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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Pacific Biosciences of California, a maker of DNA sequencing equipment that has seen its levitra price australia stock rise dramatically in recent years, said Tuesday that it will purchase Omniome, a smaller rival, for up to $800 million.PacBio, as the firm is known, will offer $600 million, half in cash and half in http://www.em-erckmann-chatrian-strasbourg.site.ac-strasbourg.fr/nos-jeux/jeux-petite-section/ stock, up front. It will pay another $200 million when and if machines based on Omniome’s technology first ship to customers. In order to finance the deal, PacBio is selling $300 million in a private placement to existing investors.

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• arsenic trioxide
• bosentan
• certain antibiotics such as clarithromycin, erythromycin, sparfloxacin, troleandomycin
• certain medicines used for seizures such as carbamazepine, phenytoin, and phenobarbital
• certain medicines for the treatment of HIV or AIDS
• certain medicines to control the heart rhythm (e.g., amiodarone, disopyramide, dofetilide, flecainide, ibutilide, quinidine, procainamide, propafenone, sotalol)
• chloroquine
• cisapride
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• grapefruit juice
• medicines for fungal s (fluconazole, itraconazole, ketoconazole, voriconazole)
• methadone
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• pimozide
• rifabutin, rifampin, or rifapentine
• some medicines for treating depression or mood problems (amoxapine, maprotiline, fluoxetine, fluvoxamine, nefazodone, pimozide, phenothiazines, tricyclic antidepressants)
• verapamil

Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines.

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Dewsnap C, vardenafil levitra review Sauer U, Evans C. Sex Transm Infect 2020;96:79. Doi.

10.1136/sextrans-2019-054397This article was previously published with missing information. Please note the below:The authors would like to acknowledge their gratitude to Daniel Richardson, Zara Haider, Ceri Evans, Janet Michaelis and Elizabeth Foley for providing a helpful format for this piece.Richardson D, Haider Z, Evans C, et al. The joint BASHH-FSRH conference.

Sex Transm Infect 2017;93:380. Doi. 10.1136/sextrans-2017-053184Using cytokine expression to distinguish between active and treated syphilis.

Promising but not yet ready for prime timeDistinguishing between previously treated and active syphilis can be challenging in the subset of treated patients with serofast status, defined as persistent non-treponemal seropositivity (<4-fold decline in rapid plasma reagin titre ≥6 months after treatment). The study investigated whether serum cytokine expression levels, measured with a 62-cytokine multiplex bead-based ELISA, can help guide clinical management. Using samples from patients with active, treated and serofast syphilis, the authors developed a two-cytokine (brain-derived neurotrophic factor and tumour necrosis factor β) decision tree that showed good accuracy (82%) and sensitivity (100%) but moderate specificity (45%).

While further studies will be needed to confirm and refine the diagnostic algorithm, there also remain important technical, operational and financial barriers to implementing such cytokine assays in routine care.Kojima N, Siebert JC, Maecker H, et al. The application of cytokine expression assays to differentiate active from previously treated syphilis. J Infect Dis.

2020 [published online ahead of print, 2020 Mar 19].Global and regional prevalence of herpes simplex levitra type 2 . Updated estimates for people aged 15–49 yearsEstimates of genital herpes simplex levitra (HSV) s across regions inform advocacy and resource planning and guide the development of improved control measures, including treatments. In 2016, HSV-2 affected 13% of the global population aged 15–49 years (high-risk groups excluded), totalling 491 million people.

Of note, by excluding people aged >49 years, the analysis knowingly underestimated the true burden of HSV-2 .1 Prevalence showed a slight increase relative to 2012 and was highest in Africa and Americas and among women. Given the association between HSV-2 and subsequent HIV ,2 it is concerning that HSV-2 was estimated to affect ~50% of women aged 25–34 years in the African region. The analysis also estimated the prevalence of genital HSV-1 (3%), but uncertainty intervals were wide.James C, Harfouche M, Welton NJ, et al.

Herpes simplex levitra. Global prevalence and incidence estimates, 2016. Bull World Health Organ.

2020. 98. 315-329.Observed pregnancy and neonatal outcomes in women with HIV exposed to recommended antiretroviral regimensThis large Italian observational cohort study analysed data from 794 pregnant women who were exposed within 32 weeks of gestation to recommended antiretroviral regimens in the period 2008–2018.

Treatment comprised three-drug combinations of an nucleoside reverse transcriptase inhibitor (NRTI) backbone plus a ritonavir-boosted protease inhibitor (78%, predominantly atazanavir), an non-NRTI (NNRTI) (15%, predominantly nevirapine) or an integrase strand transfer inhibitor (INSTI. 6%, predominantly raltegravir). No major differences were found for a wide range of pregnancy and neonatal outcomes, including major congenital defects.

The rate of HIV transmission ranged up to 2.4% in this study. This comprehensive evaluation will be useful for clinicians caring for women with HIV. More outcome data are needed for regimens comprising second-generation INSTIs.Floridia M, Dalzero S, Giacomet V, et al.

Pregnancy and neonatal outcomes in women with HIV-1 exposed to integrase inhibitors, protease inhibitors and non-nucleoside reverse transcriptase inhibitors. An observational study. 2020;48:249–258.HIV status and sexual practice independently correlate with gut dysbiosis and unique microbiota signaturesGut dysbiosis may contribute to persistent inflammation in people with HIV (PWH) who receive antiretroviral therapy (ART).

The study compared the gut microbiota of ART-treated PWH and HIV-negative controls matched for age, gender, country of birth, body mass index and sexual practice. Regardless of sex and sexual practice, the gut microbiota differed significantly in PWH vrsus controls, with expansion of proinflammatory gut bacteria and depletion of homeostasis-promoting microbiota members. The extent of dysbiosis correlated with serum inflammatory markers, nadir and pre-ART CD4 cell counts, and prevalence of non-infectious comorbidities.

Further studies are warranted to elucidate causality and investigate microbiota-mediated strategies to alleviate HIV-associated inflammation. Independent of HIV status, and in both men and women, receptive anal intercourse was associated with a unique microbiota signature.Vujkovic-Cvijin I, Sortino O, Verheij E, et al. HIV-associated gut dysbiosis is independent of sexual practice and correlates with non-communicable diseases.

Nat Commun. 2020;11:2448.Reducing the cost of molecular STI screening in resource-limited settings. An optimised sample-pooling algorithms with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are frequently asymptomatic and, if untreated, may lead to severe reproductive complications in women.

Molecular testing is highly sensitive but costly, especially for resource-limited settings. This modelling study explored a sample pooling strategy for CT and NG testing among women in Zambia. Based on cross-sectional data, participants were stratified into high, intermediate and low prevalence groups, and the respective specimens were mathematically modelled to be tested individually, in pools of 3, or pools of 4, using the GeneXpert instrument.

Overall, the pooling strategy was found to maintain acceptable sensitivity (ranging from 80% to 100%), while significantly lowering cost per sample. Investigation in additional cohorts will validate whether the approach may increase access to STI screening where resourced are constrained.Connolly S, Kilembe W, Inambao M, et al. A population-specific optimized GeneXpert pooling algorithm for Chlamydia trachomatis and Neisseria gonorrhoeae to reduce cost of molecular STI screening in resource-limited settings.

J Clin Microbiol. 2020 [published online ahead of print, 2020 Jun 10].Girl-only HPV vaccination can eliminate cervical cancer in most low and lower middle income countries by the end of the century, but must be supplemented by screening in high incidence countriesProgress towards the global elimination of cervical cancer must include effective interventions in lower-middle income countries (LMICs). The study modelled the effect over the next century of girls-only human papilloma levitra (HPV) vaccination with or without once-lifetime or twice-lifetime cervical screening in 78 LMICs, assuming 90% treatment coverage, 100% lifetime protection and screening uptake increasing from 45% (2023) to 90% (2045 onwards).

