Buy generic cipro

How do we prevent a cipro like this from happening cipro allergy rash again? buy generic cipro. As we start to tackle that question, inevitably part of it will involve looking back at the mistakes that were made with buy antibiotics, and rightly so. But it’s also important to learn from the things we got right, because this cipro could have been buy generic cipro worse, much worse. So, if we want to ensure that this is the last cipro to cause devastation on this scale, then not only do we need to build on these successes, but the time to do that is now.

Without question, one of the biggest of those successes has been the unprecedented speed at which treatments were developed, approved and rolled out, and not just to those who can afford to pay. This has already saved countless lives and made the buy generic cipro end of this global crisis a tangible reality. Even so, to avoid a repeat of this disaster we still need to figure out how to avoid supply bottlenecks so we can get there faster. By some people’s reckoning, that means being ready to delivery treatments within just 100 days after a cipro has been declared.

Solving that buy generic cipro doesn’t have to involve reinventing the wheel. What’s more, we already have a model for how to do it in the way we tackle flu. To understand how, first consider what we need. The ability to rapidly develop and approve treatments that protect against an as-yet unknown threat buy generic cipro and at breakneck speed.

To increase and globalize treatment manufacturing, by devolving it from the Global North and building capacity in the Global South, and through increased use of technology transfers, so that we have the ability to rapidly produce extremely large volumes—more than are normally produced globally in a given year—so people everywhere are protected. And we need a global distribution network and supply chains to actually get those treatments out buy generic cipro to people. With buy antibiotics, the scientific and treatment manufacturing community, and new organizations like the Coalition for Epidemic Preparedness Innovations (CEPI), rallied and got us not just one but more than a dozen approved treatments so far, and in record speed—just 327 days for the first one. Even so, we didn’t get enough doses, or at least won’t get them fast enough.

With a cipro, speed is critical buy generic cipro. It’s not enough to protect people in just some parts of the world and let the rest of the world wait. To stop transmission, high-risk people need to be prioritized everywhere. This is all the more buy generic cipro frustrating given that, with buy antibiotics, we now have a way to provide equitable access, so that people in countries that can’t afford these treatments can still get them.

Compared to the last cipro, in 2009, we’ve been able to get treatments to people in lower-income countries two times faster, to four times the number of countries and with seven times the volume of doses over a comparable period. Of course, this is still not good enough. But what is so remarkable is that, unlike with the flu, we did this without any approved antibiotics treatments to work from and, without a dedicated global buy generic cipro cipro network already in place. This was made possible because 193 economies came together in support of the COVAX Facility, an initiative created to provide rapid, fair and equitable access to buy antibiotics treatments.

Set up as one of three pillars of the Access to buy antibiotics Tools Accelerator, COVAX draws on the buy generic cipro preexisting strengths of the three organizations leading it, the World Health Organization, the Coalition of Epidemic Preparedness Innovations (CEPI) and Gavi. The latter, which I run, is itself a treatment alliance made up of a range of global health partners that also include UNICEF, the World Bank and a global network of civil society organizations—all engaged in the effort. Despite having no surge capacity or funding to start with, we were able to build on these preexisting strengths to pull all the pieces together needed to not only accelerate the development and availability of buy antibiotics treatments, but also ensure that compensation, liability and indemnification safety nets were in place, and quickly secure more than 1.3 billion doses, so far, for people in 92 lower-income countries, those that may not be able to afford them and therefore might be left behind. All this enabled us to start rolling them out to these countries, buy generic cipro ensuring that all the logistics, personnel, monitoring and data systems were in place, just 39 days after people in high-income countries got their first jab.

The single biggest missing piece by far is how we get doses faster. There have already been more than 1.5 billion produced, but we’re still seeing the same kinds of treatment nationalism and export restrictions that plagued us during the 2009 swine flu cipro, where almost the entire global supply of doses ended up in the possession of just a handful of wealthy countries, leaving few for the rest of the world. With buy antibiotics, we are trying to accelerate equitable access so people get them even quicker, by encouraging governments to donate their surplus buy generic cipro doses to COVAX until further supplies come online, but in the long term, for future cipros, we can’t assume that governments won’t continue to put national interests first. Technology transfers have also helped significantly and are one reason why we were able to get treatments in the volumes we have so quickly.

This is where treatment developers share both their intellectual property and the vital know-how needed to make treatments, with other manufacturers, particularly those in emerging economies. But there buy generic cipro aren’t enough of these transfers. We need more including more geographical diversity in the production sites. So, the only watertight solution is to increase global supply and globalize it buy generic cipro.

One way to do that is to increase manufacturing capacity across the globe. To gain the ability to suddenly produce large volumes at speed during a crisis, but without leaving factories idle the rest of the time, is to take inspiration from how we prepare for flu cipros. Until now, influenza has been the buy generic cipro main focus of cipro preparedness, and with good reason. Over the past century, there have been four flu cipros.

So, for decades we have had a global network of suppliers standing ready to produce cipro flu treatments when the need arises, but the rest of the time these facilities stay busy churning out seasonal flu treatments to protect the people most at risk from noncipro flu strains. When a flu cipro strikes, these facilities can rapidly shift production to produce treatments targeting the buy generic cipro cipro strain. It’s a system that largely works, but we now need to replicate that model for a broader range of cipro threats. The way to do that is to build on our existing global supply chains, such as the routine immunization programs that are currently used to vaccinate 90 percent of the world’s children from treatment-preventable diseases.

Here we buy generic cipro already have a global supply and distribution network, and over the last 20 years organizations like Gavi have helped expand and grow that, from five manufacturers to 17 just for developing countries. If we expand that further and, in particular, build capacity in emerging economies, and make sure that the supply chains for equipment and materials are robust, so the Global South has the ability to produce its own treatments, not only can we increase supply of these treatments, but with technology transfers the same facilities can be used to increase global supply of and access to cipro treatments when the need arises. Most of what we need to avoid a repeat of this crisis already exists, particularly now that we have a networked solution buy generic cipro like COVAX. We just need to ensure that partners have the surge capacity to scale up quickly and there is contingency funding so that the effort is properly resourced to deal with the sudden needs caused by a cipro.

But we also urgently need to invest in additional manufacturing capacity in the Global South. That won’t buy generic cipro happen overnight. But if we start now then we can be sure we’ll be prepared for the next one, because it is an evolutionary certainty there will be a next one. This is an opinion and analysis article.

The views expressed by the author or authors are not necessarily those of Scientific American.“When you’re dealing with an institutional structure like global science, one of its core features is that it has been a racial structure,” says sociologist Anthony Ryan Hatch, an associate professor and buy generic cipro chair of the Science in Society Program at Wesleyan University. €œTo dismantle and chip away at that system requires concerted effort, concerted resources, clear thinking, and a concern for equity and making things right.” But Hatch believes that even the effort to diversify institutions of higher learning, in terms of students and administration, has a potentially fraught set of challenges. These structures are very resistant to change. And they are difficult to challenge, because in some cases, it involves directly not just calling out individual gatekeepers (key faculty members or deans or university heads or center heads) who are making biased decisions and buy generic cipro who are letting assumptions about the excellence of, say, a candidate, the perceived excellence or lack thereof..., determine who gets a job—basically, just being racist.

It’s one thing to think about the individual people you might need to challenge, but when a structure produces these kinds of racial patterns, it’s so much more challenging to intervene. Hatch works buy generic cipro and lives at the intersection of several fields. Health, the environment, criminal justice and medicine. He says he was able to access that many disciplines through a combination of the “empathy and grace” he was shown as a student and a series of mentoring programs for students of color.

Those experiences helped Hatch navigate the predominately white buy generic cipro institutions he was attending. €œI never felt that I was cast out to sea—that I didn’t have a support network to help me with my research, to help me improve my teaching, to help me pursue funding opportunities for my work,” he says. Hatch began his academic career in community-based public health research at Emory University, where he worked on projects related to drug use, HIV/AIDS and mental health. He is the buy generic cipro author of Silent Cell.

The Secret Drugging of Captive America and Blood Sugar. Racial Pharmacology and Food Justice in Black America. He has also held training fellowships at the American Sociological Association, the National Institute of Mental Health buy generic cipro and the National Science Foundation, and was a faculty fellow at Wesleyan’s Center for the Humanities. Hatch knows that he was lucky.

And he also knows that his success—and that of other researchers of color like him—does not mean that the work is done or that apparent progress is always true buy generic cipro progress. €œI think that we’re at a very interesting moment, and it’s one that’s filled with tension or contradiction,” he says. €œOn one hand, you have a small class of well-trained scientists of color, and they have, through struggle and through sacrifice and through being positioned in the right networks..., risen to positions of power. And they’re buy generic cipro highly visible.

And in their visibility, they become both target and object to be consumed.” Hatch says that to make real and lasting progress on diversity in science, one must look past that objectification. €œOne thing ... That is needed,” he says, “is for people to have a good, clear-eyed sense of that distinction between the representation, the image of diversity—the image that we fixed the problem—and looking carefully at the structural reality.” In this interview, Hatch discusses his thoughts on the hierarchy in STEM, buy generic cipro the importance of mentorship from his experiences and his favorite innovator. Henry “Box” Brown.

Click here to watch an extended version of the interview. This discussion is part of a speaker series hosted buy generic cipro by the Black Employee Network at Springer Nature, the publisher of Scientific American. The series aims to highlight Black contributions to STEM (science, technology, engineering and mathematics)—a history that has not been widely recognized. It will cover career paths, role models and mentorship, and buy generic cipro diversity in STEM.Property owners on the front lines of climate disasters often stay put for reasons that have little to do with risk but everything to do with quality of life, familial bonds and shared history, experts told a major adaptation conference being hosted this week by Columbia University.

