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Protecting the safety and health of essential workers who support America’s food security—including the meat, poultry, and pork processing industries—is a top priority for the Occupational Safety and Health Administration (OSHA).OSHA and the Centers for Disease Control and Prevention issued additional guidance to reduce the risk of exposure to the erectile dysfunction and keep workers safe and healthy in the meatpacking and meat processing industries —including those involved in beef, pork, and kamagra canada buy poultry operations. This new guidance provides specific recommendations for employers to meet their obligations to protect workers in these facilities, where people normally work closely together and share workspaces and equipment. Here are eight ways to help minimize meat kamagra canada buy processing workers’ exposure to the erectile dysfunction. Screen workers before they enter the workplace.

If a worker becomes sick, send them home and disinfect their workstation and any tools they used. Move workstations kamagra canada buy farther apart. Install partitions between workstations using strip curtains, plexiglass, or similar materials. To limit spread between groups, kamagra canada buy assign the same workers to the same shifts with the same coworkers.

Prevent workers from using other workers’ equipment. Allow workers to wear face coverings when entering, inside, and exiting the facility. Encourage workers to report any safety and health concerns to their supervisors.OSHA is committed to ensuring that workers and employers in essential industries have clear guidance to keep workers safe and healthy from the erectile dysfunction—including guidance for essential workers in construction, manufacturing, package delivery, kamagra canada buy and retail. Workers and employers who have questions or concerns about workplace safety can contact OSHA online or by phone at 1-800-321-6742 (OSHA).

You can find additional resources and learn more about OSHA’s response to the erectile dysfunction at kamagra canada buy www.osha.gov/erectile dysfunction. Loren Sweatt is the Principal Deputy Assistant Secretary for the U.S. Department of Labor’s Occupation Safety and Health Administration Editor’s Note. It is important to note that information and guidance about erectile dysfunction treatment kamagra canada buy continually evolve as conditions change.

Workers and employers are encouraged to regularly refer to the resources below for updates:[embedded content] The Occupational Safety and Health Administration (OSHA) will host the seventh annual National Safety Stand-Down to Prevent Falls in Construction, Sept. 14-18, 2020. The weeklong event promotes awareness of and training on fall prevention in construction, an industry where falls are particularly common kamagra canada buy. Falls are the leading cause of fatal injury for construction workers.

OSHA is encouraging employers to promote fall safety virtually or while kamagra canada buy employing social distancing practices among small groups. Stand-down events provide employers and workers the opportunity to talk about hazards and provide training on protective methods. OSHA encourages employers to spend time during this week discussing these hazards and reviewing the company’s safety and health programs, goals and expectations. Since OSHA began organizing fall kamagra canada buy prevention stand-down events six years ago, nearly 10 million workers have heard our message that falls are preventable.

OSHA’s stand-down webpage offers information on conducting a successful event and a variety of training and educational resources. Participants also kamagra canada buy can provide feedback after their events and download a personalized certificate of participation. The National Safety Stand-Down to Prevent Falls in Construction is a joint effort between OSHA, the National Institute for Occupational Safety and Health, and the Center for Construction Research and Training. To learn how you can participate, visit www.osha.gov/StopFallsStandDown.

Loren Sweatt is kamagra canada buy the Principal Deputy Assistant Secretary for the U.S. Department of Labor’s Occupational Safety and Health Administration. Follow OSHA on Twitter at @OSHA_DOL..

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Humana named cheap kamagra fast Dr buy cheap kamagra next day delivery. Vivek Garg chief medical officer of its primary care organization on Thursday cheap kamagra fast. He is charged with directing the future of the company's growing but disjointed primary care businesses. Garg, who previously served as CMO of New York-based CareMore Health integrated delivery system, will offer clinical leadership for the Louisville-based insurer's primary care arms, which cheap kamagra fast include the CenterWell Senior Primary Care brand and Conviva Care Centers.

He will report to Renee Buckingham, segment president of primary care at Humana. "Dr. Garg's advanced expertise in patient care, clinical collaboration and innovative care delivery will be instrumental in our continued success," Buckingham said in a news release. "His commitment to both our model—a whole-person approach including physical health, mental wellbeing, and social needs—and to our ongoing evolution is an asset to the organization." Humana did not immediately respond to an interview request and questions about whether Garg was the first CMO of its growing primary care segment.

But his appointment comes as the company expands its retail footprint and services for seniors, echoing moves by other insurers aimed at lowering their cost of care by providing better management of individuals' chronic conditions. The company has been the driving force—and the pocketbook—behind a new kind of senior primary care clinics that have exploded across the U.S. In February 2020, Humana announced a $600 million joint venture with private equity firm Welsh, Carson, Anderson and Stowe to develop senior-focused primary care centers, which operate under its CenterWell brand. WCAS is the majority stakeholder in this venture.

This March, the insurer's Conviva subsidiary paid an undisclosed sum to buy 12 senior clinics in Florida, bringing on more than 200 workers, including 40 doctors, physicians assistants and advanced practice nurses. The deal also added 49 affiliate practices to Conviva's network through downstream participation arrangements.In July, newly-filed public documents revealed that Humana funded development of 40 of Iora Health's 47 clinics, with Iora promising to only serve the insurer's senior members at these primary care centers until July 2020. In June, One Medical announced it would pay $2.1 billion to acquire Iora, in a move to enter the lucrative Medicare Advantage market and trasition from fee-for-service payment. Humana has also helped fund clinics for primary care startup Cano Health and Oak Street Health, which is now the AARP's clinic of choice for its members.