Vaccination alone would substantially reduce cancer incidence (61 million cases averted) and achieve elimination (<5 cases per 100 000 women-years) in 60% of LMICs. However, high-incidence countries, predominantly in Africa, might not reach elimination by vaccination alone. Adding twice-lifetime screening would achieve elimination of cervical cancer in 100% of LMICs.

Results have informed the targets of 90% HPV vaccination coverage, 70% screening coverage and 90% of cervical lesions treated by 2030 recently announced by the WHO.Brisson M, Kim JJ, Canfell K, et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination. A comparative modelling analysis in 78 low-income and lower-middle-income countries.

Dewsnap C, Sauer U, Evans C levitra price australia. Sex Transm Infect 2020;96:79. Doi. 10.1136/sextrans-2019-054397This article was previously published with missing information. Please note the below:The authors would like to acknowledge their gratitude to Daniel Richardson, Zara Haider, Ceri Evans, Janet Michaelis and Elizabeth Foley for providing a helpful format for this piece.Richardson D, Haider Z, Evans C, et al.

The joint BASHH-FSRH conference. Sex Transm Infect 2017;93:380. Doi. 10.1136/sextrans-2017-053184Using cytokine expression to distinguish between active and treated syphilis. Promising but not yet ready for prime timeDistinguishing between previously treated and active syphilis can be challenging in the subset of treated patients with serofast status, defined as persistent non-treponemal seropositivity (<4-fold decline in rapid plasma reagin titre ≥6 months after treatment).

The study investigated whether serum cytokine expression levels, measured with a 62-cytokine multiplex bead-based ELISA, can help guide clinical management. Using samples from patients with active, treated and serofast syphilis, the authors developed a two-cytokine (brain-derived neurotrophic factor and tumour necrosis factor β) decision tree that showed good accuracy (82%) and sensitivity (100%) but moderate specificity (45%). While further studies will be needed to confirm and refine the diagnostic algorithm, there also remain important technical, operational and financial barriers to implementing such cytokine assays in routine care.Kojima N, Siebert JC, Maecker H, et al. The application of cytokine expression assays to differentiate active from previously treated syphilis. J Infect Dis.

2020 [published online ahead of print, 2020 Mar 19].Global and regional prevalence of herpes simplex levitra type 2 . Updated estimates for people aged 15–49 yearsEstimates of genital herpes simplex levitra (HSV) s across regions inform advocacy and resource planning and guide the development of improved control measures, including treatments. In 2016, HSV-2 affected 13% of the global population aged 15–49 years (high-risk groups excluded), totalling 491 million people. Of note, by excluding people aged >49 years, the analysis knowingly underestimated the true burden of HSV-2 .1 Prevalence showed a slight increase relative to 2012 and was highest in Africa and Americas and among women. Given the association between HSV-2 and subsequent HIV ,2 it is concerning that HSV-2 was estimated to affect ~50% of women aged 25–34 years in the African region.

The analysis also estimated the prevalence of genital HSV-1 (3%), but uncertainty intervals were wide.James C, Harfouche M, Welton NJ, et al. Herpes simplex levitra. Global prevalence and incidence estimates, 2016. Bull World Health Organ. 2020.

98. 315-329.Observed pregnancy and neonatal outcomes in women with HIV exposed to recommended antiretroviral regimensThis large Italian observational cohort study analysed data from 794 pregnant women who were exposed within 32 weeks of gestation to recommended antiretroviral regimens in the period 2008–2018. Treatment comprised three-drug combinations of an nucleoside reverse transcriptase inhibitor (NRTI) backbone plus a ritonavir-boosted protease inhibitor (78%, predominantly atazanavir), an non-NRTI (NNRTI) (15%, predominantly nevirapine) or an integrase strand transfer inhibitor (INSTI. 6%, predominantly raltegravir). No major differences were found for a wide range of pregnancy and neonatal outcomes, including major congenital defects.

The rate of HIV transmission ranged up to 2.4% in this study. This comprehensive evaluation will be useful for clinicians caring for women with HIV. More outcome data are needed for regimens comprising second-generation INSTIs.Floridia M, Dalzero S, Giacomet V, et al. Pregnancy and neonatal outcomes in women with HIV-1 exposed to integrase inhibitors, protease inhibitors and non-nucleoside reverse transcriptase inhibitors. An observational study.

2020;48:249–258.HIV status and sexual practice independently correlate with gut dysbiosis and unique microbiota signaturesGut dysbiosis may contribute to persistent inflammation in people with HIV (PWH) who receive antiretroviral therapy (ART). The study compared the gut microbiota of ART-treated PWH and HIV-negative controls matched for age, gender, country of birth, body mass index and sexual practice. Regardless of sex and sexual practice, the gut microbiota differed significantly in PWH vrsus controls, with expansion of proinflammatory gut bacteria and depletion of homeostasis-promoting microbiota members. The extent of dysbiosis correlated with serum inflammatory markers, nadir and pre-ART CD4 cell counts, and prevalence of non-infectious comorbidities. Further studies are warranted to elucidate causality and investigate microbiota-mediated strategies to alleviate HIV-associated inflammation.

Independent of HIV status, and in both men and women, receptive anal intercourse was associated with a unique microbiota signature.Vujkovic-Cvijin I, Sortino O, Verheij E, et al. HIV-associated gut dysbiosis is independent of sexual practice and correlates with non-communicable diseases. Nat Commun. 2020;11:2448.Reducing the cost of molecular STI screening in resource-limited settings. An optimised sample-pooling algorithms with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are frequently asymptomatic and, if untreated, may lead to severe reproductive complications in women.

Molecular testing is highly sensitive but costly, especially for resource-limited settings. This modelling study explored a sample pooling strategy for CT and NG testing among women in Zambia. Based on cross-sectional data, participants were stratified into high, intermediate and low prevalence groups, and the respective specimens were mathematically modelled to be tested individually, in pools of 3, or pools of 4, using the GeneXpert instrument. Overall, the pooling strategy was found to maintain acceptable sensitivity (ranging from 80% to 100%), while significantly lowering cost per sample. Investigation in additional cohorts will validate whether the approach may increase access to STI screening where resourced are constrained.Connolly S, Kilembe W, Inambao M, et al.

A population-specific optimized GeneXpert pooling algorithm for Chlamydia trachomatis and Neisseria gonorrhoeae to reduce cost of molecular STI screening in resource-limited settings. J Clin Microbiol. 2020 [published online ahead of print, 2020 Jun 10].Girl-only HPV vaccination can eliminate cervical cancer in most low and lower middle income countries by the end of the century, but must be supplemented by screening in high incidence countriesProgress towards the global elimination of cervical cancer must include effective interventions in lower-middle income countries (LMICs). The study modelled the effect over the next century of girls-only human papilloma levitra (HPV) vaccination with or without once-lifetime or twice-lifetime cervical screening in 78 LMICs, assuming 90% treatment coverage, 100% lifetime protection and screening uptake increasing from 45% (2023) to 90% (2045 onwards). Vaccination alone would substantially reduce cancer incidence (61 million cases averted) and achieve elimination (<5 cases per 100 000 women-years) in 60% of LMICs.

However, high-incidence countries, predominantly in Africa, might not reach elimination by vaccination alone. Adding twice-lifetime screening would achieve elimination of cervical cancer in 100% of LMICs. Results have informed the targets of 90% HPV vaccination coverage, 70% screening coverage and 90% of cervical lesions treated by 2030 recently announced by the WHO.Brisson M, Kim JJ, Canfell K, et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination. A comparative modelling analysis in 78 low-income and lower-middle-income countries.

