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Cybersecurity researchers this week released a report order kamagra gel detailing a leak that appeared to expose the data of thousands of medical workers, nurses and caregivers. According to the report, released by Security Discovery Co-Founder Jeremiah Fowler and Website Planet, the non-password protected database seemed to be linked to Gale Healthcare Solutions, which connects facilities with locally available nurses and caregivers. "These employee profiles exposed names, order kamagra gel phone, email, home addresses. The accounts also contained links to images of the employees, and files that indicated credentials, and tax documents (SSN / Social Security Number)," wrote Fowler in the report.

Gale did not respond to Healthcare IT News' requests for comment by press time. WHY IT MATTERSAs outlined by Fowler, the 170,239 records were contained in two folders, comprising 139,000 records of contacts and 31,500 of employees order kamagra gel. The exposed data included:Internal records including first and last names, phone, emails, home addresses, hire dates, apply dates, skill level and in some cases detailed notes of incidents and terminationsPasswords in plain text, with usernames appearing to be the user’s name or email address that was also listed in the account Links to AWS storage accounts that contained photos of the employee and files named “SSN Card” or “credentials” Fowler also noted that images linked in accounts were named in a format that contained the employees’ full name and a number titled "SSN" in the file name, such as "Jane_Doe-CNA-SSN-123456789.jpeg." He drew attention to the uncommon nature of such a labeling system, saying that the file theoretically wouldn't have to be opened to expose sensitive information. "This exposed data could be used for a range of crimes including identity theft, scams, and extortion," wrote Fowler.

"With email addresses cyber criminals could launch a targeted phishing campaign or social engineering attack using insider information to establish trust." He pointed to the potential danger of the exposed name, Social Security Number and home address information from an identity theft perspective, in addition order kamagra gel to passwords (which are often reused). "It is unclear how long the database was exposed and who else may have gained access to the publicly accessible records. It is also unclear if medical workers or authorities were notified of the potential exposure as required by Florida Information Protection Act of 2014 (FIPA)," Flower wrote. Gale is headquartered order kamagra gel in Tampa.

Fowler said that upon discovery, his team immediately sent a disclosure notice to Gale Healthcare Solutions. Public access was closed the same day. "We are not implying any order kamagra gel wrongdoing by Gale Healthcare Solutions, their partners, or users and we are highlighting our discovery to raise data protection awareness and promote cybersecurity best practices," he said. THE LARGER TREND Fowler has drawn attention to similar apparently vulnerable databases in the past.

This summer, he and Website Planet flagged a database containing more than 1 billion CVS Health records that had not been password protected. And order kamagra gel in August, a research team from UpGuard also drew attention to a data leak from Microsoft Power Apps, containing 38 million records. ON THE RECORD "Any service that allows hospitals to fill their shifts is extremely important and valuable to sick patients. It is unfortunate that this incident may have exposed the data of frontline workers during an already difficult time," wrote Fowler.

Kat Jercich order kamagra gel is senior editor of Healthcare IT News.Twitter. @kjercichEmail. Kjercich@himss.orgHealthcare IT News is a HIMSS Media publication..

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WHY IT MATTERS The guidance outlines several circumstances in which such disclosures are permitted without an individual's authorization, including:When the disclosure is required by federal, state, local or other law.When an HIE is a business associate of the covered entity that wishes to provide the information to a public health authority for public health.When an HIE is acting under a grant of authority or contract with a public health authority for a public health activity."A covered laboratory may report patient test results (PHI) through an HIE that receives and transmits the PHI to a PHA, when the HIE is performing this data transmission on behalf of the laboratory as the laboratory’s business associate," explained the guidance.OCR also noted that it will not impose penalties on a business associate HIE for disclosing information to a public health authority during the erectile dysfunction treatment emergency when its business associate agreements do not authorize the disclosure.The guidance likely will be particularly relevant as kamagra jelly for women the erectile dysfunction treatment kamagra continues to wreak havoc throughout the country. As OCR noted, "A state PHA can engage an HIE to collect test results and associated patient information from health care providers and then transmit that information into the state’s electronic contact tracing system." OCR also said that when a public health authority requests a summary record or another specified data set of protected health information, a covered hospital, laboratory or other provider may reasonably rely on that authority to be requesting the minimum necessary information. "In such cases, the Privacy Rule does not require a covered entity to make an independent determination of minimum necessary when responding to a request from a PHA for the PHA’s public health activities," wrote OCR.For example, this could be the case when "the Centers for Disease Control and Prevention (CDC), in its capacity as a PHA, requests that health care providers disclose PHI on an ongoing basis for all prior and current cases of patients exposed to erectile dysfunction treatment, whether kamagra jelly for women suspected or confirmed, using Electronic Case Reporting (eCR), the automated generation and transmission of case reports from EHRs to public health agencies, for review and action." A covered entity can also disclose information to an authority through an HIE without receiving a direct request from the authority, said OCR. During the public health emergency, an HIE may also provide protected health information it's received from a business associate to an authority without obtaining permission from the covered entity.

THE LARGER TREND Health information exchanges already have proved useful during the erectile dysfunction treatment crisis kamagra jelly for women. For instance, Health Current, Arizona's statewide HIE, told Healthcare IT News in March that it had pivoted to focus on marshalling healthcare-data resources across the state in response to the erectile dysfunction treatment crisis. "We see ourselves as a partner here in Arizona to make sure that we're kamagra jelly for women providing the best care possible. So we see ourselves definitely as a piece of that puzzle," Health Current CIO Keith Parker told HITN.

The Office of the National Coordinator for Health IT also announced in August that it plans to bolster existing HIE kamagra jelly for women infrastructure, so public health agencies are able to better access, share and use health data, during and after the erectile dysfunction treatment kamagra. ON THE RECORD "An HIE that is in a business associate relationship with a covered entity will not be subject to HIPAA penalties if the HIE (1) transmits summary records about individuals diagnosed with erectile dysfunction treatment to the city health department that is collecting the information to track erectile dysfunction treatment, regardless of whether that public health disclosure is permitted by the HIE’s [business associate agreement] with the covered health care provider. And (2) notifies the covered entity, within 10 days after it first transmitted such information to the city health department, that kamagra jelly for women it is providing such information to the health department," explained OCR. Kat Jercich is senior editor of Healthcare IT News.Twitter.

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The U.S order kamagra gel Cialis black 80mg for sale. Department of Health and Human Services' Office of Civil Rights on Friday issued guidance addressing how HIPAA permits the use of health information exchanges to disclose protected health information for public health purposes. A covered entity is required to provide individuals with notice that it discloses protected health information for public health activities, order kamagra gel the guidance read. "OCR is issuing this guidance to highlight how HIPAA supports the use of health information exchanges in sharing health data to improve the public's health, particularly during the erectile dysfunction treatment public health emergency," OCR Director Roger Severino said in a statement. WHY IT MATTERS The guidance outlines several circumstances in which such disclosures are permitted without an individual's authorization, including:When the disclosure is required by federal, state, local or other law.When an HIE is a business associate of the covered entity that wishes to provide the information to a public health authority for public health.When an HIE is acting under a grant of authority or contract with a public health authority for a public health activity."A covered laboratory may order kamagra gel report patient test results (PHI) through an HIE that receives and transmits the PHI to a PHA, when the HIE is performing this data transmission on behalf of the laboratory as the laboratory’s business associate," explained the guidance.OCR also noted that it will not impose penalties on a business associate HIE for disclosing information to a public health authority during the erectile dysfunction treatment emergency when its business associate agreements do not authorize the disclosure.The guidance likely will be particularly relevant as the erectile dysfunction treatment kamagra continues to wreak havoc throughout the country.

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erectile dysfunction treatment outbreak is "disturbing," disagreeing with President Donald Trump, who said the U.S. Outbreak was "rounding the corner."While cases are growing in 11 states, the overall daily average of new cases order kamagra gel in the U.S. Is declining. Over the past seven days, the country has reported an average of about order kamagra gel 34,300 new cases per day, down more than 15% compared with a week ago, according to a CNBC analysis of Hopkins data. That's far lower than the roughly 70,000 new cases a order kamagra gel day the U.S.

Was reporting weeks ago. Still, the 34,300 new cases a day is order kamagra gel alarmingly high, infectious disease experts say, and U.S. Health officials fear the outbreak could get worse as the nation enters the fall and winter seasons. Health officials have repeatedly warned that they are preparing to battle two bad kamagraes circulating later this year as the order kamagra gel erectile dysfunction outbreak runs into flu season. Earlier this month, Fauci said daily new cases were "unacceptably high" this close to fall order kamagra gel.

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If the FDA approves the treatment, the company is prepared to distribute "hundreds of thousands of doses," he said. Even if a order kamagra gel treatment is approved to be distributed before the end of the year, it will likely be in short supply. The treatment will likely require two doses at varying intervals, and states still face logistical challenges such as setting up distribution sites and acquiring enough needles, syringes and bottles needed for immunizations.For now, leaders can stop new outbreaks by practicing the "basics" of public health and disease control, medical experts and officials say.The World Health Organization recommends that people wear masks as a way to slow the spread of the kamagra. Scientists say erectile dysfunction treatment can spread through respiratory droplets that pass when an infected person order kamagra gel coughs or sneezes. Studies suggest the masks may serve as a helpful barrier to spreading .The agency also order kamagra gel recommends people wash their hands regularly, maintain their distance from others and avoid going to crowded places.

If you have a fever, cough and difficulty breathing, seek medical attention, but call by telephone in advance if possible and follow the directions of your local health authority, the WHO said.Albert Bourla, PfizerGian Ehrenzeller | Keystone | APPfizer's erectile dysfunction treatment could be distributed to Americans before the end of the year if found to be safe and effective, CEO Albert Bourla said Sunday. The drugmaker should have key data from its late-stage trial for the Food and Drug Administration by the end of October, Bourla order kamagra gel said during an interview on CBS' "Face the Nation." If the FDA approves the treatment, the company is prepared to distribute "hundreds of thousands of doses," he said. Because of the kamagra, U.S. Health officials order kamagra gel and drugmakers have been accelerating the development of treatment candidates by investing in multiple stages of research even though doing so could be for naught if the treatment ends up not being effective or safe.The U.S. Pharmaceutical giant order kamagra gel has been working alongside German drugmaker BioNTech.

In July, the U.S. Government announced it would pay the companies $1.95 order kamagra gel billion to produce and deliver 100 million doses of their treatment if it proves safe and effective. The deal was signed as part of Operation Warp Speed, the Trump administration's effort to accelerate development and production of treatments and treatments to order kamagra gel fight the erectile dysfunction.Bourla said Sunday that the company has already invested $1.5 billion for the development of the potential treatment. He said if the treatment failed to work it would be financially "painful" for the company. "At the end of the day, order kamagra gel it's only money.

But that will not break the company, although it's going to be painful,'" he said. Pfizer's experimental treatment contains genetic material called messenger RNA, or mRNA, which scientists hope provokes the immune system to order kamagra gel fight the kamagra. Pfizer is one order kamagra gel of three companies currently in late-stage testing for a treatment. The other two are Moderna and AstraZeneca, which announced Saturday it would resume its trial after temporarily pausing it for safety reasons.On Saturday, Pfizer submitted a proposal to the FDA to expand the late-stage trial to include up to 44,000 participants, a significant increase from its previous target of 30,000. The developments come as infectious disease experts and scientists in order kamagra gel recent weeks have said they have concerns that President Donald Trump is pressuring the FDA to approve a treatment before it's been adequately tested.

