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EL PASO, Texas — Alfredo “Freddy” Valles was an accomplished trumpeter and a beloved music teacher for nearly four decades at one of the city’s poorest buy kamagra australia middle schools. He was known for buying his students shoes and bow ties for their band concerts, his effortlessly positive demeanor and a suave personal style — “he looked like he stepped out of a different era, the 1950s,” said his niece Ruby Montana. While Valles was singular in life, his death at buy kamagra australia age 60 in February was part of a devastating statistic. He was one of thousands of deaths in Texas border counties — where erectile dysfunction mortality rates far outpaced state and national averages. In the state’s border communities, including El Paso, not only did people die of erectile dysfunction treatment at significantly higher rates than elsewhere, but people under age 65 were also more likely to die, according to a KHN-El Paso Matters analysis of erectile dysfunction treatment death data through January.

More than buy kamagra australia 7,700 people died of erectile dysfunction treatment in the border area during that period. In Texas, erectile dysfunction treatment death rates for border residents younger than 65 were nearly three times the national average for that age group and more than twice the state average. And those ages 18-49 were nearly four times more likely to die than those in the same age range across the U.S. €œThis was like a perfect storm,” said Heide Castañeda, an anthropology professor at the University of South Florida who buy kamagra australia studies the health of border residents. She said a higher-than-normal prevalence of underlying health issues combined with high uninsurance rates and flagging access to care likely made the kamagra even more lethal for those living along the border than elsewhere.

That pattern was buy kamagra australia not as stark in neighboring New Mexico. Border counties there recorded erectile dysfunction treatment death rates 41% lower than those in Texas, although the New Mexico areas were well above the national average as of January, the KHN-El Paso Matters analysis found. Texas border counties tallied 282 deaths per 100,000, compared with 166 per 100,000 in New Mexico. That stark divide could be seen even when buy kamagra australia looking at neighboring El Paso County, Texas, and Doña Ana County, New Mexico. The death rate for residents under 65 was 70% higher in El Paso County.

Health experts said Texas’ refusal to expand Medicaid under the Affordable Care Act, a shortage of health care options and the state’s lax strategy toward the kamagra also contributed to a higher death rate at the border. Texas GOP leaders have opposed buy kamagra australia Medicaid expansion for a litany of economic and political reasons, though largely because they object to expanding the role or size of government. €œHaving no Medicaid expansion and an area that is already underserved by primary care and preventive care set the stage for a serious situation,” Castañeda said. €œA lot of this is caused by state politics.” Texas was one of the first states to reopen following the nationwide erectile dysfunction buy kamagra australia shutdown in March and April last year. Last June — even as cases were rising — Gov.

Greg Abbott allowed all businesses, including restaurants, to operate at up to 50% capacity, with limited exceptions. And he refused to put any capacity restrictions on buy kamagra australia churches and other religious facilities or let local governments impose mask requirements. In November, Texas Attorney General Ken Paxton filed an injunction to stop a lockdown order implemented by the El Paso county judge, the top administrative officer, at a time when El Paso hospitals were so overwhelmed with erectile dysfunction treatment patients that 10 mobile morgues had to be set up at an area hospital to accommodate the dead. Unlike Texas, New Mexico expanded Medicaid under the ACA and, as a result, has a much lower uninsured rate than Texas for people under age 65 — 12% compared with Texas’ 21%, according to Census figures. And New Mexico had aggressive rules for face masks and buy kamagra australia public gatherings.

Still, that didn’t spare New Mexico from the crisis. Outbreaks in buy kamagra australia and around the Navajo reservation hit hard. Overall, its state death rate exceeded the state rate for Texas, but along the border New Mexico’s rates were lower in all age groups. For some border families, the immense toll of the kamagra meant multiple deaths among loved ones. Ruby Montana lost not only her uncle to buy kamagra australia erectile dysfunction treatment in recent months, but also her cousin Julieta “Julie” Apodaca, a former elementary school teacher and speech therapist.

Montana said Valles’ death surprised the family. He had been teaching remotely at Guillen Middle School in El Paso’s Segundo Barrio neighborhood, an area known as “the other Ellis Island” because of its adjacency to the border and its history as an enclave for Mexican immigrant families. Alfredo “Freddy” Valles was an accomplished trumpeter and a beloved music teacher for buy kamagra australia nearly four decades in El Paso, Texas. He died of erectile dysfunction treatment in February. (Ruby Montana) When Valles first got sick with erectile dysfunction treatment in December, Montana and the family were not worried, not only because he had no preexisting buy kamagra australia health conditions, but also because they knew his lungs were strong from practicing his trumpet daily over the course of decades.

In early January, he went to an urgent care center after his condition deteriorated. He had pneumonia and was told to go straight to the emergency room. €œWhen I buy kamagra australia took him to the [hospital], I dropped him off and went to go park,” said his wife, Elvira. But when she returned, she was not allowed inside. €œI never saw him again,” she said.

Valles, a father of three, had been teaching one buy kamagra australia of his three grandchildren, 5-year-old Aliq Valles, to play the trumpet. They “were joined at the hip,” Montana said. €œThat part buy kamagra australia has been really hard to deal with too. [Aliq] should have a whole lifetime with his grandpa.” Hispanic adults are more than twice as likely to die of erectile dysfunction treatment as white adults, according to the Centers for Disease Control and Prevention. In Texas, Hispanic residents died of erectile dysfunction treatment at a rate four times as high as that of non-Hispanic white people, according to a December analysis by The Dallas Morning News.

Ninety percent of residents under 65 buy kamagra australia in Texas border counties are Hispanic, compared with 37% in the rest of the state. Latinos have high rates of chronic conditions like diabetes and obesity, which increases their risks of erectile dysfunction treatment complications, health experts say. Because they were more likely to die of erectile dysfunction treatment at earlier ages, Latinos are losing the most years of potential life among all racial and ethnic groups, said Coda Rayo-Garza, an advocate for policies to aid Hispanic populations and a professor of political science at the University of Texas-San Antonio. Expanding Medicaid, she said, would have aided the border communities in their fight against erectile dysfunction treatment, as they have some of buy kamagra australia the highest rates of residents without health coverage in the state. €œThere has been a disinvestment in border areas long before that led to this outcome that you’re finding,” she said.

€œThe legislature did not end up passing Medicaid expansion, which would have largely benefited border towns.” The higher death rates among border communities are “unfortunately buy kamagra australia not surprising,” said Democratic U.S. Rep. Veronica Escobar, who represents El Paso. “It’s exactly what we warned buy kamagra australia about,” Escobar said. €œPeople in Texas died at disproportionate rates because of a dereliction on behalf of the governor.

He chose not to govern … and the results are deadly.” Abbott spokesperson Renae Eze said the governor mourns every life lost to erectile dysfunction treatment. €œThroughout the entire kamagra, the state of Texas has worked diligently with local officials to quickly provide the resources needed to combat erectile dysfunction treatment buy kamagra australia and keep Texans safe,” she said. ErnestoCastañeda, a sociology professor at American University in Washington, D.C., who is not related to Heide Castañeda, said structural racism is integrally linked to poor health outcomes in border communities. Generations of institutional discrimination — through policing, educational and job opportunities, and health care — worsens buy kamagra australia the severity of crisis events for people of color, he explained. €œWe knew it was going to be bad in El Paso,” Ernesto Castañeda said.

