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California does not have enough health workers for its large and increasingly diverse population best online kamagra. In partnership with the California Health Care Foundation, Mathematica has produced a suite of new publications on Health Workforce Strategies for California. This work highlights the evidence on the impact of various health workforce policy interventions in an effort to support California’s policymakers and thought leaders as they endeavor to prioritize workforce investments to realize the greatest impact.“We’re facing a best online kamagra health care workforce shortage across professions and geographies, and it’s particularly severe for urban and rural underserved populations,” said Diane Rittenhouse, senior fellow and lead author for the project.

€œWe’re pleased to help state leaders work together to close the gap between the health workforce we have and the one we need.”Although California is becoming increasingly diverse, current health professionals don’t reflect these demographic shifts. For example, in 2019, 39 percent of Californians identified as Latinx, but only 14 percent of medical school matriculants and 6 percent of active patient care physicians in California were Latinx best online kamagra. An infographic summarizes key findings from the evidence review addressing this issue.

Other publications in the Health best online kamagra Workforce Strategies for California Series include the following. A research brief on efforts to expand postbaccalaureate programs to help train health professionals so that the workforce better reflects California’s demographics A research brief on expanding teaching hospitals in underserved regions of the state A research brief on identifying strategies to increase the number of health care professionals who speak the same language as their patientsHHS Technology Group, LLC™ (HTG) and Mathematica announced their collaboration on a new health assessment platform that will account for individual health factors to provide a personalized risk score for helping individuals estimate their personal probability of contracting erectile dysfunction treatment as a result of engaging in common activities, such as attending sporting events and dining in restaurants. The comprehensive digital health tool for smart phones, tablets and personal computers will compute personal health risk beyond a simple red, yellow or green threat.

This unique solution will enable individuals to perform a health self-assessment as a means of protecting themselves against erectile dysfunction treatment, as local economies around best online kamagra the country re-open. The Health Risk Calculator will calculate a personal risk score for users, accounting for health markers based on individuals’ demographics, pre-existing conditions, vaccination status, and health behaviors to enable users to gauge the threat of potentially adverse situations. The risk score will be derived from users’ personal data, in addition to a risk best online kamagra methodology that will synthesize reported erectile dysfunction treatment geographic case data and rapidly evolving scientific research to help users estimate their potential risk of or complications.

The blockchain-based system, developed on Amazon GovCloud Infrastructure, will use the latest in geo-fencing technology to assess geographical risk and provide the most advanced approach to protecting individual privacy.“Many Americans are resuming the once-common activities they gave up during the kamagra, but face confusion and uncertainty due to sometimes-conflicting health advice and guidelines from various local, regional and federal authorities,” said Brett Furst, President of HTG. €œThis tool will help empower individuals in assessing their own risk and guiding more informed decisions, as kamagra-related restrictions continue to relax.” “For many people, ready access to a health assessment tool like this alleviates privacy concerns about sharing sensitive health information,” said Bill Reeves, director of strategic partnerships, Mathematica.About HHS Technology Group, LLCHHS Technology Group is a software and solutions best online kamagra company serving the needs of commercial enterprises and government agencies. HHS Tech Group delivers modular software solutions, custom development, and integration services for modernization and operation of systems supporting a wide spectrum of business and government needs.

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Joni Kazantzis kamagra oral jelly online was kamagra vs viagra 15 years old when she woke up one morning covered with red, scaly spots that looked a lot like chickenpox. It happened overnight, so her kamagra vs viagra mother thought it may have been an allergic reaction. But within the same week, she got a diagnosis. Guttate psoriasis kamagra vs viagra.

That’s a type of psoriasis that shows up as small, round spots called papules. The papules are raised and sometimes scaly.As a high schooler, being covered in spots kamagra vs viagra made Kazantzis incredibly self-conscious and affected her confidence. In fact, she says kamagra vs viagra she has no photos from that time because she wouldn’t let anyone take them. Treatment was an ordeal, too.“When I was first diagnosed, I was sent home with a bunch of creams -- really greasy and gross creams -- with the instructions to put them on before bed and put on Saran Wrap to make sure it stayed on all night.

I just remember it feeling disgusting and gross,” says Kazantzis, now 38 and living in Princeton Junction, NJ.The StigmaResearch kamagra vs viagra shows psoriasis can negatively affect body image, self-esteem, and quality of life. It may also impact your mental health and cause anxiety in social situations.There’s often a level of stigma attached to the condition, according to Rebecca Pearl, PhD. She’s an assistant professor in the Department of Clinical and Health Psychology at the University of Florida.“One of the common stereotypes that’s documented in the literature and that we hear from patients is the assumption that the skin disease is caused by poor hygiene, and that people are dirty when these physical lesions are seen,” she says.Howard Chang, an ordained kamagra vs viagra minister who’s had severe psoriasis since age 9, says he was bullied in high school. An incident in the boy’s locker room still stands out to Chang, now 49.“A couple of boys from the football team kamagra vs viagra really started to go at me.

They asked me if I had AIDS and they said, ‘Get away from me. €¦ ’ I thought that they were going kamagra vs viagra to get violent,” he says. €œI was really depressed and socially withdrawn, especially through those younger years into college.”Continued Kazantzis had a very accepting and supportive group of family and friends. It was kamagra vs viagra assumptions and rude comments about her skin by adult strangers that left her feeling uncomfortable.

As a teenager, she vividly remembers a middle-aged lady berating her for being on the beach with what she thought was chickenpox.“A simple question would have changed the situation,” Kazantzis says.Everyday ChallengesSomething as simple as picking out what to wear each day can be hard. This was true for kamagra vs viagra both Kazantzis and Chang. Each tried to hide their red, scaly skin as much as possible.“I wore pants up until it was probably way over 80 degrees,” Kazantzis kamagra vs viagra says.For Chang, who grew up in Northern California, long sleeves and full-length slacks or pants became a wardrobe staple despite the scorching 105-degree summers. The only time he didn’t have a choice was when he ran track in high school, a sport he loved.

Chang just wanted to run but couldn’t help feeling “self-conscious all the time.”Continued “Always being on guard” can take a toll on your mental health and affect day-to-day quality of life, says Pearl.“These kinds of concerns about being kamagra vs viagra judged by others, or being rejected by others, is a form of stress. And that kind of anticipated rejection from others, be [it] on one's body or stigmatized characteristics, can be sort of a constant threat in their daily life,” Pearl says.Coming to TermsJoining a faith fellowship his sophomore year of college and finding a supportive group of friends, along with his wife, was a turning point for Chang.“I found acceptance there,” he says. €œThey saw kamagra vs viagra me, including my skin.”“As I got older, I accepted that psoriasis was just a part of my life and it's going be a part of who I am,” Kazantzis says.While treatments like phototherapy, lotions, creams, and other medications can slow cell growth and keep skin from scaling too much, there’s no cure for psoriasis. But there are steps you can take to make peace with your skin.Continued Start with self-acceptance.

€œI still don't kamagra vs viagra like psoriasis,” Chang says. €œBut I also understand that while kamagra vs viagra it's hard, it's made me probably who I am.”This doesn’t mean giving up, Pearl says. Instead, it’s a way to acknowledge what the situation is.“Even just saying it out loud, [like], ‘I have psoriasis,’ and sitting with that, because those kinds of statements can be painful to really sit with,” she says.Continued Join a psoriasis community. Connecting with others who have similar conditions helps remind you that you’re not alone and brings about a “sense of belonging,” Pearl says.Kazantzis does this through her blog, Just a Girl With Spots, where she shares personal experiences living with and navigating psoriasis day-to-day.Chang turned to blogging and advocacy to share his journey -- be it doctor visits, new drugs, or the kamagra vs viagra social stigma -- with the psoriasis community online.

If you’re not sure where to start, visit the National Psoriasis Foundation’s website. You can kamagra vs viagra also ask your doctor. They may be able to point you to a local support group or other resources.Continued Exercise kamagra vs viagra and eat well. One study found that exercising regularly may help make your symptoms less severe.

If you’re overweight, losing those extra pounds kamagra vs viagra can help, too.“It's not just what you're putting on your skin, but it’s what you’re putting in your body. And also how you’re managing your stress and your mental health. It all kamagra vs viagra just connects,” Kazantzis says.Talk to your doctor before you pick up a new exercise routine or diet plan. You can always start with a light exercise like walking and work your way up.

If you have any pain or psoriasis flare-ups, let your doctor know.Practice kamagra vs viagra mindfulness. Pearl says skin exposure exercises kamagra vs viagra can help you become more accepting of your condition. This may include standing in front of a mirror -- even if only for a minute.“[N]otice if negative judgments come up, like about how one looks, and letting those go and not holding on to those,” Pearl says.Continued You can also build body positivity by focusing on what your body does for you rather than what it looks like. Pearl says it also helps to describe new lesion patches from a kamagra vs viagra neutral place of emotion.

Mindful practices like mediation and tai chi may also ease any stress you may have.Get professional help. Tell the doctor kamagra vs viagra if you’re feeling depressed or anxious because of your psoriasis. There may be new treatments you can try kamagra vs viagra. They also might be able to refer you to a mental health professional.

This person can help you work through kamagra vs viagra what you’re feeling. If you’re having suicidal thoughts, call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255). Trained counselors are available 24 hours a day, 7 days a week to help.If you just found out you have sleep apnea, kamagra vs viagra you may wonder what to do next. The first step is to talk to your doctor about the lifestyle changes and treatments you can use to manage it and improve your quality of life.