FDA Commissioner Stephen Hahn, insisting he wasn't being pressured by Trump to fast-track a treatment, told The Financial Times last month the agency is prepared to bypass the full federal approval process in order to make a erectile dysfunction treatment available as soon as possible.On Sept. 8, nine drug companies, including Pfizer, released a letter pledging that they would prioritize safety and uphold " the integrity of the scientific process" in their efforts to develop erectile dysfunction treatments.Even if a treatment is approved to be distributed before the end of the year, it order kamagra gel will likely be in short supply. The treatment will likely require two doses at varying intervals, and states still face logistical challenges such as setting up distribution sites and acquiring enough needles, syringes and bottles needed for immunizations.Earlier this month, the National Academies of Sciences, Engineering, and Medicine released a order kamagra gel draft proposal for distributing a treatment in the U.S. If and when one is approved for public use. The report was requested by the National Institutes of Health and the Centers for order kamagra gel Disease Control and Prevention.The treatment would be distributed in four phases, with health-care workers, the elderly and people with underlying health conditions getting vaccinated first, according to the group.

Essential workers, teachers and people in homeless shelters as well as people in prisons would be next on the list, followed by children and young adults.The Register of Innovative Drugs is maintained pursuant to C.08.004.1 of the Food and Drug Regulations. The register indicates the drugs that are eligible order kamagra gel for data protection. Under C.08.004.1 (3) a subsequent manufacturer that seeks a notice of compliance on the basis of a direct or indirect comparison between the new drug and an innovative drug may not file a submission before the end of a period of six years after the day on which the first notice of compliance was issued for the innovative new drug order kamagra gel. In addition, the notice of compliance cannot be issued before the end of a period of eight years after the day on which the first notice of compliance was issued to the innovator. The format of the Register of Innovative Drugs is an electronic table, which is updated weekly order kamagra gel.

The register lists, in alphabetical order, the medicinal ingredients in the innovative drugs which were not previously approved in a drug by the Minister and that are not variations of a previously approved medicinal ingredient. Please note that there may be other order kamagra gel medicinal ingredients included in the drugs. The register was re-formatted in summer 2016 to increase the order kamagra gel clarity of the information provided regarding the medicinal ingredient, brand name and manufacturer of each innovative drug. For information related to treatment options, choices of medications and their uses, illnesses, side effects or drug interactions, please contact your health care professional (for example, doctor, pharmacist, etc.). We do not provide medical order kamagra gel advice regarding the use of the products identified in this database.

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Medical staff members prepare to perform a percutaneous tracheostomy procedure on a patient in the erectile dysfunction treatment intensive care unit (ICU) during Thanksgiving at the United Memorial Medical Center on November 26, 2020 in Houston, Texas.Go Nakamura | Getty ImagesMore than 100,000 people are currently in hospitals across the buy cheap kamagra jelly U.S. Sick with erectile dysfunction treatment, as the kamagra pushes doctors, nurses and other health workers to their limits.The current number of hospitalized patients underscores the scope and buy cheap kamagra jelly severity of the current phase of the U.S. Outbreak. Never before had the number of hospitalized erectile dysfunction treatment patients surpassed 60,000, according to data compiled by the erectile dysfunction treatment Tracking Project, which is run by journalists at buy cheap kamagra jelly The Atlantic.In fact, Dr. Janis Orlowski, chief health care officer at the Association of American Medical Colleges, said in a phone interview with CNBC that buy cheap kamagra jelly she doesn't recall any disease sickening so many Americans all at once ever before."I don't think we've ever seen this number.

We certainly never saw this number with HIV or any of the other new diseases that we've had," Orlowksi said. "It's an astonishing, astonishing number and the shame of it is it's a number that we could have impacted and we didn't."Crisis careEarlier this week, buy cheap kamagra jelly Orlowski's organization, the AAMC, announced that it is encouraging all health systems to prepare to deploy "Crisis Standards of Care," which is typically used in severe situations such as the Sept. 11 terrorist attacks and natural disasters.Orlowski explained that buy cheap kamagra jelly crisis care essentially means the rationing of care in hospitals. The goal is "to provide the best care possible to the largest number of people with the resources available," AAMC said. But it also means difficult decisions will be made about whom to use scarce resources on, Orlowski added.Hospitals in some parts of the country are already at the point of crisis care, Orlowski said, such as El Paso, Texas, parts of Utah, buy cheap kamagra jelly North Dakota and parts of Nebraska.

She added that "most hospitals are going to be there in the next two weeks" if current trends persist or get worse, owing to a surge driven by Thanksgiving travel and gatherings.The situation is further complicated, Orlowski said, by the backlog of elective surgeries that were delayed in the spring when buy cheap kamagra jelly hospitals prepared for an initial surge in erectile dysfunction treatment patients. Most hospitals resumed elective surgeries over the summer, but with hospitalizations rising so rapidly some state officials are again warning that hospitals should be prepared to cancel elective procedures."What we have found is people suffered harm because of delays," she said. "What we had thought in the fall is we're going to be able to do some of those cases in buy cheap kamagra jelly the winter. Now I worry that we're not going to be able to do those buy cheap kamagra jelly cases. ...

We're headed into a bad, bad, bad two or three weeks."'Exhausting'Dr buy cheap kamagra jelly. Megan Ranney, an emergency physician and director of the Brown-Lifespan Center for Digital Health, said that her hospital system in Rhode Island has about 1,000 beds. She said she buy cheap kamagra jelly struggled to imagine 100 more systems like hers all filled with erectile dysfunction treatment patients."We're running out of beds, and we're also going to run out of staff," she said. "Our health-care system is full even in normal times, so to add an extra 100,000 patients on top of our existing burden of disease and injury is almost unfathomable."The situation in Rhode Island is bad, Ranney said, but she's heard from colleagues elsewhere of buy cheap kamagra jelly dire situations, where health workers have to ration care, like in "low-income countries." Ranney said her time training in East Africa as a Peace Corps volunteer helped her prepare for the current crisis."I witnessed decisions being made about patients being put on ventilators that I never thought I would experience in the United States," she said.The staff in Ranney's hospital work hard every day and come prepared to "do battle with erectile dysfunction treatment, but it is exhausting," she said."We're all on edge. We made it through the first week in the spring, and it is frustrating and exhausting to be going through this again," Ranney said.

"It feels sometimes hopeless buy cheap kamagra jelly. ... And it feels even more hopeless because we don't see any sign of the surge stopping."She added, however, that no matter how bleak the situation seems, she and her colleagues won't be giving up. treatments, and hope, are on the horizon, she said.'Surge with no staff'Dr. Syra Madad, senior director of the systemwide special pathogens program at New York City Health + Hospitals, said the country is in a "very dire moment.""This is a surge with no staff," she said.

"This is widespread, and it's happening all at the same time, and everybody's getting hit simultaneously. Before, we were able to share resources and assets, whether it's staffing, whether it's supplies, whether it's the bed space, but now that's something that is a luxury."Hospitalizations aren't rising as rapidly in New York City as they did in the spring, Madad said, but hospital systems across the state are preparing for a potential surge. Gov. Andrew Cuomo announced Monday that the state is implementing emergency measures to help hospitals cope with what he called "a new phase in the war against erectile dysfunction treatment."One of these measures is the identification of retired nurses and doctors in case their service is needed as hospitals fill up."You can add as many beds as you want, but if you have nobody to man those beds and actually be able to provide patient care, then that is absolutely useless," she said. "Staffed beds are everything.

Medical staff members prepare to perform a percutaneous tracheostomy procedure on a patient in the erectile dysfunction treatment intensive care unit (ICU) during Thanksgiving at the United Memorial Medical Center on November 26, 2020 in Houston, Texas.Go Nakamura | Getty ImagesMore order kamagra gel than 100,000 people are currently in hospitals across the U.S. Sick with erectile dysfunction treatment, as the kamagra pushes doctors, nurses and other health workers to their limits.The current number of order kamagra gel hospitalized patients underscores the scope and severity of the current phase of the U.S. Outbreak. Never before had the number of hospitalized erectile dysfunction treatment patients surpassed 60,000, according to data compiled by the erectile dysfunction treatment Tracking Project, which is run by journalists at The Atlantic.In order kamagra gel fact, Dr. Janis Orlowski, chief health order kamagra gel care officer at the Association of American Medical Colleges, said in a phone interview with CNBC that she doesn't recall any disease sickening so many Americans all at once ever before."I don't think we've ever seen this number.

We certainly never saw this number with HIV or any of the other new diseases that we've had," Orlowksi said. "It's an astonishing, order kamagra gel astonishing number and the shame of it is it's a number that we could have impacted and we didn't."Crisis careEarlier this week, Orlowski's organization, the AAMC, announced that it is encouraging all health systems to prepare to deploy "Crisis Standards of Care," which is typically used in severe situations such as the Sept. 11 terrorist attacks and natural disasters.Orlowski explained that crisis care essentially means the rationing of order kamagra gel care in hospitals. The goal is "to provide the best care possible to the largest number of people with the resources available," AAMC said. But it also means difficult decisions order kamagra gel will be made about whom to use scarce resources on, Orlowski added.Hospitals in some parts of the country are already at the point of crisis care, Orlowski said, such as El Paso, Texas, parts of Utah, North Dakota and parts of Nebraska.

She added that "most hospitals are going to be there in the next two weeks" if current trends persist or get worse, owing order kamagra gel to a surge driven by Thanksgiving travel and gatherings.The situation is further complicated, Orlowski said, by the backlog of elective surgeries that were delayed in the spring when hospitals prepared for an initial surge in erectile dysfunction treatment patients. Most hospitals resumed elective surgeries over the summer, but with hospitalizations rising so rapidly some state officials are again warning that hospitals should be prepared to cancel elective procedures."What we have found is people suffered harm because of delays," she said. "What we had thought in the fall is we're going to be able to order kamagra gel do some of those cases in the winter. Now I worry that we're not going to be order kamagra gel able to do those cases. ...

We're headed order kamagra gel into a bad, bad, bad two or three weeks."'Exhausting'Dr. Megan Ranney, an emergency physician and director of the Brown-Lifespan Center for Digital Health, said that her hospital system in Rhode Island has about 1,000 beds. She said she struggled to order kamagra gel imagine 100 more systems like hers all filled with erectile dysfunction treatment patients."We're running out of beds, and we're also going to run out of staff," she said. "Our health-care system is full even in normal times, so to add an extra 100,000 patients on top of our existing burden of disease and injury is almost unfathomable."The situation in Rhode Island is bad, Ranney said, but she's heard from colleagues elsewhere of dire situations, where health workers have to ration care, like in "low-income countries." Ranney said her time training in East Africa as a Peace Corps volunteer helped her prepare order kamagra gel for the current crisis."I witnessed decisions being made about patients being put on ventilators that I never thought I would experience in the United States," she said.The staff in Ranney's hospital work hard every day and come prepared to "do battle with erectile dysfunction treatment, but it is exhausting," she said."We're all on edge. We made it through the first week in the spring, and it is frustrating and exhausting to be going through this again," Ranney said.

"It feels order kamagra gel sometimes hopeless. ... And it feels even more hopeless because we don't see any sign of the surge stopping."She added, however, that no matter how bleak the situation seems, she and her colleagues won't be giving up. treatments, and hope, are on the horizon, she said.'Surge with no staff'Dr. Syra Madad, senior director of the systemwide special pathogens program at New York City Health + Hospitals, said the country is in a "very dire moment.""This is a surge with no staff," she said.

"This is widespread, and it's happening all at the same time, and everybody's getting hit simultaneously. Before, we were able to share resources and assets, whether it's staffing, whether it's supplies, whether it's the bed space, but now that's something that is a luxury."Hospitalizations aren't rising as rapidly in New York City as they did in the spring, Madad said, but hospital systems across the state are preparing for a potential surge. Gov. Andrew Cuomo announced Monday that the state is implementing emergency measures to help hospitals cope with what he called "a new phase in the war against erectile dysfunction treatment."One of these measures is the identification of retired nurses and doctors in case their service is needed as hospitals fill up."You can add as many beds as you want, but if you have nobody to man those beds and actually be able to provide patient care, then that is absolutely useless," she said. "Staffed beds are everything.