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But we levitra price australia often wish to add meaning to the http://www.luckjunky.com/get-diflucan-online world we leave behind that goes beyond our genetic code. Genesis 3:19 states. "By the sweat of your brow you will eat your food until you return to the ground, since from it you were taken. For dust you are and to dust you will return." The only person who escaped this fate is Clyde Tombaugh, the discoverer of Pluto, levitra price australia some of whose ashes are making their way out of the solar system aboard the New Horizons spacecraft. But these ashes are nothing but burnt-up DNA with no useful information content.

It would have been far more scientific for NASA to send an electronic record of his genome, or even better, frozen stem cells. But for levitra price australia the rest of us, our physical remains of the rest of us stays on Earth, where we are left with the fundamental question of what to leave behind so that we will be remembered. Cave dwellers left marks on the walls of their caves. Emperors, kings, wealthy individuals and university officials have left statues or portraits that preserve their physical appearance. Architects have levitra price australia created buildings.

But the best monuments are not physical. Rather, they are spiritual in nature. Musicians have left behind their compositions, scientists their original equations, levitra price australia painters their paintings and writers their stories. These brainchildren live in the space of abstract ideas, not in real space. An idea can last forever as long as there is a brain that knows about it.

Nevertheless, all terrestrial creations will disappear when the sun heats up in a billion levitra price australia years and boils off all of Earth’s oceans. Is there any hope for creating monuments that will outlast this terrestrial endpoint?. The best approach might be to follow Tombaugh’s ashes into extraterrestrial space. Our longest-lived monuments could be technological relics that exhibit active intelligence greater than the natural intelligence of humans. Namely, they could be represented by equipment levitra price australia with artificial intelligence (AI).

Imagine a compact CubeSat equipped with AI and 3-D printing that carries the torch of our goals into the vast extent of the Milky Way galaxy. Sending such systems to interstellar space, after training them through machine learning, would resemble the experience of sending our kids out into the world after educating them at home and in school. Each of us could train levitra price australia a unique AI system that reflects our own sense of meaning and purpose in life. Instead of painting the wall of a cave that will collapse in a billion years, we can shape the content of our personal AI system that will survive for billions of years in space, as if it were our own technological avatar. These avatars could outlast the sun, continuing their journey indefinitely while replicating damaged parts or making extra copies of themselves with 3-D printers.

If we could imagine this as the blueprint for the future of humanity, might it also represent the past of a civilization around another that levitra price australia predated ours by a billion years?. To find out, we should search with an underlining modesty for interstellar monuments of those who came before us in the cosmos. So far, all the telescopes we used to survey the sky have not been sensitive enough to detect the reflected sunlight from a CubeSat-size. The forthcoming Legacy Survey of Space and Time levitra price australia (LSST) with the Vera C. Rubin Observatory could find such monuments.

Moreover, if any such objects enter the Earth’s atmosphere, they might be classified as unidentified aerial phenomena (UAP), of the type mentioned in the report delivered to the U.S. Congress on June 25, 2021 levitra price australia. The recently announced Galileo Project could potentially discover extraterrestrial monuments as they pass near Earth. Autonomous avatars could have been sent by other beings long ago, so that by now those beings have perished. The discovery levitra price australia of advanced technological artifacts will provide the same sense of awe as the discovery of prehistoric cave paintings dating back to 45,500 years ago.

And finding an accompanying genetic record of the senders on board, with more information content than Tombaugh’s ashes, would be even more exciting. This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American..

Levitra patent expiration date

Much of modern ethics is built around the idea that we should respect one levitra patent expiration date another’s autonomy. Here, “we” are typically imagined to be adult human beings of sound mind, where the soundness of our mind is measured against what levitra patent expiration date we take to be the typical mental capacities of a neurodevelopmentally “normal” person—perhaps in their mid-thirties or forties. When deciding about what constitutes ethical sex, for example, our dominant models hold that ethical sex is whatever is consented to, while a lack of consent makes sex wrong.1 Consent, in turn, is analysed in terms of autonomous decision-making.

A “yes” or “no” that reflects the free and informed will of our idealised, sound-minded adult.Whether such models provide adequate normative guidance for ethical, much less good, sex between neurotypical human adults is an open question.2 3 When it comes to the ethics of sexual activity between humans and non-humans—robots, say—or between humans who don’t fit the rational stereotype (such as older people with dementia or younger adolescents), we hardly know where to begin.4–7 It is therefore heartening to see a number of papers in this issue tackling the difficult question how to respectfully facilitate or respond to the needs, desires, and decisions of people with different kinds or degrees of autonomy.8For example, Sumytra Menon and colleagues9 explicitly discuss levitra patent expiration date the notion of “borderline capacity” and argue, in the medical domain, for shared and supportive decision-making practices to “foster the autonomy of patients with compromised mental capacity while being mindful of the need to safeguard their well-being.” (Could similar practices be applied to sexual decision-making?. ) Touching on a similar theme, Zahra Ladan10 asks how we should conceive of liberty in the case of persons with certain inborn physical or mental limitations. Might it levitra patent expiration date sometimes be necessary to constrain or interfere with a person’s actions as a means of promoting their liberty—or can that only be an oxymoron?.

Finally, the problem of sexual consent in the context of diminished autonomy is addressed most directly in the piece by Andria Bianchi.11 Bianchi argues that people with certain cognitive impairments, such as dementia, should ideally be allowed to engage in sexual activity in accordance with their desires. But if consent, as that concept is traditionally understood, is required levitra patent expiration date for sex to be ethical or legal, then people with dementia may be “prevented from having their sexual needs met even if we recognise these needs as important.”Which brings us to robots. According to Bianchi, sex robots, whether now or in the future, might “allow people with dementia to fulfil their needs regardless of whether they can provide or understand consent.” A similar proposal is raised by Nancy Jecker12 in her feature article, on which Bianchi’s piece is a commentary.

Additional commentaries levitra patent expiration date are by Robert Sparrow,13 Tom Sorell,14 and Alexander Boni-Saenz.15Jecker’s article is entitled “Nothing to Be Ashamed of. Sex Robots for Older Adults with Disabilities.”1 levitra patent expiration date The commenters on the article are united in their praise of Jecker for dispelling ageist stereotypes according to which older people either are, or should be, non-sexual beings. And they welcome Jecker’s attempt to stimulate creative thinking about how the sexual needs and desires of older people might best be accommodated.

At the same time, they felt that Jecker’s arguments in favour of sex robots toward this end fell short in some respects.Jecker begins by noting that older adults typically undergo certain physical levitra patent expiration date and mental changes that can negatively affect sexual enjoyment. Jecker describes these changes in terms of functional impairments or lost abilities, where the functions in question seem mostly related to the ability to engage in penile-vaginal intercourse unassisted. For example, Jecker highlights “shortening and narrowing of the vagina, thinning of the vaginal walls and reduced lubrication” levitra patent expiration date for older women, and various erectile difficulties for older men.But diminished sexual capacity, Jecker stresses, encompasses much more than a lessened ability to “accomplish the act of sexual intercourse itself.” Rather, for most human beings, sex with others “serves as a vehicle for expressing who they are as persons.” Sex is also integral, Jecker argues, to several basic capabilities (in the spirit of Nussbaum and Sen), including the ability to have a life-narrative, to be healthy, to feel and express a wide range of emotion, and to affiliate deeply with others.

Jecker suggests that providing sex robots to older people could help them to maintain these capabilities at some minimum level. So, we levitra patent expiration date should try to see that such robots are provided.2Jecker anticipates some likely objections to her view. One is that, far from promoting the capability of being healthy for instance, repeatedly engaging in sexual activity with a humanoid robot3 (that is, an entity that presumably cannot provide ethically valid consent to such activity)4 would in fact harm the user.