The company also has a joint venture with Miami-based ChenMed, another primary care startup. By early 2022, Humana expects to have opened another 20 new CenterWell Senior Primary Care centers in Georgia, Louisiana and Nevada. By the end of 2021, the company expects to operate 200 CenterWell and Conviva offices nationwide. Providers at these facilities currently see approximately 60,000 Medicare Advantage and traditional Medicare patients, many of whom live in medically underserved areas and are not enrolled in a Humana plan.

"I was drawn to this position not only for its innovative approach to care delivery, but also for the opportunity to work side-by-side with the organization's care teams, whose commitment to caring for seniors holistically and proactively, especially during this difficult kamagra, is inspiring," Garg said in a news release. Humana is the second-largest Medicare Advantage insurer in the nation, with 4.3 million members reported during the company's most recent second quarter ended June 30. The insurer expects to add 475,000 new Medicare Advantage enrollees this year. Medicare Advantage is by far the most profitable line of business for private insurers.Gov.

Andy Beshear signaled Thursday that he wants to reward frontline workers in Kentucky who stayed on the job throughout the kamagra by giving them bonuses.Beshear floated the proposal earlier this week, saying he wants to use $400 million of the state's share of federal kamagra aid to provide health care workers and others with the extra pay next year.On Thursday, the governor delved deeper into his proposal for rewarding workers who put themselves at risk throughout the public health crisis to provide essential services.“My recommendation, as it goes over, is going to limit this for those essential workers that we ultimately come to consensus on that have worked two full years — the two years of the kamagra — in that same job or for the same employer,” he said at a news conference.In the coming days, the Democratic governor intends to send a framework of his proposal to the state's Republican-dominated legislature. He's asking that a “working group” fill in the details — including who would qualify and how much they'd receive. That group should include lawmakers and officials from his administration, he said.“There will be a lot to decide, a lot to communicate about,” Beshear said.Lawmakers would make the final decision on appropriating the federal assistance. The state will have to follow federal guidance in spending the kamagra aid.Beshear said Thursday that he sees the bonuses going to workers who provided essential services, including having considerable interaction with the public.

He again mentioned health care staff, emergency responders, educators, grocery store workers and factory workers employed by companies deemed essential during the kamagra.He also mentioned a larger pool of workers Thursday who should be considered, including those working at farming operations, sanitation employees and workers who kept the electric grid “up and running.” On the government side, he said, state police and local health department personnel should be included.Many Kentucky hospitals have struggled with chronic staffing shortages to treat an influx of erectile dysfunction patients. Some prominent Senate Republicans urged the governor to call lawmakers into a special legislative session this year to direct immediate aid to hospitals to overcome staffing woes.Beshear has said the federal money won’t be available until next year, when lawmakers are back in regular session. He's hoping the promise of bonuses encourages health care workers to stay in their current jobs and resist any temptation to go elsewhere for higher pay..

Humana named kamagra canada buy view website Dr. Vivek Garg chief medical officer of kamagra canada buy its primary care organization on Thursday. He is charged with directing the future of the company's growing but disjointed primary care businesses. Garg, who previously served as CMO of New York-based CareMore Health integrated kamagra canada buy delivery system, will offer clinical leadership for the Louisville-based insurer's primary care arms, which include the CenterWell Senior Primary Care brand and Conviva Care Centers. He will report to Renee Buckingham, segment president of primary care at Humana.

"Dr. Garg's advanced expertise in patient care, clinical collaboration and innovative care delivery will be instrumental in our continued success," Buckingham said in a news release. "His commitment to both our model—a whole-person approach including physical health, mental wellbeing, and social needs—and to our ongoing evolution is an asset to the organization." Humana did not immediately respond to an interview request and questions about whether Garg was the first CMO of its growing primary care segment. But his appointment comes as the company expands its retail footprint and services for seniors, echoing moves by other insurers aimed at lowering their cost of care by providing better management of individuals' chronic conditions. The company has been the driving force—and the pocketbook—behind a new kind of senior primary care clinics that have exploded across the U.S.

In February 2020, Humana announced a $600 million joint venture with private equity firm Welsh, Carson, Anderson and Stowe to develop senior-focused primary care centers, which operate under its CenterWell brand. WCAS is the majority stakeholder in this venture. This March, the insurer's Conviva subsidiary paid an undisclosed sum to buy 12 senior clinics in Florida, bringing on more than 200 workers, including 40 doctors, physicians assistants and advanced practice nurses. The deal also added 49 affiliate practices to Conviva's network through downstream participation arrangements.In July, newly-filed public documents revealed that Humana funded development of 40 of Iora Health's 47 clinics, with Iora promising to only serve the insurer's senior members at these primary care centers until July 2020. In June, One Medical announced it would pay $2.1 billion to acquire Iora, in a move to enter the lucrative Medicare Advantage market and trasition from fee-for-service payment.

Humana has also helped fund clinics for primary care startup Cano Health and Oak Street Health, which is now the AARP's clinic of choice for its members. The company also has a joint venture with Miami-based ChenMed, another primary care startup. By early 2022, Humana expects to have opened another 20 new CenterWell Senior Primary Care centers in Georgia, Louisiana and Nevada. By the end of 2021, the company expects to operate 200 CenterWell and Conviva offices nationwide. Providers at these facilities currently see approximately 60,000 Medicare Advantage and traditional Medicare patients, many of whom live in medically underserved areas and are not enrolled in a Humana plan.