You may be surprised what a difference the right tools can make in your life.“Sleep apnea is treatable,” says Kannan Ramar, MD, a sleep medicine specialist in Rochester, MN, and former kamagra vs viagra president of the American Academy of Sleep Medicine. €œMany of the damaging effects of sleep apnea can be stopped, and even reversed, through diagnosis and treatment.”If you stick with your treatment, Ramar says, you’ll kamagra vs viagra have less daytime sleepiness. You’ll also lower your risk of more serious effects of sleep apnea, like heart attack, stroke, and things like motor vehicle accidents due to fatigue. What You Can ExpectLifestyle changes and treatments like continuous positive airway pressure (CPAP), oral kamagra vs viagra appliance therapy, positional therapy, and weight loss may make big improvements in your quality of life.Continued Here are some changes you can expect when you start treating your sleep apnea:Better sleep.

€œTreatment can restore your regular sleep pattern and increase your total sleep time by eliminating breathing pauses in your sleep,” Ramar says. €œThis will help you wake up feeling more refreshed and boost your energy throughout kamagra vs viagra the day.”More productivity. €œUsing CPAP kamagra vs viagra may improve your ability to think, concentrate, and make decisions,” Ramar says. He points out that this can also improve your productivity and lessen the chances of making a costly mistake at work.Improved quality of life.

With better sleep comes kamagra vs viagra more wellness. Ramar says treatment may improve your mood, lower your risk of depression, and improve your overall quality of life.Treating Sleep ApneaWhen you find out you have sleep apnea, your doctor will review your treatment options with you.Your doctor may suggest lifestyle changes, devices that open up your blocked airway, or surgery. Your doctor will base their recommendations on how mild kamagra vs viagra or severe your sleep apnea is. Together, you’ll decide what to try.

€œYour doctor will work with you to find the most comfortable option,” Ramar says.Common treatments for sleep apnea include lifestyle changes and therapies prescribed by your doctor.Lifestyle ChangesIf you have mild sleep apnea, it’s possible that lifestyle changes may be all kamagra vs viagra you need to manage the condition. These changes may make a big difference:Lose kamagra vs viagra weight. Carrying extra weight puts pressure on your throat, which leads to airway constriction. Just a 10% reduction in body weight can lessen the severity of your sleep apnea by 30%.Exercise kamagra vs viagra.

Working out can ease symptoms of obstructive sleep apnea. Your doctor may recommend regular exercise, like brisk walking, on most days.Avoid smoking, alcohol, and kamagra vs viagra certain medications. Your doctor may recommend that you stay away from things that constrict your throat and get kamagra vs viagra in the way of your breathing. These can include smoking, alcohol, sleeping pills, and other medications.Change your sleep position.

If you sleep on your back, your tongue and soft palate lie against the back of kamagra vs viagra your throat. This blocks your airway. It may help to sleep on your side kamagra vs viagra or stomach. Try wedging a pillow behind your back or use a tennis ball or other device to alert you when you turn over in your sleep.Devices and TherapiesIf you have moderate or severe sleep apnea, your doctor may recommend devices or treatments that open up your blocked airway.

Common therapies include:Continuous positive kamagra vs viagra airway pressure (CPAP). This is a machine that gently kamagra vs viagra delivers air pressure while you sleep. It gently blows air through a mask you wear over your nose and mouth to stop your upper airway tissues from collapsing as you sleep.It may feel uncomfortable at first, but in time, you’ll learn how to adjust the tension so it’s comfortable and secure. Your doctor can help you manage your CPAP.Other positive airway pressure devices are similar to a CPAP, but automatically adjust kamagra vs viagra the pressure as you asleep.

They include auto-CPAPs and bilevel positive airway pressure, or BPAP devices.Other devices and appliances. Your doctor may suggest that you try one of these other devices or appliances.An adaptive servo-ventilation (ASV) device, which uses a computer to analyze your kamagra vs viagra breathing and then normalizes it through an airflow machineA device to deliver extra oxygen to your lungs while you sleepA hypoglossal nerve stimulator, which is implanted under your skin. It stimulates your hypoglossal nerve to move your tongue forward and open up your airwayAn oral kamagra vs viagra (mouth) appliance to keep your throat openSurgeryIf lifestyle changes and therapies like CPAP don’t work, or if you have a jaw structure problem, your doctor may recommend surgery.Surgery for sleep apnea may include:Bariatric surgery (weight loss surgery)ImplantsJaw repositioningNasal surgeryNerve stimulationSurgery for enlarged tonsils or adenoidsTissue removalTissue shrinkageTracheostomyGetting SupportYou have many options for treating sleep apnea. If one isn’t the right fit, your doctor will help you find another that may work better.For more support, talk to your primary care provider.

You can find a sleep provider through kamagra vs viagra an AASM-accredited sleep center. To find an accredited sleep center, visit sleepeducation.org/find-a-facility.Remember, you have many tools and resources to improve your quality of life. €œSleep apnea is a condition that we can work together to treat,” Ramar says.By Cara MurezHealthDay ReporterFRIDAY, June 18, 2021 (HealthDay News) – A diet designed to boost brain health appears to benefit people with multiple sclerosis (MS), new research suggests.For the study, a team from Icahn School of kamagra vs viagra Medicine at Mount Sinai in New York City examined 185 people diagnosed with MS within the past five years. Each had MRI kamagra vs viagra brain scans and responded to detailed questionnaires.The upshot.

Those who ate more of the "good" foods from a brain-health eating regimen known as the MIND diet and fewer "bad" ones tended to have more preserved tissue in a critical relay station in the brain called the thalamus. The study also found a link between eating kamagra vs viagra more full-fat dairy products and fewer MS brain lesions. Eating omega-3 fatty acids from fish also had brain benefits.The MIND diet combines aspects of the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet. MIND is kamagra vs viagra short for Mediterranean-DASH Intervention for Neurodegenerative Delay.

The diet is designed to benefit brain health, and past studies have suggested it may help prevent Alzheimer's disease and help preserve thinking skills in older adults.Continued Foods considered "good" include leafy vegetables, berries, nuts and fish, and those considered "bad" include fried foods, butter, cheese, red and processed meats and sweets.About 1 million Americans have MS, a central nervous system disorder with symptoms that can range from numbness and tingling to blindness and paralysis. Most people kamagra vs viagra are diagnosed between the ages of 20 and 50. The disease affects women three times kamagra vs viagra as often as men. There is currently no cure.Dr.

Ilana Katz Sand, a neurologist, led the study.The study had a couple kamagra vs viagra of key limitations. Research was restricted to patients in the early stages of MS and it took only a one-time snapshot.But the findings provide additional evidence about the impact of diet and nutrition on outcomes for people with MS, researchers said. They will continue to follow participants to determine whether healthy diets continue to have benefits as MS progresses.The findings kamagra vs viagra were recently published recently in the journal MS and Related Disorders.Continued More informationThe U.S. National Library of Medicine has kamagra vs viagra more information about multiple sclerosis.SOURCE.

National Multiple Sclerosis Society, news release, June 10, 2021In the early 2000s, Caroline Williams started to notice tiny white flakes of skin on the shoulders of her clothes. €œDandruff,” she thought, and tried to treat it with over-the-counter kamagra vs viagra remedies. But it got worse, and in 2004, she went to a doctor, who diagnosed psoriasis.For years afterward, doctors prescribed any number of creams, lotions, and shampoos for her to apply to her scalp. She even tried phototherapy, which kamagra vs viagra is when you expose your skin to special uaviolet (UV) lights at the doctor’s office.

But nothing seemed to help much, and her psoriasis continued to worsen.Even though it was so far limited to her scalp, her symptoms started to intrude on her life. It wasn’t just the embarrassment of kamagra vs viagra the constant flakes -- it was the itchiness. It could get so intense that it became almost impossible to think about anything else, much less to work or socialize.“The constant desire to scratch can be overwhelming,” kamagra vs viagra she says. But of course, scratching just made it worse.

Every doctor she’s been to, says Williams, is clear on kamagra vs viagra one thing. €œDon’t scratch.”“The next one that tells me that will get a swift kick to the shin,” she says.Relief, Finally, and a QuestionThen, in 2008, she switched to a dermatologist who prescribed her first biologic medication. Enbrel. It was a revelation.“It was literally life-changing for me after so many years of intense itching -- not to mention self-consciously and constantly brushing flakes off my shoulders and office chair.” Williams was elated.

Why, she wondered, hadn’t she been offered one of these biologic medications years earlier?. What Are Biologics?. Biologics are specialized drugs that target specific parts of the immune system. When used to treat psoriasis, they block the actions of certain cells and proteins that are part of the process of developing the disease.You get biologic therapy either through an IV or as a shot.

With some of the medications, you may be able to give yourself the shots at home.The Issue of SafetyAs to why these drugs weren’t widely offered at first, “It was different in the early years of biologics,” says Mary Spraker, MD, a clinical dermatologist and associate professor of medicine at Emory University.Continued Doctors and pharmaceutical companies weren’t yet sure how safe and effective the medications were, so they were more wary about prescribing them too easily, she says.In fact, the FDA only approved biologics for psoriasis in 2004. In 2008, it added a “black box” warning to some of the medications about possible reactivation of tuberculosis and hepatitis B.“These are serious medications, and we still don’t know all of the possible long-term effects,” Spraker says.But over time, with more research and newer biologics that may be safer, doctors could start to feel more comfortable recommending these drugs for people with a milder form of the disease.That’s why, even if your doctor hasn’t recommended them in the past, you can continue to ask about whether a biologic would be a good option, especially if you notice your symptoms getting worse.The Cost FactorBiologic therapy is very expensive. A recent study found a 3-year biologic treatment program can run to more than $180,000.Continued When Williams first started with it, her out-of-pocket expenses were relatively low, in part because of copay assistance from the pharmaceutical company. It probably didn’t hurt that she had excellent insurance at the large company where she worked.Because of the high cost of this therapy, insurance providers, including Medicare, typically have strict requirements.

