyone who enters NSW from Victoria.

NSW Police is conducting regular compliance checks for people told to go into ‘Home Isolation’ as well as responding to reports from the community in relation to suspected breaches. Over the weekend, kamagra for sale online NSW Police visited almost 600 homes to check that those that were meant to be self-isolating were doing so. In addition to that, over the same period NSW Police received 374 calls to Crime Stoppers reporting suspected breaches of the health orders, the majority of which were for people suspected of not following self-isolation rules. ​Seven cutting-edge NSW research projects have been awarded almost $15 million in NSW Government grants to improve the health of people with spinal cord injuries (SCI).Treasurer Dominic Perrottet and Minister for Health and Medical Research Brad Hazzard today announced the grants at the opening of the Neuroscience Research Australia (NeuRA) Spinal Cord Injury Research Centre at Randwick where three of the projects will be carried out. €œThe investment of close to $15 million over four years was a centrepiece of our last Budget and it’s exciting to see the range of kamagra for sale online research projects now underway,” Mr Perrottet said.

€œThis is about improving the health and wellbeing of people with spinal cord injuries, and these projects could help people not just in NSW but right around the world.” Minister Hazzard said every one of the innovative projects holds tremendous promise to improve treatment for people living with spinal cord injuries, giving back muscle function, sense of touch and other abilities that most of us take for granted. €œA spinal injury brings very substantial life challenges, but advances in research now mean survivors kamagra for sale online can have a better quality of life – and even the hope of a cure,” Mr Hazzard said. €œThese projects have great scope, from investigating ways to restore touch sensation through immersive virtual reality through to using electrical stimulation to improve breathing for people affected by the most severe form of paralysis.” The following grant recipients will conduct their research at the new NeuRA centre. Associate Professor Sylvia Gustin, The University of NSW, Neuroscience Research Australia – received $2.5 million for her research project on using virtual reality training to restore touch sensation kamagra for sale online. Professor Jane Butler – Neuroscience Research Australia, The University of NSW, received $1.5 million to develop a treatment to restore voluntary function after spinal cord injury.

And Dr Euan McCaughey, Neuroscience Research Australia, The University of NSW, received $2.4 million for his research into using muscle stimulation to improve respiratory function for people with tetraplegia. The projects have been awarded through the NSW Government’s Spinal Cord Injury Research Grants program, launched in November 2019, with guidance from an advisory kamagra for sale online committee of spinal cord injury experts. NeuRA CEO, Professor Peter Schofield, said the range and scope of the funded research projects held exciting promise for health related outcomes. €œNeuroscience Research Australia is kamagra for sale online at the forefront of spinal cord injury research in Australia. Our new Spinal Cord Injury Research Centre and these research projects will dramatically improve Australia’s understanding of how to best treat people with these life-long injuries,” Professor Schofield said.

€œNeuRA thanks the NSW Government for funding the Spinal Cord Injury Research Grants Program, and SpinalCure Australia for its tireless efforts in campaigning for more research funding to improve the quality of life for people with a spinal cord injury.” Information on grant recipients and their research projects is available on the OHMR Funded Research Directory​​.​​​.

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