€œEl Paso has relatively low socioeconomic status, relatively low education levels, high levels of diabetes and overweight [population].” In some Texas counties along the border more than a third of workers are uninsured, according to an analysis by Georgetown University’s Center for Children and Families. €œThe border is a very troubled area in terms of high uninsured rates, and we see all of those are folks put at increased risk by the buy kamagra australia kamagra,” said Joan Alker, director of the center. In addition, because of a shortage of health workers along much of the border, the kamagra surge was all the deadlier, said Dr. Ogechika Alozie, an El Paso specialist in infectious diseases. €œWhen you buy kamagra australia layer on top not having enough medical personnel with a sicker-on-average population, this is really what you find happens, unfortunately,” he said.

The federal government has designated the entire Texas border region as both a health professional shortage area and a medically underserved area. Jagdish Khubchandani, a professor of public health at New Mexico buy kamagra australia State University in Las Cruces, about 40 miles northwest of El Paso, said the two cities were like night and day in their response to the crisis. €œRestrictions were far more rigid in New Mexico,” he said. €œIt almost felt like two different countries.” Manny Sanchez, a commissioner in Doña Ana County, credits the lower death rates in New Mexico to state and local officials’ united message to residents about erectile dysfunction treatment and the need to wear masks and maintain physical distance. €œI would like to think we made a difference in saving lives,” Sanchez said buy kamagra australia.

But, because containing a kamagra requires community buy-in, even El Paso residents who understood the risks were susceptible to erectile dysfunction treatment. Julie Apodaca, who had recently retired, had been especially careful, in part because her asthma and diabetes put her at increased risk. As the primary caregiver for her elderly mother, she was likely exposed to the kamagra through one of the nurse caretakers who came to her mother’s home and later tested positive, said her sister Ana Apodaca buy kamagra australia. Julie Apodaca had registered for a erectile dysfunction treatment in December as soon as it was available but had not been able to get an appointment for a shot by the time she fell ill. Montana found out that Apodaca had been hospitalized the day after her buy kamagra australia uncle died.

One month later, and after 16 days on a ventilator, she too died on March 13. She was 56. This story was done in partnership with El Paso Matters, a member-supported, nonpartisan media organization that focuses on in-depth and investigative reporting about El Paso, Texas, Ciudad Juárez across the border in Mexico, buy kamagra australia and neighboring communities. MethodologyTo analyze erectile dysfunction treatment deaths rates along the border with Mexico, KHN and El Paso Matters requested erectile dysfunction treatment-related death counts by age group and county from Texas, New Mexico, California and Arizona. California and Arizona were unable to fulfill the requests.

The Texas Department of State Health Services and the New Mexico Department of Health provided death counts as of Jan buy kamagra australia. 31, 2021.Texas’ data included totals by age group for border counties as a group and for the state with no suppression of data. New Mexico provided data for individual counties, and small numbers were suppressed, totaling 1.6% of all deaths in the state. (Data on deaths is commonly suppressed when it involves very small numbers to protect individual identities.)National death counts by age group were calculated using provisional death data from the Centers for Disease buy kamagra australia Control and Prevention, and included deaths as of Jan. 31, 2021.Rates were calculated per 100,000 people using the 2019 American Community Survey.The ethnic breakdown in Texas’ border counties comes from the Census Bureau’s 2019 population estimates.

Phil buy kamagra australia Galewitz. pgalewitz@kff.org, @philgalewitz Elizabeth Lucas. elucas@kff.org, @eklucas Related Topics Contact Us Submit a Story TipFive months after her husband died of erectile dysfunction treatment, Valerie Villegas can see how grief has wounded her children. Nicholas, the baby, who was 1 and almost weaned when his father died, now wants to nurse at all buy kamagra australia hours and calls every tall, dark-haired man “Dada,” the only word he knows. Robert, 3, regularly collapses into furious tantrums, stopped using the big-boy potty and frets about sick people giving him germs.

Ayden, 5, recently announced it’s his job to “be strong” and protect his mom and brothers. Her older kids — Kai Flores, 13, Andrew Vaiz, 16, and Alexis Vaiz, 18 — are often buy kamagra australia quiet and sad or angry and sad, depending on the day. The two eldest, gripped by anxiety that makes it difficult to concentrate or sleep, were prescribed antidepressants soon after losing their stepfather. €œI spend half the nights buy kamagra australia crying,” said Villegas, 41, a hospice nurse from Portland, Texas. She became a widow on Jan.

25, just three weeks after Robert Villegas, 45, a strong, healthy truck driver and jiujitsu expert, tested positive for the kamagra. €œMy kids, they’re my buy kamagra australia primary concern,” she said. €œAnd there’s help that we need.” But in a nation where researchers calculate that more than 46,000 children have lost one or both parents to erectile dysfunction treatment since February 2020, Villegas and other survivors say finding basic services for their bereaved kids — counseling, peer support groups, financial assistance — has been difficult, if not impossible. €œThey say it’s out there,” Villegas said. €œBut trying to get it has been a nightmare.” buy kamagra australia Interviews with nearly two dozen researchers, therapists and other experts on loss and grief, as well as families whose loved ones died of erectile dysfunction treatment, reveal the extent to which access to grief groups and therapists grew scarce during the kamagra.

Providers scrambled to switch from in-person to virtual visits and waiting lists swelled, often leaving bereft children and their surviving parents to cope on their own. €œLosing a parent is devastating to a child,” said Alyssa Label, a San Diego therapist and program manager with SmartCare Behavioral Health Consultation buy kamagra australia Services. €œLosing a parent during a kamagra is a special form of torture.” Children can receive survivor benefits when a parent dies if that parent worked long enough in a job that required payment of Social Security taxes. During the kamagra, the number of minor children of deceased workers who received new benefits has surged, reaching nearly 200,000 in 2020, up from an average of 180,000 in the previous three years. Social Security Administration officials don’t track cause of death, but the latest figures marked the most awards granted since 1994 buy kamagra australia.

erectile dysfunction treatment deaths “undoubtedly” fueled that spike, according to the SSA’s Office of the Chief Actuary. And the number of children eligible for those benefits is surely higher. Only about half of the 2 million children in the U.S buy kamagra australia. Who have lost a parent as of 2014 received the Social Security benefits to which they were entitled, according to a 2019 analysis by David Weaver of the Congressional Budget Office. Counselors said they find many families have no idea that children qualify for benefits when a working parent dies, or don’t buy kamagra australia know how to sign up.