Kamagra tabletten

People rarely walk at https://really-delicious.com/who-can-buy-levitra-online/ a constant speed and kamagra tabletten a single incline. We change speed when rushing to the next appointment, catching a crosswalk signal, or going for a casual stroll in the park. Slopes change all the time too, whether we're going for a hike or up a kamagra tabletten ramp into a building.

In addition to environmental variably, how we walk is influenced by sex, height, age, and muscle strength, and sometimes by neural or muscular disorders such as stroke or Parkinson's Disease.This human and task variability is a major challenge in designing wearable robotics to assist or augment walking in real-world conditions. To date, customizing wearable robotic assistance to an individual's walking requires hours of manual or automatic tuning -- a tedious task for healthy individuals and kamagra tabletten often impossible for older adults or clinical patients.Now, researchers from the Harvard John A. Paulson School of Engineering and Applied Sciences (SEAS) have developed a new approach in which robotic exosuit assistance can be calibrated to an individual and adapt to a variety of real-world walking tasks in a matter of seconds.

The bioinspired system uses uasound measurements of muscle dynamics to develop a personalized and activity-specific assistance profile for users of the exosuit."Our muscle-based approach enables relatively rapid generation of individualized assistance profiles that provide real benefit to kamagra tabletten the person walking," said Robert D. Howe, the Abbott and James Lawrence Professor of Engineering, and co-author of the paper.The research is published in Science Robotics. Previous bioinspired attempts at developing individualized assistance profiles for robotic exosuits focused on the dynamic kamagra tabletten movements of the limbs of the wearer.

The SEAS researchers took a different approach. The research was a collaboration between Howe's Harvard Biorobotics Laboratory, which has extensive experience in uasound imaging and real-time kamagra tabletten image processing, and the Harvard Biodesign Lab, run by Conor J. Walsh, the Paul A.

Maeder Professor of Engineering and Applied Sciences at SEAS, which develops soft wearable robots for augmenting and restoring human performance. advertisement "We used uasound to look under the skin and directly measured kamagra tabletten what the user's muscles were doing during several walking tasks," said Richard Nuckols, a Postdoctoral Research Associate at SEAS and co-first author of the paper. "Our muscles and tendons have compliance which means there is not necessarily a direct mapping between the movement of the limbs and that of the underlying muscles driving their motion."The research team strapped a portable uasound system to the calves of participants and imaged their muscles as they performed a series of walking tasks."From these pre-recorded images, we estimated the assistive force to be applied in parallel with the calf muscles to offset the additional work they need to perform during the push off phase of the walking cycle," said Krithika Swaminathan, a graduate student at SEAS and the Graduate School of Arts and Sciences (GSAS) and co-first author of the study.The new system only needs a few seconds of walking, even one stride may be sufficient, to capture the muscle's profile.For each of the uasound-generated profiles, the researchers then measured how much metabolic energy the person used during walking with and without the exosuit.

The researchers found that the muscle-based assistance provided by the exosuit significantly reduced the metabolic energy of walking kamagra tabletten across a range of walking speeds and inclines. advertisement The exosuit also applied lower assistance force to achieve the same or improved metabolic energy benefit than previous published studies."By measuring the muscle directly, we can work more intuitively with the person using the exosuit," said Sangjun Lee, a graduate student at SEAS and GSAS and co-first author of the study. "With this approach, the exosuit isn't overpowering the wearer, it's working cooperatively with them."When tested in real-world situations, the exosuit was able to quickly adapt to changes in walking speed and incline.Next, the research team aims to test the system making constant, real-time adjustments."This approach may help support the adoption of wearable robotics in real-world, dynamic situations by enabling comfortable, tailored, and adaptive assistance," said kamagra tabletten Walsh, the senior author of the paper.This research was also co-authored by Dorothy Orzel.

It was supported by National Institutes of Health grants BRG-R01HD088619, U01TR002775 and R21AR076686, National Science Foundation grant CMMI-1925085.Video of a personalized exosuit for real-world walking. Https://www.youtube.com/watch?. V=4XFvoW3Z9l8&t=1sUsually diagnosed in children, teens and young adults, type 1 diabetes is an autoimmune disease in which the immune system attacks and destroys insulin-secreting β-cells in the pancreas.

As a result, people with type 1 diabetes can't regulate their blood sugar levels and require insulin treatment for survival. Now, researchers reporting in ACS Applied Materials &. Interfaces have reversed new-onset type 1 diabetes in mice with pyramid-like DNA molecules called tetrahedral framework nucleic acids (tFNAs).About 64,000 people in the U.S.

Are diagnosed with type 1 diabetes each year, according to the Juvenile Diabetes Research Foundation. There is no cure for the disease, and to manage symptoms, people must measure their blood sugar levels throughout the day and administer insulin through an injection or pump. Although scientists still don't know exactly what causes the body to turn against itself and attack insulin-secreting cells, people with type 1 diabetes have fewer regulatory T cells (Tregs) -- immune cells that suppress the differentiation and activation of other, self-attacking T cells.

In a recent study published in ACS' Nano Letters, Yunfeng Lin and colleagues showed that treating mice with tFNAs could prevent type 1 diabetes, in part by increasing Treg numbers. Originally designed to carry other therapeutic molecules into cells, tFNAs have recently been shown to modulate the immune system on their own. Now, the researchers wanted to find out if these molecules could reverse new-onset type 1 diabetes, before pancreatic β-cells were completely destroyed.The researchers made tFNAs from four single-stranded DNA segments that self-assembled into pyramid-like shapes, called tetrahedrons.

But whereas a pyramid is square at its base, tetrahedrons are triangular. Then, every other day for 4 weeks, they injected the tFNAs into 10 mice with new-onset type 1 diabetes, while 10 other diabetic mice were injected with saline. In the control mice, blood glucose levels continued to rise, and 60% of the mice died during the 12-week follow-up period.

In contrast, blood glucose levels in mice treated with tFNAs went down to normal levels, and none of the rodents died. In a further analysis of the tFNA-treated mice, the team found that pancreatic β-cells were protected, and Tregs were restored to normal levels, while auto-reactive T cells decreased in the pancreas. Although the findings still need to be verified in people, tFNAs are one of the most promising candidates for type 1 diabetes immunotherapy, the researchers say.

Story Source. Materials provided by American Chemical Society. Note.

Content may be edited for style and length.A gene-silencing therapy protected against Zika kamagra transmission from pregnant mice to the mouse fetuses, finds a study published November 10th in the journal Molecular Therapy. The treatment, which harnesses nanoparticles called small extracellular vesicles (sEVs) for drug delivery, crossed the placenta and blood-brain barrier to greatly reduce fetal neurological damage, including kamagra-induced brain shrinkage."Our experiments indicated that targeted delivery via modified sEVs is a promising alternative to the traditional methods of delivery, especially for the treatment of brain viral ," says senior study author Zhiwei Wu of Nanjing University. "Increasing the yield and efficiency of producing sEVs and developing sEVs that target other tissues will broaden their application and will expand the effectiveness of this gene delivery technique."The Zika kamagra epidemic swept across the Asia-Pacific region in 2015-2017 and remains a global health threat to this day.

The kamagra causes neurological and congenital conditions such as microcephaly, in which the baby's head is smaller than expected. It can cross the placenta and the blood-brain barrier -- a network of blood vessels and tissue that is made up of closely spaced cells.The blood-brain barrier controls the exchange of substances between the central nervous system (CNS) and the blood, helping to keep harmful substances from reaching the brain. Few drugs specifically target brain tissue, and most are highly toxic and do not efficiently cross the blood-brain barrier.

Treatment for viral s of the brain is generally ineffective due to blood-brain barrier blocking of drugs. "Currently, there is no Zika kamagra-specific therapy or treatment available," Wu says. "Safe and effective antiviral drugs that can effectively cross the blood-brain barrier and placental barrier are urgently needed, especially to prevent microcephaly."In particular, gene silencing therapies using oligonucleotides have demonstrated unique advantages in clinical settings, but the delivery of nucleic acids into cells remains a major challenge.

One potential solution is offered by sEVs -- natural, biodegradable nanoparticles that are released from cells and are important mediators of cell-to-cell communication. Emerging evidence suggests that they could be a powerful tool to deliver drugs for the treatment of cancer, cardiovascular conditions, and infectious diseases. Recently, Wu and his collaborators leveraged sEVs to deliver an antiviral molecule across the placental barrier to inhibit Zika kamagra in the mouse fetus.In the new study, Wu and his team demonstrated for the first time that sEVs could deliver antiviral drugs to achieve targeted suppression of Zika kamagra in the fetal CNS and to control neurological damage.

To home in on neurons, the researchers engineered sEVs that expressed rabies kamagra glycoprotein (RVG) on their surface. They then loaded them with Zika kamagra-specific small interfering RNA (siRNA) and injected them into pregnant mice.The RVG-modified sEVs crossed the placental barrier and blood-brain barrier, protecting against Zika kamagra transmission to the fetus. They concentrated in the fetal brain, where they suppressed and reduced inflammation and neurological damage, including microcephaly and defects in a brain region called the cerebellum.

The findings echo another recent study showing that RVG-modified sEVs could cross the blood-brain barrier in mice to treat manifestations of Parkinson's disease. "Our therapeutic approach expanded the application of sEVs to treat viral of brains by intravenous injection," Wu says.Despite the promising results, many questions remain. For example, the researchers delivered the kamagra and the first dose of the therapy simultaneously, so it is not clear whether treatment after a time lag would also be effective.

"A delayed injection after viral may provide more confidence in the ability to translate this research to human trials," Wu says. "Nevertheless, our study provides a proof of concept for such a possibility."Moving forward, the researchers plan to investigate the molecular mechanisms by which the sEVs penetrate the placenta and blood-brain barrier. They will also pin down the precise rate of sEV penetration and determine the factors that control delivery efficiency.

"Since small extracellular vesicles are of biological origin, they can be a safe drug delivery vehicle," Wu says. "However, the current study remains preliminary and many more issues need to be resolved. For human use, there is a long way to go."This work was supported by National Natural Science Foundation of China, the Major Research and Development Project, Nanjing University-Ningxia University Collaborative Project.

Story Source. Materials provided by Cell Press. Note.

Content may be edited for style and length.Cognitive training designed to focus on what’s important while ignoring distractions can enhance the brain’s information processing, enabling the ability to “learn to learn,” finds a new study on mice. €œAs any educator knows, merely recollecting the information we learn in school is hardly the point of an education,” says André Fenton, a professor of neural science at New York University and the senior author of the study, which appears in the journal Nature. €œRather than using our brains to merely store information to recall later, with the right mental training, we can also ‘learn to learn,’ which makes us more adaptive, mindful, and intelligent.”Researchers have frequently studied the machinations of memory--specifically, how neurons store the information gained from experience so that the same information can be recalled later.

However, less is known about the underlying neurobiology of how we “learn to learn”--the mechanisms our brains use to go beyond drawing from memory to utilize past experiences in meaningful, novel ways.A greater understanding of this process could point to new methods to enhance learning and to design precision cognitive behavioral therapies for neuropsychiatric disorders like anxiety, schizophrenia, and other forms of mental dysfunction.To explore this, the researchers conducted a series of experiments using mice, who were assessed for their ability to learn cognitively challenging tasks. Prior to the assessment, some mice received “cognitive control training” (CCT). They were put on a slowly rotating arena and trained to avoid the stationary location of a mild shock using stationary visual cues while ignoring locations of the shock on the rotating floor.

CCT mice were compared to control mice. One control group also learned the same place avoidance, but it did not have to ignore the irrelevant rotating locations. The use of the rotating arena place avoidance methodology was vital to the experiment, the scientists note, because it manipulates spatial information, dissociating the environment into stationary and rotating components.