"People say, 'The birds. We love the birds.' They say they love the water, or that's where their family is and where their history is," Thaddeus Pawlowski, director of Columbia's Center for Resilient Cities and Landscapes, told participants during a session probing why people choose to live in high-risk places. Those questions are particularly relevant for communities with deep connections to coastal zones, floodways or wildfire-prone areas, as buy generic cipro well as for people who lack the financial means, tools or opportunities to move to safer ground. Such communities — from the Red Hook neighborhood in Brooklyn, N.Y., to Pinhook, Mo., in the Mississippi River floodplain — are under increasing pressure to choose whether to stay or go, experts said.

Questions about what experts call "managed retreat" transcend geography, culture, race and socioeconomic status. In some cases, wealthy shoreline communities face buy generic cipro very high climate risks and choose to stay. But it's unequivocally true that low-income people, communities of color and Indigenous peoples often face untenable decisions when faced with "managed retreat." Beyond the prospects of safer living conditions, managed retreat also raises questions about self-determination, equity and social justice. "Some of the critical questions we have to keep in mind ...

Is. Who is pulling the strings around development in general, even in the context of managed retreat?. Who is managing, and who is being managed?. " said Jacqueline Patterson, senior director of the NAACP's environmental and climate justice program.

In many instances, she said, decisionmaking is skewed toward whiter, more affluent people who lack knowledge, empathy and even relationships with communities that are feeling the greatest impacts from climate change. "Even as we talk about solutions, climate action planning often results in displacement if not done right," Patterson said. A.R. Siders, an assistant professor of public policy at the University of Delaware and core faculty member at the university's Disaster Research Center, said that among the hurdles facing experts and elected officials is overcoming assumptions about adaptation, including that sea walls, levees and other landscape alterations are the best way to protect communities from disasters.

"Even today, there are debates as to whether [managed retreat] is adaptation or a failure to adapt," Siders said. Even so, decisions over whether to stay or go will become more pressing as seas rise, storms grow more severe, and more properties face damage or destruction from climate change impacts. "We're gaining insights into adaptation of all kinds, into environmental justice and social justice, and [patterns of] development and governance," she said. "We're also understanding how our governance strategies are failing parts of our communities.

We're learning about loss and heritage ... And about what it means for adaptation to be fair or just." The virtual conference, including discussion of research and policy issues, continues through Friday.Imagine a simple blood test that could flag most kinds of cancers at the earliest, most curable stage. For decades that idea—the “liquid biopsy”—has been a holy grail of oncology. Liquid biopsies could, in theory, detect a tumor well before it could be found by touch, symptoms or imaging.

Blood tests could obviate the need for surgeons to cut tissue samples from suspicious lumps and lesions and make it possible to reveal cancer lurking in places needles and scalpels cannot safely reach. They could also determine what type of cancer is taking root and what treatment might work best to squash it. The grail is not yet in hand, because it is hard to find definitive cancer signals in a tube of blood, but progress in recent years has been impressive. Last year the journal Science published the first big prospective study of a liquid biopsy for DNA and proteins from multiple types of cancers, conducted in 10,000 healthy older women.

Though far from perfect, the blood test called CancerSEEK, developed at Johns Hopkins University and licensed by diagnostics company Thrive, found 26 malignancies that had not been discovered with conventional screenings such as mammography and colonoscopy. An even larger study is getting underway in London with 25,000 adults who have a history of smoking, using a blood test from a company audaciously named Grail. No multicancer blood test is close to being approved, but the U.S. Food and Drug Administration has signaled its enthusiasm by designating CancerSEEK as a “breakthrough device,” due to its lifesaving potential.

That status was also achieved this year by some more narrowly targeted blood tests, including one (from Bluestar Genomics) aimed at picking up pancreatic cancer in high-risk individuals and others that look for glimmers of recurrence in patients already treated for cancer. The breakthrough listing “accelerates the review process,” explains Nickolas Papadopoulos, one of the Johns Hopkins scientists who developed CancerSEEK. Liquid biopsies can rely on a variety of biomarkers in addition to tumor DNA and proteins, such as free-floating cancer cells themselves. €œIt's believed that there's a lot of turnover within a tumor,” explains cancer biologist Ana Robles of the National Cancer Institute, “and as cells are dying, fragments are released into blood.” What makes the search difficult, Robles explains, is that “if you have an early-stage cancer or certain types of cancer, there might not be a lot of DNA being shed,” and tests might miss it.

The ideal blood test will be both very specific (uncovering a mutation or other signal that can only be cancer) and very sensitive so that even tiny tumors can be found. To tackle this challenge, CancerSEEK looks for cancer-specific mutations on 16 genes and for eight proteins that are linked to cancer and for which there are highly sensitive tests. In a study that used an updated version of the test, it detected more than 95 percent of ovary and liver tumors and about 70 percent of cancers of the stomach, pancreas and esophagus but only 33 percent of breast tumors and just 43 percent of stage 1 cancers. It will take further giant, costly studies for pan-cancer liquid biopsies to prove their efficacy for early detection.

And simple detection is not the only goal. An ideal liquid biopsy will also determine the likely location of the cancer so that it can be treated. €œMutations are often shared among different kinds of cancer, so if you find them in blood you don't know if that mutation is coming from a pancreatic cancer or lung cancer,” says Anirban Maitra, a pancreatic cancer scientist at the M.D. Anderson Cancer Center in Houston.

To solve that problem, some newer liquid biopsies look for changes in gene expression—whether they are turned on or off—as opposed to changes in the genes themselves. Such changes, Maitra notes, are “more organ-specific.” On the nearer horizon are liquid biopsies to help people already diagnosed with cancer. Last year the FDA approved the first two such tests, which scan for tumor DNA so doctors can select mutation-targeted drugs. Scientists are working on blood tests to detect the first signs of cancer recurrence in patients who have completed treatment.

This work on “minimal residual disease” is moving fast, Papadopoulos says. €œThe question is. Does it save lives?. € That is the question companies such as Thrive and Grail must answer for their broadly ambitious screening tests.

A high rate of false positives or negatives or a tendency to detect cancers that are slow-growing and trivial will not be useful. €œThese companies have to prove that they can detect early cancer and, more important, that the early detection can have an impact on cancer survival,” Maitra observes. €œThat is the holy grail of the holy grail.”.

Can you use cipro for strep throat

€‹University of California San Diego School of Medicine researchers found evidence that triclosan — an antimicrobial found in many soaps and other household items — worsens fatty liver disease in mice fed a high-fat diet.The study, published November 23, 2020 can you use cipro for strep throat in Proceedings of the National Academy of Sciences, also details the molecular mechanisms by which triclosan disrupts metabolism and the gut microbiome, while also stripping away liver cells’ natural protections. Triclosan, an antimicrobial found in many soaps and other household items, worsens fatty liver disease in mice fed a high-fat diet. Credit.

Pixabay“Triclosan’s increasingly broad use in consumer products presents a risk of liver toxicity for humans,” said Robert H. Tukey, PhD, professor in the Department of Pharmacology at UC San Diego School of Medicine. €œOur study shows that common factors that we encounter in every-day life — the ubiquitous presence of triclosan, together with the prevalence of high consumption of dietary fat —constitute a good recipe for the development of fatty liver disease in mice.”Tukey led the study with Mei-Fei Yueh, PhD, a project scientist in his lab, and Michael Karin, PhD, Distinguished Professor of Pharmacology and Pathology at UC San Diego School of Medicine.In a 2014 mouse study, the team found triclosan exposure promoted liver tumor formation by interfering with a protein responsible for clearing away foreign chemicals in the body.

In the latest study, the researchers fed a high-fat diet to mice with type 1 diabetes. As previous studies have shown, the high-fat diet led to non-alcoholic fatty liver disease (NAFLD). In humans, NAFLD is an increasingly common condition that can lead to liver cirrhosis and cancer.

Diabetes and obesity are risk factors for NAFLD. Some of the mice were also fed triclosan, resulting in blood concentrations comparable to those found in human studies. Compared to mice only fed a high-fat diet, triclosan accelerated the development of fatty liver and fibrosis.

According to the study, here’s what’s likely happening. Eating a high-fat diet normally tells cells to produce more fibroblast growth factor 21, which helps protects liver cells from damage. Tukey and team discovered that triclosan messes with two molecules, ATF4 and PPARgamma, which cells need to make the protective growth factor.

Not only that, the antimicrobial also disrupted a variety of genes involved in metabolism. In addition, the mice exposed to triclosan had less diversity in their gut microbiomes — fewer types of bacteria living in the intestines, and a makeup similar to that seen in patients with NAFLD. Less gut microbiome diversity is generally associated with poorer health.So far, these findings have only been observed in mice who ingested triclosan.

But since these same molecular systems also operate in humans, the new information will help researchers better understand risk factors for NAFLD, and give them a new place to start in designing potential interventions to prevent and mitigate the condition. €œThis underlying mechanism now gives us a basis on which to develop potential therapies for toxicant-associated NAFLD,” said Tukey, who is also director of the National Institute of Environmental Health Sciences Superfund Program at UC San Diego.In 2016, the U.S. Food and Drug Administration (FDA) ruled that over-the-counter wash products can no longer contain triclosan, given that it has not been proven to be safe or more effective than washing with plain soap and water.

However, the antimicrobial is still found in some household and medical-grade products, as well as aquatic ecosystems, including sources of drinking water.An estimated 100 million adults and children in the U.S. May have NAFLD. The precise cause of NAFLD is unknown, but diet and genetics play substantial roles.

Up to 50 percent of people with obesity are believed to have NAFLD. The condition typically isn’t detected until it’s well advanced. There are no FDA-approved treatments for NAFLD, though several medications are being developed.