Valerie Villegas (left) holds Robert Jr. As her oldest son, Andrew Vaiz, ties Ayden’s shoes. Villegas says all six of her children have been affected by the grief of losing their father and stepfather.(Scott Stephen Ball for KHN) In a country that showered philanthropic and government aid on the 3,000 children who lost parents to the 9/11 terror attacks, there’s been no organized effort to identify, track or support the tens of thousands of kids buy kamagra australia left bereaved by erectile dysfunction treatment. €œI’m not aware of any group working on this,” said Joyal Mulheron, the founder of Evermore, a nonprofit foundation that focuses on public policy related to bereavement. €œBecause the scale of the problem is so huge, the scale of the solution needs to match it.” erectile dysfunction treatment has claimed more than 600,000 lives in the U.S., and researchers writing in the journal JAMA Pediatrics calculated that for every 13 deaths caused by the kamagra, one child under 18 has lost a parent.

As of June 15, that would translate into buy kamagra australia more than 46,000 kids, researchers estimated. Three-quarters of the children are adolescents. The others are under buy kamagra australia age 10. About 20% of the children who’ve lost parents are Black, though they make up 14% of the population. Robert Villegas cuddled sons Robert Jr.

(left), Nicholas and Ayden in December 2020, weeks before he fell ill with erectile dysfunction treatment buy kamagra australia and died. €œYou can go explain to my 1-, 3- and 5-year-old that their daddy is not coming home,” his widow, Valerie Villegas, told doctors.(Valerie Villegas) “There’s this shadow kamagra,” said Rachel Kidman, an associate professor at Stony Brook University in New York, who was part of the team that found a way to calculate the impact of erectile dysfunction treatment deaths. €œThere’s a huge amount of children who have been bereaved.” The Biden administration, which launched a program to help pay funeral costs for erectile dysfunction treatment victims, did not respond to questions about offering targeted services for families with children. Failing to address the growing buy kamagra australia cohort of bereaved children, whether in a single family or in the U.S. At large, could have long-lasting effects, researchers said.

The loss of a parent in childhood has been linked to higher buy kamagra australia risks of substance use, mental health problems, poor performance in school, lower college attendance, lower employment and early death. €œBereavement is the most common stress and the most stressful thing people go through in their lives,” said clinical psychologist Christopher Layne of the UCLA/Duke University National Center for Child Traumatic Stress. €œIt merits our care and concern.” Perhaps 10% to 15% of children and others bereaved by erectile dysfunction treatment might meet the criteria of a new diagnosis, prolonged grief disorder, which can occur when people have specific, long-lasting responses to the death of a loved one. That could mean buy kamagra australia thousands of children with symptoms that warrant clinical care. €œThis is literally a national, very public health emergency,” Layne said.

Still, Villegas and others say they have been left largely on their own to navigate a confusing patchwork of community services for their children even as they struggle with their own grief. €œI called buy kamagra australia the counselor at school. She gave me a few little resources on books and stuff,” Villegas said. €œI called some crisis hotline buy kamagra australia. I called counseling places, but they couldn’t help because they had waiting lists and needed insurance.

My kids lost their insurance when their dad died.” Valerie Villegas plays with her three youngest sons — Robert Jr., Ayden and Nicholas — at their Portland, Texas, home. Her husband, Robert Villegas, buy kamagra australia built the tire swing for the boys in 2020. In late December, 45-year-old Robert contracted erectile dysfunction treatment. He died in January. (Scott Stephen Ball for KHN) The social disruption and isolation caused by buy kamagra australia the kamagra overwhelmed grief care providers, too.

Across the U.S., nonprofit agencies that specialize in childhood grief said they have scrambled to meet the need and to switch from in-person to virtual engagement. €œIt was a huge buy kamagra australia challenge. It was very foreign to the way we work,” said Vicki Jay, CEO of the National Alliance for Grieving Children. €œGrief work is based on relationships, and it’s very hard to get a relationship with a piece of machinery.” At Experience Camps, which each year offers free weeklong camps to about 1,000 bereaved kids across the country, the waiting list has grown more than 100% since 2020, said Talya Bosch, an Experience Camps associate. €œIt is something that we are concerned about — a lot of kids are not getting buy kamagra australia the support they need,” she said.

Private counselors, too, have been swamped. Jill Johnson-Young, co-owner of Central Counseling Services in Riverside, California, said her nearly three dozen therapists have been booked solid for months. €œI don’t know a buy kamagra australia therapist in the area who isn’t full right now,” she said. Dr. Sandra McGowan-Watts, 47, a family practice doctor in Chicago, lost her husband, Steven, to buy kamagra australia erectile dysfunction treatment in May 2020.

She feels fortunate to have found an online therapist for her daughter, Justise, who helped explain why the 12-year-old was suddenly so sad in the mornings. €œMy husband was the one who woke her up for school. He helped her get ready for school.” Valerie Villegas and her buy kamagra australia husband, Robert Villegas, celebrated his 45th birthday on Nov. 10, 2020, weeks before he died of erectile dysfunction treatment. €œHe was a fighter, not only physically but mentally,” she says.

€œHe was a very strong man.” (Valerie Villegas) Justise was also able to get a spot at an Experience Camps session buy kamagra australia this summer. €œI am nervous about going to camp, but I am excited about meeting new kids who have also lost someone close in their life,” she said. Jamie Stacy, 42, of San Jose, California, was connected with an online counselor for her daughter, Grace, 8, and twin sons, Liam and Colm, 6, after their father, Ed Stacy, died of erectile dysfunction treatment in March 2020 at age 52. Only then did she learn buy kamagra australia that children can grieve differently than adults. They tend to focus on concrete concerns, such as where they’ll live and whether their favorite toys or pets will be there.

They often alternate periods of play with sadness, buy kamagra australia cycling rapidly between confronting and avoiding their feelings of loss. €œThe boys will be playing Legos, having a great time, and all of a sudden drop a bomb on you. €˜I know how I can see Daddy again. I just have to die, and I’ll see Daddy again,’” she buy kamagra australia said. €œAnd then they’re back to playing Legos.” Stacy said counseling has been crucial in helping her family navigate a world where many people are marking the end of the kamagra.

€œWe can’t escape the topic of erectile dysfunction treatment even for one day,” she said. €œIt’s always in our face, wherever buy kamagra australia we go, a reminder of our painful loss.” Villegas, in Texas, has returned to her work in hospice care and is starting to reassemble her life. But she thinks there should be formal aid and grief support for families like hers whose lives have been indelibly scarred by the deadly kamagra. €œNow everybody’s lives are going back to normal,” she said buy kamagra australia. €œThey can get back to their lives.

And I’m thinking my life will never be normal again.” JoNel Aleccia. jaleccia@kff.org, @JoNel_Aleccia Related Topics buy kamagra australia Contact Us Submit a Story TipLast week, Sen. Rand Paul (R-Ky.) posted a Twitter thread asserting that people who have survived a erectile dysfunction treatment were unlikely to be reinfected and have better immunity against variants than those who have been vaccinated against — but not infected by — erectile dysfunction, the kamagra that causes erectile dysfunction treatment. The social media communication represented his latest salvo in the ongoing debate over whether natural immunity is equivalent or even better than vaccination. While the science on the subject is still evolving, a look at the evidence behind Paul’s series buy kamagra australia of tweets seemed in order.