Previously, the lab had shown that learning to avoid shock on the rotating arena requires using the hippocampus, the brain’s memory and navigation center, as well as the persistent activity of a molecule (protein kinase M zeta [PKM?. ]) that is crucial for maintaining increases in the strength of neuronal connections and for storing long-term memory. €œIn short, there were molecular, physiological, and behavioral reasons to examine long-term place avoidance memory in the hippocampus circuit as well as a theory for how the circuit could persistently improve,” explains Fenton.Analysis of neural activity in the hippocampus during CCT confirmed the mice were using relevant information for avoiding shock and ignoring the rotating distractions in the vicinity of the shock.

Notably, this process of ignoring distractions was essential for the mice learning to learn as it allowed them to do novel cognitive tasks better than the mice that did not receive CCT. Remarkably, the researchers could measure that CCT also improves how the mice’s hippocampal neural circuitry functions to process information. The hippocampus is a crucial part of the brain for forming long-lasting memories as well as for spatial navigation, and CCT improved how it operates for months.“The study shows that two hours of cognitive control training causes learning to learn in mice and that learning to learn is accompanied by improved tuning of a key brain circuit for memory,” observes Fenton.

€œConsequently, the brain becomes persistently more effective at suppressing noisy inputs and more consistently effective at enhancing the inputs that matter.”The paper’s other authors were. Ain Chung and Eliott Levy, NYU doctoral students at the time of the research. Claudia Jou a doctoral student at the City University of New York’s Hunter College and the Graduate Center.

Alejandro Grau-Perales and Dino Dvorak, NYU postdoctoral fellows at the time of the study. And Nida Hussain, a student at NYU’s College of Arts and Science at the time of the study.The research was supported by grants from the National Institutes of Health (R01MH115304, R01NS105472, and R01AG043688). Story Source.

Materials provided by New York University. Note. Content may be edited for style and length.Neurons communicate with each other via electrical impulses, which are produced by ion channels that control the flow of ions such as potassium and sodium.

In a surprising new finding, MIT neuroscientists have shown that human neurons have a much smaller number of these channels than expected, compared to the neurons of other mammals.The researchers hypothesize that this reduction in channel density may have helped the human brain evolve to operate more efficiently, allowing it to divert resources to other energy-intensive processes that are required to perform complex cognitive tasks."If the brain can save energy by reducing the density of ion channels, it can spend that energy on other neuronal or circuit processes," says Mark Harnett, an associate professor of brain and cognitive sciences, a member of MIT's McGovern Institute for Brain Research, and the senior author of the study.Harnett and his colleagues analyzed neurons from 10 different mammals, the most extensive electrophysiological study of its kind, and identified a "building plan" that holds true for every species they looked at -- except for humans. They found that as the size of neurons increases, the density of channels found in the neurons also increases.However, human neurons proved to be a striking exception to this rule."Previous comparative studies established that the human brain is built like other mammalian brains, so we were surprised to find strong evidence that human neurons are special," says former MIT graduate student Lou Beaulieu-Laroche. advertisement Beaulieu-Laroche is the lead author of the study, which appears today in Nature.A building planNeurons in the mammalian brain can receive electrical signals from thousands of other cells, and that input determines whether or not they will fire an electrical impulse called an action potential.

In 2018, Harnett and Beaulieu-Laroche discovered that human and rat neurons differ in some of their electrical properties, primarily in parts of the neuron called dendrites -- tree-like antennas that receive and process input from other cells.One of the findings from that study was that human neurons had a lower density of ion channels than neurons in the rat brain. The researchers were surprised by this observation, as ion channel density was generally assumed to be constant across species. In their new study, Harnett and Beaulieu-Laroche decided to compare neurons from several different mammalian species to see if they could find any patterns that governed the expression of ion channels.

They studied two types of voltage-gated potassium channels and the HCN channel, which conducts both potassium and sodium, in layer 5 pyramidal neurons, a type of excitatory neurons found in the brain's cortex.They were able to obtain brain tissue from 10 mammalian species. Etruscan shrews (one of the smallest known mammals), gerbils, mice, rats, Guinea pigs, ferrets, rabbits, marmosets, and macaques, as well as human tissue removed from patients with epilepsy during brain surgery. This variety allowed the researchers to cover a range of cortical thicknesses and neuron sizes across the mammalian kingdom.

advertisement The researchers found that in nearly every mammalian species they looked at, the density of ion channels increased as the size of the neurons went up. The one exception to this pattern was in human neurons, which had a much lower density of ion channels than expected.The increase in channel density across species was surprising, Harnett says, because the more channels there are, the more energy is required to pump ions in and out of the cell. However, it started to make sense once the researchers began thinking about the number of channels in the overall volume of the cortex, he says.In the tiny brain of the Etruscan shrew, which is packed with very small neurons, there are more neurons in a given volume of tissue than in the same volume of tissue from the rabbit brain, which has much larger neurons.

But because the rabbit neurons have a higher density of ion channels, the density of channels in a given volume of tissue is the same in both species, or any of the nonhuman species the researchers analyzed."This building plan is consistent across nine different mammalian species," Harnett says. "What it looks like the cortex is trying to do is keep the numbers of ion channels per unit volume the same across all the species. This means that for a given volume of cortex, the energetic cost is the same, at least for ion channels."Energy efficiencyThe human brain represents a striking deviation from this building plan, however.

Instead of increased density of ion channels, the researchers found a dramatic decrease in the expected density of ion channels for a given volume of brain tissue.The researchers believe this lower density may have evolved as a way to expend less energy on pumping ions, which allows the brain to use that energy for something else, like creating more complicated synaptic connections between neurons or firing action potentials at a higher rate."We think that humans have evolved out of this building plan that was previously restricting the size of cortex, and they figured out a way to become more energetically efficient, so you spend less ATP per volume compared to other species," Harnett says.He now hopes to study where that extra energy might be going, and whether there are specific gene mutations that help neurons of the human cortex achieve this high efficiency. The researchers are also interested in exploring whether primate species that are more closely related to humans show similar decreases in ion channel density.The research was funded by the Natural Sciences and Engineering Research Council of Canada, a Friends of the McGovern Institute Fellowship, the National Institute of General Medical Sciences, the Paul and Daisy Soros Fellows Program, the Dana Foundation David Mahoney Neuroimaging Grant Program, the National Institutes of Health, and the Harvard-MIT Joint Research Grants Program in Basic Neuroscience..

People rarely order kamagra gel walk at a constant speed and a single incline. We change speed when rushing to the next appointment, catching a crosswalk signal, or going for a casual stroll in the park. Slopes change all the time too, whether we're going for a hike or up a ramp into order kamagra gel a building. In addition to environmental variably, how we walk is influenced by sex, height, age, and muscle strength, and sometimes by neural or muscular disorders such as stroke or Parkinson's Disease.This human and task variability is a major challenge in designing wearable robotics to assist or augment walking in real-world conditions.

To date, customizing wearable robotic assistance to an individual's walking requires hours of manual or automatic tuning -- a tedious task for healthy individuals and order kamagra gel often impossible for older adults or clinical patients.Now, researchers from the Harvard John A. Paulson School of Engineering and Applied Sciences (SEAS) have developed a new approach in which robotic exosuit assistance can be calibrated to an individual and adapt to a variety of real-world walking tasks in a matter of seconds. The bioinspired system uses uasound measurements of muscle dynamics to develop a personalized and activity-specific assistance profile for users of the exosuit."Our muscle-based approach enables order kamagra gel relatively rapid generation of individualized assistance profiles that provide real benefit to the person walking," said Robert D. Howe, the Abbott and James Lawrence Professor of Engineering, and co-author of the paper.The research is published in Science Robotics.

Previous bioinspired attempts at developing individualized assistance order kamagra gel profiles for robotic exosuits focused on the dynamic movements of the limbs of the wearer. The SEAS researchers took a different approach. The research was a collaboration between Howe's Harvard Biorobotics Laboratory, which has extensive experience in uasound imaging and real-time image processing, and the Harvard Biodesign Lab, run by Conor order kamagra gel J. Walsh, the Paul A.

Maeder Professor of Engineering and Applied Sciences at SEAS, which develops soft wearable robots for augmenting and restoring human performance. advertisement "We order kamagra gel used uasound to look under the skin and directly measured what the user's muscles were doing during several walking tasks," said Richard Nuckols, a Postdoctoral Research Associate at SEAS and co-first author of the paper. "Our muscles and tendons have compliance which means there is not necessarily a direct mapping between the movement of the limbs and that of the underlying muscles driving their motion."The research team strapped a portable uasound system to the calves of participants and imaged their muscles as they performed a series of walking tasks."From these pre-recorded images, we estimated the assistive force to be applied in parallel with the calf muscles to offset the additional work they need to perform during the push off phase of the walking cycle," said Krithika Swaminathan, a graduate student at SEAS and the Graduate School of Arts and Sciences (GSAS) and co-first author of the study.The new system only needs a few seconds of walking, even one stride may be sufficient, to capture the muscle's profile.For each of the uasound-generated profiles, the researchers then measured how much metabolic energy the person used during walking with and without the exosuit. The researchers order kamagra gel found that the muscle-based assistance provided by the exosuit significantly reduced the metabolic energy of walking across a range of walking speeds and inclines.

advertisement The exosuit also applied lower assistance force to achieve the same or improved metabolic energy benefit than previous published studies."By measuring the muscle directly, we can work more intuitively with the person using the exosuit," said Sangjun Lee, a graduate student at SEAS and GSAS and co-first author of the study. "With this approach, the exosuit isn't overpowering the wearer, it's working cooperatively with them."When tested in real-world situations, the exosuit was able to quickly adapt to changes in walking speed and incline.Next, the research team aims to test the order kamagra gel system making constant, real-time adjustments."This approach may help support the adoption of wearable robotics in real-world, dynamic situations by enabling comfortable, tailored, and adaptive assistance," said Walsh, the senior author of the paper.This research was also co-authored by Dorothy Orzel. It was supported by National Institutes of Health grants BRG-R01HD088619, U01TR002775 and R21AR076686, National Science Foundation grant CMMI-1925085.Video of a personalized exosuit for real-world walking. Https://www.youtube.com/watch?.

V=4XFvoW3Z9l8&t=1sUsually diagnosed in children, teens and young adults, type 1 diabetes is an autoimmune disease in which the immune system attacks and destroys insulin-secreting β-cells in the pancreas. As a result, people with type 1 diabetes can't regulate their blood sugar levels and require insulin treatment for survival. Now, researchers reporting in ACS Applied Materials &. Interfaces have reversed new-onset type 1 diabetes in mice with pyramid-like DNA molecules called tetrahedral framework nucleic acids (tFNAs).About 64,000 people in the U.S.

Are diagnosed with type 1 diabetes each year, according to the Juvenile Diabetes Research Foundation. There is no cure for the disease, and to manage symptoms, people must measure their blood sugar levels throughout the day and administer insulin through an injection or pump. Although scientists still don't know exactly what causes the body to turn against itself and attack insulin-secreting cells, people with type 1 diabetes have fewer regulatory T cells (Tregs) -- immune cells that suppress the differentiation and activation of other, self-attacking T cells. In a recent study published in ACS' Nano Letters, Yunfeng Lin and colleagues showed that treating mice with tFNAs could prevent type 1 diabetes, in part by increasing Treg numbers.

Originally designed to carry other therapeutic molecules into cells, tFNAs have recently been shown to modulate the immune system on their own. Now, the researchers wanted to find out if these molecules could reverse new-onset type 1 diabetes, before pancreatic β-cells were completely destroyed.The researchers made tFNAs from four single-stranded DNA segments that self-assembled into pyramid-like shapes, called tetrahedrons. But whereas a pyramid is square at its base, tetrahedrons are triangular. Then, every other day for 4 weeks, they injected the tFNAs into 10 mice with new-onset type 1 diabetes, while 10 other diabetic mice were injected with saline.