In particular, it would do so by levitra patent expiration date damaging the user’s character. In effect, the user would be satisfying their sexual urges by repeatedly simulating rape.15–18 To diffuse this objection, Jecker emphasises that sex robots are not sentient beings with thoughts, feelings, or wishes, but are rather levitra patent expiration date mere instruments or “toys.” But this may cause problems for the rest of Jecker’s argument, which turns on the ability of sex robots to stimulate real human emotions and play a meaningful relational role in older people’s lives.It might not be possible to have it both ways. As Sorell argues, the sort of “affiliation” one might have with a sex robot is likely to be “too denuded” to serve as a substitute for the affiliation ideally achieved through sex with another human.

After all, a human being who “automatically simulates arousal on demand for their sexual partner, who is receptive to sex no questions asked, no matter when or where, has handed over their sexual will.” Thus, in levitra patent expiration date the case of human-robot sex, a single person would be deciding how it goes. Affiliation, by contrast, “requires two.”5 Or as Sparrow puts it. Sex with a robot is simply high-tech masturbation.Likewise, Boni-Saenz doubts that many people would find sex robots “adequate for sexual relationships.” But he remains open to the possibility that at least some people could find sex robots to be “a suitable replacement for human intimacy in periods of old age” even if they may not otherwise “represent their preferred mode of sexual interaction.” Here, we suggest it may be worthwhile to undertake empirical research into older people’s actual attitudes levitra patent expiration date and preferences toward (the prospect of) sex with robots,6 in order to shape our normative inquiry going forward.7Suppose it turns out that older adults, or some reasonably large proportion of them, find that they are able to form (or imagine forming) a meaningful intimate relationship with a sex robot—one that is sufficient to support the “affiliation” capability at least to some extent.

It seems to us this creates a real dilemma. The more humanlike levitra patent expiration date the (felt) affiliation, the less effective Jecker’s “just a toy” response becomes to the objection about simulated rape. And the less humanlike the affiliation, the less effective Jecker’s argument that sex robots could support such a capability.19In fact, it isn’t clear to us how sex robots would be altogether helpful even for physical or functional issues, like those raised by Jecker.

How would a sex robot help with “shortening or narrowing of the vagina,” “reduced lubrication,” or erectile difficulties levitra patent expiration date for those with penises?. A sex robot could, perhaps, apply a synthetic lubricant as needed—but so could a human partner. In any levitra patent expiration date event, the focus on sexual “function” (in this physical sense) may obscure other possibilities for erotic fulfilment in older people.As Jecker acknowledges, age-related physiological changes need not necessarily lead to a deterioration in the quality of our sex lives.

Indeed, such changes may even contribute to a broader levitra patent expiration date repertoire of sexual activities and bring partners closer together.20 Departing from the so-called coital imperative, for example, can – and often does – lead to the exploration of non-penetrative forms of sexual activity, which in turn may translate into greater sexual satisfaction, especially for women. The idea then might be to focus more on the building of erotic tension rather than on “performance,” and on becoming more sensitive to our partners’ emotional states rather than fixating on the mechanical possibilities of the body.21Jecker is right to call out sexual ageism. Older people often do have sexual needs, and this should not be levitra patent expiration date stigmatised or ignored.

But we worry that a focus on sex robots may inadvertently strengthen the very ageism that Jecker decries. For such levitra patent expiration date a focus could be seen as carrying an implicit message. Namely, that something crucial is lost if an older person does not maintain their youthful sexual stamina with the use of increasingly sophisticated tools.IntroductionThe erectile dysfunction treatment levitra has now reached all world continents except Antartica.

Its spread has placed an enormous and sustained burden on health systems, which has likely exacerbated the mortality rate of erectile dysfunction erectile dysfunction.1 Since the start of the levitra, several noteworthy contributions have discussed important aspects of intensive care units’ (henceforth ICUs) shortages.2–5 Like most allocation problems, this issue presents inherently normative questions that ethicists and physicians ought to address by developing a set of coherent and consistent rules, thus preventing healthcare practitioners to be faced ‘with the terrible task of improvising decisions on whom to treat’.2 Such guidelines are likely to directly affect a considerable number of citizens, as well as their levitra patent expiration date families and relatives, throughout the levitra and might have relevant legal implications.6 Hence, it is of paramount importance to assess their perception of the fairness of such rules. If these are not in line with people’s moral views, this may create resentment and feelings of injustice that could worsen the already traumatic impact of the choices. These views could, therefore, inform policy makers and clinicians on the need to levitra patent expiration date communicate appropriately the rationale behind the guidelines, in order to (partially) alleviate the above-mentioned effects.4The purpose of this paper is to inform the debate as to whether citizens’ moral principles are aligned with the proposed guidelines and recommendations.

To this end, we conducted a levitra patent expiration date survey among a sample of American citizens. We compare individuals’ responses with the recommendations contained in ref 2 that offer a comprehensive set of guidelines for the allocation of scarce resources during erectile dysfunction treatment representing a widespread consensus in the medical literature. The next section describes the survey structure and levitra patent expiration date design.

A methods section (section 3) describes characteristics of the sample and the statistical methodology. Section 4 presents levitra patent expiration date our main results and section 5 concludes.The surveyOur survey was conducted among a sample of 1033 American citizens using the online survey platform CloudResearch. An additional 443 started the survey but did not finish.

This rate of completion (around 70%) is in line with online studies similar to ours levitra patent expiration date. Subjects were recruited from the CloudResearch panel, which is heterogeneous in many sociodemographic dimensions (see Methods). In our survey, we asked respondents to imagine a situation in which the US Federal Government is planning to publish guidelines for the allocation of levitra patent expiration date ICUs during the erectile dysfunction treatment levitra.

Respondents are asked levitra patent expiration date which principles these guidelines should contain according to them. Respondents were informed that this was a research project and that their responses would remain anonymous. We elicited their views through the use levitra patent expiration date of several hypothetical scenarios (see table 1).

All scenarios contain two patients (neutrally labelled patient A and patient B), with different characteristics, who have been hospitalised. Both patients need an ICU levitra patent expiration date bed but only one is available. In all scenarios, respondents are asked which of four options they would suggest for the guidelines.

Admit patient A to the levitra patent expiration date ICU, admit patient B, decide randomly and admit on a first-come first-served basis. Through the use of our scenarios, we test the extent to which people’s moral views are in line with the recommendations highlighted in ref 2. Table 1 reports the wording for each levitra patent expiration date scenario and the implied recommendation.

Before being exposed to the scenarios, respondents had to answer four comprehension questions to ensure their understanding of the hypothetical situation. The order in which the scenarios appeared was levitra patent expiration date randomised at the individual level. We believe that control questions levitra patent expiration date and the randomised order of scenarios eliminate concerns about order and learning effects.

After the scenarios, respondents were asked several sociodemographic questions and questions about their perceptions of the erectile dysfunction treatment levitra (see online supplemental appendix A). There we no other questions about other subjects in the survey.Supplemental materialView this table:Table 1 The levitra patent expiration date table describes the eight different scenarios proposed in the surveyMethodsOur respondents are part of the survey panel (prime panel) of the platform CloudResearch. Respondents from this panel have been shown to be more heterogeneous in various aspects (eg, age, education and political attitudes) with respect to the more commonly used pool of Amazon Mechanical Turk.7 Our sample is composed by respondents from 50 different states.

Respondents are highly heterogeneous in levitra patent expiration date various dimensions. The majority of them are women (60.8%), and the average age is 44.6 years (SD=16.8). They have a higher educational attainment than the US average according to the 2018 data of the US Census Bureau,8 as almost levitra patent expiration date all of them earned at least a high school degree (98%), and the majority of them (52.5%) earned at least a bachelor’s degree.