"I was drawn to this position not only for its innovative approach to care delivery, but also for the opportunity to work side-by-side with the organization's care teams, whose commitment to caring for seniors holistically and proactively, especially during this difficult kamagra, is inspiring," Garg said in a news release. Humana is the second-largest Medicare Advantage insurer in the nation, with 4.3 million members reported during the company's most recent second quarter ended June 30. The insurer expects to add 475,000 new Medicare Advantage enrollees this year. Medicare Advantage is by far the most profitable line of business for private insurers.Gov. Andy Beshear signaled Thursday that he wants to reward frontline workers in Kentucky who stayed on the job throughout the kamagra by giving them bonuses.Beshear floated the proposal earlier this week, saying he wants to use $400 million of the state's share of federal kamagra aid to provide health care workers and others with the extra pay next year.On Thursday, the governor delved deeper into his proposal for rewarding workers who put themselves at risk throughout the public health crisis to provide essential services.“My recommendation, as it goes over, is going to limit this for those essential workers that we ultimately come to consensus on that have worked two full years — the two years of the kamagra — in that same job or for the same employer,” he said at a news conference.In the coming days, the Democratic governor intends to send a framework of his proposal to the state's Republican-dominated legislature.

He's asking that a “working group” fill in the details — including who would qualify and how much they'd receive. That group should include lawmakers and officials from his administration, he said.“There will be a lot to decide, a lot to communicate about,” Beshear said.Lawmakers would make the final decision on appropriating the federal assistance. The state will have to follow federal guidance in spending the kamagra aid.Beshear said Thursday that he sees the bonuses going to workers who provided essential services, including having considerable interaction with the public. He again mentioned health care staff, emergency responders, educators, grocery store workers and factory workers employed by companies deemed essential during the kamagra.He also mentioned a larger pool of workers Thursday who should be considered, including those working at farming operations, sanitation employees and workers who kept the electric grid “up and running.” On the government side, he said, state police and local health department personnel should be included.Many Kentucky hospitals have struggled with chronic staffing shortages to treat an influx of erectile dysfunction patients. Some prominent Senate Republicans urged the governor to call lawmakers into a special legislative session this year to direct immediate aid to hospitals to overcome staffing woes.Beshear has said the federal money won’t be available until next year, when lawmakers are back in regular session.

He's hoping the promise of bonuses encourages health care workers to stay in their current jobs and resist any temptation to go elsewhere for higher pay..

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Wealthy nations must do much more, much faster.The United Nations General Assembly sildenafil citrate kamagra kamagra oral jelly wholesalers in September 2021 will bring countries together at a critical time for marshalling collective action to tackle the global environmental crisis. They will meet again at the sildenafil citrate kamagra biodiversity summit in Kunming, China, and the climate conference (Conference of the Parties (COP)26) in Glasgow, UK. Ahead of these pivotal meetings, we—the editors of health journals worldwide—call for urgent action to keep average global temperature increases below 1.5°C, halt the destruction of nature and protect health.Health is already being harmed by global temperature increases and the destruction of the natural world, a state of affairs health professionals have been bringing attention to for decades.1 The science is unequivocal. A global increase of 1.5°C above the preindustrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse.2 3 sildenafil citrate kamagra Despite the world’s necessary preoccupation with erectile dysfunction treatment, we cannot wait for the kamagra to pass to rapidly reduce emissions.Reflecting the severity of the moment, this editorial appears in health journals across the world. We are united in recognising that only fundamental and equitable changes to societies will reverse our current trajectory.The risks to health of increases above 1.5°C are now well established.2 Indeed, no temperature rise is ‘safe’.

In the past 20 years, heat-related mortality among people aged over 65 has increased by more than 50%.4 Higher temperatures have brought increased dehydration and renal function loss, dermatological malignancies, tropical s, adverse mental health outcomes, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality.5 6 Harms disproportionately affect the most vulnerable, including children, older populations, ethnic minorities, poorer communities and those with underlying sildenafil citrate kamagra health problems.2 4Global heating is also contributing to the decline in global yield potential for major crops, falling by 1.8%–5.6% since 1981. This, together with the effects of extreme weather and soil depletion, is hampering efforts to reduce undernutrition.4 Thriving ecosystems are essential to human health, and the widespread destruction of nature, sildenafil citrate kamagra including habitats and species, is eroding water and food security and increasing the chance of kamagras.3 7 8The consequences of the environmental crisis fall disproportionately on those countries and communities that have contributed least to the problem and are least able to mitigate the harms. Yet no country, no matter how wealthy, can shield itself from these impacts. Allowing the consequences to fall disproportionately on the most vulnerable will breed more conflict, food insecurity, forced displacement and zoonotic disease, with severe implications for all countries and communities sildenafil citrate kamagra. As with the erectile dysfunction treatment kamagra, we are globally as strong as our weakest member.Rises above 1.5°C increase the chance of reaching tipping points in natural systems that could lock the world into an acutely unstable state.

This would critically impair our ability to mitigate harms and to prevent catastrophic, runaway environmental change.9 sildenafil citrate kamagra 10Global targets are not enoughEncouragingly, many governments, financial institutions and businesses are setting targets to reach net-zero emissions, including targets for 2030. The cost of renewable energy is dropping rapidly. Many countries are aiming to protect at least 30% of the world’s land and oceans by 2030.11These promises are not sildenafil citrate kamagra enough. Targets are easy to set and hard to achieve sildenafil citrate kamagra. They are yet to be matched with credible short-term and longer-term plans to accelerate cleaner technologies and transform societies.

Emissions reduction plans do not adequately incorporate health considerations.12 Concern is growing that temperature rises above 1.5°C are beginning to be seen as inevitable, or even acceptable, to powerful members of the global community.13 Relatedly, current strategies for reducing emissions to net zero by the middle of the century implausibly assume that the world will acquire great capabilities to remove greenhouse gases from the atmosphere.14 15This insufficient action means sildenafil citrate kamagra that temperature increases are likely to be well in excess of 2°C,16 a catastrophic outcome for health and environmental stability. Critically, the destruction of nature does not have parity of esteem with the climate element of the crisis, and every single global target to restore biodiversity loss by 2020 was missed.17 This is an overall environmental crisis.18Health professionals are united with environmental scientists, businesses and many others in rejecting that this outcome is inevitable. More can and must be sildenafil citrate kamagra done now—in Glasgow and Kunming—and in the immediate years that follow. We join health professionals worldwide who have already supported calls for rapid action.1 19Equity must be at the centre of the global response. Contributing a fair share to the global effort means that reduction commitments must account for the sildenafil citrate kamagra cumulative, historical contribution each country has made to emissions, as well as its current emissions and capacity to respond.