In the control mice, blood glucose levels continued to rise, and 60% of the mice died during the 12-week follow-up period. In contrast, blood glucose levels in mice treated with tFNAs went down to normal levels, and none of the rodents died. In a further analysis of the tFNA-treated mice, the team found that pancreatic β-cells were protected, and Tregs were restored to normal levels, while auto-reactive T cells decreased in the pancreas. Although the findings still need to be verified in people, tFNAs are one of the most promising candidates for type 1 diabetes immunotherapy, the researchers say.

Story Source. Materials provided by American Chemical Society. Note. Content may be edited for style and length.A gene-silencing therapy protected against Zika kamagra transmission from pregnant mice to the mouse fetuses, finds a study published November 10th in the journal Molecular Therapy.

The treatment, which harnesses nanoparticles called small extracellular vesicles (sEVs) for drug delivery, crossed the placenta and blood-brain barrier to greatly reduce fetal neurological damage, including kamagra-induced brain shrinkage."Our experiments indicated that targeted delivery via modified sEVs is a promising alternative to the traditional methods of delivery, especially for the treatment of brain viral ," says senior study author Zhiwei Wu of Nanjing University. "Increasing the yield and efficiency of producing sEVs and developing sEVs that target other tissues will broaden their application and will expand the effectiveness of this gene delivery technique."The Zika kamagra epidemic swept across the Asia-Pacific region in 2015-2017 and remains a global health threat to this day. The kamagra causes neurological and congenital conditions such as microcephaly, in which the baby's head is smaller than expected. It can cross the placenta and the blood-brain barrier -- a network of blood vessels and tissue that is made up of closely spaced cells.The blood-brain barrier controls the exchange of substances between the central nervous system (CNS) and the blood, helping to keep harmful substances from reaching the brain.

Few drugs specifically target brain tissue, and most are highly toxic and do not efficiently cross the blood-brain barrier. Treatment for viral s of the brain is generally ineffective due to blood-brain barrier blocking of drugs. "Currently, there is no Zika kamagra-specific therapy or treatment available," Wu says. "Safe and effective antiviral drugs that can effectively cross the blood-brain barrier and placental barrier are urgently needed, especially to prevent microcephaly."In particular, gene silencing therapies using oligonucleotides have demonstrated unique advantages in clinical settings, but the delivery of nucleic acids into cells remains a major challenge.

One potential solution is offered by sEVs -- natural, biodegradable nanoparticles that are released from cells and are important mediators of cell-to-cell communication. Emerging evidence suggests that they could be a powerful tool to deliver drugs for the treatment of cancer, cardiovascular conditions, and infectious diseases. Recently, Wu and his collaborators leveraged sEVs to deliver an antiviral molecule across the placental barrier to inhibit Zika kamagra in the mouse fetus.In the new study, Wu and his team demonstrated for the first time that sEVs could deliver antiviral drugs to achieve targeted suppression of Zika kamagra in the fetal CNS and to control neurological damage. To home in on neurons, the researchers engineered sEVs that expressed rabies kamagra glycoprotein (RVG) on their surface.

They then loaded them with Zika kamagra-specific small interfering RNA (siRNA) and injected them into pregnant mice.The RVG-modified sEVs crossed the placental barrier and blood-brain barrier, protecting against Zika kamagra transmission to the fetus. They concentrated in the fetal brain, where they suppressed and reduced inflammation and neurological damage, including microcephaly and defects in a brain region called the cerebellum. The findings echo another recent study showing that RVG-modified sEVs could cross the blood-brain barrier in mice to treat manifestations of Parkinson's disease. "Our therapeutic approach expanded the application of sEVs to treat viral of brains by intravenous injection," Wu says.Despite the promising results, many questions remain.

For example, the researchers delivered the kamagra and the first dose of the therapy simultaneously, so it is not clear whether treatment after a time lag would also be effective. "A delayed injection after viral may provide more confidence in the ability to translate this research to human trials," Wu says. "Nevertheless, our study provides a proof of concept for such a possibility."Moving forward, the researchers plan to investigate the molecular mechanisms by which the sEVs penetrate the placenta and blood-brain barrier. They will also pin down the precise rate of sEV penetration and determine the factors that control delivery efficiency.

"Since small extracellular vesicles are of biological origin, they can be a safe drug delivery vehicle," Wu says. "However, the current study remains preliminary and many more issues need to be resolved. For human use, there is a long way to go."This work was supported by National Natural Science Foundation of China, the Major Research and Development Project, Nanjing University-Ningxia University Collaborative Project. Story Source.

Materials provided by Cell Press. Note. Content may be edited for style and length.Cognitive training designed to focus on what’s important while ignoring distractions can enhance the brain’s information processing, enabling the ability to “learn to learn,” finds a new study on mice. €œAs any educator knows, merely recollecting the information we learn in school is hardly the point of an education,” says André Fenton, a professor of neural science at New York University and the senior author of the study, which appears in the journal Nature.

€œRather than using our brains to merely store information to recall later, with the right mental training, we can also ‘learn to learn,’ which makes us more adaptive, mindful, and intelligent.”Researchers have frequently studied the machinations of memory--specifically, how neurons store the information gained from experience so that the same information can be recalled later. However, less is known about the underlying neurobiology of how we “learn to learn”--the mechanisms our brains use to go beyond drawing from memory to utilize past experiences in meaningful, novel ways.A greater understanding of this process could point to new methods to enhance learning and to design precision cognitive behavioral therapies for neuropsychiatric disorders like anxiety, schizophrenia, and other forms of mental dysfunction.To explore this, the researchers conducted a series of experiments using mice, who were assessed for their ability to learn cognitively challenging tasks. Prior to the assessment, some mice received “cognitive control training” (CCT). They were put on a slowly rotating arena and trained to avoid the stationary location of a mild shock using stationary visual cues while ignoring locations of the shock on the rotating floor.

CCT mice were compared to control mice. One control group also learned the same place avoidance, but it did not have to ignore the irrelevant rotating locations. The use of the rotating arena place avoidance methodology was vital to the experiment, the scientists note, because it manipulates spatial information, dissociating the environment into stationary and rotating components. Previously, the lab had shown that learning to avoid shock on the rotating arena requires using the hippocampus, the brain’s memory and navigation center, as well as the persistent activity of a molecule (protein kinase M zeta [PKM?.

]) that is crucial for maintaining increases in the strength of neuronal connections and for storing long-term memory. €œIn short, there were molecular, physiological, and behavioral reasons to examine long-term place avoidance memory in the hippocampus circuit as well as a theory for how the circuit could persistently improve,” explains Fenton.Analysis of neural activity in the hippocampus during CCT confirmed the mice were using relevant information for avoiding shock and ignoring the rotating distractions in the vicinity of the shock. Notably, this process of ignoring distractions was essential for the mice learning to learn as it allowed them to do novel cognitive tasks better than the mice that did not receive CCT. Remarkably, the researchers could measure that CCT also improves how the mice’s hippocampal neural circuitry functions to process information.

The hippocampus is a crucial part of the brain for forming long-lasting memories as well as for spatial navigation, and CCT improved how it operates for months.“The study shows that two hours of cognitive control training causes learning to learn in mice and that learning to learn is accompanied by improved tuning of a key brain circuit for memory,” observes Fenton. €œConsequently, the brain becomes persistently more effective at suppressing noisy inputs and more consistently effective at enhancing the inputs that matter.”The paper’s other authors were. Ain Chung and Eliott Levy, NYU doctoral students at the time of the research. Claudia Jou a doctoral student at the City University of New York’s Hunter College and the Graduate Center.

Alejandro Grau-Perales and Dino Dvorak, NYU postdoctoral fellows at the time of the study. And Nida Hussain, a student at NYU’s College of Arts and Science at the time of the study.The research was supported by grants from the National Institutes of Health (R01MH115304, R01NS105472, and R01AG043688). Story Source. Materials provided by New York University.

Note. Content may be edited for style and length.Neurons communicate with each other via electrical impulses, which are produced by ion channels that control the flow of ions such as potassium and sodium. In a surprising new finding, MIT neuroscientists have shown that human neurons have a much smaller number of these channels than expected, compared to the neurons of other mammals.The researchers hypothesize that this reduction in channel density may have helped the human brain evolve to operate more efficiently, allowing it to divert resources to other energy-intensive processes that are required to perform complex cognitive tasks."If the brain can save energy by reducing the density of ion channels, it can spend that energy on other neuronal or circuit processes," says Mark Harnett, an associate professor of brain and cognitive sciences, a member of MIT's McGovern Institute for Brain Research, and the senior author of the study.Harnett and his colleagues analyzed neurons from 10 different mammals, the most extensive electrophysiological study of its kind, and identified a "building plan" that holds true for every species they looked at -- except for humans. They found that as the size of neurons increases, the density of channels found in the neurons also increases.However, human neurons proved to be a striking exception to this rule."Previous comparative studies established that the human brain is built like other mammalian brains, so we were surprised to find strong evidence that human neurons are special," says former MIT graduate student Lou Beaulieu-Laroche.

advertisement Beaulieu-Laroche is the lead author of the study, which appears today in Nature.A building planNeurons in the mammalian brain can receive electrical signals from thousands of other cells, and that input determines whether or not they will fire an electrical impulse called an action potential. In 2018, Harnett and Beaulieu-Laroche discovered that human and rat neurons differ in some of their electrical properties, primarily in parts of the neuron called dendrites -- tree-like antennas that receive and process input from other cells.One of the findings from that study was that human neurons had a lower density of ion channels than neurons in the rat brain. The researchers were surprised by this observation, as ion channel density was generally assumed to be constant across species. In their new study, Harnett and Beaulieu-Laroche decided to compare neurons from several different mammalian species to see if they could find any patterns that governed the expression of ion channels.

They studied two types of voltage-gated potassium channels and the HCN channel, which conducts both potassium and sodium, in layer 5 pyramidal neurons, a type of excitatory neurons found in the brain's cortex.They were able to obtain brain tissue from 10 mammalian species. Etruscan shrews (one of the smallest known mammals), gerbils, mice, rats, Guinea pigs, ferrets, rabbits, marmosets, and macaques, as well as human tissue removed from patients with epilepsy during brain surgery. This variety allowed the researchers to cover a range of cortical thicknesses and neuron sizes across the mammalian kingdom. advertisement The researchers found that in nearly every mammalian species they looked at, the density of ion channels increased as the size of the neurons went up.

The one exception to this pattern was in human neurons, which had a much lower density of ion channels than expected.The increase in channel density across species was surprising, Harnett says, because the more channels there are, the more energy is required to pump ions in and out of the cell. However, it started to make sense once the researchers began thinking about the number of channels in the overall volume of the cortex, he says.In the tiny brain of the Etruscan shrew, which is packed with very small neurons, there are more neurons in a given volume of tissue than in the same volume of tissue from the rabbit brain, which has much larger neurons. But because the rabbit neurons have a higher density of ion channels, the density of channels in a given volume of tissue is the same in both species, or any of the nonhuman species the researchers analyzed."This building plan is consistent across nine different mammalian species," Harnett says. "What it looks like the cortex is trying to do is keep the numbers of ion channels per unit volume the same across all the species.