Even when you meet them, your copayments can be in the thousands of dollars.Drug companies are aware of this. Many have programs to lessen the cost of the copay. Some programs are for people who have almost no money at all (indigent), but others cater to people like Williams, who simply can’t afford the huge copay that some of these drugs require, even with good private insurance.Williams was lucky enough to qualify for one of these programs, which made her copay very affordable. So if you’re on biologics, it’s a good idea to check with the drugmaker for a program that could help with payment.The Insurance GantletAfter a few years, as can happen with biologic medications, the drug’s effects started to fade for Williams.

Like a bad dream, the flakes and the relentless itching began to return.Continued “We don’t really know all the reasons why these medications sometimes grow less effective over time,” Spraker says, “but it’s important to talk to your doctor when it starts to happen, because there are a number of different things we can do to fix the problem, including switching the type of biologic medication.”That’s exactly what happened to Williams in 2016. Her doctor switched her to another biologic. Stelara. Again, relief came quickly and, with the help of copay assistance from the drug company, the cost to her was nominal.Then in 2018, something changed.

Williams was closing in on retirement age, and she needed to move back to her home country of England to tend to her ailing mother.She soon found out that getting biologics in the U.K. Was a lot more difficult. €œI literally would have to have been a fully walking flake on legs to qualify for a biological -- which I wasn't at the time.”Continued She managed to keep her psoriasis symptoms somewhat in check with topical medications from the U.K.’s National Health Service. It helped, she says, that she was mostly home with her mother and didn’t need to go to an office or even out in public much.But after she moved back to the United States in October of 2020, she tried to get in to see a dermatologist who could put her back on biologics right away.

In the meantime, her psoriasis started to flare badly. It wasn’t just her scalp this time. It was down her neck, back, and legs as well. And it was severe.“By the time I went to see the doctor, it was worse than it's ever been in my life.”Her new doctor immediately prescribed Stelara, the biologic that had worked so well in 2016.

But this time around, Williams didn’t have insurance through her job. She was retired and on Medicare.The problem wasn’t approval -- Medicare eventually approved her for biologic medication. The problem was that Medicare disqualified her from the copay assistance programs that made the medication affordable.Continued On Medicare, even with prescription drug coverage, she would be out of pocket $5,600 just for the first couple of months of treatment, with a copay of about $2,800 per shot.Although that sounds like a lot, it’s only a tiny fraction of the cost of the drugs. Still, it was more than Williams could afford.

She didn’t have that much in retirement savings, and she didn’t want to dip into them to pay for medication that she’ll need for life.But to requalify for the copay assistance, she needed private insurance. And to get affordable private insurance, she needed to get a job. So that’s just what she did.“It was 25 hours a week, which I didn't want to do. I mean, I'm supposed to be retired.

But that to me was a better alternative than having to use up my savings.”All this took time, and it was April before she got her first dose of Stelara. Her copay was $5.A Never-Ending JourneySadly, the new dose of Stelara has not worked for Williams. She estimates she still has psoriasis over about 75% of her body. Her doctor says she will likely need to try a different biologic drug.Now, Williams and her doctor have to navigate the gantlet again in order to make sure she qualifies to switch medications through her new insurance provider.It feels, she says, like a never-ending journey.Each insurance company has separate rules for switching medications.The problem is bigger than just biologics and psoriasis, says Emory’s Spraker.“Everyone’s befuddled about health insurance.”“Even through your employer, every year when you sign up for insurance, there’s different fine print.

It really is hard to understand what’s going to happen until you get the bill, and then you have to make phone calls.”Still, there are resources to help you get the treatment you need for your psoriasis. Organizations like the National Psoriasis Foundation can help guide you to the right place.Continued Your health care provider can help, too. Emory Healthcare recently hired a full-time pharmacist whose sole job is to help patients navigate the gantlet of insurance approval for expensive medications. It’s the same at the other two hospitals where Spraker works.You can also ask your pharmacist or your insurance provider or look online for resources.

They can’t typically do it all for you, but they can usually give you some useful help and guidance.“Most of the time,” says Spraker, “we can figure out a way.”By Robert Preidt HealthDay ReporterFRIDAY, June 18, 2021 (HealthDay News) -- Fish oil supplements are often touted as good for your heart health, but a new study finds they may also help fight depression."Using a combination of laboratory and patient research, our study has provided exciting new insight into how omega-3 fatty acids bring about anti-inflammatory effects that improve depression," said lead author Alessandra Borsini, a postdoctoral neuroscientist at King's College London.Borsini said it's been known that omega-3 polyunsaturated fatty acids have anti-depressant and anti-inflammatory effects, but exactly how that happens has been unclear. "Our study has helped shine a light on the molecular mechanisms involved in this relationship, which can inform the development of potential new treatments for depression using omega-3 PUFA," Borsini said in a university news release.Previous studies have shown that people with major depression have elevated levels of inflammation, but no proven anti-inflammatory treatments for depression exist.The patient portion of this new study included 22 people with major depression. Continued Once a day for 12 weeks, they were given one of two omega-3 polyunsaturated fatty acids (PUFAs) — either 3 grams of eicosapentaenoic acid (EPA) or 1.4 grams of docosahexaenoic acid (DHA).EPA and DHA are omega-3 PUFAs found in oily fish.Byproducts of EPA and DHA were measured in the patients' blood before and after treatment, and their depression symptoms were assessed.Treatment with both omega-3s was associated with a significant improvement in depression, with an average 64% drop in symptoms for the EPA group and 71% in the DHA group. It does not prove cause-and-effect, however.The findings were published June 16 in the journal Molecular Psychiatry.The levels of EPA and DHA used in this study can't be achieved by eating oily fish, the researchers noted.Senior study author Carmen Pariante, a professor of biological psychiatry, said the research has provided vital information to help shape clinical trials of therapeutic approaches with omega-3 fatty acids."It is important to highlight that our research has not shown that by simply increasing omega-3 fatty acids in our diets or through taking nutritional supplements we can reduce inflammation or depression," she said.

"The mechanisms behind the associations between depression and omega-3 PUFA are complicated and require further research and clinical trials to fully understand how they work and inform future therapeutic approaches."Continued More information The U.S. National Institute of Mental Health has more on depression. SOURCE. King's College London, news release, June 15, 2021.

Joni Kazantzis was 15 years old when she woke up one morning website here covered with red, best online kamagra scaly spots that looked a lot like chickenpox. It happened overnight, best online kamagra so her mother thought it may have been an allergic reaction. But within the same week, she got a diagnosis. Guttate psoriasis best online kamagra.

That’s a type of psoriasis that shows up as small, round spots called papules. The papules are raised and sometimes scaly.As a high schooler, being covered in spots made best online kamagra Kazantzis incredibly self-conscious and affected her confidence. In fact, best online kamagra she says she has no photos from that time because she wouldn’t let anyone take them. Treatment was an ordeal, too.“When I was first diagnosed, I was sent home with a bunch of creams -- really greasy and gross creams -- with the instructions to put them on before bed and put on Saran Wrap to make sure it stayed on all night.

I just remember it feeling disgusting and best online kamagra gross,” says Kazantzis, now 38 and living in Princeton Junction, NJ.The StigmaResearch shows psoriasis can negatively affect body image, self-esteem, and quality of life. It may also impact your mental health and cause anxiety in social situations.There’s often a level of stigma attached to the condition, according to Rebecca Pearl, PhD. She’s an assistant professor in the Department of Clinical and Health Psychology at the University of Florida.“One of the common stereotypes that’s documented in the literature and that we hear from patients is the assumption that the skin disease is caused by poor hygiene, and that people are dirty when these physical lesions are seen,” she says.Howard Chang, an ordained minister best online kamagra who’s had severe psoriasis since age 9, says he was bullied in high school. An incident in the boy’s locker room still stands out to Chang, now 49.“A couple of boys from best online kamagra the football team really started to go at me.

They asked me if I had AIDS and they said, ‘Get away from me. €¦ ’ I thought best online kamagra that they were going to get violent,” he says. €œI was really depressed and socially withdrawn, especially through those younger years into college.”Continued Kazantzis had a very accepting and supportive group of family and friends. It was assumptions and rude comments about her skin by adult strangers that left her feeling uncomfortable best online kamagra.

As a teenager, she vividly remembers a middle-aged lady berating her for being on the beach with what she thought was chickenpox.“A simple question would have changed the situation,” Kazantzis says.Everyday ChallengesSomething as simple as picking out what to wear each day can be hard. This was best online kamagra true for both Kazantzis and Chang. Each tried to hide their red, scaly skin best online kamagra as much as possible.“I wore pants up until it was probably way over 80 degrees,” Kazantzis says.For Chang, who grew up in Northern California, long sleeves and full-length slacks or pants became a wardrobe staple despite the scorching 105-degree summers. The only time he didn’t have a choice was when he ran track in high school, a sport he loved.