Eating a healthy diet, exercising and losing weight can help patients with NAFLD improve.Additional co-authors of the study include. Feng He, Chen Chen, Catherine Vu, Anupriya Tripathi, Rob Knight, and Shujuan Chen, all at UC San Diego.Funding for this research came, in part, from the National Institutes of Health (grants ES010337, R21-AI135677, GM126074, CA211794, CA198103, DK120714), Eli Lilly and UC San Diego Center for Microbiome Innovation. Disclosure.

Michael Karin is a founder, inventor and an Advisory Board Member of Elgia Therapeutics and has equity in the company..

€‹University of California San Diego https://www.amaltunga.com/buy-zithromax-1000mg-online/ School of Medicine researchers found evidence that triclosan — an antimicrobial found in many soaps and other household items — worsens fatty liver disease in mice fed a high-fat diet.The study, published November 23, 2020 in Proceedings of the National Academy of Sciences, also details the molecular mechanisms by which triclosan disrupts metabolism and the gut microbiome, while also stripping away liver cells’ natural protections buy generic cipro. Triclosan, an antimicrobial found in many soaps and other household items, worsens fatty liver disease in mice fed a high-fat diet. Credit. Pixabay“Triclosan’s increasingly broad use in consumer products presents a risk of liver toxicity for humans,” said Robert H.

Tukey, PhD, professor in the Department of Pharmacology at UC San Diego School of Medicine. €œOur study shows that common factors that we encounter in every-day life — the ubiquitous presence of triclosan, together with the prevalence of high consumption of dietary fat —constitute a good recipe for the development of fatty liver disease in mice.”Tukey led the study with Mei-Fei Yueh, PhD, a project scientist in his lab, and Michael Karin, PhD, Distinguished Professor of Pharmacology and Pathology at UC San Diego School of Medicine.In a 2014 mouse study, the team found triclosan exposure promoted liver tumor formation by interfering with a protein responsible for clearing away foreign chemicals in the body. In the latest study, the researchers fed a high-fat diet to mice with type 1 diabetes. As previous studies have shown, the high-fat diet led to non-alcoholic fatty liver disease (NAFLD).

In humans, NAFLD is an increasingly common condition that can lead to liver cirrhosis and cancer. Diabetes and obesity are risk factors for NAFLD. Some of the mice were also fed triclosan, resulting in blood concentrations comparable to those found in human studies. Compared to mice only fed a high-fat diet, triclosan accelerated the development of fatty liver and fibrosis.

According to the study, here’s what’s likely happening. Eating a high-fat diet normally tells cells to produce more fibroblast growth factor 21, which helps protects liver cells from damage. Tukey and team discovered that triclosan messes with two molecules, ATF4 and PPARgamma, which cells need to make the protective growth factor. Not only that, the antimicrobial also disrupted a variety of genes involved in metabolism.

In addition, the mice exposed to triclosan had less diversity in their gut microbiomes — fewer types of bacteria living in the intestines, and a makeup similar to that seen in patients with NAFLD. Less gut microbiome diversity is generally associated with poorer health.So far, these findings have only been observed in mice who ingested triclosan. But since these same molecular systems also operate in humans, the new information will help researchers better understand risk factors for NAFLD, and give them a new place to start in designing potential interventions to prevent and mitigate the condition. €œThis underlying mechanism now gives us a basis on which to develop potential therapies for toxicant-associated NAFLD,” said Tukey, who is also director of the National Institute of Environmental Health Sciences Superfund Program at UC San Diego.In 2016, the U.S.

Food and Drug Administration (FDA) ruled that over-the-counter wash products can no longer contain triclosan, given that it has not been proven to be safe or more effective than washing with plain soap and water. However, the antimicrobial is still found in some household and medical-grade products, as well as aquatic ecosystems, including sources of drinking water.An estimated 100 million adults and children in the U.S. May have NAFLD. The precise cause of NAFLD is unknown, but diet and genetics play substantial roles.

Up to 50 percent of people with obesity are believed to have NAFLD. The condition typically isn’t detected until it’s well advanced. There are no FDA-approved treatments for NAFLD, though several medications are being developed. Eating a healthy diet, exercising and losing weight can help patients with NAFLD improve.Additional co-authors of the study include.

Feng He, Chen Chen, Catherine Vu, Anupriya Tripathi, Rob Knight, and Shujuan Chen, all at UC San Diego.Funding for this research came, in part, from the National Institutes of Health (grants ES010337, R21-AI135677, GM126074, CA211794, CA198103, DK120714), Eli Lilly and UC San Diego Center for Microbiome Innovation. Disclosure. Michael Karin is a founder, inventor and an Advisory Board Member of Elgia Therapeutics and has equity in the company..

What is Cipro?

CIPROFLOXACIN is a quinolone antibiotic. It can kill bacteria or stop their growth. It is used to treat many kinds of s, like urinary, respiratory, skin, gastrointestinal, and bone s. It will not work for colds, flu, or other viral s.

Cipro side effects tendon

U.S Cialis usa buy cipro side effects tendon. Sen. Dianne Feinstein (D-CA) is calling on Washington to address the emerging threat methamphetamine cipro side effects tendon addiction has become.

In an Op-Ed published Dec. 29 in the L.A cipro side effects tendon. Times, Feinstein said that although opioids like oxycodone and fentanyl continue to dominate addiction news, methamphetamine is becoming a problem, causing tens of thousands of fatalities each year.

“Meth cipro side effects tendon addiction isn’t new, but it has quickly emerged in recent years as a particularly deadly threat, and Los Angeles has been hard-hit. According to county statistics, between 2008 and 2018, meth-related deaths in L.A. Increased tenfold, from 43 to 435.

By 2018, meth was involved in 44% of all drug overdose deaths in Los cipro side effects tendon Angeles County,” Feinstein wrote. €œLast summer, Mark Casanova, of Homeless Health Care Los Angeles, told The Times that meth accounted for 70% of drug use among L.A.’s homeless population. Between 2005 and 2019, according to county data, more than 185,000 individuals who entered publicly funded cipro side effects tendon treatment programs in Los Angeles were admitted for meth.” The problem is not limited to California, she said.

Researchers at the Centers for Disease Control and Prevention, between 2008 and 2017, found that the number of people admitted nationwide for meth-related treatment rose 43 percent, from 260,000 to 373,000. The number who were admitted for meth treatment that were also using heroin cipro side effects tendon increased by 530 percent from 14,000 to more than 88,000. In September, Feinstein and Sen.

Charles Grassley cipro side effects tendon (R-Iowa) introduced the Methamphetamine Response Act, which will direct the White House Office of National Drug Control Policy to develop a plan to address the growing use of meth. While the bill passed the Senate, it has not yet passed the House and is unlikely to pass before the 116th Congress ends. Feinstein said that Congress must act to ensure the drug control policy office declares meth an emerging drug threat, and then develop and implement a plan specific to the meth threat, including plans on how to reduce demand, expand prevention and treatment programs, and reduce supply..

U.S Cialis usa buy buy generic cipro. Sen. Dianne Feinstein (D-CA) buy generic cipro is calling on Washington to address the emerging threat methamphetamine addiction has become.

In an Op-Ed published Dec. 29 in the L.A buy generic cipro. Times, Feinstein said that although opioids like oxycodone and fentanyl continue to dominate addiction news, methamphetamine is becoming a problem, causing tens of thousands of fatalities each year.

“Meth addiction isn’t new, but it has quickly buy generic cipro emerged in recent years as a particularly deadly threat, and Los Angeles has been hard-hit. According to county statistics, between 2008 and 2018, meth-related deaths in L.A. Increased tenfold, from 43 to 435.

By 2018, meth was involved in buy generic cipro 44% of all drug overdose deaths in Los Angeles County,” Feinstein wrote. €œLast summer, Mark Casanova, of Homeless Health Care Los Angeles, told The Times that meth accounted for 70% of drug use among L.A.’s homeless population. Between 2005 and 2019, according to county data, more than 185,000 individuals who entered publicly funded treatment programs in Los Angeles were admitted for meth.” The problem is not limited buy generic cipro to California, she said.

Researchers at the Centers for Disease Control and Prevention, between 2008 and 2017, found that the number of people admitted nationwide for meth-related treatment rose 43 percent, from 260,000 to 373,000. The number who were admitted for meth treatment that were also using heroin increased by 530 percent from 14,000 to more than 88,000 buy generic cipro. In September, Feinstein and Sen.

Charles Grassley (R-Iowa) introduced the Methamphetamine Response Act, which will direct the White House Office of National Drug Control Policy to develop a plan to address the growing use of meth. While the bill passed the Senate, it has not yet passed the House and is unlikely to pass before the 116th Congress ends. Feinstein said that Congress must act to ensure the drug control policy office declares meth an emerging drug threat, and then develop and implement a plan specific to the meth threat, including plans on how to reduce demand, expand prevention and treatment programs, and reduce supply..

Trichomoniasis cipro

Consider a scenario where, at the start of an appointment with a therapist, she trichomoniasis cipro explains to you that ‘the success of the therapy will depend on your own positive expectations, the respect and esteem that you have for me as a qualified health professional, the warm tone and empathic approach that I adopt towards you, and the trust that you place in me, during the course of treatment’. You might find this transparency about the therapeutic process to trichomoniasis cipro be refreshingly honest. You might, however, be surprised if this openness turned out to be an ethical obligation that she owed you.