After all, though almost 65% of Americans have received at least one dose of a erectile dysfunction treatment, some people who have recovered from erectile dysfunction treatment may not feel a need to get shot. Paul, who was the first buy kamagra australia senator to be diagnosed with the kamagra, is among them. Here’s a deeper look at what Paul said on Twitter, the studies he cited and how researchers characterized his comments. Breaking Down the Twitter Thread In his first tweet, Paul referenced a recent Cleveland Clinic study finding that among subjects who were unvaccinated but had already had erectile dysfunction treatment, there were no re-s in a five-month observation period. €œGreat news! buy kamagra australia.

Cleveland clinic study of 52,238 employees shows unvaccinated people who have had erectile dysfunction treatment 19 have no difference in re- rate than people who had erectile dysfunction treatment 19 and who took the treatment.” In subsequent tweets, the senator said. €œThe immune response to natural is highly likely to provide protective immunity even against the erectile dysfunction variants. €¦ Thus, recovered erectile dysfunction treatment patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing treatments only.” All three treatments authorized for emergency use in buy kamagra australia the U.S. (Pfizer-BioNTech, Moderna and Johnson &. Johnson) contain genetic instructions that buy kamagra australia tell our cells how to make a spike protein associated with the erectile dysfunction.

The presence of that spike protein then causes our bodies to make antibodies to protect against erectile dysfunction treatment. At the end of his final tweet, Rand then linked to a second study led by scientists at the Fred Hutchinson Cancer Research Center in Seattle to support his assertions. Digesting the Scientific Papers Paul referenced two scientific papers in his tweet thread — both of which are preprints, meaning they have not yet been published in scientific buy kamagra australia journals or been peer-reviewed. One was a study from the Cleveland Clinic following four categories of health care workers. Unvaccinated but previously infected.

Unvaccinated but not previously infected buy kamagra australia. Vaccinated and previously infected. And vaccinated buy kamagra australia but not previously infected. The workers were followed for five months. The researchers found that no one who was unvaccinated but had previously been infected with erectile dysfunction treatment became infected again during the five-month study period.

s were almost zero among those who were vaccinated, while there was a steady increase in s among those who were buy kamagra australia unvaccinated and previously uninfected. When asked whether he believed Paul’s tweet had interpreted his study results correctly, the study’s lead author, Dr. Nabin Shrestha, an infectious diseases specialist at Cleveland Clinic, said “it was an accurate interpretation of the study’s findings.” However, Dr. George Rutherford, an epidemiologist at the University of California-San Francisco, wrote buy kamagra australia in an email that he would add one caveat to the wording of Paul’s tweet. €œNote that in his tweet Senator Paul seems to suggest that the denominator of previously infected health care workers at the Cleveland Clinic was 52,238 — that was the total number in the whole study.

There were 1,359 that were previously infected and never vaccinated, and there were no buy kamagra australia res noted over a median follow up of 143 days. So, the tweet itself is accurate if read literally but the denominator is really 1,359.” As for the other study Paul mentioned, researchers analyzed erectile dysfunction treatment immunity in those who had been infected with the erectile dysfunction treatment kamagra and those who hadn’t and found that activated a range of immune cells and immunity lasted at least eight months. In his last two tweets in the thread, Paul quotes directly from the study’s “discussion” section. €œThe immune response to natural is highly likely to provide protective buy kamagra australia immunity even against the erectile dysfunction variants. €¦ Thus, recovered erectile dysfunction treatment patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing treatments only.” The lead study author, Kristen Cohen, a senior staff scientist in the treatment and Infectious Disease Division at the Fred Hutchinson Cancer Research Center in Seattle, acknowledged that Paul’s tweet was a direct quote from the study.

Still, she said, in her view, the quote was taken out of context and presented to suit Paul’s objective — but does not accurately reflect the overall take-home message from the study’s findings. That’s because, she said, Paul was quoting from the discussion buy kamagra australia section of the paper. The discussion is the final section of a scientific paper, and Cohen said its purpose here was to project what the study’s findings could imply for a broader scientific significance. €œWe wrote that recovering erectile dysfunction treatment patients are “likely” to better defend against variants than those who have just been immunized, but it’s not saying they do,” said buy kamagra australia Cohen. €œIt’s not saying they have been known to.

It’s making a hypothesis or basically saying this could be the case.” In fact, Cohen’s study did not include any subjects who had been vaccinated. The researchers were merely reasoning in the sentence Paul quoted that, based on the data showing the immune system’s broad natural response, those who recover from erectile dysfunction treatment and then receive a treatment may be better protected against erectile dysfunction treatment buy kamagra australia variants than those who had only treatment-induced immunity. €œWe did not intend to argue that infected people do not need to get vaccinated or that their immune responses are superior,” Cohen wrote in an email. However, Cohen recognized the sentence was confusing when taken out of context and said she will eliminate it from the paper when it gets submitted for publication. Cohen pointed buy kamagra australia us to another Fred Hutchinson-led study with which she was involved.

It did show that people who previously had erectile dysfunction treatment benefited from also getting vaccinated, because there was a significant boost in immune response, especially against variants. The Conventional Wisdom on Natural Immunity So, what’s known from these two studies is that surviving a erectile dysfunction treatment confers a buy kamagra australia significant amount of immunity against the kamagra. Other studies also support this assertion. €œExisting literature does show natural immunity provides protection against erectile dysfunction treatment,” said Shane Crotty, a professor at the Center for Infectious Disease and treatment Research at the La Jolla Institute for Immunology who has published numerous peer-reviewed studies on natural immunity against erectile dysfunction treatment. He said buy kamagra australia such immunity particularly protects against hospitalizations and severe illness.

In Crotty’s own recent study, the largest yet to measure the molecules and cells involved in immune protection, his team found that natural immunity against erectile dysfunction treatment lasted at least eight months. Based on projections, it could last up to a couple of years. While that is good news, Crotty said, there buy kamagra australia are three points of caution. First, though natural immunity appears to be very effective against the current dominant U.S. Variant (known as alpha), it also appears weaker than treatment immunity against some of buy kamagra australia the variants circulating, such as the delta variant, first detected in India.

That means if those variants eventually become dominant in the U.S., people relying on natural immunity would be less protected than those who are vaccinated. Second, there is a lack of data about whether natural immunity prevents asymptomatic transmission and . Several other studies, though, show treatments buy kamagra australia do. Third, Crotty said his studies have shown that levels of natural immunity can vary widely in individuals. His team even found a hundredfold difference in the number of immune cells among people.