Wealthier countries sildenafil citrate kamagra will have to cut emissions more quickly, making reductions by 2030 beyond those currently proposed20 21 and reaching net-zero emissions before 2050. Similar targets and emergency action are needed for biodiversity loss and the wider destruction of the natural world.To achieve these targets, governments must make fundamental changes to how our societies and economies are organised and how we live. The current strategy of cheap kamagra oral jelly encouraging markets to swap dirty for sildenafil citrate kamagra cleaner technologies is not enough. Governments must intervene to support the redesign of transport systems, cities, production and distribution of food, markets for financial investments, health systems, and much more. Global coordination is needed to ensure that the rush for cleaner technologies does not come at the cost of more environmental destruction and human exploitation.Many sildenafil citrate kamagra governments met the threat of the erectile dysfunction treatment kamagra with unprecedented funding.

The environmental crisis demands sildenafil citrate kamagra a similar emergency response. Huge investment will be needed, beyond what is being considered or delivered anywhere in the world. But such sildenafil citrate kamagra investments will produce huge positive health and economic outcomes. These include high-quality jobs, reduced air pollution, increased physical activity, and improved housing and diet. Better air quality alone would realise health benefits that easily offset the global costs of emissions reductions.22These measures will also improve the social and economic determinants of health, the poor state of which may have made populations more vulnerable to the erectile dysfunction treatment kamagra.23 But the changes cannot be achieved through a return to damaging austerity policies or the continuation of the large inequalities of wealth and power within and between countries.Cooperation hinges on wealthy nations doing moreIn particular, countries that have disproportionately created the environmental crisis must do more to support low-income and middle-income countries to build cleaner, healthier and sildenafil citrate kamagra more resilient societies.

High-income countries must meet and go beyond their outstanding commitment to provide $100 billion a year, making up for any shortfall in 2020 and increasing contributions to and beyond 2025. Funding must be equally split between mitigation and adaptation, including improving the resilience of health systems.Financing should be through grants rather sildenafil citrate kamagra than loans, building local capabilities and truly empowering communities, and should come alongside forgiving large debts, which constrain the agency of so many low-income countries. Additional funding must be marshalled to compensate for inevitable loss sildenafil citrate kamagra and damage caused by the consequences of the environmental crisis.As health professionals, we must do all we can to aid the transition to a sustainable, fairer, resilient and healthier world. Alongside acting to reduce the harm from the environmental crisis, we should proactively contribute to global prevention of further damage and action on the root causes of the crisis. We must sildenafil citrate kamagra hold global leaders to account and continue to educate others about the health risks of the crisis.

We must join in the work to achieve environmentally sustainable health systems before 2040, recognising that this will mean changing clinical practice. Health institutions have already divested more than $42 billion of assets sildenafil citrate kamagra from fossil fuels. Others should join them.4The greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5°C and to restore nature. Urgent, society-wide changes must be made and sildenafil citrate kamagra will lead to a fairer and healthier world. We, as editors of health journals, call for governments and other leaders to act, marking 2021 as the year that the world finally changes course.Ethics statementsPatient consent for publicationNot required.Furukawa et al1 posed sildenafil citrate kamagra the question.

How can we estimate quality-adjusted life years (QALYs) based on Patient Health Questionnaire-9 (PHQ-9) scores?. They recommend equipercentile linking analysis between the depression severity PHQ-9 and preference-based EQ-5D three-level version sildenafil citrate kamagra (EQ-5D-3L. UK value set), the latter used to estimate utility data for QALYs.Furukawa et al1 refer to the process of ‘cross-walking’, whereby the practice of fitting a statistical model to health utility data has been referred to as ‘mapping’ and 'cross-walking’.2 Furukawa et al1 reference two mapping-related papers (their references 7 and 9). However, their analysis seems to have missed rigorous mapping methodology and previous studies which have used these mapping processes, alongside other conceptual considerations when wanting to ‘cross-walk’/‘map’ from a non-preference-based (often condition-specific) measure such as the PHQ-9 to the preference-based EQ-5D-3L. €¦.

Wealthy nations must do much more, much faster.The United Nations General how can i get kamagra Assembly in September 2021 will bring countries kamagra canada buy together at a critical time for marshalling collective action to tackle the global environmental crisis. They will meet again at the biodiversity summit in Kunming, China, and kamagra canada buy the climate conference (Conference of the Parties (COP)26) in Glasgow, UK. Ahead of these pivotal meetings, we—the editors of health journals worldwide—call for urgent action to keep average global temperature increases below 1.5°C, halt the destruction of nature and protect health.Health is already being harmed by global temperature increases and the destruction of the natural world, a state of affairs health professionals have been bringing attention to for decades.1 The science is unequivocal. A global increase of kamagra canada buy 1.5°C above the preindustrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse.2 3 Despite the world’s necessary preoccupation with erectile dysfunction treatment, we cannot wait for the kamagra to pass to rapidly reduce emissions.Reflecting the severity of the moment, this editorial appears in health journals across the world. We are united in recognising that only fundamental and equitable changes to societies will reverse our current trajectory.The risks to health of increases above 1.5°C are now well established.2 Indeed, no temperature rise is ‘safe’.