Yet, for some commentators, this ‘open’ approach to psychotherapy – where there is openness about the common factors that can explain the efficacy of the therapy –is required by ethical standards of informed consent and trichomoniasis cipro (more generally) respect for patient autonomy.In this edition of the Journal of Medical Ethics, Garson Leder formulates two responses to this type of ‘open therapy claim’. That ‘….informed consent does not require the practitioners ‘go open’ about the therapeutic common factors in psychotherapy, and clarity about the mechanism of change shows us that…psychotherapy, as it is commonly practiced, is not deceptive…’.1 This edition also contains a comment by Charlotte Blease on Leder’s paper, and a response by Leder to Blease’s comment. All of which makes for an engaging exchange between a proponent of, and an opponent to, open therapy.The open therapy claim stems from ‘common factors findings in psychotherapy’, specifically, the consensus that there is a set of “common factors mediate some, and possibly most, of the ameliorative effects in psychotherapeutic interventions”.1 These factors include:client characteristics (eg, positive expectations trichomoniasis cipro and hope), therapist qualities (eg, the ability to cultivate positive client characteristics), change processes (eg, the acceptance of a theoretical rationale for the therapy on offer), treatment structure (eg, the delivery of concrete treatments and techniques) and therapeutic relationship (eg, the development of a working alliance between therapist and patient).1There are, therefore, common factors that help explain the efficacy of therapy that are incidental to the theory that grounds or explains the specific psychotherapeutic intervention.

Since these incidental common factors – client characteristics, therapist qualities, and the therapeutic relationship – are necessary components to a sufficient understanding of the efficacy of psychotherapy, we can appreciate why proponents of open therapy want patients to be informed of these ‘incidental’ common factors that explain why therapy works (when it does work).Leder’s response to open therapy, is to differentiate between mechanisms of change and mediators of change. The mechanisms of change amount to ‘the reasons trichomoniasis cipro why change occurred or how change came about’ whereas the mediators are the ‘variables that are statistically correlated with this change’.1 In Leder’s example of cognitive therapy, he explains that where a therapist seeks to address maladaptive cognitions (ie, thoughts, beliefs, and assumptions), the therapist may adopt techniques of ‘identifying and challenging maladaptive thoughts and beliefs and training patients to challenge maladaptive patterns of thought (eg, all-or-nothing thinking, catastrophising, and overgeneralisation)’.1 In order to explain the therapy, the therapist may then make a ‘theory-specific claim’ about the intervention, that it ‘works by modifying maladaptive core beliefs’.1 Leder argues that, while it remains true that the incidental common factors also explain ‘how it works’, one is a mechanism for change (that needs to be explained to the patient), the others are mediators for the change.For Blease, this will not do. Her concern is that, given the enormous difficulty in isolating and testing the ‘efficacy of the so-called specific factors of any psychological modality’, it entirely plausible that the important agents of change are the mediators themselves, and the mechanisms may even be immaterial to the efficacy of any given therapy.2 Which is why ‘ethicists have argued patients should know about them’.2 According to Blease, until basic research can ‘take up the baton’ and provide ‘a clear mechanistic explanation about how a treatment is effective’,2 psychotherapy should be open therapy.Leder’s response to the problem of isolating and testing the efficacy of therapeutic interventions is also call for openness.

But it is an openness about the uncertainty that surrounds the therapeutic intervention (the mechanism) trichomoniasis cipro itself. Since ‘there is currently no consensus about mechanisms of change in psychotherapy’, Leder suggests that patients need to be informed that ‘the therapy on…is based on disputed theoretical foundations’ and that ‘theory-specific techniques are not necessary for healing’.3 At dispute, therefore, is how open should open therapy be. An openness about what we know about how the therapeutic intervention (the mechanism) works or an openness about what we know about how therapy (the mechanism and the mediators) works.Both Leder trichomoniasis cipro and Blease seem to agree on one thing, at least.

They agree on the question that needs to be answered. For them, it is the ‘how does the therapy work’ question trichomoniasis cipro. For Leder, the answer lies in the mechanisms of change (the specific psychotherapeutic intervention).

For Blease, the answer must also include trichomoniasis cipro the mediators of change (the incidental common factors). Answering this question is then equated with providing informed consent. Now, if ‘explaining efficacy’ amounts to ‘providing informed consent’ then Blease might be on strong ground trichomoniasis cipro.

But there may be a baton that needs to be taken up by ethicists. To clarify whether satisfying the ethical requirement of informed consent is the same as, or differs from, a scientific explanation of a treatment’s efficacy.Ethics statementsPatient consent for publicationNot required.AbstractSeveral authors have recently trichomoniasis cipro argued that psychotherapy, as it is commonly practiced, is deceptive and undermines patients’ ability to give informed consent to treatment. This ‘deception’ claim is based on the findings that some, and possibly most, of the ameliorative effects in psychotherapeutic interventions are mediated by therapeutic common factors shared by successful treatments (eg, expectancy effects and therapist effects), rather than because of theory-specific techniques.

These findings have led to claims that psychotherapy is, at least partly, likely a placebo, and that practitioners of psychotherapy have a duty to ‘go open’ to patients about the role of common factors in trichomoniasis cipro therapy (even if this risks negatively affecting the efficacy of treatment). To not ‘go open’ is supposed to unjustly restrict patients’ autonomy. This paper makes two related arguments against the ‘go open’ trichomoniasis cipro claim.

(1) While therapies ought to provide patients with sufficient information to make informed treatment decisions, informed consent does not require that practitioners ‘go open’ about therapeutic common factors in psychotherapy, and (2) clarity about the mechanisms of change in psychotherapy shows us that the common-factors findings are consistent with, rather than undermining of, the truth of many theory-specific forms of psychotherapy. Psychotherapy, as it is commonly practiced, is not deceptive and is not a placebo trichomoniasis cipro. The call to ‘go open’ should be resisted and may have serious detrimental effects on patients via the dissemination of a false view about how therapy works.psychotherapyinformed consentpaternalismethics.

Consider a scenario where, at the start of an appointment with a therapist, buy generic cipro she explains to you that ‘the success of the therapy will depend on your own positive expectations, the respect and esteem that you have for me as a qualified health professional, the warm tone and empathic approach that I adopt towards you, and the trust that you place in me, during the course of treatment’. You might find this transparency buy generic cipro about the therapeutic process to be refreshingly honest. You might, however, be surprised if this openness turned out to be an ethical obligation that she owed you.

Yet, for some commentators, this ‘open’ approach to psychotherapy – where there is openness about the common factors that can explain the efficacy of the therapy –is required by ethical standards of informed consent and (more generally) respect for patient autonomy.In this edition of the Journal of Medical Ethics, Garson Leder formulates two responses to this type of buy generic cipro ‘open therapy claim’. That ‘….informed consent does not require the practitioners ‘go open’ about the therapeutic common factors in psychotherapy, and clarity about the mechanism of change shows us that…psychotherapy, as it is commonly practiced, is not deceptive…’.1 This edition also contains a comment by Charlotte Blease on Leder’s paper, and a response by Leder to Blease’s comment. All of which makes for an engaging exchange between a proponent of, and an opponent to, open therapy.The open therapy claim stems from ‘common factors findings in psychotherapy’, specifically, the consensus that there is a set of “common factors mediate some, and possibly most, of the ameliorative effects in psychotherapeutic interventions”.1 These factors include:client characteristics (eg, positive expectations and hope), therapist qualities (eg, the ability to cultivate positive buy generic cipro client characteristics), change processes (eg, the acceptance of a theoretical rationale for the therapy on offer), treatment structure (eg, the delivery of concrete treatments and techniques) and therapeutic relationship (eg, the development of a working alliance between therapist and patient).1There are, therefore, common factors that help explain the efficacy of therapy that are incidental to the theory that grounds or explains the specific psychotherapeutic intervention.

Since these incidental common factors – client characteristics, therapist qualities, and the therapeutic relationship – are necessary components to a sufficient understanding of the efficacy of psychotherapy, we can appreciate why proponents of open therapy want patients to be informed of these ‘incidental’ common factors that explain why therapy works (when it does work).Leder’s response to open therapy, is to differentiate between mechanisms of change and mediators of change. The mechanisms of change amount to ‘the reasons why change occurred or how change came about’ whereas the mediators are buy generic cipro the ‘variables that are statistically correlated with this change’.1 In Leder’s example of cognitive therapy, he explains that where a therapist seeks to address maladaptive cognitions (ie, thoughts, beliefs, and assumptions), the therapist may adopt techniques of ‘identifying and challenging maladaptive thoughts and beliefs and training patients to challenge maladaptive patterns of thought (eg, all-or-nothing thinking, catastrophising, and overgeneralisation)’.1 In order to explain the therapy, the therapist may then make a ‘theory-specific claim’ about the intervention, that it ‘works by modifying maladaptive core beliefs’.1 Leder argues that, while it remains true that the incidental common factors also explain ‘how it works’, one is a mechanism for change (that needs to be explained to the patient), the others are mediators for the change.For Blease, this will not do. Her concern is that, given the enormous difficulty in isolating and testing the ‘efficacy of the so-called specific factors of any psychological modality’, it entirely plausible that the important agents of change are the mediators themselves, and the mechanisms may even be immaterial to the efficacy of any given therapy.2 Which is why ‘ethicists have argued patients should know about them’.2 According to Blease, until basic research can ‘take up the baton’ and provide ‘a clear mechanistic explanation about how a treatment is effective’,2 psychotherapy should be open therapy.Leder’s response to the problem of isolating and testing the efficacy of therapeutic interventions is also call for openness.

But it buy generic cipro is an openness about the uncertainty that surrounds the therapeutic intervention (the mechanism) itself. Since ‘there is currently no consensus about mechanisms of change in psychotherapy’, Leder suggests that patients need to be informed that ‘the therapy on…is based on disputed theoretical foundations’ and that ‘theory-specific techniques are not necessary for healing’.3 At dispute, therefore, is how open should open therapy be. An openness about what we know about how the therapeutic intervention (the mechanism) works or an openness about what we know about how therapy (the mechanism and the mediators) works.Both Leder and Blease seem to agree on one thing, buy generic cipro at least.

They agree on the question that needs to be answered. For them, it buy generic cipro is the ‘how does the therapy work’ question. For Leder, the answer lies in the mechanisms of change (the specific psychotherapeutic intervention).