Chang just wanted to run but couldn’t help feeling “self-conscious all the time.”Continued “Always being on guard” can take a toll on your mental health and best online kamagra affect day-to-day quality of life, says Pearl.“These kinds of concerns about being judged by others, or being rejected by others, is a form of stress. And that kind of anticipated rejection from others, be [it] on one's body or stigmatized characteristics, can be sort of a constant threat in their daily life,” Pearl says.Coming to TermsJoining a faith fellowship his sophomore year of college and finding a supportive group of friends, along with his wife, was a turning point for Chang.“I found acceptance there,” he says. €œThey saw me, including best online kamagra my skin.”“As I got older, I accepted that psoriasis was just a part of my life and it's going be a part of who I am,” Kazantzis says.While treatments like phototherapy, lotions, creams, and other medications can slow cell growth and keep skin from scaling too much, there’s no cure for psoriasis. But there are steps you can take to make peace with your skin.Continued Start with self-acceptance.

€œI still best online kamagra don't like psoriasis,” Chang says. €œBut I best online kamagra also understand that while it's hard, it's made me probably who I am.”This doesn’t mean giving up, Pearl says. Instead, it’s a way to acknowledge what the situation is.“Even just saying it out loud, [like], ‘I have psoriasis,’ and sitting with that, because those kinds of statements can be painful to really sit with,” she says.Continued Join a psoriasis community. Connecting with others who have similar conditions helps remind you that you’re not alone and brings about a “sense of belonging,” Pearl says.Kazantzis does this through her blog, Just a Girl best online kamagra With Spots, where she shares personal experiences living with and navigating psoriasis day-to-day.Chang turned to blogging and advocacy to share his journey -- be it doctor visits, new drugs, or the social stigma -- with the psoriasis community online.

If you’re not sure where to start, visit the National Psoriasis Foundation’s website. You can also best online kamagra ask your doctor. They may be able to point you to a local support group or other resources.Continued best online kamagra Exercise and eat well. One study found that exercising regularly may help make your symptoms less severe.

If you’re overweight, best online kamagra losing those extra pounds can help, too.“It's not just what you're putting on your skin, but it’s what you’re putting in your body. And also how you’re managing your stress and your mental health. It all just connects,” Kazantzis best online kamagra says.Talk to your doctor before you pick up a new exercise routine or diet plan. You can always start with a light exercise like walking and work your way up.

If you have any pain or psoriasis flare-ups, let your doctor best online kamagra know.Practice mindfulness. Pearl says best online kamagra skin exposure exercises can help you become more accepting of your condition. This may include standing in front of a mirror -- even if only for a minute.“[N]otice if negative judgments come up, like about how one looks, and letting those go and not holding on to those,” Pearl says.Continued You can also build body positivity by focusing on what your body does for you rather than what it looks like. Pearl says best online kamagra it also helps to describe new lesion patches from a neutral place of emotion.

Mindful practices like mediation and tai chi may also ease any stress you may have.Get professional help. Tell the doctor if you’re feeling depressed or anxious because of your psoriasis best online kamagra. There may best online kamagra be new treatments you can try. They also might be able to refer you to a mental health professional.

This person can help you work best online kamagra through what you’re feeling. If you’re having suicidal thoughts, call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255). Trained counselors best online kamagra are available 24 hours a day, 7 days a week to help.If you just found out you have sleep apnea, you may wonder what to do next. The first step is to talk to your doctor about the lifestyle changes and treatments you can use to manage it and improve your quality of life.

You may be surprised what a difference the right tools can make in your life.“Sleep apnea is treatable,” says Kannan Ramar, MD, a sleep medicine specialist in Rochester, MN, and former president best online kamagra of the American Academy of Sleep Medicine. €œMany of the damaging effects of sleep apnea can be stopped, and best online kamagra even reversed, through diagnosis and treatment.”If you stick with your treatment, Ramar says, you’ll have less daytime sleepiness. You’ll also lower your risk of more serious effects of sleep apnea, like heart attack, stroke, and things like motor vehicle accidents due to fatigue. What You Can ExpectLifestyle changes and treatments like best online kamagra continuous positive airway pressure (CPAP), oral appliance therapy, positional therapy, and weight loss may make big improvements in your quality of life.Continued Here are some changes you can expect when you start treating your sleep apnea:Better sleep.

€œTreatment can restore your regular sleep pattern and increase your total sleep time by eliminating breathing pauses in your sleep,” Ramar says. €œThis will help you wake up feeling more refreshed and boost your energy throughout the day.”More best online kamagra productivity. €œUsing CPAP may improve your ability to best online kamagra think, concentrate, and make decisions,” Ramar says. He points out that this can also improve your productivity and lessen the chances of making a costly mistake at work.Improved quality of life.

With better sleep best online kamagra comes more wellness. Ramar says treatment may improve your mood, lower your risk of depression, and improve your overall quality of life.Treating Sleep ApneaWhen you find out you have sleep apnea, your doctor will review your treatment options with you.Your doctor may suggest lifestyle changes, devices that open up your blocked airway, or surgery. Your doctor will base their recommendations on how mild or severe your sleep apnea is best online kamagra. Together, you’ll decide what to try.

€œYour doctor will work with you to find the most comfortable option,” Ramar says.Common treatments for sleep apnea include lifestyle changes and therapies prescribed by your doctor.Lifestyle ChangesIf you have mild sleep apnea, it’s possible that lifestyle changes may be all you best online kamagra need to manage the condition. These changes may make a best online kamagra big difference:Lose weight. Carrying extra weight puts pressure on your throat, which leads to airway constriction. Just a 10% reduction in body weight can lessen the severity of best online kamagra your sleep apnea by 30%.Exercise.

Working out can ease symptoms of obstructive sleep apnea. Your doctor may recommend regular exercise, best online kamagra like brisk walking, on most days.Avoid smoking, alcohol, and certain medications. Your doctor may recommend that you stay best online kamagra away from things that constrict your throat and get in the way of your breathing. These can include smoking, alcohol, sleeping pills, and other medications.Change your sleep position.

If you best online kamagra sleep on your back, your tongue and soft palate lie against the back of your throat. This blocks your airway. It may help to sleep on your side or stomach best online kamagra. Try wedging a pillow behind your back or use a tennis ball or other device to alert you when you turn over in your sleep.Devices and TherapiesIf you have moderate or severe sleep apnea, your doctor may recommend devices or treatments that open up your blocked airway.

Common therapies include:Continuous best online kamagra positive airway pressure (CPAP). This is a best online kamagra machine that gently delivers air pressure while you sleep. It gently blows air through a mask you wear over your nose and mouth to stop your upper airway tissues from collapsing as you sleep.It may feel uncomfortable at first, but in time, you’ll learn how to adjust the tension so it’s comfortable and secure. Your doctor can help you manage your CPAP.Other positive airway best online kamagra pressure devices are similar to a CPAP, but automatically adjust the pressure as you asleep.

They include auto-CPAPs and bilevel positive airway pressure, or BPAP devices.Other devices and appliances. Your doctor may suggest that you try one best online kamagra of these other devices or appliances.An adaptive servo-ventilation (ASV) device, which uses a computer to analyze your breathing and then normalizes it through an airflow machineA device to deliver extra oxygen to your lungs while you sleepA hypoglossal nerve stimulator, which is implanted under your skin. It stimulates your best online kamagra hypoglossal nerve to move your tongue forward and open up http://www.ec-leclerc-schiltigheim.ac-strasbourg.fr/expo/ your airwayAn oral (mouth) appliance to keep your throat openSurgeryIf lifestyle changes and therapies like CPAP don’t work, or if you have a jaw structure problem, your doctor may recommend surgery.Surgery for sleep apnea may include:Bariatric surgery (weight loss surgery)ImplantsJaw repositioningNasal surgeryNerve stimulationSurgery for enlarged tonsils or adenoidsTissue removalTissue shrinkageTracheostomyGetting SupportYou have many options for treating sleep apnea. If one isn’t the right fit, your doctor will help you find another that may work better.For more support, talk to your primary care provider.

You can find a sleep best online kamagra provider through an AASM-accredited sleep center. To find an accredited sleep center, visit sleepeducation.org/find-a-facility.Remember, you have many tools and resources to improve your quality of life. €œSleep apnea is a condition that we can work together best online kamagra to treat,” Ramar says.By Cara MurezHealthDay ReporterFRIDAY, June 18, 2021 (HealthDay News) – A diet designed to boost brain health appears to benefit people with multiple sclerosis (MS), new research suggests.For the study, a team from Icahn School of Medicine at Mount Sinai in New York City examined 185 people diagnosed with MS within the past five years. Each had MRI brain best online kamagra scans and responded to detailed questionnaires.The upshot.

Those who ate more of the "good" foods from a brain-health eating regimen known as the MIND diet and fewer "bad" ones tended to have more preserved tissue in a critical relay station in the brain called the thalamus. The study also found a link between eating more best online kamagra full-fat dairy products and fewer MS brain lesions. Eating omega-3 fatty acids from fish also had brain benefits.The MIND diet combines aspects of the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet. MIND is best online kamagra short for Mediterranean-DASH Intervention for Neurodegenerative Delay.

The diet is designed to benefit brain health, and past studies have suggested it may help prevent Alzheimer's disease and help preserve thinking skills in older adults.Continued Foods considered "good" include leafy vegetables, berries, nuts and fish, and those considered "bad" include fried foods, butter, cheese, red and processed meats and sweets.About 1 million Americans have MS, a central nervous system disorder with symptoms that can range from numbness and tingling to blindness and paralysis. Most people are diagnosed between the ages of best online kamagra 20 and 50. The disease affects best online kamagra women three times as often as men. There is currently no cure.Dr.