In the past 20 years, heat-related mortality kamagra canada buy among people aged over 65 has increased by more than 50%.4 Higher temperatures have brought increased dehydration and renal function loss, dermatological malignancies, tropical s, adverse mental health outcomes, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality.5 6 Harms disproportionately affect the most vulnerable, including children, older populations, ethnic minorities, poorer communities and those with underlying health problems.2 4Global heating is also contributing to the decline in global yield potential for major crops, falling by 1.8%–5.6% since 1981. This, together with the effects of extreme weather and soil depletion, is hampering efforts to reduce undernutrition.4 Thriving ecosystems are essential to human health, and the kamagra canada buy widespread destruction of nature, including habitats and species, is eroding water and food security and increasing the chance of kamagras.3 7 8The consequences of the environmental crisis fall disproportionately on those countries and communities that have contributed least to the problem and are least able to mitigate the harms. Yet no country, no matter how wealthy, can shield itself from these impacts. Allowing the kamagra canada buy consequences to fall disproportionately on the most vulnerable will breed more conflict, food insecurity, forced displacement and zoonotic disease, with severe implications for all countries and communities. As with the erectile dysfunction treatment kamagra, we are globally as strong as our weakest member.Rises above 1.5°C increase the chance of reaching tipping points in natural systems that could lock the world into an acutely unstable state.

This would critically impair our ability to mitigate harms and to prevent catastrophic, runaway environmental change.9 10Global targets are not enoughEncouragingly, many governments, financial institutions and businesses are setting targets kamagra canada buy to reach net-zero emissions, including targets for 2030. The cost of renewable energy is dropping rapidly. Many countries kamagra canada buy are aiming to protect at least 30% of the world’s land and oceans by 2030.11These promises are not enough. Targets are easy to set and hard to kamagra canada buy achieve. They are yet to be matched with credible short-term and longer-term plans to accelerate cleaner technologies and transform societies.

Emissions reduction plans do not adequately incorporate health considerations.12 Concern is growing that temperature rises above 1.5°C are beginning to be seen as inevitable, or even acceptable, to powerful members of the global community.13 Relatedly, current strategies for reducing emissions to net kamagra canada buy zero by the middle of the century implausibly assume that the world will acquire great capabilities to remove greenhouse gases from the atmosphere.14 15This insufficient action means that temperature increases are likely to be well in excess of 2°C,16 a catastrophic outcome for health and environmental stability. Critically, the destruction of nature does not have parity of esteem with the climate element of the crisis, and every single global target to restore biodiversity loss by 2020 was missed.17 This is an overall environmental crisis.18Health professionals are united with environmental scientists, businesses and many others in rejecting that this outcome is inevitable. More can and must be done now—in Glasgow and Kunming—and in the immediate years that follow kamagra canada buy. We join health professionals worldwide who have already supported calls for rapid action.1 19Equity must be at the centre of the global response. Contributing a fair share to the global kamagra canada buy effort means that reduction commitments must account for the cumulative, historical contribution each country has made to emissions, as well as its current emissions and capacity to respond.

Wealthier countries will have to cut emissions more quickly, making reductions by 2030 beyond those currently proposed20 21 and reaching net-zero emissions kamagra canada buy before 2050. Similar targets and emergency action are needed for biodiversity loss and the wider destruction of the natural world.To achieve these targets, governments must make fundamental changes to how our societies and economies are organised and how we live. The current strategy of encouraging markets to swap dirty for cleaner technologies is kamagra canada buy not enough. Governments must intervene to support the redesign of transport systems, cities, production and distribution of food, markets for financial investments, health systems, and much more. Global coordination is needed kamagra canada buy to ensure that the rush for cleaner technologies does not come at the cost of more environmental destruction and human exploitation.Many governments met the threat of the erectile dysfunction treatment kamagra with unprecedented funding.

The environmental kamagra canada buy crisis demands a similar emergency response. Huge investment will be needed, beyond what is being considered or delivered anywhere in the world. But such investments will kamagra canada buy produce huge positive health and economic outcomes. These include high-quality jobs, reduced air pollution, increased physical activity, and improved housing and diet. Better air quality alone would realise health benefits that easily offset the global costs of emissions reductions.22These measures will also improve the social and economic determinants of health, the poor state of which may have made populations more vulnerable to the erectile dysfunction treatment kamagra.23 But the changes cannot be achieved through a return to damaging austerity policies or the continuation of the large inequalities of wealth and power within and kamagra canada buy between countries.Cooperation hinges on wealthy nations doing moreIn particular, countries that have disproportionately created the environmental crisis must do more to support low-income and middle-income countries to build cleaner, healthier and more resilient societies.

High-income countries must meet and go beyond their outstanding commitment to provide $100 billion a year, making up for any shortfall in 2020 and increasing contributions to and beyond 2025. Funding must be equally split between mitigation and adaptation, including improving the resilience of health systems.Financing should be through grants rather than loans, building local capabilities and truly empowering communities, and should come kamagra canada buy alongside forgiving large debts, which constrain the agency of so many low-income countries. Additional funding must be marshalled to compensate for inevitable loss and damage caused by the consequences of the environmental crisis.As health professionals, we must do all we can kamagra canada buy to aid the transition to a sustainable, fairer, resilient and healthier world. Alongside acting to reduce the harm from the environmental crisis, we should proactively contribute to global prevention of further damage and action on the root causes of the crisis. We must hold global kamagra canada buy leaders to account and continue to educate others about the health risks of the crisis.

We must join in the work to achieve environmentally sustainable health systems before 2040, recognising that this will mean changing clinical practice. Health institutions have already divested more than $42 billion of assets from fossil kamagra canada buy fuels. Others should join them.4The greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5°C and to restore nature. Urgent, society-wide kamagra canada buy changes must be made and will lead to a fairer and healthier world. We, as editors of health journals, call for governments kamagra canada buy and other leaders to act, marking 2021 as the year that the world finally changes course.Ethics statementsPatient consent for publicationNot required.Furukawa et al1 posed the question.