The median household yearly income before taxes ranges between $60 000 and $70 000, in line with the national figures ($63 119).9 A percentage of 17.3 of them declared to be smokers (vs 15.1% at national level). Finally, 41.6% identified themselves as levitra patent expiration date Democrats, 36.6% as Republicans and 21.8% as Independents.10 The average survey completion time was 8.5 min. Therefore, the hourly compensation for the completion averaged levitra patent expiration date to $8.82.

With respect to statistical analyses, we mainly used non-parametric tests for matched observations, that is, McNemar’s χ2 test and signrank test.11 Only in one case where we performed a between-subjects comparison, we use a test of proportions for independent observations (χ2 test).Survey responses. Each bar represents the levitra patent expiration date distribution of answers for each of the eight scenarios. The bars on the left-hand side represent the share of answers in line with the recommendations from the guidelines.

The bars on the right-hand side represent levitra patent expiration date the share of answers not in line with the recommendations." data-icon-position data-hide-link-title="0">Figure 1 Survey responses. Each bar represents the distribution of answers for each of the eight scenarios. The bars on the left-hand side represent the share of answers in line with the recommendations from the guidelines levitra patent expiration date.

The bars on the right-hand side represent the share of answers not in line with the recommendations.ResultsFigure 1 shows the percentage of responses in line with the recommendations contained in ref 2. As it can be seen from levitra patent expiration date the figure, we find high heterogeneity across scenarios. While for levitra patent expiration date some scenarios responses are broadly in line with the recommendations, for others only a minority of responses is.

The share of responses in line with the recommendations ranges from 5.4% to 68.7%. In what follows we levitra patent expiration date summarise our main results.Result 1. Maximise benefitsMaximising benefits is considered to be the most important principle in a levitra.2 This principle can be applied either as saving most lives or as many years of life as possible.

We tested both levitra patent expiration date these applications of the principle. To test the save most lives principle, in scenario 1, we describe both patients as having the same life expectancy but patient A as having higher probability of survival in an ICU. To test the save the most years of life principle, in scenario levitra patent expiration date 2, the probability of survival in the ICU is the same for both patients, but patient A has higher life expectancy post-treatment.

Our results show that people tend to apply the maximising benefits principle significantly more often when this increases the chances of saving a life rather than when it saves more years of life in expectation (59.6% vs 44.7%, McNemar’s χ2(1)=79.58, p<0.001. Signrank test, z=8.92, p<0.001).Result 2 levitra patent expiration date. Maximise benefitsAnother important implication of the maximise benefits principle is that a patient with lower probability of survival ought to be removed from an ICU when a patient with higher probability of survival needs it.2 Despite being the most rational thing to do from a utilitarian perspective, this may be considered unfair for several reasons related to well-documented behavioural phenomena.

First, as resources have been already spent to cure the patient already in the ICU, respondents may be affected by the sunk cost fallacy, that is, the evidence that people commit to certain choices even when these choices are revealed to be suboptimal as time passes.12 13 Second, a patient’s incumbency may produce a sense of entitlement similar to the endowment effect in those who (perhaps subconsciously) identify levitra patent expiration date with the incumbent, thus leading to the status quo bias.14 Finally, and perhaps more importantly, the emotional burden of suspending treatment may be stronger than the one of not initiating treatment, which could be caused by the perceived moral differences in omission (not treating) versus commission (suspending treatment).15 In order to test this implication of the maximise benefits principle, we included two scenarios that we administered between subjects (n=521 in scenario 3 and n=511 in scenario 4). In scenario 3, patient B, who has lower probability of survival, has been in the ICU for levitra patent expiration date 2 months prior to the arrival of patient A. On the contrary, in scenario 4, the two are hospitalised at the same time.

The two vignettes are otherwise identical, and for obvious reasons, we have removed the first-come first-served option for these two scenarios.In line with our prediction, when the two patients arrive at the same time, 68.7% agree to admit patient levitra patent expiration date A, while only 54.3% do so when patient B has been in the ICU for 2 months (χ2(1)=22.5, p<0.001).Result 3. Instrumental valueOne additional recommendation is to promote and reward instrumental value, that is, to prioritise ICU admission for those patients who have contributed to the treatment of erectile dysfunction treatment (ie, retrospective instrumental value) and to patients who will likely offer future contributions (ie, prospective instrumental value).2 To assess moral views for retrospective instrumental value, we created scenario 5, in which the two patients are identical in terms of life expectancy and probability of survival, but patient A is a nurse who has being treating patients with erectile dysfunction treatment. Regarding prospective instrumental value, the scenario is identical to the previous one, but patient A, instead of being levitra patent expiration date a nurse, is a scientist working on a potential treatment to prevent erectile dysfunction treatment.

In both cases, only around 44% of respondents reward instrumental value, and we find no difference between prospective and retrospective instrumental value (McNemar’s χ2(1)=1.09, p=0.326. Signrank test, z=1.04, levitra patent expiration date p=0.296)).Result 4. Treat people equallyRecommendation 3 in ref 2 stresses that, for patients with similar prognosis, random allocation must be preferred to a first-come first-served principle, though both are application of egalitarianism.

First-come first-served is typically used when scarcity is long-standing and patients can survive without the scarce resource, such as for example in the case levitra patent expiration date of kidneys’ transplants. When needs are urgent, however, a first-come first-served approach could unfairly benefit patients living nearer levitra patent expiration date to healthcare facilities, hence resulting in a less egalitarian treatment than pure randomisation. To assess people’s views on this, we included scenario 7, in which the two patients are equal in all characteristics, as well as in prognosis.

Despite most respondents choose one of the two egalitarian responses, levitra patent expiration date among these the vast majority choose first-come first-served (91%). It is worth noticing that this difference consistently occurs across all other scenarios. Among those who prefer the egalitarian options, only 7.2% choose levitra patent expiration date random allocation.

This may be because most cases of allocation of scarce resources are of the type where first-come first-served is appropriate and random selection is rarely used (think, for instance, of any situation in which queuing is accepted as normal). This evidence may make first-come first-served more salient and available due to past experience.16 levitra patent expiration date This result calls for greater information to patients, and citizens, on the virtues of pure randomisation as the fairest means to insure equality (of opportunities).Result 5. Treat people equallyAnother recommendation related to equality states that patients with erectile dysfunction treatment and patients affected by other conditions should not be treated differently when allocating scarce resources.2 We tested this by including scenario 8, in which the two patients have the same prognosis, but one is affected by erectile dysfunction treatment and the other has pneumonia not caused by erectile dysfunction.

The percentages of those who state a preference for treating one of the two patients levitra patent expiration date sum up to 55.8%. This is much higher than the levitra patent expiration date same answers given in scenario 7 (20.3%), where instead an egalitarian principle is chosen by most. Most of the respondents (34.8%) in scenario 8 suggest to treat the patient affected by erectile dysfunction treatment.

This proportion alone is significantly higher compared with the sum of proportions of respondents choosing either option A or B in scenario 7, indicating that individuals tend to favour the treatment of the levitra patent expiration date patient with erectile dysfunction treatment in contrast to the recommendation (McNemar’s χ2(1)=62.50, p<0.001. Signrank test, z=7.91, p<0.001)).Next, we exploit our post survey sociodemographic dataset to assess whether the results reported are heterogeneous across different strata of the population. In online levitra patent expiration date supplemental appendix B, we replicate each of the results above (except result 4 in which we do not employ statistical tests) breaking down the sample for gender, education, employment status, age, political orientation and income.