Ilana Katz Sand, best online kamagra a neurologist, led the study.The study had a couple of key limitations. Research was restricted to patients in the early stages of MS and it took only a one-time snapshot.But the findings provide additional evidence about the impact of diet and nutrition on outcomes for people with MS, researchers said. They will continue to follow participants to best online kamagra determine whether healthy diets continue to have benefits as MS progresses.The findings were recently published recently in the journal MS and Related Disorders.Continued More informationThe U.S. National Library of Medicine has more information about multiple sclerosis.SOURCE best online kamagra.

National Multiple Sclerosis Society, news release, June 10, 2021In the early 2000s, Caroline Williams started to notice tiny white flakes of skin on the shoulders of her clothes. €œDandruff,” she thought, and tried to treat it best online kamagra with over-the-counter remedies. But it got worse, and in 2004, she went to a doctor, who diagnosed psoriasis.For years afterward, doctors prescribed any number of creams, lotions, and shampoos for her to apply to her scalp. She even tried phototherapy, which best online kamagra is when you expose your skin to special uaviolet (UV) lights at the doctor’s office.

But nothing seemed to help much, and her psoriasis continued to worsen.Even though it was so far limited to her scalp, her symptoms started to intrude on her life. It wasn’t just the embarrassment of the constant flakes -- it was best online kamagra the itchiness. It could best online kamagra get so intense that it became almost impossible to think about anything else, much less to work or socialize.“The constant desire to scratch can be overwhelming,” she says. But of course, scratching just made it worse.

Every doctor she’s been to, best online kamagra says Williams, is clear on one thing. €œDon’t scratch.”“The next one that tells me that will get a swift kick to the shin,” she says.Relief, Finally, and a QuestionThen, in 2008, she switched to a dermatologist who prescribed her first biologic medication. Enbrel. It was a revelation.“It was literally life-changing for me after so many years of intense itching -- not to mention self-consciously and constantly brushing flakes off my shoulders and office chair.” Williams was elated.

Why, she wondered, hadn’t she been offered one of these biologic medications years earlier?. What Are Biologics?. Biologics are specialized drugs that target specific parts of the immune system. When used to treat psoriasis, they block the actions of certain cells and proteins that are part of the process of developing the disease.You get biologic therapy either through an IV or as a shot.

With some of the medications, you may be able to give yourself the shots at home.The Issue of SafetyAs to why these drugs weren’t widely offered at first, “It was different in the early years of biologics,” says Mary Spraker, MD, a clinical dermatologist and associate professor of medicine at Emory University.Continued Doctors and pharmaceutical companies weren’t yet sure how safe and effective the medications were, so they were more wary about prescribing them too easily, she says.In fact, the FDA only approved biologics for psoriasis in 2004. In 2008, it added a “black box” warning to some of the medications about possible reactivation of tuberculosis and hepatitis B.“These are serious medications, and we still don’t know all of the possible long-term effects,” Spraker says.But over time, with more research and newer biologics that may be safer, doctors could start to feel more comfortable recommending these drugs for people with a milder form of the disease.That’s why, even if your doctor hasn’t recommended them in the past, you can continue to ask about whether a biologic would be a good option, especially if you notice your symptoms getting worse.The Cost FactorBiologic therapy is very expensive. A recent study found a 3-year biologic treatment program can run to more than $180,000.Continued When Williams first started with it, her out-of-pocket expenses were relatively low, in part because of copay assistance from the pharmaceutical company. It probably didn’t hurt that she had excellent insurance at the large company where she worked.Because of the high cost of this therapy, insurance providers, including Medicare, typically have strict requirements.

Even when you meet them, your copayments can be in the thousands of dollars.Drug companies are aware of this. Many have programs to lessen the cost of the copay. Some programs are for people who have almost no money at all (indigent), but others cater to people like Williams, who simply can’t afford the huge copay that some of these drugs require, even with good private insurance.Williams was lucky enough to qualify for one of these programs, which made her copay very affordable. So if you’re on biologics, it’s a good idea to check with the drugmaker for a program that could help with payment.The Insurance GantletAfter a few years, as can happen with biologic medications, the drug’s effects started to fade for Williams.

Like a bad dream, the flakes and the relentless itching began to return.Continued “We don’t really know all the reasons why these medications sometimes grow less effective over time,” Spraker says, “but it’s important to talk to your doctor when it starts to happen, because there are a number of different things we can do to fix the problem, including switching the type of biologic medication.”That’s exactly what happened to Williams in 2016. Her doctor switched her to another biologic. Stelara. Again, relief came quickly and, with the help of copay assistance from the drug company, the cost to her was nominal.Then in 2018, something changed.

Williams was closing in on retirement age, and she needed to move back to her home country of England to tend to her ailing mother.She soon found out that getting biologics in the U.K. Was a lot more difficult. €œI literally would have to have been a fully walking flake on legs to qualify for a biological -- which I wasn't at the time.”Continued She managed to keep her psoriasis symptoms somewhat in check with topical medications from the U.K.’s National Health Service. It helped, she says, that she was mostly home with her mother and didn’t need to go to an office or even out in public much.But after she moved back to the United States in October of 2020, she tried to get in to see a dermatologist who could put her back on biologics right away.

In the meantime, her psoriasis started to flare badly. It wasn’t just her scalp this time. It was down her neck, back, and legs as well. And it was severe.“By the time I went to see the doctor, it was worse than it's ever been in my life.”Her new doctor immediately prescribed Stelara, the biologic that had worked so well in 2016.

But this time around, Williams didn’t have insurance through her job. She was retired and on Medicare.The problem wasn’t approval -- Medicare eventually approved her for biologic medication. The problem was that Medicare disqualified her from the copay assistance programs that made the medication affordable.Continued On Medicare, even with prescription drug coverage, she would be out of pocket $5,600 just for the first couple of months of treatment, with a copay of about $2,800 per shot.Although that sounds like a lot, it’s only a tiny fraction of the cost of the drugs. Still, it was more than Williams could afford.

She didn’t have that much in retirement savings, and she didn’t want to dip into them to pay for medication that she’ll need for life.But to requalify for the copay assistance, she needed private insurance. And to get affordable private insurance, she needed to get a job. So that’s just what she did.“It was 25 hours a week, which I didn't want to do. I mean, I'm supposed to be retired.

But that to me was a better alternative than having to use up my savings.”All this took time, and it was April before she got her first dose of Stelara. Her copay was $5.A Never-Ending JourneySadly, the new dose of Stelara has not worked for Williams. She estimates she still has psoriasis over about 75% of her body. Her doctor says she will likely need to try a different biologic drug.Now, Williams and her doctor have to navigate the gantlet again in order to make sure she qualifies to switch medications through her new insurance provider.It feels, she says, like a never-ending journey.Each insurance company has separate rules for switching medications.The problem is bigger than just biologics and psoriasis, says Emory’s Spraker.“Everyone’s befuddled about health insurance.”“Even through your employer, every year when you sign up for insurance, there’s different fine print.

It really is hard to understand what’s going to happen until you get the bill, and then you have to make phone calls.”Still, there are resources to help you get the treatment you need for your psoriasis. Organizations like the National Psoriasis Foundation can help guide you to the right place.Continued Your health care provider can help, too. Emory Healthcare recently hired a full-time pharmacist whose sole job is to help patients navigate the gantlet of insurance approval for expensive medications. It’s the same at the other two hospitals where Spraker works.You can also ask your pharmacist or your insurance provider or look online for resources.

They can’t typically do it all for you, but they can usually give you some useful help and guidance.“Most of the time,” says Spraker, “we can figure out a way.”By Robert Preidt HealthDay ReporterFRIDAY, June 18, 2021 (HealthDay News) -- Fish oil supplements are often touted as good for your heart health, but a new study finds they may also help fight depression."Using a combination of laboratory and patient research, our study has provided exciting new insight into how omega-3 fatty acids bring about anti-inflammatory effects that improve depression," said lead author Alessandra Borsini, a postdoctoral neuroscientist at King's College London.Borsini said it's been known that omega-3 polyunsaturated fatty acids have anti-depressant and anti-inflammatory effects, but exactly how that happens has been unclear. "Our study has helped shine a light on the molecular mechanisms involved in this relationship, which can inform the development of potential new treatments for depression using omega-3 PUFA," Borsini said in a university news release.Previous studies have shown that people with major depression have elevated levels of inflammation, but no proven anti-inflammatory treatments for depression exist.The patient portion of this new study included 22 people with major depression. Continued Once a day for 12 weeks, they were given one of two omega-3 polyunsaturated fatty acids (PUFAs) — either 3 grams of eicosapentaenoic acid (EPA) or 1.4 grams of docosahexaenoic acid (DHA).EPA and DHA are omega-3 PUFAs found in oily fish.Byproducts of EPA and DHA were measured in the patients' blood before and after treatment, and their depression symptoms were assessed.Treatment with both omega-3s was associated with a significant improvement in depression, with an average 64% drop in symptoms for the EPA group and 71% in the DHA group. It does not prove cause-and-effect, however.The findings were published June 16 in the journal Molecular Psychiatry.The levels of EPA and DHA used in this study can't be achieved by eating oily fish, the researchers noted.Senior study author Carmen Pariante, a professor of biological psychiatry, said the research has provided vital information to help shape clinical trials of therapeutic approaches with omega-3 fatty acids."It is important to highlight that our research has not shown that by simply increasing omega-3 fatty acids in our diets or through taking nutritional supplements we can reduce inflammation or depression," she said.

"The mechanisms behind the associations between depression and omega-3 PUFA are complicated and require further research and clinical trials to fully understand how they work and inform future therapeutic approaches."Continued More information The U.S. National Institute of Mental Health has more on depression. SOURCE. King's College London, news release, June 15, 2021.

What side effects may I notice from Kamagra?