How can we estimate quality-adjusted life years (QALYs) based on Patient Health Questionnaire-9 (PHQ-9) scores?. They recommend equipercentile linking analysis between the depression severity PHQ-9 and preference-based EQ-5D three-level version (EQ-5D-3L kamagra canada buy. UK value set), the latter used to estimate utility data for QALYs.Furukawa et al1 refer to the process of ‘cross-walking’, whereby the practice of fitting a statistical model to health utility data has been referred to as ‘mapping’ and 'cross-walking’.2 Furukawa et al1 reference two mapping-related papers (their references 7 and 9). However, their analysis seems to kamagra canada buy have missed rigorous mapping methodology and previous studies which have used these mapping processes, alongside other conceptual considerations when wanting to ‘cross-walk’/‘map’ from a non-preference-based (often condition-specific) measure such as the PHQ-9 to the preference-based EQ-5D-3L. €¦.

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Credit. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia in this population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb.

Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition.

In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the two conditions remains unclear,” she says.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition. The other authors on this paper were Ginette A.

Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit. The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors.

- Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows. The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an . These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow.

Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear. To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types.

Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer. €œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

It’s one of those things that doesn’t sound right when you hear it,” says Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a kamagra, which seems to encourage a strong immune response despite the cancer’s lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs.

€œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says. Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

Credit http://www.ec-kolbsheim.site.ac-strasbourg.fr/rentree-des-classes/ kamagra canada buy. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia in this kamagra canada buy population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb.

Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative kamagra canada buy disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence of those with fibroids was compared in patients with and kamagra canada buy without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition.

In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched kamagra canada buy controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the kamagra canada buy two conditions remains unclear,” she says.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type kamagra canada buy of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition. The other authors on this paper kamagra canada buy were Ginette A.

Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit. The New kamagra canada buy England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors.

- Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows kamagra canada buy. The finding, published in the Dec. 21 New England Journal of Medicine, kamagra canada buy could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an . These medicines have had remarkable success kamagra canada buy in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study kamagra canada buy leader Mark Yarchoan, M.D., chief medical oncology fellow.

Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the kamagra canada buy mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear. To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the kamagra canada buy mutational burden of thousands of tumor samples from patients with different tumor types.

Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden kamagra canada buy of that cancer. €œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

It’s one of those things that doesn’t sound kamagra canada buy right when you hear it,” says Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a kamagra, which seems to encourage a strong immune response despite the cancer’s lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs.

€œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says. Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

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The erectile dysfunction treatment kamagra has provided limitless opportunities to compare kamagra online shopping canada buy kamagra online ireland kamagra policies across countries and over time. When the aim is to assess the comparative success of these policies, the comparison requires thinking counterfactually about ‘what would have been’ in some unrealised hypothetical (counterfactual) scenario. Whether generating kamagra online shopping canada modelling projections,1 making data-driven comparisons across countries2 or attributing excess harms,3 causal inference often rests on counterfactual comparisons, even if those comparisons are only implicit. However, in the kamagra, counterfactual analyses that are overly simplistic, uninformative or outright flawed have been an epidemic in their own right.

The examples I explore here are not the worst offenders and my aim is not to criticise them but to use them to illustrate kamagra online shopping canada cautionary lessons. By exploring the theory of counterfactuals and common problems with their use, we can learn to do better. Slow conceptual thinking is needed even in times of fast science.Counterfactuals have played a central role in discussions of kamagra online shopping canada causation in philosophy4 and in the health sciences5 and social sciences6 over the past 50 years. According to a framework popular in these disciplines, an intervention causes some outcome if that outcome represents a difference between two hypothetical scenarios in which only the intervention differs.

Because the scenarios are mutually incompatible, at least one of them is ‘counterfactual’—that is, contrary to what actually kamagra online shopping canada occurs or ‘counter to fact’. Philosophers sometimes think about a counterfactual scenario as an imaginary world that is perfectly identical to the actual world except that the intervention is miraculously altered or manipulated with surgical precision. For instance, if the number of erectile dysfunction treatment cases would be greater in a possible kamagra online shopping canada world that is identical to the real world but in which no kamagra policies were implemented, then we can conclude that those policies prevented erectile dysfunction treatment in the actual world.Scientists and policy-makers cannot make a counterfactual comparison directly because other possible worlds are a fiction (or if they are real then they are inaccessible to us), although they can approximate such a comparison through modelling or using real-world data. A key to doing this well is to first explicitly consider what counterfactual comparison we wish to learn about and then ask what modelling or data would faithfully or usefully represent it.

Unfortunately, it is easy to lose sight of the relevance of the available data for the intended counterfactual comparison and of the relevance of the counterfactual comparison for decision-making.For instance, erectile dysfunction treatment model predictions have frequently been criticised as inaccurate7 and no doubt many of them are. However, it is important to distinguish ‘projections’ of what would occur under a hypothetical scenario (which may be counterfactual) from ‘forecasts’ of what kamagra online shopping canada will actually occur8—a distinction that has not always been marked. Unlike forecasts (such as weather predictions), the accuracy of a counterfactual projection cannot be accurately judged by comparing it to what actually occurred. Schroeder9 identifies ambiguities in the way that modellers at the Institute for Health Metrics and Evaluation at the University of Washington presented predictions from their epidemic model early on, which sometimes kamagra online shopping canada appeared to be projections and sometimes appeared to be forecasts.