€œIf you thought about the immune system as a basketball game and you thought about that as a team scoring 1 point, and another team scoring 100 points, buy kamagra australia that’s a big difference,” said Crotty. €œWe’re not so confident that people at the low end of immunity levels would be as protected against erectile dysfunction treatment.” But those who receive a treatment shot have a much more consistent number of immune cells, since everyone receives the same dose amount, said Crotty. With all that in mind, the Centers for Disease Control and buy kamagra australia Prevention recommends that those who previously had erectile dysfunction treatment should get vaccinated and receive both doses of a treatment, whether it’s the Pfizer-BioNTech or Moderna treatment. Fauci, the nation’s leading infectious disease expert, reiterated this message during a White House erectile dysfunction treatment briefing last month. Victoria Knight.

vknight@kff.org, @victoriaregisk Related Topics Contact buy kamagra australia Us Submit a Story TipIn the eyes of the tech industry, mental health treatment is an area ripe for disruption. In any given year, 1 in 5 adults in the U.S. Experience a form of mental illness, according to federal estimates. And research indicates only about half of them receive treatment in a system that is understaffed buy kamagra australia and ill distributed to meet demand. For tech startups looking to cash in on unmet need, that translates into more than 50 million potential customers.

Venture capital firms invested more than $2.4 billion in digital behavioral health apps in 2020 — more than twice the amount invested in 2019 — touting support or treatment for issues from burnout and depression to ADHD and bipolar disorder. At least seven mental health app companies have achieved “unicorn” status and are buy kamagra australia valued at more than $1 billion. But even as industry hype mounts, researchers and companies are scrambling to prove these apps actually work. Of the estimated 20,000 mental health apps available for download on personal computers and smartphones, just five have been formally vetted and approved by the Food and Drug Administration, which largely has buy kamagra australia taken a hands-off approach to regulating the space. €œDevelopment has really outpaced the science,” said Stephen Schueller, a clinical psychologist at the University of California-Irvine who specializes in the development and evaluation of digital mental health products.

Type “depression” or “anxiety” into an app store, and you’ll be met with a dizzying list of results. There are thousands of “wellness” apps like Headspace that counsel people on breathing exercises buy kamagra australia and other techniques to help them feel more mindful. Apps such as Woebot and TalkLife profess to help manage conditions like anxiety and postpartum depression using games, mood journaling or text exchanges with peers or automated bots. Some apps are meant to be used alongside in-person therapy, and others on their own. Several of the most popular, like Talkspace, BetterHelp and Ginger, promise access to treatment with a licensed therapist over text message, buy kamagra australia phone or video.

Others, including Brightside and Cerebral, connect users to psychiatrists who can prescribe antidepressants. Most products make their money by charging consumers a monthly or annual fee, with the option to purchase extras like buy kamagra australia video sessions with a therapist. Others contract directly with employers or insurers. And, yes, a small portion of these apps have promising research to back them up. Several studies, for example, have buy kamagra australia found that cognitive behavioral therapy, a mainstay of treatment for depression and anxiety that seeks to help patients change negative thought patterns, is as effective when delivered using web-based platforms as when done in person by a licensed professional.

And the kamagra has bolstered claims that patients are willing to trade in-person visits for the ease of online connection. €œDigital mental health can be viewed as a way to extend the mental resources that we have,” said David Mohr, who directs the Center for Behavioral Intervention Technologies at the Northwestern University Feinberg School of Medicine. A step-care model, for example, would allow patients with milder symptoms to be treated via technology buy kamagra australia while reserving in-person care for patients who need something more. The challenge for consumers is separating the apps that might help from those that offer little more than distraction — or could actually do harm. Some companies offering buy kamagra australia mental health treatment had recently been doing something totally different — for example, an online seller of erectile dysfunction and hair loss treatments has started offering psychiatric evaluations and prescribing and selling antidepressants.

Tech companies are by nature for-profit and, in the rush to compete in a saturated market, many are selling a product with an appealing user interface but little evidence of effectiveness. A 2020 analysis by Australian researchers reviewing nearly 300 apps for anxiety and depression found just 6% of the companies that boasted an evidence-based framework in the app store description for their products had published any evidence. Nor do buy kamagra australia star ratings and download totals offer much context. An April study from Beth Israel Deaconess Medical Center and Harvard Medical School found little correlation between app store metrics and treatment quality. €œNo one is competing based on privacy, safety or evidence.

They’re competing on aesthetics, in part, on page ranking, buy kamagra australia marketing on brand awareness,” said Dr. John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center and one of the authors of the April study. €œThere’s an implicit assumption buy kamagra australia that the app is better than nothing. But what if it isn’t better than nothing?. € One problem, said Dr.

Ipsit Vahia, a geriatric psychiatrist and medical director of the McLean Institute for Technology in Psychiatry, is that randomized control studies of the kind that might prove an app’s effectiveness can take years, far slower than the buy kamagra australia rapid innovation in tech. €œIn general, the health care industry and the technology industry work at very different paces,” Vahia said. Dr. David Mou, a psychiatrist at Massachusetts General Hospital who is chief medical officer at Cerebral, buy kamagra australia said he agrees that everything new in health care must be done deliberately and conservatively to avoid patient harm. But he said some people in the mental health field are painting all companies with the same brush and failing to differentiate those that are data-driven from those trying to grow at any cost.

€œThey look at us and say buy kamagra australia we’re all VC-backed bros in a basement trying to redesign health care. And that’s not true. It may have been true 10 years ago, but it isn’t true today,” said Mou. The long-term winners, he said, will be those that are “evidence-based and measure quality like crazy.” Cerebral offers online therapy and medication buy kamagra australia management and delivery for a range of mental illnesses. The monthly subscription fees range from $29 to $325, depending on the level and frequency of care, as well as insurance coverage.

Mou said Cerebral is already able to demonstrate some advantages. While many top hospital systems might have a months-long wait for care, he said, someone in crisis can reach a Cerebral buy kamagra australia provider almost immediately. €œWithin minutes you are able to talk with someone with one of our instant live visits. That in itself is a huge win.” Even critics of the tech explosion are quick to acknowledge that the current brick-and-mortar system of mental health is buy kamagra australia dated and inadequate. In recent years, the issues surrounding mental illness and lack of access to treatment have infiated public dialogue.

Brain illnesses that many families once squirreled away from view have become the stuff of celebrity culture and dinner-table chatter. Yet even as advocates have made strides in buy kamagra australia acceptance, truly improving the lives of people with mental illness has proven stubbornly difficult. Over the past several decades — while the U.S. Successfully lowered death rates for cancer, heart disease and other major illnesses — deaths by suicide and drug overdose have continued to climb. Federal law theoretically requires insurance companies to cover brain buy kamagra australia illness as they would any other illness.

But finding affordable care remains a challenge, largely because of a shortage of licensed mental health professionals and ongoing inequities in insurance coverage. In a nation where huge swaths of the population lack a primary care doctor and health insurance — but most everyone has a cellphone — connecting people to treatment via mobile buy kamagra australia apps would seem a logical solution. And, for some, the opportunity to talk about their mental health challenges anonymously makes online treatment an attractive alternative. Still, many of the experts who welcome the potential for innovation in mental health treatment acknowledge that consumers are getting little guidance in how to choose a reputable option. €œWellness” apps that promote buy kamagra australia a healthy lifestyle or apps that help people manage their disease without providing specific treatment suggestions can avoid FDA regulation.