Side effects that you should report to your doctor or health care professional as soon as possible:

  • allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
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  • chest pain
  • fast, irregular heartbeat
  • men: prolonged or painful erection (lasting more than 4 hours)
  • seizures

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

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This list may not describe all possible side effects.

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An effective response to the erectile dysfunction (erectile dysfunction treatment) kamagra oral gel kamagra requires the understanding and use of social see this here and behavioural data alongside biomedical data. Recognizing this need, the Behavioural Insights and Sciences Unit of the World Health Organization (WHO) and the WHO Regional Office for Africa (AFRO) designed a survey tool tailored to Africa, to make it easier for countries to collect context-specific social and behavioural data. The objective was to inform the erectile dysfunction treatment response at the country level while also allowing kamagra oral gel regional comparisons.

This case study describes how the tool was adapted and used in a pilot study in Nigeria and Zambia and complements the WHO guidance on how to use the tool.WHO today published the new edition of its Model Lists of Essential Medicines and Essential Medicines for Children, which include new treatments for various cancers, insulin analogues and new oral medicines for diabetes, new medicines to assist people who want to stop smoking, and new antimicrobials to treat serious bacterial and fungal s. The listings aim to address global health priorities, identifying the medicines that provide the greatest benefits, and which should be available kamagra oral gel and affordable for all. However, high prices for both new, patented medicines and older medicines, like insulin, continue to keep some essential medicines out of reach for many patients.

€œDiabetes is on the rise globally, and rising faster in low- and middle-income countries,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. €œToo many people who need insulin encounter financial hardship in accessing it or go without it and lose kamagra oral gel their lives. Including insulin analogues in the Essential Medicines List, coupled with efforts to ensure affordable access to all insulin products and expand use of biosimilars, is a vital step towards ensuring everyone who needs this life-saving product can access it.”Medicines for diabetesInsulin was discovered as a treatment for diabetes 100 years ago and human insulin has been on WHO’s List of Essential Medicines since it was first published in 1977.

Unfortunately, limited insulin supply kamagra oral gel and high prices in several low- and middle-income countries are currently a significant barrier to treatment. For example, in Ghana’s capital, Accra, the amount of insulin needed for a month would cost a worker the equivalent of 5.5 days of pay per month. Insulin production is concentrated in a small number of manufacturing facilities, and three manufacturers control most of the global market, with the lack of competition resulting in high prices that are prohibitive for many people and health systems.The move to list long-acting insulin kamagra oral gel analogues (insulin degludec, detemir and glargine) and their biosimilars, along with human insulin, is intended to increase access to diabetes treatment by expanding the choice of treatment.

Inclusion in the List means that biosimilar insulin analogues can be eligible for WHO’s prequalification programme. WHO prequalification can result in more quality-assured biosimilars entering the international market, creating competition to bring prices down and giving countries a greater choice of products. Long-acting insulin analogues offer some extra clinical benefits for patients through their prolonged duration of action, which ensures that blood glucose levels can be controlled over longer periods of time without needing kamagra oral gel a booster dose.

They offer particular benefit for patients who experience dangerously low blood glucose levels with human insulin. The greater flexibility in timing and dosing of kamagra oral gel insulin analogues has been shown to improve quality of life for patients living with diabetes. However, human insulin remains a staple in the treatment of diabetes and access to this life-saving medicine must continue to be supported through better availability and affordability.The list also includes Sodium-Glucose Co-transporter-2 (SGLT2) inhibitors empagliflozin, canagliflozin and dapagliflozin as second line therapy in adults with type 2 diabetes.

These orally administered medicines have been shown to offer several benefits, including a lower risk of death, kidney failure and cardiovascular events. Because SGLT2 inhibitors are still patented and high-priced, their inclusion in the list comes with the recommendation that WHO work with kamagra oral gel the Medicines Patent Pool to promote access through potential licencing agreements with the patent-holders to allow generic manufacturing and supply in low- and middle-income countries. Improving access to diabetes medicines including insulin and SGLT2 inhibitors is one of the workstreams of the Global Diabetes Compact, launched by WHO in April 2021, and a key topic under discussion with manufacturers of diabetes medicines and health technologies.Cancer medicinesCancers are among the leading causes of illness and death worldwide, accounting for nearly 10 million deaths in 2020, with seven out of 10 occurring in low- and middle-income countries.

New breakthroughs have been made in cancer treatment in the last years, such as medicines that target specific molecular characteristics of the tumour, some of which offer much kamagra oral gel better outcomes than “traditional” chemotherapy for many types of cancer. Four new medicines for cancer treatment were added to the Model Lists:Enzalutamide, as an alternative to abiraterone, for prostate cancer;Everolimus, for subependymal giant cell astrocytoma (SEGA), a type of brain tumour in children;Ibrutinib, a targeted medicine for chronic lymphocytic leukaemia. AndRasburicase, for tumour lysis syndrome, a serious complication of some cancer treatments.The listing for imatinib was extended to include targeted treatment of kamagra oral gel leukaemia.

New childhood cancer indications were added for 16 medicines already listed, including for low-grade glioma, the most common form of brain tumour in children. A group of antibodies that enhance the immune response to tumour cells, called PD-1 / PD-L1 immune-checkpoint inhibitors, were not recommended for listing for the treatment of a number of lung cancers, despite being effective, mainly because of their exceedingly high price and concerns that they are difficult to manage in low-resourced health systems. Other cancer medicines were kamagra oral gel not recommended for listing due to uncertain additional clinical benefit compared with already listed medicines, high price, and management issues in low-resource settings.

These included osimertinib for lung cancer, daratumumab for multiple myeloma, and three types of treatment (CDK4/6 inhibitors, fulvestrant and pertuzumab) for breast cancer. Other developmentsInfectious kamagra oral gel diseases - New medicines listed include cefiderocol, a ‘Reserve’ group antibiotic effective against multi-drug resistant bacteria, echinocandin antifungals for severe fungal s and monoclonal antibodies for rabies prevention – the first monoclonal antibodies against an infectious disease to be included on the Model Lists. The updated lists also see new formulations of medicines for common bacterial s, hepatitis C, HIV and tuberculosis, to better meet dosing and administration needs of both children and adults.

An additional 81 antibiotics were classified as Access, Watch or Reserve under the AWaRe framework, to support antimicrobial stewardship kamagra oral gel and surveillance of antibiotic use worldwide.Smoking cessation – Two non-nicotine-based medicines – bupropion and varenicline – join nicotine-replacement therapy on the Model List, providing alternative treatment options for people who want to stop smoking. Listing aims to support the race to reach WHO’s ‘ Commit to Quit’ campaign goal that would see 100 million people worldwide quitting smoking over the coming year.Note to EditorsThe meeting of the 23rd Expert Committee on the Selection and Use of Essential Medicines was held virtually from 21 June to 2 July. The Expert Committee considered 88 applications for medicines to be added to the 21st WHO Model List of Essential Medicines (EML) and the 7th WHO Model List of Essential Medicines for Children (EMLc).

WHO technical departments were involved and consulted kamagra oral gel with regard to applications relating to their disease areas.The updated Essential Medicines Lists include 20 new medicines for adults and 17 for children and specify new uses for 28 already-listed medicines. The changes recommended by the Expert Committee bring the number of medicines deemed essential to address key public health needs to 479 on the EML and 350 on the EMLc. While these numbers may seem high, they are only a small proportion of the total number of medicines available on the market.Governments and institutions around the world continue kamagra oral gel to use the WHO Model Lists to guide the development of their own essential medicines lists, because they know that every medicine listed has been vetted for efficacy and safety and delivers value for money for the health outcomes they produce.

The Model Lists are updated every two years by an Expert Committee, made up of recognized specialists from academia, research and the medical and pharmaceutical professions. This year, the Committee underscored the urgent need to take action to promote equitable and affordable access to essential medicines through the list and complementary measures such as voluntary licensing mechanisms, pooled procurement, and price negotiation..

An effective response to best online kamagra the erectile dysfunction (erectile dysfunction treatment) kamagra requires the understanding and use of social and behavioural data see this alongside biomedical data. Recognizing this need, the Behavioural Insights and Sciences Unit of the World Health Organization (WHO) and the WHO Regional Office for Africa (AFRO) designed a survey tool tailored to Africa, to make it easier for countries to collect context-specific social and behavioural data. The objective was to inform the erectile dysfunction treatment response at the country level while best online kamagra also allowing regional comparisons.

This case study describes how the tool was adapted and used in a pilot study in Nigeria and Zambia and complements the WHO guidance on how to use the tool.WHO today published the new edition of its Model Lists of Essential Medicines and Essential Medicines for Children, which include new treatments for various cancers, insulin analogues and new oral medicines for diabetes, new medicines to assist people who want to stop smoking, and new antimicrobials to treat serious bacterial and fungal s. The listings aim to address global health priorities, identifying the medicines that best online kamagra provide the greatest benefits, and which should be available and affordable for all. However, high prices for both new, patented medicines and older medicines, like insulin, continue to keep some essential medicines out of reach for many patients.

€œDiabetes is on the rise globally, and rising faster in low- and middle-income countries,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. €œToo many people who need insulin encounter financial hardship in accessing it or go without it and best online kamagra lose their lives. Including insulin analogues in the Essential Medicines List, coupled with efforts to ensure affordable access to all insulin products and expand use of biosimilars, is a vital step towards ensuring everyone who needs this life-saving product can access it.”Medicines for diabetesInsulin was discovered as a treatment for diabetes 100 years ago and human insulin has been on WHO’s List of Essential Medicines since it was first published in 1977.