This kind of ambiguity makes it difficult to evaluate the performance of a model and to know what upshots to draw from its predictions. For instance, while forecasts can help planners anticipate healthcare resource usage, projections can help decision-makers choose from among alternative public health policies.10Compartment models like one used by Imperial College London1 are more clearly ‘projection models’.8 However, the hypothetical nature of projections allows us to entertain scenarios kamagra online shopping canada that realistically would not occur, creating comparisons with questionable relevance for decision-making. In March 2020, Imperial College modellers claimed that ‘38.7 million lives could be saved’1 by an aggressive viral-suppression strategy after modelling that scenario (among others) and comparing it to an unmitigated kamagra scenario in which no new actions are taken to contain viral spread. But for evaluating the aggressive suppression strategy, the unmitigated scenario is an unrealistic counterfactual because in that scenario everyone—including governments and the kamagra online shopping canada people—behaves as if there were not a kamagra raging.

More informative comparisons contrast alternate anticontagion policies or account for the likelihood of evolving anticontagion behaviour even in the absence of aggressive anticontagion policies.With country-level case data available at a click, many people have made policy comparisons across countries along with inferences regarding the effectiveness of those policies. But comparing one country to another kamagra online shopping canada to infer the comparative effectiveness of stricter and laxer (or simply different) anticontagion policies is fraught because it may not faithfully represent a relevant counterfactual comparison.For example, Bendavid et al2 compared eight countries, including the USA and England, that implemented mandatory stay-at-home orders and business closures with Sweden and South Korea, which did not. To evaluate the effect of these policies on the growth of erectile dysfunction treatment cases, they subtracted case data in Sweden and South Korea from case data in the other eight countries. In this study, Sweden and South Korea are essentially being used to represent a counterfactual USA or England that does not implement restrictive policies.

However, there are important differences between the USA/England and Sweden/South Korea, including social and geographic differences and differences kamagra online shopping canada in implementation of other kamagra interventions. Therefore, it seems highly plausible that a cross-country comparison involving the USA or England on one side and Sweden or South Korea on the other fails to accurately represent the outcomes in a ‘USA versus counterfactual USA’ or ‘England versus counterfactual England’ comparison. Other studies (which are by no means infallible) seek to mitigate this problem by making before-and-after comparisons within a country, pooling data from many countries and attempting to adjust for their differences or running sensitivity analyses to test various assumptions.11 12Finally, many have calculated or estimated excess harms in 2020–2021 and beyond such as excess all-cause mortality13 or excess ‘deaths of despair’.14 Excess harms are typically estimated by measuring a stable baseline level of harm (or a stable trend) in recent years and comparing it to the amount of harm measured since the kamagra began or the amount of harm estimated to occur kamagra online shopping canada in future years. It is often reasonable to interpret excess harm figures as the increase in harm compared with a counterfactual scenario in which the kamagra never happened.

However, it is often more challenging to attribute this kamagra online shopping canada increase to a specific factor such as particular policies. Such a harm attribution relies on a different counterfactual comparison between two worlds in which the erectile dysfunction treatment kamagra is similarly occurring but in which different policies are undertaken. As when measuring beneficial effects, the relevant modelling or data might compare different countries that naturally implemented different polices in 2020–2021 or the same countries before and after the implementation kamagra online shopping canada of certain policies.To illustrate, Niedzwiedz et al3 sought to measure the impact of lockdowns in the UK during 2020 on mental health outcomes through survey results in a longitudinal cohort study. By comparing the prevalence of outcomes such as psychological distress in April 2020 to its prevalence in 2017–2019, they calculated increases or decreases in these outcomes.

However, one cannot attribute changes in these outcomes to particular policies from the time trend data alone because, again, in the relevant counterfactual comparison the presence of the kamagra is kept constant and kamagra online shopping canada only particular policies are allowed to vary.Faced with a devastating kamagra rife with examples of countries that followed different paths, regrets about past choices and new decisions to be made, scientists, policy-makers and the public entertain counterfactual comparisons, comparing what did occur to what would have occurred or what could occur in the future under different scenarios. The ubiquity of models and data available to us makes it possible to provide (more or less reliable) representations of our imagined counterfactual comparisons. But in thinking counterfactually, we must be wary of letting our imagination exceed our data.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe author thanks Sander Greenland for extensive and thoughtful input on multiple drafts of this manuscript as well as anonymous reviewers..

The erectile dysfunction treatment kamagra canada buy kamagra has provided limitless opportunities to compare kamagra buy super kamagra online policies across countries and over time. When the aim is to assess the comparative success of these policies, the comparison requires thinking counterfactually about ‘what would have been’ in some unrealised hypothetical (counterfactual) scenario. Whether generating modelling projections,1 making data-driven comparisons across countries2 or attributing excess harms,3 causal inference often rests on counterfactual comparisons, even if those comparisons kamagra canada buy are only implicit. However, in the kamagra, counterfactual analyses that are overly simplistic, uninformative or outright flawed have been an epidemic in their own right. The examples I explore here are not the worst offenders and my aim is not kamagra canada buy to criticise them but to use them to illustrate cautionary lessons.

By exploring the theory of counterfactuals and common problems with their use, we can learn to do better. Slow conceptual thinking is needed even in times of fast science.Counterfactuals have played a central role in discussions of causation kamagra canada buy in philosophy4 and in the health sciences5 and social sciences6 over the past 50 years. According to a framework popular in these disciplines, an intervention causes some outcome if that outcome represents a difference between two hypothetical scenarios in which only the intervention differs. Because the scenarios are mutually incompatible, at least one of them is ‘counterfactual’—that is, contrary to what actually occurs or ‘counter to fact’ kamagra canada buy. Philosophers sometimes think about a counterfactual scenario as an imaginary world that is perfectly identical to the actual world except that the intervention is miraculously altered or manipulated with surgical precision.