For Blease, the answer must also include the mediators of change (the incidental common factors) buy generic cipro. Answering this question is then equated with providing informed consent. Now, if ‘explaining efficacy’ amounts to ‘providing informed consent’ then Blease buy generic cipro might be on strong ground.

But there may be a baton that needs to be taken up by ethicists. To clarify whether satisfying the ethical requirement of buy generic cipro informed consent is the same as, or differs from, a scientific explanation of a treatment’s efficacy.Ethics statementsPatient consent for publicationNot required.AbstractSeveral authors have recently argued that psychotherapy, as it is commonly practiced, is deceptive and undermines patients’ ability to give informed consent to treatment. This ‘deception’ claim is based on the findings that some, and possibly most, of the ameliorative effects in psychotherapeutic interventions are mediated by therapeutic common factors shared by successful treatments (eg, expectancy effects and therapist effects), rather than because of theory-specific techniques.

These findings have led to claims that psychotherapy is, at least partly, likely a placebo, and that practitioners of psychotherapy have buy generic cipro a duty to ‘go open’ to patients about the role of common factors in therapy (even if this risks negatively affecting the efficacy of treatment). To not ‘go open’ is supposed to unjustly restrict patients’ autonomy. This paper makes two related arguments against buy generic cipro the ‘go open’ claim.

(1) While therapies ought to provide patients with sufficient information to make informed treatment decisions, informed consent does not require that practitioners ‘go open’ about therapeutic common factors in psychotherapy, and (2) clarity about the mechanisms of change in psychotherapy shows us that the common-factors findings are consistent with, rather than undermining of, the truth of many theory-specific forms of psychotherapy. Psychotherapy, as it is commonly practiced, is not deceptive and is buy generic cipro not a placebo. The call to ‘go open’ should be resisted and may have serious detrimental effects on patients via the dissemination of a false view about how therapy works.psychotherapyinformed consentpaternalismethics.

Does cipro expire

A saying often attributed does cipro expire to George Bernard Shaw is ‘The single biggest problem in communication is the illusion that it has taken place.’ While it has been debated who originally made this statement, this expression has been used across several industries in different ways.1–4 Communication is an http://dpfcleaningkent.co.uk/viagra-online-canada/ essential aspect of patient safety. One could argue for expanding this proverb to emphasise the importance of recognising that communication at key moments is intrinsically does cipro expire valuable. The biggest problems in communication are the illusion that it has taken place and the assumption that it is not necessary.Over the past 100 years, cognitive aids for crisis events during patient care have been called for, developed, refined and examined.5–12 While much of this literature comes from high-risk industries and medical simulation, there is increasing supporting evidence from healthcare on how these tools can act as cognitive aids in clinical settings.

Regarding terminology, we cite a review article on emergency manuals does cipro expire (EMs). €˜EMs are context-relevant sets of cognitive aids, such as crisis checklists, that are intended to does cipro expire provide professionals with key information for managing rare emergency events. Synonyms and related terms include crisis checklists.

Emergency checklists and cognitive aids, a much broader term, although often also used does cipro expire to describe tools for use during emergency events specifically.’13 Published accounts from healthcare professionals who experienced real-life events have described the power of these tools to prevent errors of omission, commission and lapses in communication.14–18 These events can be both common in large health systems and rare at the level of the individual clinician.10 It is also hard to predict when they will occur. These attributes create a meaningful role to study crisis checklists, EMs and other cognitive aids using medical simulation, particularly in healthcare settings (such as the emergency department (ED)) where they have been understudied.In this issue of BMJ Quality and Safety, Dryver et al make a major contribution to the expanding scope of these evidence-based tools into the realm of emergency medicine.19 In a simulation-based multi-institutional, multidisciplinary randomised controlled trial on the use of medical crisis checklists in the ED, the authors evaluated resuscitation teams in performing indicated emergency interventions during simulated medical crisis events (eg, anaphylactic shock, status epilepticus), with or without access to a crisis checklist for that scenario. Emergency medicine resuscitation teams, comprised of physicians (mainly does cipro expire residents), nurses, nursing assistants and medical secretaries, participated in these simulations.

They took place during the teams’ clinical shift in the ED setting, with access does cipro expire to their usual equipment, medications and cognitive aids. The checklist for each scenario was displayed on large wall-mounted or television screens and outlined possible interventions to consider during the management of that particular crisis, including for instance medications with their indication, contraindication and risks as well as dose and route of administration. The authors found, among other findings, a notable and significant difference in the median percentage of does cipro expire indicated emergency interventions when the checklists were available.

38.8% without checklist access and 85.7% with checklist access (p<0.001). They also found that the vast majority of participants (94%) agreed that they would use the checklists if faced with a similar does cipro expire case during actual patient care. Consistent with findings from prior studies in the New England Journal of Medicine (studying operating room teams) and the Journal does cipro expire of Critical Care (studying intensive care unit teams), Dryver et al have demonstrated yet another setting (the ED) where crisis checklists, EMs and other critical event cognitive aids may be beneficial.10 20The study should be interpreted in the context of its study design, strengths and limitations.

The study was conducted using in situ simulation, that is, the performance of medical simulation in a clinical care area pertaining to the events being studied. When done safely, this method provides opportunities for participants to practise the management of critical events in the does cipro expire actual location where they may encounter them during actual patient care situations.21–23 It is also a multi-institutional study that involved two EDs from an academic centre. One from a rural community hospital, and one from a large community hospital.

The checklists were tailored to the medications available at does cipro expire each institution’s ED location as opposed to a generic pocket-card cognitive aid. The value of such local customisation has been noted across several publications on crisis checklists and EMs, also highlighting the broader factors to consider (in addition to medication details) such as the medium used (eg, paper vs digital, tablet vs computer), device models and settings (eg, transcutaneous pacemakers settings, defibrillator settings), and methods to call for help (eg, local emergency phone numbers).10 12 24This study does cipro expire focused on the presence or absence of a readily displayed checklist with a medical crisis made readily apparent from the simulated scenario’s introduction. It was not aimed to evaluate the ability of teams to correctly diagnose the critical event of interest.

While the authors note that this allowed the simulations to focus on treatment, other studies on crisis checklists/EMs have intentionally included scenarios where the diagnosis was unclear or not within the EM available.10 25 One simulation-based study that included scenarios not within the EM available showed variable usage of the EMs (‘with some teams not using the [emergency manual] at all’) and variable impact on team performance.25 Future studies on the use of ED crisis checklists by resuscitation teams may want to factor in the complexity of an undifferentiated medical scenario, where a patient may present with an unknown diagnosis, or where a clinical presentation may be confounded by comorbidities.Not only the range of care settings expands where cognitive does cipro expire aids are considered beneficial when dealing with crisis situations, ongoing work also extends the use of such tools temporally. (1) preventing the crisis and/or its manifestations from occurring in the first place, and (2) dealing with does cipro expire the aftermath of the crisis event. The WHO Safe Surgery Saves Lives Surgical Safety Checklist is a well-known example of the first category, containing a set of evidence-based processes of care meant to be carried out at key pause points during surgery.

This tool includes a pause-point to allow anticipated critical events to be reviewed, as well as processes that could lead to a critical event if missed (eg, reviewing allergies, confirming counts are correct towards the end of a procedure).26 A systematic review of articles describing the actual use of surgical safety checklists does cipro expire found that they were associated with increased detection of potential safety hazards, decreased surgical complications and improved staff communication.27 Regarding the second category, dealing with the aftermath of a crisis, critical event debriefing is a long-standing practice that has been noted for its potential benefits to healthcare professionals at the individual, team and systems level.28–33 It can help mitigate the negative impact of crisis events on healthcare providers, offer opportunities for education and learning, and serve as a vehicle to identify systems gaps in overall quality and safety.33 34 Something as simple as a well-timed drop of WATER (Welfare check, Acute/short-term corrections, Team reactions and reflection, Education, and Resource awareness/longer term needs), the beginnings of a cognitive aid in itself, can have a meaningful ripple effect if used when indicated (figure 1). Several cognitive aids for various forms of debriefing have been described. The Promoting Excellence And Reflective Learning in Simulation (PEARLS) debriefing tool was developed based on experiences in medical simulation.35 Versions of PEARLS have been adapted for healthcare debriefing and systems-focused debriefing.32 36 The Debriefing In-Situ Conversation after Emergent Resuscitation Now tool was developed in the study of resuscitations at a paediatric ED.37 An adapted version was created during the buy antibiotics cipro for end-of-shift debriefing in EDs (Debriefing In Situ buy antibiotics to Encourage Reflection and Plus-Delta in Healthcare After Shifts End).38 There is a large body of literature from medical simulation and other does cipro expire disciplines supporting critical event debriefing.33 34 Considerations to avoid psychological iatrogenic effects from debriefing (such as customisation to local culture and available resources/debriefing training) have been noted.33 34 39 Future research, both via simulation and after real events, can help inform ways to improve the quality and frequency of debriefing after the very events that have been studied with crisis checklists and EMs.40Elements to consider for debriefing just after a perioperative critical event.

These elements are not meant to be comprehensive does cipro expire. Customisation to local culture and available resources is essential.33 34 The responsibility for interpretation/application lies with the reader. Image.

Restivo D. Water Drop impact on water surface. Available at https://commons.wikimedia.org/wiki/File:Water_drop_impact_on_a_water-surface_-_(5).jpg.

Accessed 13 Feb 2021. With permission via Creative Commons CC BY-SA 2.0 License (https://creativecommons.org/licenses/by-sa/2.0/legalcode). QI, quality improvement." data-icon-position data-hide-link-title="0">When translating these interventions from medical simulation to the point of care, there are many lessons to be learnt from the implementation sciences.