Unfortunately, limited insulin best online kamagra supply and high prices in several low- and middle-income countries are currently a significant barrier to treatment. For example, in Ghana’s capital, Accra, the amount of insulin needed for a month would cost a worker the equivalent of 5.5 days of pay per month. Insulin production is concentrated in a small number of manufacturing facilities, and three manufacturers control most of the global market, with the lack of competition resulting in high prices that are prohibitive for many people and health systems.The move to list long-acting insulin analogues (insulin degludec, detemir and glargine) and their best online kamagra biosimilars, along with human insulin, is intended to increase access to diabetes treatment by expanding the choice of treatment.

Inclusion in the List means that biosimilar insulin analogues can be eligible for WHO’s prequalification programme. WHO prequalification can result in more quality-assured biosimilars entering the international market, creating competition to bring prices down and giving countries a greater choice of products. Long-acting insulin analogues offer some extra clinical benefits for patients through their prolonged duration of action, which best online kamagra ensures that blood glucose levels can be controlled over longer periods of time without needing a booster dose.

They offer particular benefit for patients who experience dangerously low blood glucose levels with human insulin. The greater flexibility in timing and dosing of insulin analogues has been shown to improve quality of life for patients living best online kamagra with diabetes. However, human insulin remains a staple in the treatment of diabetes and access to this life-saving medicine must continue to be supported through better availability and affordability.The list also includes Sodium-Glucose Co-transporter-2 (SGLT2) inhibitors empagliflozin, canagliflozin and dapagliflozin as second line therapy in adults with type 2 diabetes.

These orally administered medicines have been shown to offer several benefits, including a lower risk of death, kidney failure and cardiovascular events. Because SGLT2 inhibitors are still best online kamagra patented and high-priced, their inclusion in the list comes with the recommendation that WHO work with the Medicines Patent Pool to promote access through potential licencing agreements with the patent-holders to allow generic manufacturing and supply in low- and middle-income countries. Improving access to diabetes medicines including insulin and SGLT2 inhibitors is one of the workstreams of the Global Diabetes Compact, launched by WHO in April 2021, and a key topic under discussion with manufacturers of diabetes medicines and health technologies.Cancer medicinesCancers are among the leading causes of illness and death worldwide, accounting for nearly 10 million deaths in 2020, with seven out of 10 occurring in low- and middle-income countries.

New breakthroughs have been made best online kamagra in cancer treatment in the last years, such as medicines that target specific molecular characteristics of the tumour, some of which offer much better outcomes than “traditional” chemotherapy for many types of cancer. Four new medicines for cancer treatment were added to the Model Lists:Enzalutamide, as an alternative to abiraterone, for prostate cancer;Everolimus, for subependymal giant cell astrocytoma (SEGA), a type of brain tumour in children;Ibrutinib, a targeted medicine for chronic lymphocytic leukaemia. AndRasburicase, for tumour lysis syndrome, a serious complication of some cancer treatments.The listing best online kamagra for imatinib was extended to include targeted treatment of leukaemia.

New childhood cancer indications were added for 16 medicines already listed, including for low-grade glioma, the most common form of brain tumour in children. A group of antibodies that enhance the immune response to tumour cells, called PD-1 / PD-L1 immune-checkpoint inhibitors, were not recommended for listing for the treatment of a number of lung cancers, despite being effective, mainly because of their exceedingly high price and concerns that they are difficult to manage in low-resourced health systems. Other cancer medicines were not recommended for listing due to uncertain additional clinical benefit compared with already listed medicines, best online kamagra high price, and management issues in low-resource settings.

These included osimertinib for lung cancer, daratumumab for multiple myeloma, and three types of treatment (CDK4/6 inhibitors, fulvestrant and pertuzumab) for breast cancer. Other developmentsInfectious diseases - New medicines listed include cefiderocol, a ‘Reserve’ group antibiotic effective against multi-drug resistant bacteria, echinocandin antifungals for severe fungal s and monoclonal antibodies for rabies prevention – the first monoclonal antibodies against best online kamagra an infectious disease to be included on the Model Lists. The updated lists also see new formulations of medicines for common bacterial s, hepatitis C, HIV and tuberculosis, to better meet dosing and administration needs of both children and adults.

An additional 81 antibiotics were classified as best online kamagra Access, Watch or Reserve under the AWaRe framework, to support antimicrobial stewardship and surveillance of antibiotic use worldwide.Smoking cessation – Two non-nicotine-based medicines – bupropion and varenicline – join nicotine-replacement therapy on the Model List, providing alternative treatment options for people who want to stop smoking. Listing aims to support the race to reach WHO’s ‘ Commit to Quit’ campaign goal that would see 100 million people worldwide quitting smoking over the coming year.Note to EditorsThe meeting of the 23rd Expert Committee on the Selection and Use of Essential Medicines was held virtually from 21 June to 2 July. The Expert Committee considered 88 applications for medicines to be added to the 21st WHO Model List of Essential Medicines (EML) and the 7th WHO Model List of Essential Medicines for Children (EMLc).

WHO technical departments were involved and consulted with regard to applications relating to their disease areas.The updated Essential Medicines Lists include 20 new medicines for adults and 17 for children and specify new best online kamagra uses for 28 already-listed medicines. The changes recommended by the Expert Committee bring the number of medicines deemed essential to address key public health needs to 479 on the EML and 350 on the EMLc. While these numbers may seem high, they are only a small proportion of the total number of medicines available on the market.Governments and institutions around the world continue to use the WHO Model Lists to guide the development of their own essential medicines lists, because they know that every medicine best online kamagra listed has been vetted for efficacy and safety and delivers value for money for the health outcomes they produce.

The Model Lists are updated every two years by an Expert Committee, made up of recognized specialists from academia, research and the medical and pharmaceutical professions. This year, the Committee underscored the urgent need to take action to promote equitable and affordable access to essential medicines through the list and complementary measures such as voluntary licensing mechanisms, pooled procurement, and price negotiation..

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Therapeutic creep in provision of hypothermia for hypoxic ischaemic encephalopathyThree articles kamagra bestellen relate to the changing practices of UK clinicians in the provision of therapeutic hypothermia for hypoxic ischaemic encephalopathy (HIE). Lori Hage and colleagues report the clinical characteristics of term born infants treated with therapeutic hypothermia for a diagnosis of HIE in the UK between 2010 and 2017. The data came from the National Neonatal Research Database and include infants who were treated for 3 days or who died during kamagra bestellen this period.

There were 5201 infants who met this definition. The number of infants treated increased year on year until 2015 and then levelled out. Markers of condition at birth suggested kamagra bestellen inclusion over time of greater numbers of infants with less severe disease.

The number of infants treated with a diagnosis of mild encephalopathy increased four-fold from 31 infants per year to 133 infants per year over the study period. There was no important change in the number of infants treated with kamagra bestellen severe encephalopathy over the same time period. Lara Shipley and colleagues report temporal changes in the incidence of hypoxic-ischaemic encephalopathy in the UK between the time periods 2011–13 and 2014–16.

The incidence of mild and of moderate or severe HIE remained stable between epochs suggesting that there has not been diagnostic creep driving the therapeutic creep. The proportion of infants with mild HIE who were treated with therapeutic hypothermia significantly increased over time between kamagra bestellen 2011–2013 (24.9%) and 2014–2016 (35.8%). The number of late preterm infants diagnosed with HIE also remained stable over time but again the proportion treated with hypothermia increased from 34% to 47%.

This therapeutic creep, where larger numbers of infants are cooled who do not fulfil the criteria used to select infants for enrolment in the randomised controlled trials has been observed in other health systems. On the one hand it represents invasive treatment that kamagra bestellen is not well supported by the evidence base. Further trials are called for to determine whether hypothermia is beneficial in milder cases.

The authors also point out that there is some kamagra bestellen is some subjectivity in the assessment of encephalopathy meaning that some clinicians don't cool borderline infants where others would classify them with more severe encephalopathy. Unrelated to these articles but on the same theme we received a viewpoint from Mohamed Ali Tagin and Alastair Gunn. They argue that the criteria used to select infants for the trials were deliberately biased towards selecting infants at highest risk (and by inference not likely to have selected all infants that stand to benefit).

The individual components of the inclusion criteria perform kamagra bestellen poorly and are subjective. They encourage clinicians in doubt about whether an infant should be cooled to choose cooling because there is still an appreciable risk of adverse outcome and the treatment can be delivered safely, so that the potential benefits outweigh the potential harms. They argue that the limitations of the evidence kamagra bestellen should be discussed with the families involved.

Perhaps therapeutic creep will push the trials out of reach. When new treatments are shown to be effective it is understandable that clinicians are keen to use them and this makes research more difficult before we know everything we want to know. This again is a situation that would become less likely if we continue to work towards inclusive research models kamagra bestellen normalising routine involvement in enhancing the knowledge base.

See pages F529, F501 and F458Methods for surfactant administrationA network meta-analysis by Ioannis Bellos and colleagues of 16 RCTs and 20 observational studies including data from more than 13 000 infants, suggests that thin catheter administration of surfactant is associated with lower rates of mortality, PVL, BPD and mechanical ventilation. See page F474The cost of neonatal abstinence syndromePhilippa Rees and colleagues estimated the direct NHS costs of neonatal unit in-patient care for Neonatal Abstinence Syndrome in England between 2012 and 2017 using the National Neonatal Research Database. There were 6411 admissions with this diagnosis during the study period kamagra bestellen (1.6 per 1000 births) and the incidence increased over time.