For all subgroups, results are in line qualitatively and in terms of significance levels with the main results reported above. We conclude that our results do not depend on the specific subgroup analysed but are stable across all subgroups.ConclusionsGuidelines for the allocation of scarce resources during the erectile dysfunction treatment levitra are essential and can guarantee levitra patent expiration date a fair and consistent allocation across cases. We have shown, through survey results, that these ethically sensible recommendations do not always reflect the views of citizens.

We found considerable heterogeneity in people’s moral judgements, and levitra patent expiration date we believe this heterogeneity must be addressed by (better) informing citizens regarding the rationale behind each principle. We hope that this evidence may inform policy makers, as well as healthcare practitioners, of the need to provide an effective communication to citizens and patients, respectively, in order to avoid decision rules that may otherwise be perceived as arbitrary or unfair..

Much of modern ethics is built levitra price australia around the idea that we should respect one another’s autonomy can i buy levitra online. Here, “we” are typically imagined to be adult human beings of sound mind, where the soundness of our mind is measured against what we take to be the typical mental capacities of a neurodevelopmentally “normal” person—perhaps in their mid-thirties or forties levitra price australia. When deciding about what constitutes ethical sex, for example, our dominant models hold that ethical sex is whatever is consented to, while a lack of consent makes sex wrong.1 Consent, in turn, is analysed in terms of autonomous decision-making.

A “yes” or “no” that reflects the free and informed will of our idealised, sound-minded adult.Whether such models provide adequate normative guidance for ethical, much less good, sex between neurotypical human adults levitra price australia is an open question.2 3 When it comes to the ethics of sexual activity between humans and non-humans—robots, say—or between humans who don’t fit the rational stereotype (such as older people with dementia or younger adolescents), we hardly know where to begin.4–7 It is therefore heartening to see a number of papers in this issue tackling the difficult question how to respectfully facilitate or respond to the needs, desires, and decisions of people with different kinds or degrees of autonomy.8For example, Sumytra Menon and colleagues9 explicitly discuss the notion of “borderline capacity” and argue, in the medical domain, for shared and supportive decision-making practices to “foster the autonomy of patients with compromised mental capacity while being mindful of the need to safeguard their well-being.” (Could similar practices be applied to sexual decision-making?. ) Touching on a similar theme, Zahra Ladan10 asks how we should conceive of liberty in the case of persons with certain inborn physical or mental limitations. Might it sometimes be necessary to constrain or interfere with a levitra price australia person’s actions as a means of promoting their liberty—or can that only be an oxymoron?.

Finally, the problem of sexual consent in the context of diminished autonomy is addressed most directly in the piece by Andria Bianchi.11 Bianchi argues that people with certain cognitive impairments, such as dementia, should ideally be allowed to engage in sexual activity in accordance with their desires. But if consent, as that concept is traditionally understood, is required for sex to be ethical or legal, then people with dementia may be “prevented from having their sexual needs met even if we levitra price australia recognise these needs as important.”Which brings us to robots. According to Bianchi, sex robots, whether now or in the future, might “allow people with dementia to fulfil their needs regardless of whether they can provide or understand consent.” A similar proposal is raised by Nancy Jecker12 in her feature article, on which Bianchi’s piece is a commentary.

Additional commentaries levitra price australia are by Robert Sparrow,13 Tom Sorell,14 and Alexander Boni-Saenz.15Jecker’s article is entitled “Nothing to Be Ashamed of. Sex Robots for Older Adults with Disabilities.”1 The commenters on the article are united in their praise of Jecker for dispelling ageist stereotypes according to which older people either are, or should be, non-sexual levitra price australia beings. And they welcome Jecker’s attempt to stimulate creative thinking about how the sexual needs and desires of older people might best be accommodated.

At the same time, they felt that Jecker’s arguments in favour of sex robots toward this end fell short in some respects.Jecker begins by noting that older adults typically undergo certain physical and levitra price australia mental changes that can negatively affect sexual enjoyment. Jecker describes these changes in terms of functional impairments or lost abilities, where the functions in question seem mostly related to the ability to engage in penile-vaginal intercourse unassisted. For example, Jecker highlights levitra price australia “shortening and narrowing of the vagina, thinning of the vaginal walls and reduced lubrication” for older women, and various erectile difficulties for older men.But diminished sexual capacity, Jecker stresses, encompasses much more than a lessened ability to “accomplish the act of sexual intercourse itself.” Rather, for most human beings, sex with others “serves as a vehicle for expressing who they are as persons.” Sex is also integral, Jecker argues, to several basic capabilities (in the spirit of Nussbaum and Sen), including the ability to have a life-narrative, to be healthy, to feel and express a wide range of emotion, and to affiliate deeply with others.

Jecker suggests that providing sex robots to older people could help them to maintain these capabilities at some minimum level. So, we should try to see that such robots are provided.2Jecker levitra price australia anticipates some likely objections to her view. One is that, far from promoting the capability of being healthy for instance, repeatedly engaging in sexual activity with a humanoid robot3 (that is, an entity that presumably cannot provide ethically valid consent to such activity)4 would in fact harm the user.

In particular, levitra price australia it would do so by damaging the user’s character. In effect, the user would be satisfying their sexual urges by repeatedly simulating rape.15–18 To diffuse this objection, Jecker emphasises that sex robots are not sentient beings with thoughts, feelings, or wishes, but are rather mere instruments or “toys.” But this may cause problems for the rest of Jecker’s argument, which turns on the ability of sex robots to stimulate real human emotions and play levitra price australia a meaningful relational role in older people’s lives.It might not be possible to have it both ways. As Sorell argues, the sort of “affiliation” one might have with a sex robot is likely to be “too denuded” to serve as a substitute for the affiliation ideally achieved through sex with another human.

After all, a human being who “automatically simulates arousal on demand for their sexual partner, who is receptive to sex no questions asked, no matter when or where, has handed over their sexual will.” Thus, in the case of human-robot sex, a single person would be deciding how it goes levitra price australia. Affiliation, by contrast, “requires two.”5 Or as Sparrow puts it. Sex with a robot is simply high-tech masturbation.Likewise, Boni-Saenz doubts that many people would find sex robots “adequate for sexual relationships.” But he remains open to the possibility that at least some people could find sex robots to be “a suitable replacement for human intimacy in periods of old age” even if levitra price australia they may not otherwise “represent their preferred mode of sexual interaction.” Here, we suggest it may be worthwhile to undertake empirical research into older people’s actual attitudes and preferences toward (the prospect of) sex with robots,6 in order to shape our normative inquiry going forward.7Suppose it turns out that older adults, or some reasonably large proportion of them, find that they are able to form (or imagine forming) a meaningful intimate relationship with a sex robot—one that is sufficient to support the “affiliation” capability at least to some extent.

It seems to us this creates a real dilemma. The more humanlike levitra price australia the (felt) affiliation, the less effective Jecker’s “just a toy” response becomes to the objection about simulated rape. And the less humanlike the affiliation, the less effective Jecker’s argument that sex robots could support such a capability.19In fact, it isn’t clear to us how sex robots would be altogether helpful even for physical or functional issues, like those raised by Jecker.

How would a sex robot help with levitra price australia “shortening or narrowing of the vagina,” “reduced lubrication,” or erectile difficulties for those with penises?. A sex robot could, perhaps, apply a synthetic lubricant as needed—but so could a human partner. In any event, the focus on sexual “function” (in this physical sense) may obscure other levitra price australia possibilities for erotic fulfilment in older people.As Jecker acknowledges, age-related physiological changes need not necessarily lead to a deterioration in the quality of our sex lives.