Editorials and perspective pieces have called for checklists to be viewed within a broader sociocultural or sociotechnical context, including factors such as team training and thoughtful implementation.41 42 Original research on team training initiatives that include surgical safety checklists has been associated with improved patient outcomes.43 Crisis checklists and EMs are substantially less effective if they are sitting in a drawer collecting dust during an emergency. To minimise the likelihood of this happening, it is important that their implementation is approached with the same rigour as all good quality improvement work. Including conducting a needs assessment, customising the cognitive aids, obtaining key stakeholder buy-in, establishing implementation champions, developing training programmes, evaluation and ongoing measurement and iterative improvement, which all have been well described.11 44 45 As another example of an implementation framework, the Consolidated Framework for Implementation Research is composed of five major domains.

Intervention characteristics, outer setting, inner setting, characteristics of the individuals involved and the process of implementation.46 Another popular example is the plan–do–study–act model.47 48 Specific to crisis checklists and EMs, Goldhaber-Fiebert and Howard proposed four vital elements for widespread and successful implementation. Create, familiarise, use and integrate.11 12 Agarwala et al reported an institutional case study of perioperative EM implementation that centred around three goals. (1) place EMs in every anaesthetising location, (2) create interprofessional engagement and (3) demonstrate that a majority of anaesthesia clinicians would use the EMs in some way within the first year.49 Factors such as leadership support and dedicated time to train staff can be essential.45 50 51 More successful implementation of crisis checklists and EMs has been reported when institutions used these tools to assist both during the management of the critical events and in debriefing after critical events.45 An association between the quality of implementation and improved outcomes has similarly been seen with routine surgical safety checklists.52 53 There is also value in research that considers not only whether the tool is used, but also how implementation and training strategies can be leveraged to improve thoughtful adherence to the items on the checklist and avoid issues from going unnoticed.54–56 For critical event debriefing, there is potentially a wide gap between principle and practice.

Studies across different medical disciplines have reported that debriefing after critical events takes place only a fraction of the time.34 57 58 Barriers mentioned in studies and other publications include competing clinical priorities, lack of debriefing training, interpersonal dynamics and leadership buy-in.33 34 37 58–61 Several of these barriers potentially overlap with the goals of implementing crisis checklists, and there may be synergy in viewing prevention, crisis events and their aftermath within a continuum.At a fundamental level, many of the cognitive aids discussed in this editorial are designed to both improve cognition and foster interdisciplinary communication about essential best practices at key moments in time. There should not be an illusion that this communication is already taking place or an assumption that it is not necessary. There also should not be a fallacy that these critical event cognitive aids are simply ‘memory aids’.

Growing evidence of EMs during real-time use has described providers reporting the use of these tools associated with decreased stress, improved teamwork, a calmer atmosphere and better care.14 16 There is active work, including collaboration with expertise from the Human Systems Integration Division from the National Aeronautics and Space Administration, exploring how to optimise critical event cognitive aid design relative to the high cognitive load and other factors intrinsic to a crisis.62–66 Emerging research has explored whether it is beneficial to have a crisis checklist reader role, separate from the crisis event leader, when resources allow.13 67Future work on cognitive aids for medical crises should not only address whether they are present, but also how they are designed, used, simulated and implemented towards the most successful outcomes, and its effect on communication. As the scope of patient safety efforts surrounding crisis management continues to expand, there is value in thinking both spatially and temporally via both medical simulation and real events.Ethics statementsPatient consent for publicationNot required.The haemoglobin A1c (HbA1c) level has become the standard of care for monitoring type 2 diabetes as it reflects a person’s average blood glucose level over the previous 2–3 months, is correlated with risk of long-term complications and can be measured cheaply and easily. International guidelines recommend testing HbA1c every 6–12 months for those with stable type 2 diabetes, and every 3–6 months in adults with unstable type 2 diabetes until HbA1c is controlled on unchanging therapy.1–3 However, these guidelines are based on expert consensus rather than robust evidence on whether the frequency of HbA1c measurement impacts patient outcomes.

To date, most studies have focused on the association between testing frequency and glycaemic control.4–6In this issue of BMJ Quality &. Safety Imai and colleagues go further, demonstrating an association between adherence to guideline-recommended testing frequency and health outcomes.7 Using data from electronic health records (EHRs), they examined adherence to guideline-recommended HbA1c testing frequency over a 5-year period in 6424 people with type 2 diabetes across 250 general practices in Australia. An adherence rate was calculated for each person with type 2 diabetes, dividing the number of tests performed within the recommended intervals by the total number of conducted tests (minus 1).

Patients were categorised into low-adherence (<33%), moderate-adherence (34%–66%) and high-adherence groups (>66%). Where there was high adherence to guideline-recommended testing frequency, HbA1c values remained stable or improved over time. In contrast, with low adherence, HbA1c values remained unstable or deteriorated over the 5-year period.

The risk of developing chronic kidney disease was lower among those with high adherence compared to those with low adherence (OR 0.42, 95% CI 0.18 to 0.99). There was no evidence of an association between the rate of adherence and the development of ischaemic heart disease. This study provides support for the importance of frequent HbA1c testing as recommended in current clinical guidelines for prevention of complications of diabetes.The study exploits an abundance of observational data on processes and outcomes of care readily available in EHRs in a real-life setting and among a general population with type two diabetes over a 5 year period.

However, the authors highlight methodological challenges. Using EHRs to explore the association between adherence to testing frequency and HbA1c is susceptible to selection bias, given that patients need to have HbA1c measurements recorded to be included in the study. Imai and colleagues include ‘active patients’ defined as individuals who attended the practices three or more times in the past 2 years at the time of the visit and had two or more HbA1c tests over the study period.7 While this restriction was necessary to avoid duplication of patients across primary care practices and to study the development of complications over time, it may introduce selection bias and also reduce the generalisability of the findings.

The authors suggest their findings are conservative estimates of the association between adherence to guideline-recommended testing frequency and outcomes, given the positive association between practice visits and glycaemic control. However, those who do not attend general practice regularly differ in many other ways, which may also affect the association between adherence to guideline-recommended testing frequency and health outcomes. A recent systematic review of non-attendance at outpatient diabetes appointments, including those with a general practitioner or nurse, found that younger adults, smokers and those with financial pressures were less likely to attend.8 In addition, even among those who attend general practice regularly, differences in other aspects of care such as self-management behaviour are likely to exist between those with high-adherence versus low-adherence rates.9 In the study by Imai and colleagues, data were not available on potentially important factors, such as patients’ body mass index, smoking status and adherence to medication,7 making it difficult to attribute unstable or deteriorating HbA1c to low-adherence rates.

Furthermore, the adherence rate was estimated based on average test numbers over 5 years, so adherence may vary over time. Future research could build on the work of Imai and colleagues to examine the causal relationships between a range of care processes (including testing frequency), HbA1c and health outcomes by assessing the temporality of relationships, accounting for selection bias and confounding, and exploring potential causal mechanisms such as treatment intensification.9Imai and colleagues also found that the median testing frequency in people with type 2 diabetes was less than the recommended two tests per year in Australia (median 1.6 tests per year).7 Poor adherence to recommended testing frequency is documented in several countries with similar guidelines, including countries in Europe10 11 and Asia12 as well as in the USA,13 thus raising questions about how best to improve this process of care. Diabetes care is the subject of extensive quality improvement and implementation research,14 and a variety of interventions have been shown to improve processes and outcomes of care for people with diabetes.15 How and why these interventions work is unclear because of the range of intervention components operating at the patient, professional and system levels.

Most interventions focus on a range of guideline-recommended behaviours in both health professionals and patients and are often described more broadly than changing or targeting one specific behaviour.16 For instance, adherence to HbA1c testing frequency itself is not one specific behaviour. It includes a series of behaviours by the person with diabetes, and potentially their support network, as well as behaviours by health professionals. The person with diabetes must initiate an appointment.

The health professional may prompt the person to attend for regular testing. On deciding and making the effort to attend, the person with diabetes must agree to the blood test. And the health professional must carry out the blood test and send it to a lab for analysis.

To improve adherence to HbA1c testing frequency, we may have to intervene in multiple places, but first we need to identify where the process breaks down.There also needs to be a clearer understanding of why the process breaks down. To date, there has been no systematic review of the factors associated with adherence to the frequency of HbA1c testing recommended in guidelines. Individual studies, conducted in different health systems, have identified a range of patient-level factors including age, rurality, disease duration, receipt of specialist care, glycaemic control, cardiovascular risk factors and diabetes-related complications.10–13 Few studies have examined the professional, organisational and system-level determinants of adherence.

Yet we have reason to believe that factors at these levels are also important. In a qualitative synthesis of barriers to optimal diabetes management in primary care, perceived professional barriers included limited time and resources, changing professional boundaries leading to uncertainty about clinical responsibility, and a lack of confidence in knowledge of guidelines and skills.17 A meta-analysis of professional and practice-level factors associated with the quality of diabetes management in primary care identified doctor gender and age, doctor-level diabetes volume, practice deprivation and use of EHRs as significant determinants of quality, typically measured by a collection of individual indicators or a composite measure.18 Furthermore, evidence from a systematic review and meta-analysis of quality improvement interventions for diabetes suggests that strategies that intervene on the entire system of chronic disease management are associated with the largest effects irrespective of baseline HbA1c.15 Thus, to improve adherence to the frequency of HbA1c testing frequency, the problem needs to be understood in context, and solutions should incorporate professional and system-facing interventions as well as patient-facing interventions.Based on their analysis of the content of implementation interventions to support diabetes care, Presseau and colleagues call for better reporting of who needs to do what differently at all levels, including the system level, which is often underspecified.16 This, they propose, would contribute to the development of an underlying programme theory for improvement interventions linking activities to intended outcomes.19 Such an approach is relevant to many chronic conditions where disease management involves multiple actors, actions and settings. The development of testable theories and integration of causal reasoning are increasingly advocated in improvement and implementation science as a way to enhance the generalisability of interventions.20 21 Causal diagram modelling,20 the action–effect method19 and the implementation research logic model,22 facilitate the development and communication of intervention programme theory.