The direct annual cost of care was £10 440 444, with a median cost of £7715 per infant. The median time to discharge was 10.2 days and this was higher in the 49% of infants receiving pharmacotherapy kamagra bestellen. The emerging literature suggests that changes in the model of care away from neonatal unit admission could improve patient outcomes and greatly reduce costs.

See page F494Measurement of the effect of chest compressionsResuscitation council guidance advises on the depth of chest compressions during cardiopulmonary resuscitation in the newborn. Although it makes sense that compression depth is important this is based kamagra bestellen on indirect information and extrapolation. Marlies Bruckner and colleagues developed an automated device that could deliver controlled compression depth and investigated its effect on piglets with experimental asphyxia to asystole.

Compression depth made an important difference to carotid blood flow and systolic blood pressure kamagra bestellen. See page F553Face mask versus nasal prong or nasopharyngeal tube for neonatal resuscitation in the delivery roomAvneet Magnat and colleagues performed a systematic review of evidence relating to the best interface for providing respiratory support in the delivery room. They identified five randomised controlled trials involving 873 infants.

There was no difference kamagra bestellen in mortality between devices. Confidence intervals for most outcomes were wide indicating the need for more data. Difference in rates of intubation in the delivery room and need for chest compressions during initial stabilisation suggest that more data may uncover clinically important differences.

It will kamagra bestellen be interesting to see how this meta-analysis changes after inclusion of data from the recently completed CORSAD trial. See page F561Ethics statementsPatient consent for publicationNot required.Clinical scenario‘Sarah is a baby girl born by an emergency caesarean section following a period of observation for non-reassuring cardiotocographic recordings. She was initially ‘flat’ and received positive pressure ventilation for 3 min before establishing spontaneous kamagra bestellen breathing.

Her Apgar scores were 1, 6 and 8 at 1, 5 and 10 min, respectively. Cord pH was 7.08 and standard base excess (sBE) was −12.1. Sarah stayed with her mother kamagra bestellen as she was breathing normally and centrally pink despite being mildly hypotonic with minimal activity.

At 10 hours of age, she started to develop recurrent seizures. Cerebral MRI showed extensive diffusion restriction patterns compatible with acute hypoxic–ischaemic insult.’Sarah is a composite case, kamagra bestellen developed to include real events that we and others have observed. Unfortunately, many neonatal units receive similar cases every year and they often end up not offering therapeutic hypothermia, the only available treatment with proven safety and efficacy to this condition.1 The current guidelines are not inclusive and do not consider borderline cases.2 3The simple question clinicians should ask themselves, is it unreasonable to treat a newborn with perinatal asphyxia and moderate encephalopathy?.

Babies, in a situation like Sarah, may lose the opportunity to be treated with therapeutic hypothermia because they miss a single criterion from the current cooling guidelines. The selection criteria kamagra bestellen in the initial randomised controlled trials of hypothermia were developed to identify the highest risk newborns who had been exposed to hypoxia–ischaemia. Newborns who had lower levels of risk were pragmatically excluded.

Now that the evidence for benefit is well established,1 4 we propose that those entry points ….

Therapeutic creep in provision http://thegtproject.com/planning-future-looking-input/ of hypothermia for hypoxic ischaemic encephalopathyThree articles relate to the changing practices of UK clinicians in the best online kamagra provision of therapeutic hypothermia for hypoxic ischaemic encephalopathy (HIE). Lori Hage and colleagues report the clinical characteristics of term born infants treated with therapeutic hypothermia for a diagnosis of HIE in the UK between 2010 and 2017. The data came from the National Neonatal Research Database and include infants best online kamagra who were treated for 3 days or who died during this period. There were 5201 infants who met this definition.

The number of infants treated increased year on year until 2015 and then levelled out. Markers of condition at birth suggested inclusion best online kamagra over time of greater numbers of infants with less severe disease. The number of infants treated with a diagnosis of mild encephalopathy increased four-fold from 31 infants per year to 133 infants per year over the study period. There was no important change in the number of infants treated with severe encephalopathy over the same time period best online kamagra.

Lara Shipley and colleagues report temporal changes in the incidence of hypoxic-ischaemic encephalopathy in the UK between the time periods 2011–13 and 2014–16. The incidence of mild and of moderate or severe HIE remained stable between epochs suggesting that there has not been diagnostic creep driving the therapeutic creep. The proportion of infants with mild HIE who were treated with therapeutic hypothermia significantly increased over best online kamagra time between 2011–2013 (24.9%) and 2014–2016 (35.8%). The number of late preterm infants diagnosed with HIE also remained stable over time but again the proportion treated with hypothermia increased from 34% to 47%.

This therapeutic creep, where larger numbers of infants are cooled who do not fulfil the criteria used to select infants for enrolment in the randomised controlled trials has been observed in other health systems. On the one best online kamagra hand it represents invasive treatment that is not well supported by the evidence base. Further trials are called for to determine whether hypothermia is beneficial in milder cases. The authors also point out that there is some is some subjectivity in the assessment of encephalopathy meaning that some best online kamagra clinicians don't cool borderline infants where others would classify them with more severe encephalopathy.

Unrelated to these articles but on the same theme we received a viewpoint from Mohamed Ali Tagin and Alastair Gunn. They argue that the criteria used to select infants for the trials were deliberately biased towards selecting infants at highest risk (and by inference not likely to have selected all infants that stand to benefit). The individual components best online kamagra of the inclusion criteria perform poorly and are subjective. They encourage clinicians in doubt about whether an infant should be cooled to choose cooling because there is still an appreciable risk of adverse outcome and the treatment can be delivered safely, so that the potential benefits outweigh the potential harms.

They argue that best online kamagra the limitations of the evidence should be discussed with the families involved. Perhaps therapeutic creep will push the trials out of reach. When new treatments are shown to be effective it is understandable that clinicians are keen to use them and this makes research more difficult before we know everything we want to know. This again is a situation that would become less likely if we continue to work towards best online kamagra inclusive research models normalising routine involvement in enhancing the knowledge base.

See pages F529, F501 and F458Methods for surfactant administrationA network meta-analysis by Ioannis Bellos and colleagues of 16 RCTs and 20 observational studies including data from more than 13 000 infants, suggests that thin catheter administration of surfactant is associated with lower rates of mortality, PVL, BPD and mechanical ventilation. See page F474The cost of neonatal abstinence syndromePhilippa Rees and colleagues estimated the direct NHS costs of neonatal unit in-patient care for Neonatal Abstinence Syndrome in England between 2012 and 2017 using the National Neonatal Research Database. There were 6411 admissions with this diagnosis during the study best online kamagra period (1.6 per 1000 births) and the incidence increased best online kamagra over time. The direct annual cost of care was £10 440 444, with a median cost of £7715 per infant.

The median time to discharge was 10.2 days and this was higher in the 49% of infants receiving best online kamagra pharmacotherapy. The emerging literature suggests that changes in the model of care away from neonatal unit admission could improve patient outcomes and greatly reduce costs. See page F494Measurement of the effect of chest compressionsResuscitation council guidance advises on the depth of chest compressions during cardiopulmonary resuscitation in the newborn. Although it makes sense that compression depth is best online kamagra important this is based on indirect information and extrapolation.

Marlies Bruckner and colleagues developed an automated device that could deliver controlled compression depth and investigated its effect on piglets with experimental asphyxia to asystole. Compression depth made an important difference to carotid blood flow and systolic blood pressure best online kamagra. See page F553Face mask versus nasal prong or nasopharyngeal tube for neonatal resuscitation in the delivery roomAvneet Magnat and colleagues performed a systematic review of evidence relating to the best interface for providing respiratory support in the delivery room. They identified five randomised controlled trials involving 873 infants.

There was best online kamagra no difference in mortality between devices. Confidence intervals for most outcomes were wide indicating the need for more data. Difference in rates of intubation in the delivery room and need for chest compressions during initial stabilisation suggest that more data may uncover clinically important differences. It will be interesting to see how this meta-analysis changes after inclusion of best online kamagra data from the recently completed CORSAD trial.

See page F561Ethics statementsPatient consent for publicationNot required.Clinical scenario‘Sarah is a baby girl born by an emergency caesarean section following a period of observation for non-reassuring cardiotocographic recordings. She was initially ‘flat’ and received positive best online kamagra pressure ventilation for 3 min before establishing spontaneous breathing. Her Apgar scores were 1, 6 and 8 at 1, 5 and 10 min, respectively. Cord pH was 7.08 and standard base excess (sBE) was −12.1.

Sarah stayed with best online kamagra her mother as she was breathing normally and centrally pink despite being mildly hypotonic with minimal activity. At 10 hours of age, she started to develop recurrent seizures. Cerebral MRI showed best online kamagra extensive diffusion restriction patterns compatible with acute hypoxic–ischaemic insult.’Sarah is a composite case, developed to include real events that we and others have observed. Unfortunately, many neonatal units receive similar cases every year and they often end up not offering therapeutic hypothermia, the only available treatment with proven safety and efficacy to this condition.1 The current guidelines are not inclusive and do not consider borderline cases.2 3The simple question clinicians should ask themselves, is it unreasonable to treat a newborn with perinatal asphyxia and moderate encephalopathy?.

Babies, in a situation like Sarah, may lose the opportunity to be treated with therapeutic hypothermia because they miss a single criterion from the current cooling guidelines. The selection criteria in the initial randomised controlled trials of hypothermia were developed to identify the highest risk newborns who had best online kamagra been exposed to hypoxia–ischaemia. Newborns who had lower levels of risk were pragmatically excluded. Now that the evidence for benefit is well established,1 4 we propose that those entry points ….