But even those that offer patient-specific diagnoses and treatment recommendations that would seem to fall squarely under the FDA’s authority do not seem to garner the agency’s attention, according to industry experts. €œThe FDA has been really, really lax on enforcing in digital health for reasons that are not entirely clear to me,” said Bradley Merrill Thompson, a lawyer at Epstein Becker Green who advises companies on FDA regulations. €œAnybody could spend 20 minutes on the app store and find dozens of examples of apps that make medical device claims, and that have been doing so for some time, without any buy kamagra australia effort by the FDA to rein them in.” In response to questions from KHN about its approach to regulating mental health apps, the FDA sent a brief statement. €œAs circumstances change and new needs arise, FDA is ready to meet and address these challenges, especially in the areas of mental health,” the statement reads in part. €œWe would like to see more evidence-based products in this area, which is why we remain committed to facilitating the buy kamagra australia development of additional safe and effective therapies for patients who rely on these products.” Dr.

Tom Insel, a psychiatrist and neuroscientist, has a unique view of the evolving landscape. In 2015, Insel left his job as director of the National Institute of Mental Health, a post he had held since 2002, trading the halls of government for the open floor plans of Silicon Valley to work in digital mental health. He started at Google’s Verily, then co-founded buy kamagra australia Mindstrong Health, a startup researching how smartphone technology could be used to predict and diagnose mental health crises. He has since left to advise California officials on behavioral health issues. Insel said he believes in the promise of digital mental health but that it will take time to find its highest and best use.

He noted, buy kamagra australia for example, that most of the apps on the market focus on the problem of access. They make care more convenient. But they’re buy kamagra australia overlooking a more basic problem. Quality. Unlike most fields of medicine, mental health providers rarely measure whether the care they provide makes patients better.

€œA lot buy kamagra australia of what we need is not just more access. It’s not just recreating the brick-and-mortar system and letting people do it by phone or Zoom,” Insel said. Instead, he argued, digital health should focus on measuring whether treatments improve people’s lives. €œI have no doubt that this field will transform mental health treatment and diagnosis,” Insel said, “but we’re in the first act of a buy kamagra australia five-act play. I don’t think we’re anywhere near the kinds of solutions that we need in the real world.” Jenny Gold.

jgold@kff.org, @JennyAGold Related Topics Contact Us Submit a Story Tip.

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In this paper I (1) provide background information on the five state TDI programs, (2) discuss what studies of other social insurance programs suggest for how TDI affects labor force participation, (3) summarize recent research findings based on analyses of TDI data in California and Rhode Island, (4) consider future research options to address important unanswered questions, and (5) discuss policy implications..

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As Kant observed, ‘Thoughts without content are empty, intuitions without concepts are blind.’5 While many do not agree with aspects of Kant’s moral philosophy, his views about what’s required to have an ‘intuition’ or an ‘ethical perception’ seem correct.The ethical words we choose enable us to understand and articulate different ethical features of a buy kamagra australia situation and words that come from other cultures can enrich our perception of what matters and what we should do. For example, the Māori concept Whakawhanaungatanga refers to the process of establishing meaningful relationships between people via culturally appropriate processes. In a situation where the decision making capacity of a patient is in question and an important decision needs to be made, this is a process whereby a healthcare practitioner can build a meaningful relationship with that patient and their whānau (family).6 While that’s a process that’s particularly important for Māori patients and whānau, the emphasis on creating and valuing relationships is something that’s ethically important for buy kamagra australia this kind of decision more generally and arguably not highlighted if we view this kind of situation via the lenses of autonomy or beneficence.The JME invites those interested in writing a short discussion piece that explains an ethical concept or word that is useful and should be more widely understood to contact the journal’s Editor in Chief. €˜Words’ columns will be up to a thousand words, have no more than five references and explain a clinically relevant ethical concept that would benefit from being explained and is preferably from a non-western ethical tradition.This issue of the JME includes a number of papers that demonstrate the importance of explaining words that will then bear weight in argument.

Jecker and Atuire analyse arguments relevant to waiving intellectual property rights over erectile dysfunction treatments.7 ‘Intellectual property’ is a concept that would appear buy kamagra australia to be easily grasped. It implies an ownership right over knowledge of some kind that has been created. Yet if we are to understand that concept with the depth needed to mount an ethical analysis, we must delve into the rules that currently apply to intellectual buy kamagra australia property. As Jecker and Atuire explain, the 1995 TRIPS agreement created the means for the stricter protection of IP, including pharmaceuticals.

The agreement itself and those who have argued in support of it, emphasised reasons such as the need to nurture innovation and this, as Jecker and Atuire show, opens the door for a critical ethical analysis of whether IP should be waived buy kamagra australia for erectile dysfunction treatments.‘Emotional support animals’ can be very helpful to people with mental illnesses and that raises the question of whether those who depend on an ESA have a right to remain connected to their ESA that is similar to someone who has a prosthetic body part. As Kolmes observes, ESA’s ‘…supplement or entirely replace vital functions that their handlers are not able to perform on their own.8’ This description of ESAs characterises them in a way that distinguishes them from other animals with which we might have a strong emotional bond and helps to explain how they can be considered analogous to a prosthetic body part.We’re grateful to the JME authors and reviewers who made it possible for the journal to cover the issues raised by the erectile dysfunction treatment kamagra in depth. The kamagra continues, but many of the issues have been well explored buy kamagra australia now and there is less need for a special section in the journal. The JME has always published topical high quality analysis of health care ethics and we look forward to publishing articles that deepen and broaden scholarship in ethics.

Our new Words column is intended to help broaden the scope of scholarship in ethics and we hope to buy kamagra australia hear from those who would like to explain an important ethical concept.John McMillanEditor in ChiefEthics statementsPatient consent for publicationNot required.AbstractUnlike its friendly cousin the placebo effect, the nocebo effect (the effect of expecting a negative outcome) has been almost ignored. Epistemic and ethical confusions related to its existence have gone all but unnoticed. Contrary to what is often asserted, adverse events following from taking placebo buy kamagra australia interventions are not necessarily nocebo effects. They could have arisen due to natural history.

Meanwhile, ethical informed consent (in clinical trials and clinical practice) has centred almost exclusively on the need to inform patients about intervention buy kamagra australia risks with patients to preserve their autonomy. Researchers have failed to consider the harm caused by the way in which the information is conveyed. In this paper, I argue that the magnitude of nocebo effects must buy kamagra australia be measured using control groups consisting of untreated patients. And, because the nocebo effect can produce harm, the principle of non-maleficence must be taken into account alongside autonomy when obtaining (ethical) informed consent and communicating intervention risks with patients.informed consentautonomyresearch ethicsepidemiologyethicsData availability statementThere are no data in this work..

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Optimising therapeutic hypothermiaUsing the National Neonatal Research kamagra effervescent reviews Database, Lara Shipley and colleagues studied infants≥36 weeks gestation who were admitted to UK neonatal units with moderate or severe http://robertroyer.com/2011/01/23/state-of-the-states-2/ hypoxic ischaemic encephalopathy (HIE). Between 2011 and 2016 there were 5059 infants. Birth in a centre which provided servo controlled therapeutic hypothermia (a cooling centre) vs a non-cooling centre was associated with increased survival to discharge without seizures (35.1% kamagra effervescent reviews vs 31.8%. OR 1.15, 95% CI 1.02 to 1.31.