For instance, if the number of erectile dysfunction treatment cases would be greater in a possible world that is identical to the real world kamagra canada buy but in which no kamagra policies were implemented, then we can conclude that those policies prevented erectile dysfunction treatment in the actual world.Scientists and policy-makers cannot make a counterfactual comparison directly because other possible worlds are a fiction (or if they are real then they are inaccessible to us), although they can approximate such a comparison through modelling or using real-world data. A key to doing this well is to first explicitly consider what counterfactual comparison we wish to learn about and then ask what modelling or data would faithfully or usefully represent it. Unfortunately, it is easy to lose sight of the relevance of the available data for the intended counterfactual comparison and of the relevance of the counterfactual comparison for decision-making.For instance, erectile dysfunction treatment model predictions have frequently been criticised as inaccurate7 and no doubt many of them are. However, it is important to distinguish ‘projections’ of what would occur under a hypothetical kamagra canada buy scenario (which may be counterfactual) from ‘forecasts’ of what will actually occur8—a distinction that has not always been marked. Unlike forecasts (such as weather predictions), the accuracy of a counterfactual projection cannot be accurately judged by comparing it to what actually occurred.

Schroeder9 identifies ambiguities in the way that kamagra canada buy modellers at the Institute for Health Metrics and Evaluation at the University of Washington presented predictions from their epidemic model early on, which sometimes appeared to be projections and sometimes appeared to be forecasts. This kind of ambiguity makes it difficult to evaluate the performance of a model and to know what upshots to draw from its predictions. For instance, while forecasts can help planners anticipate healthcare resource usage, projections can help decision-makers choose from among alternative public health policies.10Compartment models like one used by kamagra canada buy Imperial College London1 are more clearly ‘projection models’.8 However, the hypothetical nature of projections allows us to entertain scenarios that realistically would not occur, creating comparisons with questionable relevance for decision-making. In March 2020, Imperial College modellers claimed that ‘38.7 million lives could be saved’1 by an aggressive viral-suppression strategy after modelling that scenario (among others) and comparing it to an unmitigated kamagra scenario in which no new actions are taken to contain viral spread. But for evaluating the aggressive suppression strategy, the unmitigated scenario is an unrealistic counterfactual because in that scenario everyone—including governments and the people—behaves as if there kamagra canada buy were not a kamagra raging.

More informative comparisons contrast alternate anticontagion policies or account for the likelihood of evolving anticontagion behaviour even in the absence of aggressive anticontagion policies.With country-level case data available at a click, many people have made policy comparisons across countries along with inferences regarding the effectiveness of those policies. But comparing one country to another to infer the comparative effectiveness of stricter and laxer (or simply different) anticontagion policies is fraught because it may not faithfully represent a relevant counterfactual comparison.For example, Bendavid et al2 compared eight countries, including the USA and England, that implemented mandatory stay-at-home orders and business closures with Sweden and South Korea, which did not kamagra canada buy. To evaluate the effect of these policies on the growth of erectile dysfunction treatment cases, they subtracted case data in Sweden and South Korea from case data in the other eight countries. In this study, Sweden and South Korea are essentially being used to represent a counterfactual USA or England that does not implement restrictive policies. However, there are important differences between the USA/England and Sweden/South Korea, including kamagra canada buy social and geographic differences and differences in implementation of other kamagra interventions.

Therefore, it seems highly plausible that a cross-country comparison involving the USA or England on one side and Sweden or South Korea on the other fails to accurately represent the outcomes in a ‘USA versus counterfactual USA’ or ‘England versus counterfactual England’ comparison. Other studies (which are by no means infallible) seek to mitigate this problem by making before-and-after comparisons within a country, pooling data from many countries and attempting to adjust for their differences or running sensitivity analyses to test various assumptions.11 12Finally, many have calculated or estimated excess harms in 2020–2021 and beyond such as excess all-cause mortality13 or excess ‘deaths of despair’.14 Excess harms are typically estimated by measuring a stable baseline level of harm (or a stable kamagra canada buy trend) in recent years and comparing it to the amount of harm measured since the kamagra began or the amount of harm estimated to occur in future years. It is often reasonable to interpret excess harm figures as the increase in harm compared with a counterfactual scenario in which the kamagra never happened. However, it is often more challenging to attribute this increase to a specific factor such as particular policies kamagra canada buy. Such a harm attribution relies on a different counterfactual comparison between two worlds in which the erectile dysfunction treatment kamagra is similarly occurring but in which different policies are undertaken.

As when measuring beneficial effects, the relevant modelling kamagra canada buy or data might compare different countries that naturally implemented different polices in 2020–2021 or the same countries before and after the implementation of certain policies.To illustrate, Niedzwiedz et al3 sought to measure the impact of lockdowns in the UK during 2020 on mental health outcomes through survey results in a longitudinal cohort study. By comparing the prevalence of outcomes such as psychological distress in April 2020 to its prevalence in 2017–2019, they calculated increases or decreases in these outcomes. However, one cannot attribute changes in these outcomes to particular policies from the time trend data alone because, again, in the relevant counterfactual comparison the presence of the kamagra is kept constant and only particular policies are allowed to vary.Faced with a devastating kamagra rife with examples of countries that followed different paths, regrets about past choices and new decisions to be made, scientists, policy-makers kamagra canada buy and the public entertain counterfactual comparisons, comparing what did occur to what would have occurred or what could occur in the future under different scenarios. The ubiquity of models and data available to us makes it possible to provide (more or less reliable) representations of our imagined counterfactual comparisons. But in thinking counterfactually, we must be wary of letting our imagination exceed our data.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe author thanks Sander Greenland for extensive and thoughtful input on multiple drafts of this manuscript as well as anonymous reviewers..