The action effect method in particular is intended as a facilitated collaborative process to enhance the practicality of programme theory and to provide an actionable guide for quality improvement teams.19The current study by Imai and colleagues underscores the importance of the link between regular HbA1c testing, better glycaemic control and reduced risk of complications.7 While the causal mechanisms require further investigation, this study provides an important piece of the puzzle. Few interventions target Hba1c testing frequency alone, and this is unlikely to be the sole priority for people with diabetes or their health professionals, given the multiple processes recommended for optimal clinical and self-management. However, given its centrality and profile in diabetes management, targeting HbA1c could be a lever for wider improvement.

The foundation for such an intervention should be a better understanding and more precise articulation of who needs to do what differently, as well as how and why this intervention is expected to change specific processes of care and ultimately improve patient outcomes.Ethics statementsPatient consent for publicationNot required..

A saying often attributed to George Bernard Shaw is ‘The single biggest Viagra online canada problem in communication is the illusion that it has taken place.’ While it has been debated who buy generic cipro originally made this statement, this expression has been used across several industries in different ways.1–4 Communication is an essential aspect of patient safety. One could argue for expanding this proverb to emphasise the importance of recognising that communication at key moments buy generic cipro is intrinsically valuable. The biggest problems in communication are the illusion that it has taken place and the assumption that it is not necessary.Over the past 100 years, cognitive aids for crisis events during patient care have been called for, developed, refined and examined.5–12 While much of this literature comes from high-risk industries and medical simulation, there is increasing supporting evidence from healthcare on how these tools can act as cognitive aids in clinical settings.

Regarding terminology, we buy generic cipro cite a review article on emergency manuals (EMs). €˜EMs are context-relevant sets of cognitive aids, such as crisis checklists, that are intended to provide professionals with key information buy generic cipro for managing rare emergency events. Synonyms and related terms include crisis checklists.

Emergency checklists and cognitive aids, a much broader term, although often also used to describe tools for use during emergency events specifically.’13 Published accounts from healthcare professionals who experienced real-life events have described the power of these buy generic cipro tools to prevent errors of omission, commission and lapses in communication.14–18 These events can be both common in large health systems and rare at the level of the individual clinician.10 It is also hard to predict when they will occur. These attributes create a meaningful role to study crisis checklists, EMs and other cognitive aids using medical simulation, particularly in healthcare settings (such as the emergency department (ED)) where they have been understudied.In this issue of BMJ Quality and Safety, Dryver et al make a major contribution to the expanding scope of these evidence-based tools into the realm of emergency medicine.19 In a simulation-based multi-institutional, multidisciplinary randomised controlled trial on the use of medical crisis checklists in the ED, the authors evaluated resuscitation teams in performing indicated emergency interventions during simulated medical crisis events (eg, anaphylactic shock, status epilepticus), with or without access to a crisis checklist for that scenario. Emergency medicine resuscitation teams, comprised of physicians (mainly residents), nurses, nursing assistants and medical secretaries, participated in these simulations buy generic cipro.

They took place during the teams’ clinical shift in the ED setting, with access to their usual equipment, medications and buy generic cipro cognitive aids. The checklist for each scenario was displayed on large wall-mounted or television screens and outlined possible interventions to consider during the management of that particular crisis, including for instance medications with their indication, contraindication and risks as well as dose and route of administration. The authors found, among other findings, a notable and significant difference in the median percentage of indicated emergency interventions when the checklists were available buy generic cipro.

38.8% without checklist access and 85.7% with checklist access (p<0.001). They also found that the buy generic cipro vast majority of participants (94%) agreed that they would use the checklists if faced with a similar case during actual patient care. Consistent with findings from prior studies in the New England Journal of Medicine (studying operating room teams) and the Journal of Critical Care (studying intensive care unit teams), Dryver et al have demonstrated yet another setting (the ED) where crisis checklists, EMs buy generic cipro and other critical event cognitive aids may be beneficial.10 20The study should be interpreted in the context of its study design, strengths and limitations.

The study was conducted using in situ simulation, that is, the performance of medical simulation in a clinical care area pertaining to the events being studied. When done safely, this method provides opportunities for participants to practise the management of critical events in the actual location where they may encounter them during actual patient care situations.21–23 It is also a multi-institutional study that involved buy generic cipro two EDs from an academic centre. One from a rural community hospital, and one from a large community hospital.

The checklists buy generic cipro were tailored to the medications available at each institution’s ED location as opposed to a generic pocket-card cognitive aid. The value of such local customisation has been noted across several publications on crisis checklists and EMs, also highlighting the broader factors buy generic cipro to consider (in addition to medication details) such as the medium used (eg, paper vs digital, tablet vs computer), device models and settings (eg, transcutaneous pacemakers settings, defibrillator settings), and methods to call for help (eg, local emergency phone numbers).10 12 24This study focused on the presence or absence of a readily displayed checklist with a medical crisis made readily apparent from the simulated scenario’s introduction. It was not aimed to evaluate the ability of teams to correctly diagnose the critical event of interest.

While the authors note that this allowed the simulations to focus on treatment, other studies on crisis checklists/EMs have intentionally included scenarios where the diagnosis was unclear or not within the EM available.10 25 One simulation-based study that included scenarios not within the EM available showed variable usage of the EMs (‘with some teams not using the [emergency manual] at all’) and variable impact on team performance.25 Future studies on the use of ED crisis checklists by resuscitation teams may want to factor in the complexity of an undifferentiated medical scenario, where a patient may present with an unknown diagnosis, or where a clinical presentation may be confounded by comorbidities.Not only the buy generic cipro range of care settings expands where cognitive aids are considered beneficial when dealing with crisis situations, ongoing work also extends the use of such tools temporally. (1) preventing the crisis and/or its manifestations from occurring in the first place, and (2) dealing buy generic cipro with the aftermath of the crisis event. The WHO Safe Surgery Saves Lives Surgical Safety Checklist is a well-known example of the first category, containing a set of evidence-based processes of care meant to be carried out at key pause points during surgery.

This tool includes a pause-point to allow anticipated critical events to be reviewed, as well as processes that could lead to a critical event if missed (eg, reviewing allergies, confirming counts are correct towards the end of a procedure).26 A systematic review of articles describing the actual use of surgical safety checklists found that they were associated with increased detection of potential safety hazards, decreased surgical complications and improved staff communication.27 Regarding the second category, dealing with the aftermath of a crisis, critical event debriefing is a long-standing practice that has been noted for its potential benefits to healthcare professionals at the individual, team and systems level.28–33 It can help mitigate the negative impact of crisis events on healthcare providers, offer opportunities for education and learning, and serve as a vehicle to identify systems gaps in overall quality and safety.33 34 Something as simple buy generic cipro as a well-timed drop of WATER (Welfare check, Acute/short-term corrections, Team reactions and reflection, Education, and Resource awareness/longer term needs), the beginnings of a cognitive aid in itself, can have a meaningful ripple effect if used when indicated (figure 1). Several cognitive aids for various forms of debriefing have been described. The Promoting Excellence And Reflective Learning in Simulation (PEARLS) debriefing tool was developed based on experiences in medical simulation.35 Versions of PEARLS have been adapted for healthcare debriefing and systems-focused debriefing.32 36 The Debriefing In-Situ Conversation after Emergent Resuscitation Now tool was developed in the study of resuscitations at a paediatric ED.37 An adapted version was created during the buy antibiotics cipro for end-of-shift debriefing in EDs (Debriefing In Situ buy antibiotics to Encourage Reflection and Plus-Delta in Healthcare After Shifts End).38 There is a large body of literature from medical simulation and other disciplines buy generic cipro supporting critical event debriefing.33 34 Considerations to avoid psychological iatrogenic effects from debriefing (such as customisation to local culture and available resources/debriefing training) have been noted.33 34 39 Future research, both via simulation and after real events, can help inform ways to improve the quality and frequency of debriefing after the very events that have been studied with crisis checklists and EMs.40Elements to consider for debriefing just after a perioperative critical event.

These elements buy generic cipro are not meant to be comprehensive. Customisation to local culture and available resources is essential.33 34 The responsibility for interpretation/application lies with the reader. Image.

Restivo D. Water Drop impact on water surface. Available at https://commons.wikimedia.org/wiki/File:Water_drop_impact_on_a_water-surface_-_(5).jpg.

Accessed 13 Feb 2021. With permission via Creative Commons CC BY-SA 2.0 License (https://creativecommons.org/licenses/by-sa/2.0/legalcode). QI, quality improvement." data-icon-position data-hide-link-title="0">When translating these interventions from medical simulation to the point of care, there are many lessons to be learnt from the implementation sciences.

Editorials and perspective pieces have called for checklists to be viewed within a broader sociocultural or sociotechnical context, including factors such as team training and thoughtful implementation.41 42 Original research on team training initiatives that include surgical safety checklists has been associated with improved patient outcomes.43 Crisis checklists and EMs are substantially less effective if they are sitting in a drawer collecting dust during an emergency. To minimise the likelihood of this happening, it is important that their implementation is approached with the same rigour as all good quality improvement work. Including conducting a needs assessment, customising the cognitive aids, obtaining key stakeholder buy-in, establishing implementation champions, developing training programmes, evaluation and ongoing measurement and iterative improvement, which all have been well described.11 44 45 As another example of an implementation framework, the Consolidated Framework for Implementation Research is composed of five major domains.