P=0.02). Fewer infants born in cooling centres were diagnosed with seizures (60.7% vs 64.6%). Survival was similar. There were 2364 infants who were born in a non-cooling centre.

Non-cooling centres would initiate passive cooling pending transfer of the infant to a cooling centre. Amongst the 2027 of these infants with a recorded admission temperature at the time of arrival at the cooling centre, 259 (12.7%) had a temperature in the recommended therapeutic range before 6 hours of age. There were a further 48.3% who arrived at the cooling centre between 6 and 12 hours of age with a temperature in the recommended range. The authors conclude that almost half of all infants with a diagnosis of moderate or severe HIE are born in non-cooling centres and the disparity of access to immediate therapeutic hypothermia could impact on outcomes.

They encourage further equipping, training and support of non-cooling centres to minimise delays in optimal treatment. In an accompanying editorial, Topun Austin and Ela Chakkarapani review the evidence that, within the therapeutic window, earlier treatment is likely to be more effective. They encourage wider implementation and support of active cooling prior to transport. They point out that although there were fewer seizures in the infants born in cooling centres, this may be in part explained by greater access to aEEG monitoring in cooling centres, so this cannot be considered a reliable proxy for adverse neurological outcome.In a separate editorial, Seetha Shankaran and colleagues discuss the evidence that late hypothermia treatment may still be of some benefit depending on the interpretation of the results of the NICHD NRN late hypothermia trial.

They also discuss the article by Mohamed Ali Tagin and Alastair Gunn that appeared in the September issue of the journal.1 Tagin and Gunn had encouraged clinicians who are uncertain about whether an infant meets cooling criteria to choose cooling because they consider the potential benefits to outweigh the potential harms. Shankaran and colleague discuss potential downsides to this therapeutic creep (cooling for the wrong diagnosis, overtreatment, iatrogenic problems from a therapy not needed) and they stress the importance of completing ongoing studies of treatment in infants with mild encephalopathy and of treatment of preterm infants. See pages F6, F2 and F4Life threatening BPDRebecca Naples and colleagues report a prospective national study conducted through the British Paediatric Surveillance Unit of Infants with life threatening BPD. This was defined as a requirement for positive pressure respiratory support or pulmonary vasodilators at 38 weeks corrected gestational age after birth before 32 weeks gestation.

From June 2017 to July 2018 153 infants were reported from the UK and Ireland, giving a minimum incidence of 13.9 per 1000 infants born before 32 weeks. From this statistic, level three neonatal units in the UK and Ireland will see around one such infant per year. The statistic does not include the infants with severe BPD who have already died by 38 weeks so it will underestimate the mortality from severe BPD. It is easy to be tempted into pessimism about the outcomes of infants with such severe BPD, but the results of this study give grounds for a more positive outlook.

By 1 year of age 16% of the infants had died, so survival was the usual outcome. Discharge home was achieved by 81%, mostly on low flow oxygen – 9% required long term ventilation. Median age at discharge http://rabbitsunlimited.org/?p=50 was 143 days. Post-discharge, two infants required new invasive ventilation, one required CPAP and eight required high flow during readmissions in the first year of life.

Major concern about neurodevelopmental impairment was present at 1 year in around 1 out of 5 surviving infants. See page F13Automated control of FiO2Numerous systems have now been reported for delivering automated control of FiO2 to newborn infants on ventilation and non-invasive respiratory support. All have shown that automated control results in more time intended target range. It remains to be shown that their use improves clinical outcomes.

This will require large trials and for these to be interpretable we will need to know whether the different devices result in similar or different achieved oxygen saturation profiles for a given target, as it may be inappropriate to consider the devices to be interchangeable. Hylke Salverda and colleagues performed a cross-over study comparing two different devices that are in current use and showed potentially important differences in performance, with one device achieving more time in target range than the other. Onc device resulted in more time with lower than intended SpO2 and the other in more time with higher than intended SpO2. See page F20Spontaneous breathing during delayed cord clampingHere are some more data on the haemodynamics of transition with the cord intact.

Emma Brouwer and colleagues performed continuous uasound recordings of blood flow during transition in 15 term born infants with delayed cord clamping. They found that during inspiration the inferior vena cava collapsed and blood flow into the foetus from the placenta increased, suggesting that inspiration may be an important driver of net placental transfusion. See page F65HFNC versus CPAP for primary support in preterm infantsShaam Bruet and colleagues performed a systematic review and meta-analysis of studies comparing nasal CPAP with high flow nasal cannula (HFNC) as primary treatment for preterm infants. They included 10 studies that enrolled 1830 patients.

Treatment failure, as defined by the authors of the individual studies, was more common with HFNC than with CPAP (RR=1.34, 95% CI 1.01 to 1.68, I2=16.2%), but there was not a significant difference in the number of patients who required intubation. Nasal trauma was less common with HFNC (RR=0.48, 95% CI 0.31 to 0.65, I²=0.0%). Protocols of six studies allowed cross over to CPAP in infants on HFNC meeting failure criteria, meaning that infants crossed over to CPAP and were not intubated. Individual morbidities were not significantly different.

The authors of the review prefer initial treatment with HFNC to avoid nasal trauma, with cross over to CPAP if required. The data are not strong enough to give rise to a clear recommendation for all. See page F56Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants.It is now over 25 years since publication of the first experimental study demonstrating that mild hypothermia after transient hypoxia-ischaemia ameliorates delayed energy failure in a newborn piglet model.1 Since then, and following several large randomised controlled trials, therapeutic hypothermia (TH) has become, and currently remains the only, treatment shown to reduce death and disability in infants born following perinatal hypoxia-ischaemia. In the early experimental studies, cooling was initiated immediately after the insult.

Subsequent studies have shown that delayed initiation of cooling results in a significant reduction in the therapeutic effect of cooling.2 The Total Body Hypothermia (TOBY) trial showed a trend to improved outcome in infants cooled within 4 hours of delivery and it has been shown that motor outcomes improved in infants who were cooled within 3 hours of delivery compared with those cooled after 3 hours of delivery.3 Conversely, there is limited evidence regarding the efficacy of cooling started beyond 12 hours of age. Therefore, current evidence would suggest that the sooner cooling is commenced, the more likely it is to be beneficial.Translating experimental science into clinical practice is immensely challenging. In designing the first clinical trials of TH, investigators had to take a pragmatic view on when to start cooling infants, allowing enough time for eligible infants to be identified and enrolled into the studies. It is to the investigators’ credit that the three largest trials (CooCap, NICHD and TOBY trials) all used similar entry criteria (mild-to-moderate hypoxic-ischaemic encephalopathy (HIE)), depth of cooling (33.5°C), time of commencement of cooling ….