This means that for a given volume of cortex, the energetic cost is the same, at least for ion channels."Energy efficiencyThe human brain represents a striking deviation from this building plan, however. Instead of increased density of ion channels, the researchers found a dramatic decrease in the expected density of ion channels for a given volume of brain tissue.The researchers believe this lower density may have evolved as a way to expend less energy on pumping ions, which allows the brain to use that energy for something else, like creating more complicated synaptic connections between neurons or firing action potentials at a higher rate."We think that humans have evolved out of this building plan that was previously restricting the size of cortex, and they figured out a way to become more energetically efficient, so you spend less ATP per volume compared to other species," Harnett says.He now hopes to study where that extra energy might be going, and whether there are specific gene mutations that help neurons of the human cortex achieve this high efficiency. The researchers are also interested in exploring whether primate species that are more closely related to humans show similar decreases in ion channel density.The research was funded by the Natural Sciences and Engineering Research Council of Canada, a Friends of the McGovern Institute Fellowship, the National Institute of General Medical Sciences, the Paul and Daisy Soros Fellows Program, the Dana Foundation David Mahoney Neuroimaging Grant Program, the National Institutes of Health, and the Harvard-MIT Joint Research Grants Program in Basic Neuroscience..

Who can buy kamagra online

What are the key features of who can buy kamagra online hospitals that consistently deliver safe care on labour and http://matthewmusser.com/how-to-get-zithromax-without-a-doctor/ delivery?. This is the primary question posed by Liberati and colleagues in this issue of BMJ Quality & who can buy kamagra online. Safety.1 The authors propose a framework distilled from observations on a group of high-performing units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and focus groups and involved over 400 hours of total observations at six different maternity care who can buy kamagra online sites. The seven features in their resulting For Us framework correspond well to existing theoretical as well as applied quality improvement strategies.

While we agree that their framework describes features that every labour and delivery unit should strive who can buy kamagra online to include, this approach has some limitations in terms of generalisability. Specifically, Liberati and colleagues studied maternity units that are high performing, but their sample included only large-volume hospitals in what appear to be well-resourced settings. What is potentially missing who can buy kamagra online is observations on underperforming units, and how these findings may or may not apply to smaller, lower resourced settings. Additionally, the structure of the UK’s National Health Service (NHS) also limits generalisability. For example, this is most analogous to employed physician who can buy kamagra online models in the USA, with the potential advantage of a more organisationally oriented provider workforce.

Given that most US hospitals do not have an employed provider model, we can’t assume that these factors will have the same impact in other models of care.In the USA, the Agency for Healthcare Research and Quality (AHRQ) developed a Culture of Safety framework that delineates four key features. (1) organisations recognise who can buy kamagra online that their primary activities are inherently high risk and make it their goal to operate in a reliably safe manner. (2) organisations create a safe and blame-free who can buy kamagra online reporting environment. (3) interdisciplinary and interprofessional collaboration is encouraged to address safety problems. And (4) resources are deliberately allocated and made available to address safety.2 This framework, as does For Us, focuses on a who can buy kamagra online healthcare-oriented conceptualisation of safety and quality, and details medical outcomes as the primary metrics by which to measure success.

Although achievement of these medical quality outcomes is imperative, we propose that there are additional domains needed to provide safe intrapartum care. (A) prioritising patient experience—including emotional safety, birthing with dignity and an expectation who can buy kamagra online of person-centred care. And (B) a unit culture that values low intervention births. Let us consider these domains who can buy kamagra online in more depth.Patient experience and safety are inextricable. While much work has been done to improve physician–patient communication,3 4 few have successfully targeted the perpetuation of dysfunctional behaviours grounded in healthcare professionals’ implicit and explicit biases.5 This may be in part due to the tendency to observe and look for answers from the standpoint of the healthcare system rather than patients.

Women who had recently given birth were included in the study of Liberati and colleagues, but represented only 8 of 65 individual stakeholder interviews, and who can buy kamagra online were not included in focus groups. The framework who can buy kamagra online thus describes a high-functioning system from primarily the healthcare system’s perspective. In general, the patient’s role in achieving safe care includes many aspects, including providing personal information to reach the correct diagnosis, providing their values and lived experience in shared decision-making discussions, choosing their provider such that their needs regarding provider experience and safe practice are met, making sure that they receive the recommended treatments in a timely manner, as well as identifying and reporting errors.6 The detriment to health outcomes among patients who have failed interactions with providers is well documented (eg, leaving against medical advice or experiencing disrespect during their care) while other harms, such as psychological trauma, often go unmeasured.7Emotional and psychological trauma are safety errors, whether or not a patient leaves the hospital physically intact.8 Research has shown that patients experience psychological trauma both as a result of an adverse outcome and as a result of how the incident was managed. In birth, patients conceptualise the meaning of safety who can buy kamagra online very differently from that of the medical system, with physical and emotional safety being inextricably interwoven into a single concept.9 Psychological trauma may manifest in postpartum depression, post-traumatic stress disorder10 and, some studies suggest, reduced childbearing in patients who experience traumatic birth.11 The experience of emotional safety on the part of the patient is only knowable to the patient, and only addressable when health systems—and health services research—ask the appropriate questions. Therefore, patient-reported experience measures and critical examination of the process of patient-centred care should be at the centre of quality improvement.High-performing units prioritise patient voice and patient experience as a part of their culture.

In a recent article, Morton and Simkin12 delineate steps to promote respectful maternity care in institutions, including obtaining unit commitment to respectful care, implementing training programmes to support respectful care as the norm and, finally, instituting respectful treatment of healthcare staff and clinicians by administrators and leaders—in other who can buy kamagra online words, a unit culture of mutual respect and care among the entire team enables respectful care of the patient. Liberati and colleagues address the issue of hierarchies on labour and delivery, making the key observation that high-performing units create hierarchies around expertise rather than formal titles or disciplinary silos. However, this who can buy kamagra online power differential applies to patients as well. The existing hierarchy on most labour units places physicians at the top and patients at the bottom, which often acts to silence patients’ voices.13 Implicit bias and interpersonal racism and sexism contribute to this cycle of silence and mistreatment on labour and delivery units.14 Disrespect and dismissal of patient concerns have been increasingly described, but still lack quantitative measurement in association with maternal and child health outcomes.15 Interventions aimed at harm reduction are emerging,16 but more work is desperately needed in this area.Valuing low intervention is an important dimension of safety. Safety culture, as it who can buy kamagra online is conceptualised by AHRQ and the current study, is ideally created to prevent or respond to harmful safety lapses.

This model is more difficult to apply to an environment where the goal is safe facilitation of a normal biological process. In this setting, interventions (that often beget more who can buy kamagra online interventions) can increase complications. High rates of primary and repeat caesarean deliveries, and other invasive obstetric interventions seen in many birthing units are now widely acknowledged to be overused and overuse constitutes a patient safety risk.17 In our work in California, we who can buy kamagra online have been able to demonstrate that provider attitudes, beliefs and unit culture can drive caesarean delivery overuse in ways that do not contribute to patient safety.18 19 Each intervention needs to be carefully and jointly considered for value and safety. This in no way diminishes the life-saving nature of caesarean delivery when it is medically indicated, but it sets up the expectation that safety measures, processes and procedures must be in place to actively work towards supporting vaginal birth rather than treating each labour as an emergency waiting to happen. The striking variation in obstetric intervention rates among hospitals and providers can provide critical who can buy kamagra online insights.

So, what is the right balance of intervention rates and mother/baby safety outcomes?. In many instances, who can buy kamagra online this may be a false dichotomy. In a study of California hospital labour practices, Lundsberg et al found that hospitals that prioritised low labour interventions and actively supported vaginal birth (eg, delaying admission until active labour onset, use of doulas, intermittent auscultation of fetal heart tones, non-pharmacological pain relief, and so on) had reduced caesarean delivery rates with well-preserved neonatal outcomes.20 It should be noted that in the USA, rates of intervention are starting at a high level so there is less danger of harm from achieving too low a rate. This may not be the case in the UK where there are now formal inquiries examining obstetric care in multiple NHS hospital trusts where poor perinatal outcomes who can buy kamagra online have been linked to a systematic aversion to medical interventions even when indicated.21 Getting this balance right has been referred to as the Goldilocks quandary. Doing too little, too much or just right?.

22In conclusion, physical safety is the bare minimum of who can buy kamagra online what should be expected in childbirth. Patients have a right, and healthcare providers and systems have an obligation to aim higher, to ensure patients emerge from childbirth as healthy or healthier—both physically and psychologically—than before entering the hospital. This can be best achieved by broadening the lens of what we consider essential to safety on maternity units to include who can buy kamagra online prioritising patient experience, birthing with dignity and valuing low intervention rates. All of these domains need to be in balance. Good mother or baby medical outcomes at the cost of high rates of who can buy kamagra online intervention and high maternal psychological trauma are not a success, nor is the opposite.

The true ‘safe’ maternity unit who can buy kamagra online is one that does well on all of these dimensions, which, of course, means that we need to be able to measure each of them. Finally, all of these safety domains, including the ‘For Us’ framework proposed by Liberati and colleagues, focus on unit culture, provider behaviours and processes of care, and thus are within the reach of all maternity units no matter their level of resources.Healthcare-associated s (HCAIs) are those s acquired by an individual who is seeking medical care in any healthcare facility, including acute care hospitals, long-term care facilities (including nursing homes), outpatient surgical centres, dialysis centres or ambulatory care clinics.1 They are further defined as occurring at least 48 hours after hospitalisation or within 30 days of receiving medical care.2 HCAIs have plagued hospitals, physicians and patients for centuries and likely played a role in the reputation that hospitals historically had as dangerous places.3 In the mid-19th century, Ignaz Semmelweis observed that labouring mothers in an obstetrics unit had a high incidence of Puerperal (Childbed) fever, which he thought was related to direct contact with medical students. After working with cadavers, students often moved directly from the anatomy lab to the hospital, who can buy kamagra online leading Semmelweis to postulate that students were contaminated and bringing a pathogen into the unit. He saw dramatic improvements in maternal mortality after introducing a chlorinated lime hand wash for healthcare providers.4 Though not quickly accepted at large, his observations would become part of the foundation of the germ theory that we intuitively accept today.Over a century after Semmelweis introduced the idea of hand hygiene, prevention in healthcare settings has been thrust into the spotlight worldwide. In the 1960s, the US Centers for Disease Control and Prevention (CDC) who can buy kamagra online conducted research within the Comprehensive Hospital s Project and introduced surveillance and control techniques still used today.

The creation of the National Healthcare Safety Network (NHSN) propelled control onto a national public health platform in the USA.3 Today, reduction of HCAIs has become a regulatory, financial and quality imperative across the world.Healthcare frequently involves the use of invasive devices and procedures that can increase the risk of HCAIs, including catheter-associated urinary tract s, central-line associated bloodstream s (CLABSIs), surgical site s and ventilator-associated events.5 The development of antimicrobial resistance related to antibiotic misuse or overuse6 has given rise to multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae and diarrheal s with Clostridioides difficile. Today, most states in the USA have passed legislation mandating that healthcare facilities publicly report HCAIs, most often using the CDC NHSN surveillance definition for event reporting.7 Globally, who can buy kamagra online the WHO’s Clean Care is Safer Care Programme is working alongside many nations to introduce surveillance and reporting programmes to strengthen the international response.8The patient environment has become a major focus of control interventions. Although a large proportion of HCAIs are attributed to a patient’s endogenous microflora, up to 40% of nosocomial s are cross-s from the hands of healthcare providers, including transmission from high-touch patient-care surfaces.9 In order for pathogens to be transmitted, they generally must have characteristics that make them more robust in the environment, such as the ability to frequently colonise, survive and remain virulent on environmental surfaces and the ability to transiently colonise and pass from the hands of healthcare providers to patients or environmental surfaces.9 C. Difficile poses additional challenges for environmental control because of its ability to form spores who can buy kamagra online that resist dry heat and many disinfectants.9 Even with active surveillance and the introduction of new environmental dis technologies, such as uaviolet germicidal irradiation,10 studies have demonstrated that patients hospitalised in rooms with previous occupants who were MRSA colonised or infected with C. Difficile were more likely to become contaminated,7 supporting the notion that hospital environments play an important role in HCAI transmission.Both the duration of hospitalisation and frequency of transfer between and within healthcare facilities increase the likelihood of exposure to contaminated environments.