Intervention characteristics, outer setting, inner setting, characteristics of the individuals involved and the process of implementation.46 Another popular example is the plan–do–study–act model.47 48 Specific to crisis checklists and EMs, Goldhaber-Fiebert and Howard proposed four vital elements for widespread and successful implementation. Create, familiarise, use and integrate.11 12 Agarwala et al reported an institutional case study of perioperative EM implementation that centred around three goals. (1) place EMs in every anaesthetising location, (2) create interprofessional engagement and (3) demonstrate that a majority of anaesthesia clinicians would use the EMs in some way within the first year.49 Factors such as leadership support and dedicated time to train staff can be essential.45 50 51 More successful implementation of crisis checklists and EMs has been reported when institutions used these tools to assist both during the management of the critical events and in debriefing after critical events.45 An association between the quality of implementation and improved outcomes has similarly been seen with routine surgical safety checklists.52 53 There is also value in research that considers not only whether the tool is used, but also how implementation and training strategies can be leveraged to improve thoughtful adherence to the items on the checklist and avoid issues from going unnoticed.54–56 For critical event debriefing, there is potentially a wide gap between principle and practice.

Studies across different medical disciplines have reported that debriefing after critical events takes place only a fraction of the time.34 57 58 Barriers mentioned in studies and other publications include competing clinical priorities, lack of debriefing training, interpersonal dynamics and leadership buy-in.33 34 37 58–61 Several of these barriers potentially overlap with the goals of implementing crisis checklists, and there may be synergy in viewing prevention, crisis events and their aftermath within a continuum.At a fundamental level, many of the cognitive aids discussed in this editorial are designed to both improve cognition and foster interdisciplinary communication about essential best practices at key moments in time. There should not be an illusion that this communication is already taking place or an assumption that it is not necessary. There also should not be a fallacy that these critical event cognitive aids are simply ‘memory aids’.

Growing evidence of EMs during real-time use has described providers reporting the use of these tools associated with decreased stress, improved teamwork, a calmer atmosphere and better care.14 16 There is active work, including collaboration with expertise from the Human Systems Integration Division from the National Aeronautics and Space Administration, exploring how to optimise critical event cognitive aid design relative to the high cognitive load and other factors intrinsic to a crisis.62–66 Emerging research has explored whether it is beneficial to have a crisis checklist reader role, separate from the crisis event leader, when resources allow.13 67Future work on cognitive aids for medical crises should not only address whether they are present, but also how they are designed, used, simulated and implemented towards the most successful outcomes, and its effect on communication. As the scope of patient safety efforts surrounding crisis management continues to expand, there is value in thinking both spatially and temporally via both medical simulation and real events.Ethics statementsPatient consent for publicationNot required.The haemoglobin A1c (HbA1c) level has become the standard of care for monitoring type 2 diabetes as it reflects a person’s average blood glucose level over the previous 2–3 months, is correlated with risk of long-term complications and can be measured cheaply and easily. International guidelines recommend testing HbA1c every 6–12 months for those with stable type 2 diabetes, and every 3–6 months in adults with unstable type 2 diabetes until HbA1c is controlled on unchanging therapy.1–3 However, these guidelines are based on expert consensus rather than robust evidence on whether the frequency of HbA1c measurement impacts patient outcomes.

To date, most studies have focused on the association between testing frequency and glycaemic control.4–6In this issue of BMJ Quality &. Safety Imai and colleagues go further, demonstrating an association between adherence to guideline-recommended testing frequency and health outcomes.7 Using data from electronic health records (EHRs), they examined adherence to guideline-recommended HbA1c testing frequency over a 5-year period in 6424 people with type 2 diabetes across 250 general practices in Australia. An adherence rate was calculated for each person with type 2 diabetes, dividing the number of tests performed within the recommended intervals by the total number of conducted tests (minus 1).

Patients were categorised into low-adherence (<33%), moderate-adherence (34%–66%) and high-adherence groups (>66%). Where there was high adherence to guideline-recommended testing frequency, HbA1c values remained stable or improved over time. In contrast, with low adherence, HbA1c values remained unstable or deteriorated over the 5-year period.

The risk of developing chronic kidney disease was lower among those with high adherence compared to those with low adherence (OR 0.42, 95% CI 0.18 to 0.99). There was no evidence of an association between the rate of adherence and the development of ischaemic heart disease. This study provides support for the importance of frequent HbA1c testing as recommended in current clinical guidelines for prevention of complications of diabetes.The study exploits an abundance of observational data on processes and outcomes of care readily available in EHRs in a real-life setting and among a general population with type two diabetes over a 5 year period.

However, the authors highlight methodological challenges. Using EHRs to explore the association between adherence to testing frequency and HbA1c is susceptible to selection bias, given that patients need to have HbA1c measurements recorded to be included in the study. Imai and colleagues include ‘active patients’ defined as individuals who attended the practices three or more times in the past 2 years at the time of the visit and had two or more HbA1c tests over the study period.7 While this restriction was necessary to avoid duplication of patients across primary care practices and to study the development of complications over time, it may introduce selection bias and also reduce the generalisability of the findings.

The authors suggest their findings are conservative estimates of the association between adherence to guideline-recommended testing frequency and outcomes, given the positive association between practice visits and glycaemic control. However, those who do not attend general practice regularly differ in many other ways, which may also affect the association between adherence to guideline-recommended testing frequency and health outcomes. A recent systematic review of non-attendance at outpatient diabetes appointments, including those with a general practitioner or nurse, found that younger adults, smokers and those with financial pressures were less likely to attend.8 In addition, even among those who attend general practice regularly, differences in other aspects of care such as self-management behaviour are likely to exist between those with high-adherence versus low-adherence rates.9 In the study by Imai and colleagues, data were not available on potentially important factors, such as patients’ body mass index, smoking status and adherence to medication,7 making it difficult to attribute unstable or deteriorating HbA1c to low-adherence rates.

Furthermore, the adherence rate was estimated based on average test numbers over 5 years, so adherence may vary over time. Future research could build on the work of Imai and colleagues to examine the causal relationships between a range of care processes (including testing frequency), HbA1c and health outcomes by assessing the temporality of relationships, accounting for selection bias and confounding, and exploring potential causal mechanisms such as treatment intensification.9Imai and colleagues also found that the median testing frequency in people with type 2 diabetes was less than the recommended two tests per year in Australia (median 1.6 tests per year).7 Poor adherence to recommended testing frequency is documented in several countries with similar guidelines, including countries in Europe10 11 and Asia12 as well as in the USA,13 thus raising questions about how best to improve this process of care. Diabetes care is the subject of extensive quality improvement and implementation research,14 and a variety of interventions have been shown to improve processes and outcomes of care for people with diabetes.15 How and why these interventions work is unclear because of the range of intervention components operating at the patient, professional and system levels.

Most interventions focus on a range of guideline-recommended behaviours in both health professionals and patients and are often described more broadly than changing or targeting one specific behaviour.16 For instance, adherence to HbA1c testing frequency itself is not one specific behaviour. It includes a series of behaviours by the person with diabetes, and potentially their support network, as well as behaviours by health professionals. The person with diabetes must initiate an appointment.

The health professional may prompt the person to attend for regular testing. On deciding and making the effort to attend, the person with diabetes must agree to the blood test. And the health professional must carry out the blood test and send it to a lab for analysis.

To improve adherence to HbA1c testing frequency, we may have to intervene in multiple places, but first we need to identify where the process breaks down.There also needs to be a clearer understanding of why the process breaks down. To date, there has been no systematic review of the factors associated with adherence to the frequency of HbA1c testing recommended in guidelines. Individual studies, conducted in different health systems, have identified a range of patient-level factors including age, rurality, disease duration, receipt of specialist care, glycaemic control, cardiovascular risk factors and diabetes-related complications.10–13 Few studies have examined the professional, organisational and system-level determinants of adherence.

Yet we have reason to believe that factors at these levels are also important. In a qualitative synthesis of barriers to optimal diabetes management in primary care, perceived professional barriers included limited time and resources, changing professional boundaries leading to uncertainty about clinical responsibility, and a lack of confidence in knowledge of guidelines and skills.17 A meta-analysis of professional and practice-level factors associated with the quality of diabetes management in primary care identified doctor gender and age, doctor-level diabetes volume, practice deprivation and use of EHRs as significant determinants of quality, typically measured by a collection of individual indicators or a composite measure.18 Furthermore, evidence from a systematic review and meta-analysis of quality improvement interventions for diabetes suggests that strategies that intervene on the entire system of chronic disease management are associated with the largest effects irrespective of baseline HbA1c.15 Thus, to improve adherence to the frequency of HbA1c testing frequency, the problem needs to be understood in context, and solutions should incorporate professional and system-facing interventions as well as patient-facing interventions.Based on their analysis of the content of implementation interventions to support diabetes care, Presseau and colleagues call for better reporting of who needs to do what differently at all levels, including the system level, which is often underspecified.16 This, they propose, would contribute to the development of an underlying programme theory for improvement interventions linking activities to intended outcomes.19 Such an approach is relevant to many chronic conditions where disease management involves multiple actors, actions and settings. The development of testable theories and integration of causal reasoning are increasingly advocated in improvement and implementation science as a way to enhance the generalisability of interventions.20 21 Causal diagram modelling,20 the action–effect method19 and the implementation research logic model,22 facilitate the development and communication of intervention programme theory.

The action effect method in particular is intended as a facilitated collaborative process to enhance the practicality of programme theory and to provide an actionable guide for quality improvement teams.19The current study by Imai and colleagues underscores the importance of the link between regular HbA1c testing, better glycaemic control and reduced risk of complications.7 While the causal mechanisms require further investigation, this study provides an important piece of the puzzle. Few interventions target Hba1c testing frequency alone, and this is unlikely to be the sole priority for people with diabetes or their health professionals, given the multiple processes recommended for optimal clinical and self-management. However, given its centrality and profile in diabetes management, targeting HbA1c could be a lever for wider improvement.

The foundation for such an intervention should be a better understanding and more precise articulation of who needs to do what differently, as well as how and why this intervention is expected to change specific processes of care and ultimately improve patient outcomes.Ethics statementsPatient consent for publicationNot required..