Optimising therapeutic buy kamagra australia hypothermiaUsing the National Neonatal Research Database, Lara Shipley and colleagues studied infants≥36 weeks gestation who were admitted to UK neonatal units with moderate or severe hypoxic ischaemic encephalopathy (HIE). Between 2011 and 2016 there were 5059 infants. Birth in a centre which provided servo controlled therapeutic hypothermia (a cooling centre) vs a non-cooling centre was associated buy kamagra australia with increased survival to discharge without seizures (35.1% vs 31.8%.

OR 1.15, 95% CI 1.02 to 1.31. P=0.02). Fewer infants born in cooling centres were diagnosed with seizures (60.7% vs 64.6%).

Survival was similar. There were 2364 infants who were born in a non-cooling centre. Non-cooling centres would initiate passive cooling pending transfer of the infant to a cooling centre.

Amongst the 2027 of these infants with a recorded admission temperature at the time of arrival at the cooling centre, 259 (12.7%) had a temperature in the recommended therapeutic range before 6 hours of age. There were a further 48.3% who arrived at the cooling centre between 6 and 12 hours of age with a temperature in the recommended range. The authors conclude that almost half of all infants with a diagnosis of moderate or severe HIE are born in non-cooling centres and the disparity of access to immediate therapeutic hypothermia could impact on outcomes.

They encourage further equipping, training and support of non-cooling centres to minimise delays in optimal treatment. In an accompanying editorial, Topun Austin and Ela Chakkarapani review the evidence that, within the therapeutic window, earlier treatment is likely to be more effective. They encourage wider implementation and support of active cooling prior to transport.

They point out that although there were fewer seizures in the infants born in cooling centres, this may be in part explained by greater access to aEEG monitoring in cooling centres, so this cannot be considered a reliable proxy for adverse neurological outcome.In a separate editorial, Seetha Shankaran and colleagues discuss the evidence that late hypothermia treatment may still be of some benefit depending on the interpretation of the results of the NICHD NRN late hypothermia trial. They also discuss the article by Mohamed Ali Tagin and Alastair Gunn that appeared in the September issue of the journal.1 Tagin and Gunn had encouraged clinicians who are uncertain about whether an infant meets cooling criteria to choose cooling because they consider the potential benefits to outweigh the potential harms. Shankaran and colleague discuss potential downsides to this therapeutic creep (cooling for the wrong diagnosis, overtreatment, iatrogenic problems from a therapy not needed) and they stress the importance of completing ongoing studies of treatment in infants with mild encephalopathy and of treatment of preterm infants.

See pages F6, F2 and F4Life threatening BPDRebecca Naples and colleagues report a prospective national study conducted through the British Paediatric Surveillance Unit of Infants with life threatening BPD. This was defined as a requirement for positive pressure respiratory support or pulmonary vasodilators at 38 weeks corrected gestational age after birth before 32 weeks gestation. From June 2017 to July 2018 153 infants were reported from the UK and Ireland, giving a minimum incidence of 13.9 per 1000 infants born before 32 weeks.

From this statistic, level three neonatal units in the UK and Ireland will see around one such infant per year. The statistic does not include the infants with severe BPD who have already died by 38 weeks so it will underestimate the mortality from severe BPD. It is easy to be tempted into pessimism about the outcomes of infants with such severe BPD, but the results of this study give grounds for a more positive outlook.

By 1 year of age 16% of the infants had died, so survival was the usual outcome. Discharge home was achieved by 81%, mostly on low flow oxygen – 9% required long term ventilation. Median age at discharge was 143 days.

Post-discharge, two infants required new invasive ventilation, one required CPAP and eight required high flow during readmissions in the first year of life. Major concern about neurodevelopmental impairment was present at 1 year in around 1 out of 5 surviving infants. See page F13Automated control of FiO2Numerous systems have now been reported for delivering automated control of FiO2 to newborn infants on ventilation and non-invasive respiratory support.

All have shown that automated control results in more time intended target range. It remains to be shown that their use improves clinical outcomes. This will require large trials and for these to be interpretable we will need to know whether the different devices result in similar or different achieved oxygen saturation profiles for a given target, as it may be inappropriate to consider the devices to be interchangeable.

Hylke Salverda and colleagues performed a cross-over study comparing two different devices that are in current use and showed potentially important differences in performance, with one device achieving more time in target range than the other. Onc device resulted in more time with lower than intended SpO2 and the other in more time with higher than intended SpO2. See page F20Spontaneous breathing during delayed cord clampingHere are some more data on the haemodynamics of transition with the cord intact.

Emma Brouwer and colleagues performed continuous uasound recordings of blood flow during transition in 15 term born infants with delayed cord clamping. They found that during inspiration the inferior vena cava collapsed and blood flow into the foetus from the placenta increased, suggesting that inspiration may be an important driver of net placental transfusion. See page F65HFNC versus CPAP for primary support in preterm infantsShaam Bruet and colleagues performed a systematic review and meta-analysis of studies comparing nasal CPAP with high flow nasal cannula (HFNC) as primary treatment for preterm infants.

They included 10 studies that enrolled 1830 patients. Treatment failure, as defined by the authors of the individual studies, was more common with HFNC than with CPAP (RR=1.34, 95% CI 1.01 to 1.68, I2=16.2%), but there was not a significant difference in the number of patients who required intubation. Nasal trauma was less common with HFNC (RR=0.48, 95% CI 0.31 to 0.65, I²=0.0%).

Protocols of six studies allowed cross over to CPAP in infants on HFNC meeting failure criteria, meaning that infants crossed over to CPAP and were not intubated. Individual morbidities were not significantly different. The authors of the review prefer initial treatment with HFNC to avoid nasal trauma, with cross over to CPAP if required.

The data are not strong enough to give rise to a clear recommendation for all. See page F56Ethics statementsPatient consent for publicationNot applicable.Ethics approvalThis study does not involve human participants.It is now over 25 years since publication of the first experimental study demonstrating that mild hypothermia after transient hypoxia-ischaemia ameliorates delayed energy failure in a newborn piglet model.1 Since then, and following several large randomised controlled trials, therapeutic hypothermia (TH) has become, and currently remains the only, treatment shown to reduce death and disability in infants born following perinatal hypoxia-ischaemia. In the early experimental studies, cooling was initiated immediately after the insult.

Subsequent studies have shown that delayed initiation of cooling results in a significant reduction in the therapeutic effect of cooling.2 The Total Body Hypothermia (TOBY) trial showed a trend to improved outcome in infants cooled within 4 hours of delivery and it has been shown that motor outcomes improved in infants who were cooled within 3 hours of delivery compared with those cooled after 3 hours of delivery.3 Conversely, there is limited evidence regarding the efficacy of cooling started beyond 12 hours of age. Therefore, current evidence would suggest that the sooner cooling is commenced, the more likely it is to be beneficial.Translating experimental science into clinical practice is immensely challenging. In designing the first clinical trials of TH, investigators had to take a pragmatic view on when to start cooling infants, allowing enough time for eligible infants to be identified and enrolled into the studies.

It is to the investigators’ credit that the three largest trials (CooCap, NICHD and TOBY trials) all used similar entry criteria (mild-to-moderate hypoxic-ischaemic encephalopathy (HIE)), depth of cooling (33.5°C), time of commencement of cooling ….