Intrahospital transfers refer to the movement of a patient within a healthcare facility, including transfers from the emergency room to an inpatient unit on admission, between two different units, to a different department for a procedure or diagnostic study or between rooms on the same unit.11 McHaney-Lindstrom and colleagues conducted a retrospective case-control study that found that with every additional intrahospital transfer, the odds of acquiring an who can buy kamagra online with C. Difficile increased by 7%.12 These transfers require a complex cascade of events and are affected by environmental control and communication challenges, professional conflicts related to variation in culture between units, hospital census and provider workload.13 In a systematic review, Bristol and colleagues found that intrahospital transfers are frequently associated with adverse outcomes, such as delirium, increased risk of falls, increased length of stay and prolonged duration of mechanical ventilation and central venous catheterisation.13 This therefore further highlights the who can buy kamagra online significance of intrahospital transfers on patient outcomes.In this issue, Boncea and colleagues report on a retrospective case-control study conducted to estimate the risk of developing a HCAI depending on the number of intrahospital transfers between inpatient units or the same unit.11 The study was conducted in three urban hospitals within one UK hospital organisation. The study focused on patients aged 65 or older, given their higher frequency of access to medical care. Data were collected from the electronic health record (EHR) over a 3-year period and included a total of 24 240 hospitalisations of which 2877 were cases where the patient had a positive clinical culture obtained at least 48 hours after hospitalisation who can buy kamagra online. Cases and controls were matched by potential confounding variables, including Elixhauser comorbidities, age, gender and total number of admissions.

Using multivariable logistic regression modelling, they found who can buy kamagra online that for every additional intrahospital transfer, the odds of acquiring a HCAI increased by 9%, with the most common HCAI being C. Difficile .This study is one of the first to quantify the risk associated with the number of intrahospital transfers and HCAIs. Cases and controls were well matched, and the statistical modelling provides very compelling who can buy kamagra online results. However, it is worth noting some features of the study that can affect the findings. The study does not provide specific details who can buy kamagra online on the active surveillance testing practices of the hospital network.

Without these data, theoretically (and by chance), cases selected for this study could have been colonised by MRSA more frequently than controls, which would introduce a level of bias. C. Difficile was measured from the EHR by positive toxin immunoassay results, but the clinical context of this testing is not clear, raising the possibility that some positive patients may have represented colonisation and not acute . The study also did not adjust for the indication for transfer (eg, transfer to or from the intensive care unit based on patient acuity, transfer for isolation precautions or transfer due to bed capacity or staffing issues) to determine if the patient care needs, isolation status or hospital strain modify the observed risk. As the authors acknowledge, prospective studies are needed to identify the clinical, administrative and systems factors that contribute to more frequent intrahospital transfers.Guidelines for prevention and control of HCAIs include evidence-based interventions that can be broadly categorised as either vertical or horizontal.

Vertical interventions focus on reducing colonisation, and transmission of specific pathogens,7 and include surveillance testing for asymptomatic carriers, contact isolation precautions and targeted decolonisation.7 Horizontal interventions aim to reduce the risk of by a larger group of pathogens, independent of patient-specific conditions, such as optimisation of hand hygiene, antimicrobial stewardship and environmental cleaning practices.7 control programmes are tasked with weighing the risks and benefits of interventions to reduce rates of HCAIs while also being cost effective. Vertical approaches to prevent MRSA transmission and remain controversial due to inconsistent findings.7 In a nationwide US Veteran’s Affairs study that assessed the impact of MRSA surveillance testing and contact isolation in MRSA carriers, researchers demonstrated that these interventions resulted in reduced rates of MRSA and colonisation as well as reductions in the incidence of healthcare-associated C. Difficile and vancomycin-resistant Enterococcus s.14 In contrast, other studies evaluating similar practices in intensive care units found little impact of vertical control measures on MRSA rates15 and describe unintended consequences, such as decreased provider-patient contact, increased patient anxiety and patient dissatisfaction with quality of care.16Under endemic conditions, horizontal interventions may be more cost effective and beneficial given the broader number of microorganisms that can be targeted.7 Hand hygiene remains a core horizontal intervention, but hand hygiene compliance varies widely, with some countries’ hospitals compliance reported as low as 15%.17 Several studies focused on intensive care units have shown significant declines in MRSA colonisation rates when hand hygiene practices improve.7 In addition to hand hygiene, universal decolonisation strategies that typically use chlorhexidine gluconate bathing of high risk patients are more impactful than active surveillance testing for individual pathogens at reducing rates of HCAIs such as CLABSIs.7 A central pillar of control is antimicrobial stewardship. These programmes use coordinated interventions to promote appropriate antimicrobial use, improve patient outcomes, decrease antibiotic resistance and reduce the incidence of s secondary to multidrug-resistant organisms.18 Given variation in environmental dis practices and provider-to-provider communication, reducing the frequency of intrahospital transfers is another potential horizontal intervention to reduce the burden of HCAIs.Boncea and colleagues’ study adds to the growing body of literature that intrahospital transfers may increase the risk of HCAIs. Prior studies have identified that patients experience an average of 2.4 transfers during a hospitalisation and approximately 96% of individuals experience a transfer during hospitalisation.13 Transfers within the hospital also affect patient care and safety in other ways, resulting in delays in diagnosis and treatment due, in part, to poor coordination of care and inadequate handoffs between units.19 Additionally, intrahospital transfers take an average of 1 hour to complete, adding significantly to nursing workload.19The field of control must continue to adapt to changing hospital environments in order to further reduce the risk of HCAIs.

In the most recent progress report from US CDC, one in every 31 US patients will experience a HCAI while hospitalised,20 contributing to preventable deaths and permanent harm and to a tremendous excess cost of care.21 While the impact of these s is readily recognised in the developed world, recent studies indicate that the impact of HCAIs in the developing world is staggering, with one study reporting that the pooled-prevalence of HCAIs in resource-limited settings is 15.5 per 100 patients, compared with 4.5 per 100 patients in the USA and 7.1 per 100 patients in Europe.22 control programmes must continue to survey their respective hospital populations and evolve to the demand of the time, weighing benefits, balancing measures and costs. Reducing the number of intrahospital transfers and improving care coordination across these transitions represent a future opportunity to further reduce the burden of HCAIs..

What are the http://matthewmusser.com/how-to-get-zithromax-without-a-doctor/ key features of hospitals that consistently deliver order kamagra gel safe care on labour and delivery?. This is the primary question posed by Liberati and colleagues in this issue of order kamagra gel BMJ Quality &. Safety.1 The authors propose a framework distilled from observations on a group of high-performing units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and focus groups and involved over 400 order kamagra gel hours of total observations at six different maternity care sites. The seven features in their resulting For Us framework correspond well to existing theoretical as well as applied quality improvement strategies.

While we agree that their framework describes features that every labour and delivery unit should strive to include, this approach has some order kamagra gel limitations in terms of generalisability. Specifically, Liberati and colleagues studied maternity units that are high performing, but their sample included only large-volume hospitals in what appear to be well-resourced settings. What is potentially missing is observations on underperforming units, and how these findings order kamagra gel may or may not apply to smaller, lower resourced settings. Additionally, the structure of the UK’s National Health Service (NHS) also limits generalisability. For example, this is most analogous to employed physician models in the USA, with the potential advantage of a order kamagra gel more organisationally oriented provider workforce.

Given that most US hospitals do not have an employed provider model, we can’t assume that these factors will have the same impact in other models of care.In the USA, the Agency for Healthcare Research and Quality (AHRQ) developed a Culture of Safety framework that delineates four key features. (1) organisations recognise that their primary activities are order kamagra gel inherently high risk and make it their goal to operate in a reliably safe manner. (2) organisations order kamagra gel create a safe and blame-free reporting environment. (3) interdisciplinary and interprofessional collaboration is encouraged to address safety problems. And (4) resources are deliberately allocated and made available to address safety.2 This framework, as does For Us, focuses on a healthcare-oriented conceptualisation of safety and order kamagra gel quality, and details medical outcomes as the primary metrics by which to measure success.

Although achievement of these medical quality outcomes is imperative, we propose that there are additional domains needed to provide safe intrapartum care. (A) prioritising patient experience—including emotional safety, birthing order kamagra gel with dignity and an expectation of person-centred care. And (B) a unit culture that values low intervention births. Let us consider these domains in more order kamagra gel depth.Patient experience and safety are inextricable. While much work has been done to improve physician–patient communication,3 4 few have successfully targeted the perpetuation of dysfunctional behaviours grounded in healthcare professionals’ implicit and explicit biases.5 This may be in part due to the tendency to observe and look for answers from the standpoint of the healthcare system rather than patients.

Women who had recently given birth were included in the study of Liberati and colleagues, but represented only order kamagra gel 8 of 65 individual stakeholder interviews, and were not included in focus groups. The framework thus order kamagra gel describes a high-functioning system from primarily the healthcare system’s perspective. In general, the patient’s role in achieving safe care includes many aspects, including providing personal information to reach the correct diagnosis, providing their values and lived experience in shared decision-making discussions, choosing their provider such that their needs regarding provider experience and safe practice are met, making sure that they receive the recommended treatments in a timely manner, as well as identifying and reporting errors.6 The detriment to health outcomes among patients who have failed interactions with providers is well documented (eg, leaving against medical advice or experiencing disrespect during their care) while other harms, such as psychological trauma, often go unmeasured.7Emotional and psychological trauma are safety errors, whether or not a patient leaves the hospital physically intact.8 Research has shown that patients experience psychological trauma both as a result of an adverse outcome and as a result of how the incident was managed. In birth, patients conceptualise the meaning of safety very differently from that of the medical system, with physical and emotional safety being inextricably interwoven into a single concept.9 Psychological trauma may manifest in postpartum depression, post-traumatic stress disorder10 and, some studies suggest, reduced childbearing in patients who experience traumatic birth.11 The experience of emotional safety on the part of the patient is only knowable to order kamagra gel the patient, and only addressable when health systems—and health services research—ask the appropriate questions. Therefore, patient-reported experience measures and critical examination of the process of patient-centred care should be at the centre of quality improvement.High-performing units prioritise patient voice and patient experience as a part of their culture.

In a recent article, Morton and Simkin12 delineate steps to promote respectful maternity care in institutions, including obtaining unit commitment to respectful care, implementing training programmes to support respectful care as the norm and, finally, instituting respectful treatment of healthcare staff and clinicians by order kamagra gel administrators and leaders—in other words, a unit culture of mutual respect and care among the entire team enables respectful care of the patient. Liberati and colleagues address the issue of hierarchies on labour and delivery, making the key observation that high-performing units create hierarchies around expertise rather than formal titles or disciplinary silos. However, this power differential applies to patients as order kamagra gel well. The existing hierarchy on most labour units places physicians at the top and patients at the bottom, which often acts to silence patients’ voices.13 Implicit bias and interpersonal racism and sexism contribute to this cycle of silence and mistreatment on labour and delivery units.14 Disrespect and dismissal of patient concerns have been increasingly described, but still lack quantitative measurement in association with maternal and child health outcomes.15 Interventions aimed at harm reduction are emerging,16 but more work is desperately needed in this area.Valuing low intervention is an important dimension of safety. Safety culture, as it is conceptualised by AHRQ and the current study, is ideally created to prevent or respond to harmful safety lapses order kamagra gel.