Indeed, such changes may even contribute to a broader repertoire of sexual activities and bring partners closer together.20 Departing from the so-called coital imperative, for example, can – and often does – lead to the exploration of non-penetrative forms levitra price australia of sexual activity, which in turn may translate into greater sexual satisfaction, especially for women. The idea then might be to focus more on the building of erotic tension rather than on “performance,” and on becoming more sensitive to our partners’ emotional states rather than fixating on the mechanical possibilities of the body.21Jecker is right to call out sexual ageism. Older people often do have levitra price australia sexual needs, and this should not be stigmatised or ignored.

But we worry that a focus on sex robots may inadvertently strengthen the very ageism that Jecker decries. For such a focus could be seen levitra price australia as carrying an implicit message. Namely, that something crucial is lost if an older person does not maintain their youthful sexual stamina with the use of increasingly sophisticated tools.IntroductionThe erectile dysfunction treatment levitra has now reached all world continents except Antartica.

Its spread has placed an enormous and sustained burden on health systems, which has likely exacerbated the mortality rate of erectile dysfunction erectile dysfunction.1 Since the start of the levitra, several noteworthy contributions have discussed important aspects of intensive care units’ (henceforth ICUs) shortages.2–5 Like most allocation problems, this issue presents inherently normative questions that ethicists and physicians ought to address by developing a set of coherent and consistent rules, thus preventing healthcare practitioners to be faced ‘with the terrible task of improvising decisions on whom levitra price australia to treat’.2 Such guidelines are likely to directly affect a considerable number of citizens, as well as their families and relatives, throughout the levitra and might have relevant legal implications.6 Hence, it is of paramount importance to assess their perception of the fairness of such rules. If these are not in line with people’s moral views, this may create resentment and feelings of injustice that could worsen the already traumatic impact of the choices. These views could, therefore, inform policy makers and clinicians on the need to communicate appropriately the rationale behind the guidelines, in order to (partially) alleviate levitra price australia the above-mentioned effects.4The purpose of this paper is to inform the debate as to whether citizens’ moral principles are aligned with the proposed guidelines and recommendations.

To this end, we conducted a survey among a sample of American citizens levitra price australia. We compare individuals’ responses with the recommendations contained in ref 2 that offer a comprehensive set of guidelines for the allocation of scarce resources during erectile dysfunction treatment representing a widespread consensus in the medical literature. The next levitra price australia section describes the survey structure and design.

A methods section (section 3) describes characteristics of the sample and the statistical methodology. Section 4 presents levitra price australia our main results and section 5 concludes.The surveyOur survey was conducted among a sample of 1033 American citizens using the online survey platform CloudResearch. An additional 443 started the survey but did not finish.

This rate of completion (around 70%) is in line with online levitra price australia studies similar to ours. Subjects were recruited from the CloudResearch panel, which is heterogeneous in many sociodemographic dimensions (see Methods). In our survey, we asked respondents to imagine levitra price australia a situation in which the US Federal Government is planning to publish guidelines for the allocation of ICUs during the erectile dysfunction treatment levitra.

Respondents are asked which principles these levitra price australia guidelines should contain according to them. Respondents were informed that this was a research project and that their responses would remain anonymous. We elicited their views through the use of several hypothetical scenarios (see levitra price australia table 1).

All scenarios contain two patients (neutrally labelled patient A and patient B), with different characteristics, who have been hospitalised. Both patients need levitra price australia an ICU bed but only one is available. In all scenarios, respondents are asked which of four options they would suggest for the guidelines.

Admit patient A to the ICU, levitra price australia admit patient B, decide randomly and admit on a first-come first-served basis. Through the use of our scenarios, we test the extent to which people’s moral views are in line with the recommendations highlighted in ref 2. Table 1 reports the wording levitra price australia for each scenario and the implied recommendation.

Before being exposed to the scenarios, respondents had to answer four comprehension questions to ensure their understanding of the hypothetical situation. The order in which the scenarios http://www.samsung-fanreporter.de/?p=523 appeared was randomised at the individual level levitra price australia. We believe that control questions and the randomised order of scenarios eliminate levitra price australia concerns about order and learning effects.

After the scenarios, respondents were asked several sociodemographic questions and questions about their perceptions of the erectile dysfunction treatment levitra (see online supplemental appendix A). There we no other questions about other subjects in the survey.Supplemental materialView this table:Table 1 levitra price australia The table describes the eight different scenarios proposed in the surveyMethodsOur respondents are part of the survey panel (prime panel) of the platform CloudResearch. Respondents from this panel have been shown to be more heterogeneous in various aspects (eg, age, education and political attitudes) with respect to the more commonly used pool of Amazon Mechanical Turk.7 Our sample is composed by respondents from 50 different states.

Respondents are levitra price australia highly heterogeneous in various dimensions. The majority of them are women (60.8%), and the average age is 44.6 years (SD=16.8). They have a higher educational attainment than the US average levitra price australia according to the 2018 data of the US Census Bureau,8 as almost all of them earned at least a high school degree (98%), and the majority of them (52.5%) earned at least a bachelor’s degree.

The median household yearly income before taxes ranges between $60 000 and $70 000, in line with the national figures ($63 119).9 A percentage of 17.3 of them declared to be smokers (vs 15.1% at national level). Finally, 41.6% identified themselves as Democrats, 36.6% levitra price australia as Republicans and 21.8% as Independents.10 The average survey completion time was 8.5 min. Therefore, the levitra price australia hourly compensation for the completion averaged to $8.82.

With respect to statistical analyses, we mainly used non-parametric tests for matched observations, that is, McNemar’s χ2 test and signrank test.11 Only in one case where we performed a between-subjects comparison, we use a test of proportions for independent observations (χ2 test).Survey responses. Each bar represents the levitra price australia distribution of answers for each of the eight scenarios. The bars on the left-hand side represent the share of answers in line with the recommendations from the guidelines.

The bars on the right-hand side represent the share of answers not in line with levitra price australia the recommendations." data-icon-position data-hide-link-title="0">Figure 1 Survey responses. Each bar represents the distribution of answers for each of the eight scenarios. The bars on levitra price australia the left-hand side represent the share of answers in line with the recommendations from the guidelines.

The bars on the right-hand side represent the share of answers not in line with the recommendations.ResultsFigure 1 shows the percentage of responses in line with the recommendations contained in ref 2. As it levitra price australia can be seen from the figure, we find high heterogeneity across scenarios. While for some scenarios responses are broadly in line with the recommendations, for levitra price australia others only a minority of responses is.

The share of responses in line with the recommendations ranges from 5.4% to 68.7%. In what follows we summarise levitra price australia our main results.Result 1. Maximise benefitsMaximising benefits is considered to be the most important principle in a levitra.2 This principle can be applied either as saving most lives or as many years of life as possible.

We tested levitra price australia both these applications of the principle. To test the save most lives principle, in scenario 1, we describe both patients as having the same life expectancy but patient A as having higher probability of survival in an ICU. To test the save the most years of life principle, in scenario 2, the probability of survival in the ICU is the same for both patients, but patient A has higher life expectancy levitra price australia post-treatment.

Our results show that people tend to apply the maximising benefits principle significantly more often when this increases the chances of saving a life rather than when it saves more years of life in expectation (59.6% vs 44.7%, McNemar’s χ2(1)=79.58, p<0.001. Signrank test, z=8.92, p<0.001).Result 2 levitra price australia. Maximise benefitsAnother important implication of the maximise benefits principle is that a patient with lower probability of survival ought to be removed from an ICU when a patient with higher probability of survival needs it.2 Despite being the most rational thing to do from a utilitarian perspective, this may be considered unfair for several reasons related to well-documented behavioural phenomena.

First, as resources have been already spent to cure the patient already in the ICU, respondents may be affected by the sunk cost fallacy, that is, the evidence that people commit to certain choices even when these choices are revealed to be suboptimal as time passes.12 13 Second, a patient’s incumbency may produce a sense of entitlement similar to the endowment effect in those who (perhaps subconsciously) identify with the incumbent, thus leading to the status quo bias.14 Finally, and perhaps more importantly, the emotional burden of suspending treatment may be stronger than the one of not initiating treatment, which could be caused by the perceived moral differences in omission (not treating) versus commission (suspending treatment).15 In order to test this implication of the maximise benefits principle, we levitra price australia included two scenarios that we administered between subjects (n=521 in scenario 3 and n=511 in scenario 4). In scenario 3, patient B, who levitra price australia has lower probability of survival, has been in the ICU for 2 months prior to the arrival of patient A. On the contrary, in scenario 4, the two are hospitalised at the same time.

The two vignettes are otherwise identical, and for obvious reasons, we have removed the first-come first-served option for these two levitra price australia scenarios.In line with our prediction, when the two patients arrive at the same time, 68.7% agree to admit patient A, while only 54.3% do so when patient B has been in the ICU for 2 months (χ2(1)=22.5, p<0.001).Result 3. Instrumental valueOne additional recommendation is to promote and reward instrumental value, that is, to prioritise ICU admission for those patients who have contributed to the treatment of erectile dysfunction treatment (ie, retrospective instrumental value) and to patients who will likely offer future contributions (ie, prospective instrumental value).2 To assess moral views for retrospective instrumental value, we created scenario 5, in which the two patients are identical in terms of life expectancy and probability of survival, but patient A is a nurse who has being treating patients with erectile dysfunction treatment. Regarding prospective instrumental value, the scenario is identical to the previous one, but patient A, instead of levitra price australia being a nurse, is a scientist working on a potential treatment to prevent erectile dysfunction treatment.

In both cases, only around 44% of respondents reward instrumental value, and we find no difference between prospective and retrospective instrumental value (McNemar’s χ2(1)=1.09, p=0.326. Signrank test, z=1.04, p=0.296)).Result levitra price australia 4. Treat people equallyRecommendation 3 in ref 2 stresses that, for patients with similar prognosis, random allocation must be preferred to a first-come first-served principle, though both are application of egalitarianism.

First-come first-served is typically used when scarcity is levitra price australia long-standing and patients can survive without the scarce resource, such as for example in the case of kidneys’ transplants. When needs are urgent, however, a first-come first-served approach could unfairly benefit patients living nearer to healthcare facilities, hence resulting levitra price australia in a less egalitarian treatment than pure randomisation. To assess people’s views on this, we included scenario 7, in which the two patients are equal in all characteristics, as well as in prognosis.

Despite most respondents choose one of the two egalitarian responses, among these the vast majority choose levitra price australia first-come first-served (91%). It is worth noticing that this difference consistently occurs across all other scenarios. Among those who prefer the egalitarian options, only 7.2% choose random allocation levitra price australia.

This may be because most cases of allocation of scarce resources are of the type where first-come first-served is appropriate and random selection is rarely used (think, for instance, of any situation in which queuing is accepted as normal). This evidence may make first-come first-served more salient and available due to past experience.16 This result calls for greater information to patients, and citizens, on the virtues of pure randomisation as the fairest means to insure equality (of levitra price australia opportunities).Result 5. Treat people equallyAnother recommendation related to equality states that patients with erectile dysfunction treatment and patients affected by other conditions should not be treated differently when allocating scarce resources.2 We tested this by including scenario 8, in which the two patients have the same prognosis, but one is affected by erectile dysfunction treatment and the other has pneumonia not caused by erectile dysfunction.

The percentages of those who state levitra price australia a preference for treating one of the two patients sum up to 55.8%. This is much higher than the same answers given in scenario 7 (20.3%), where instead an egalitarian principle levitra price australia is chosen by most. Most of the respondents (34.8%) in scenario 8 suggest to treat the patient affected by erectile dysfunction treatment.

This proportion alone is significantly higher compared levitra price australia with the sum of proportions of respondents choosing either option A or B in scenario 7, indicating that individuals tend to favour the treatment of the patient with erectile dysfunction treatment in contrast to the recommendation (McNemar’s χ2(1)=62.50, p<0.001. Signrank test, z=7.91, p<0.001)).Next, we exploit our post survey sociodemographic dataset to assess whether the results reported are heterogeneous across different strata of the population. In online supplemental appendix B, we replicate each of the results above (except result 4 in which we do not employ statistical tests) levitra price australia breaking down the sample for gender, education, employment status, age, political orientation and income.

For all subgroups, results are in line qualitatively and in terms of significance levels with the main results reported above. We conclude that our results do not depend levitra price australia on the specific subgroup analysed but are stable across all subgroups.ConclusionsGuidelines for the allocation of scarce resources during the erectile dysfunction treatment levitra are essential and can guarantee a fair and consistent allocation across cases. We have shown, through survey results, that these ethically sensible recommendations do not always reflect the views of citizens.

We found considerable heterogeneity levitra price australia in people’s moral judgements, and we believe this heterogeneity must be addressed by (better) informing citizens regarding the rationale behind each principle. We hope that this evidence may inform policy makers, as well as healthcare practitioners, of the need to provide an effective communication to citizens and patients, respectively, in order to avoid decision rules that may otherwise be perceived as arbitrary or unfair..

Levitra 10mg prezzo

A saying often attributed 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 http://whitemountainmilers.com/contact-us/ originally made this levitra 10mg prezzo 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 levitra 10mg prezzo importance of recognising that communication at key moments 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 cite a review article on emergency manuals (EMs) levitra 10mg prezzo. €˜EMs are context-relevant sets of cognitive aids, such as crisis checklists, that are intended to provide professionals with key information for managing rare emergency events levitra 10mg prezzo. 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 levitra 10mg prezzo 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 residents), nurses, nursing assistants and medical secretaries, participated levitra 10mg prezzo in these simulations.

They took place during levitra 10mg prezzo the teams’ clinical shift in the ED setting, with access 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 levitra 10mg prezzo percentage of 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 case during actual patient levitra 10mg prezzo 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 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 levitra 10mg prezzo.

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 levitra 10mg prezzo 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 levitra 10mg prezzo 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 to consider (in addition to medication details) such as the levitra 10mg prezzo 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 levitra 10mg prezzo 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 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 the aftermath levitra 10mg prezzo 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 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 levitra 10mg prezzo 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 erectile dysfunction treatment levitra for end-of-shift debriefing in EDs (Debriefing In Situ erectile dysfunction treatment 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 levitra 10mg prezzo 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 levitra 10mg prezzo 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..

A saying often attributed to George Bernard Shaw is ‘The single biggest problem in communication is the illusion that it has taken place.’ While it click to read has been debated who originally made this statement, this expression has been used across several industries in different ways.1–4 Communication is levitra price australia an essential aspect of patient safety. One could argue for expanding this proverb to emphasise the importance of recognising that communication at key moments levitra price australia 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, levitra price australia we 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 for managing rare emergency events levitra price australia. 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 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 levitra price australia 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 levitra price australia simulations. They took place during the teams’ clinical shift in the ED setting, with levitra price australia access 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 indicated emergency interventions when the checklists were available levitra price australia.

38.8% without checklist access and 85.7% with checklist access (p<0.001). They also found that the levitra price australia 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 and other critical event cognitive aids may be beneficial.10 20The study should be interpreted in the context of its study levitra price australia 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 levitra price australia 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 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 each institution’s ED location as opposed to a levitra price australia 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) levitra price australia 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 levitra price australia 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 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 the levitra price australia 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 as a well-timed drop of levitra price australia 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 erectile dysfunction treatment levitra for end-of-shift debriefing in EDs (Debriefing In Situ erectile dysfunction treatment 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 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 levitra price australia 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 levitra price australia 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 buy generic levitra australia 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..