This model is more difficult to apply to an environment where the goal is safe facilitation of a normal biological process. In this setting, interventions order kamagra gel (that often beget more interventions) can increase complications. High rates order kamagra gel of primary and repeat caesarean deliveries, and other invasive obstetric interventions seen in many birthing units are now widely acknowledged to be overused and overuse constitutes a patient safety risk.17 In our work in California, we have been able to demonstrate that provider attitudes, beliefs and unit culture can drive caesarean delivery overuse in ways that do not contribute to patient safety.18 19 Each intervention needs to be carefully and jointly considered for value and safety. This in no way diminishes the life-saving nature of caesarean delivery when it is medically indicated, but it sets up the expectation that safety measures, processes and procedures must be in place to actively work towards supporting vaginal birth rather than treating each labour as an emergency waiting to happen. The striking variation in obstetric intervention rates among order kamagra gel hospitals and providers can provide critical insights.

So, what is the right balance of intervention rates and mother/baby safety outcomes?. In many instances, order kamagra gel this may be a false dichotomy. In a study of California hospital labour practices, Lundsberg et al found that hospitals that prioritised low labour interventions and actively supported vaginal birth (eg, delaying admission until active labour onset, use of doulas, intermittent auscultation of fetal heart tones, non-pharmacological pain relief, and so on) had reduced caesarean delivery rates with well-preserved neonatal outcomes.20 It should be noted that in the USA, rates of intervention are starting at a high level so there is less danger of harm from achieving too low a rate. This may not be the case in the UK where there are now formal inquiries examining obstetric care in multiple NHS hospital trusts order kamagra gel where poor perinatal outcomes have been linked to a systematic aversion to medical interventions even when indicated.21 Getting this balance right has been referred to as the Goldilocks quandary. Doing too little, too much or just right?.

22In conclusion, physical safety is order kamagra gel the bare minimum of what should be expected in childbirth. Patients have a right, and healthcare providers and systems have an obligation to aim higher, to ensure patients emerge from childbirth as healthy or healthier—both physically and psychologically—than before entering the hospital. This can be best achieved by broadening the lens of what we consider essential to safety on maternity order kamagra gel units to include prioritising patient experience, birthing with dignity and valuing low intervention rates. All of these domains need to be in balance. Good mother or baby medical outcomes at the cost of high rates of intervention and high maternal psychological trauma are not a success, nor is the order kamagra gel opposite.

The true ‘safe’ maternity unit is one that does well on all of these dimensions, which, of course, order kamagra gel means that we need to be able to measure each of them. Finally, all of these safety domains, including the ‘For Us’ framework proposed by Liberati and colleagues, focus on unit culture, provider behaviours and processes of care, and thus are within the reach of all maternity units no matter their level of resources.Healthcare-associated s (HCAIs) are those s acquired by an individual who is seeking medical care in any healthcare facility, including acute care hospitals, long-term care facilities (including nursing homes), outpatient surgical centres, dialysis centres or ambulatory care clinics.1 They are further defined as occurring at least 48 hours after hospitalisation or within 30 days of receiving medical care.2 HCAIs have plagued hospitals, physicians and patients for centuries and likely played a role in the reputation that hospitals historically had as dangerous places.3 In the mid-19th century, Ignaz Semmelweis observed that labouring mothers in an obstetrics unit had a high incidence of Puerperal (Childbed) fever, which he thought was related to direct contact with medical students. After working with cadavers, students often moved directly from the anatomy lab to the hospital, leading Semmelweis order kamagra gel to postulate that students were contaminated and bringing a pathogen into the unit. He saw dramatic improvements in maternal mortality after introducing a chlorinated lime hand wash for healthcare providers.4 Though not quickly accepted at large, his observations would become part of the foundation of the germ theory that we intuitively accept today.Over a century after Semmelweis introduced the idea of hand hygiene, prevention in healthcare settings has been thrust into the spotlight worldwide. In the 1960s, the US Centers for Disease Control and Prevention (CDC) conducted research within the Comprehensive Hospital s Project and introduced surveillance and control techniques order kamagra gel still used today.

The creation of the National Healthcare Safety Network (NHSN) propelled control onto a national public health platform in the USA.3 Today, reduction of HCAIs has become a regulatory, financial and quality imperative across the world.Healthcare frequently involves the use of invasive devices and procedures that can increase the risk of HCAIs, including catheter-associated urinary tract s, central-line associated bloodstream s (CLABSIs), surgical site s and ventilator-associated events.5 The development of antimicrobial resistance related to antibiotic misuse or overuse6 has given rise to multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae and diarrheal s with Clostridioides difficile. Today, most states in the USA have passed legislation mandating that healthcare facilities publicly report HCAIs, most often using the CDC NHSN surveillance definition for event reporting.7 Globally, the WHO’s Clean Care is Safer Care Programme is working order kamagra gel alongside many nations to introduce surveillance and reporting programmes to strengthen the international response.8The patient environment has become a major focus of control interventions. Although a large proportion of HCAIs are attributed to a patient’s endogenous microflora, up to 40% of nosocomial s are cross-s from the hands of healthcare providers, including transmission from high-touch patient-care surfaces.9 In order for pathogens to be transmitted, they generally must have characteristics that make them more robust in the environment, such as the ability to frequently colonise, survive and remain virulent on environmental surfaces and the ability to transiently colonise and pass from the hands of healthcare providers to patients or environmental surfaces.9 C. Difficile poses additional challenges for environmental control because of its ability to order kamagra gel form spores that resist dry heat and many disinfectants.9 Even with active surveillance and the introduction of new environmental dis technologies, such as uaviolet germicidal irradiation,10 studies have demonstrated that patients hospitalised in rooms with previous occupants who were MRSA colonised or infected with C. Difficile were more likely to become contaminated,7 supporting the notion that hospital environments play an important role in HCAI transmission.Both the duration of hospitalisation and frequency of transfer between and within healthcare facilities increase the likelihood of exposure to contaminated environments.

Intrahospital transfers refer to the movement of a patient within a healthcare facility, including transfers order kamagra gel from the emergency room to an inpatient unit on admission, between two different units, to a different department for a procedure or diagnostic study or between rooms on the same unit.11 McHaney-Lindstrom and colleagues conducted a retrospective case-control study that found that with every additional intrahospital transfer, the odds of acquiring an with C. Difficile increased by 7%.12 These transfers require a complex cascade of events and order kamagra gel are affected by environmental control and communication challenges, professional conflicts related to variation in culture between units, hospital census and provider workload.13 In a systematic review, Bristol and colleagues found that intrahospital transfers are frequently associated with adverse outcomes, such as delirium, increased risk of falls, increased length of stay and prolonged duration of mechanical ventilation and central venous catheterisation.13 This therefore further highlights the significance of intrahospital transfers on patient outcomes.In this issue, Boncea and colleagues report on a retrospective case-control study conducted to estimate the risk of developing a HCAI depending on the number of intrahospital transfers between inpatient units or the same unit.11 The study was conducted in three urban hospitals within one UK hospital organisation. The study focused on patients aged 65 or older, given their higher frequency of access to medical care. Data were collected from the electronic health record (EHR) over a 3-year period and included a total of 24 240 hospitalisations of which 2877 were cases where the order kamagra gel patient had a positive clinical culture obtained at least 48 hours after hospitalisation. Cases and controls were matched by potential confounding variables, including Elixhauser comorbidities, age, gender and total number of admissions.

Using multivariable logistic regression modelling, they found that for every additional intrahospital transfer, the odds of acquiring a HCAI increased by order kamagra gel 9%, with the most common HCAI being C. Difficile .This study is one of the first to quantify the risk associated with the number of intrahospital transfers and HCAIs. Cases and controls were well matched, order kamagra gel and the statistical modelling provides very compelling results. However, it is worth noting some features of the study that can affect the findings. The study does not provide specific details on the active surveillance testing practices of the order kamagra gel hospital network.

Without these data, theoretically (and by chance), cases selected for this study could have been colonised by MRSA more frequently than controls, which would introduce a level of bias. C. Difficile was measured from the EHR by positive toxin immunoassay results, but the clinical context of this testing is not clear, raising the possibility that some positive patients may have represented colonisation and not acute . The study also did not adjust for the indication for transfer (eg, transfer to or from the intensive care unit based on patient acuity, transfer for isolation precautions or transfer due to bed capacity or staffing issues) to determine if the patient care needs, isolation status or hospital strain modify the observed risk. As the authors acknowledge, prospective studies are needed to identify the clinical, administrative and systems factors that contribute to more frequent intrahospital transfers.Guidelines for prevention and control of HCAIs include evidence-based interventions that can be broadly categorised as either vertical or horizontal.

Vertical interventions focus on reducing colonisation, and transmission of specific pathogens,7 and include surveillance testing for asymptomatic carriers, contact isolation precautions and targeted decolonisation.7 Horizontal interventions aim to reduce the risk of by a larger group of pathogens, independent of patient-specific conditions, such as optimisation of hand hygiene, antimicrobial stewardship and environmental cleaning practices.7 control programmes are tasked with weighing the risks and benefits of interventions to reduce rates of HCAIs while also being cost effective. Vertical approaches to prevent MRSA transmission and remain controversial due to inconsistent findings.7 In a nationwide US Veteran’s Affairs study that assessed the impact of MRSA surveillance testing and contact isolation in MRSA carriers, researchers demonstrated that these interventions resulted in reduced rates of MRSA and colonisation as well as reductions in the incidence of healthcare-associated C. Difficile and vancomycin-resistant Enterococcus s.14 In contrast, other studies evaluating similar practices in intensive care units found little impact of vertical control measures on MRSA rates15 and describe unintended consequences, such as decreased provider-patient contact, increased patient anxiety and patient dissatisfaction with quality of care.16Under endemic conditions, horizontal interventions may be more cost effective and beneficial given the broader number of microorganisms that can be targeted.7 Hand hygiene remains a core horizontal intervention, but hand hygiene compliance varies widely, with some countries’ hospitals compliance reported as low as 15%.17 Several studies focused on intensive care units have shown significant declines in MRSA colonisation rates when hand hygiene practices improve.7 In addition to hand hygiene, universal decolonisation strategies that typically use chlorhexidine gluconate bathing of high risk patients are more impactful than active surveillance testing for individual pathogens at reducing rates of HCAIs such as CLABSIs.7 A central pillar of control is antimicrobial stewardship. These programmes use coordinated interventions to promote appropriate antimicrobial use, improve patient outcomes, decrease antibiotic resistance and reduce the incidence of s secondary to multidrug-resistant organisms.18 Given variation in environmental dis practices and provider-to-provider communication, reducing the frequency of intrahospital transfers is another potential horizontal intervention to reduce the burden of HCAIs.Boncea and colleagues’ study adds to the growing body of literature that intrahospital transfers may increase the risk of HCAIs. Prior studies have identified that patients experience an average of 2.4 transfers during a hospitalisation and approximately 96% of individuals experience a transfer during hospitalisation.13 Transfers within the hospital also affect patient care and safety in other ways, resulting in delays in diagnosis and treatment due, in part, to poor coordination of care and inadequate handoffs between units.19 Additionally, intrahospital transfers take an average of 1 hour to complete, adding significantly to nursing workload.19The field of control must continue to adapt to changing hospital environments in order to further reduce the risk of HCAIs.

In the most recent progress report from US CDC, one in every 31 US patients will experience a HCAI while hospitalised,20 contributing to preventable deaths and permanent harm and to a tremendous excess cost of care.21 While the impact of these s is readily recognised in the developed world, recent studies indicate that the impact of HCAIs in the developing world is staggering, with one study reporting that the pooled-prevalence of HCAIs in resource-limited settings is 15.5 per 100 patients, compared with 4.5 per 100 patients in the USA and 7.1 per 100 patients in Europe.22 control programmes must continue to survey their respective hospital populations and evolve to the demand of the time, weighing benefits, balancing measures and costs. Reducing the number of intrahospital transfers and improving care coordination across these transitions represent a future opportunity to further reduce the burden of HCAIs..