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Seen her? propecia online http://2darray.net/where-to-get-propecia-pills/. An alert has been issued by the New York State Missing Persons Clearing House as they seek the public’s assistance in locating a missing Orange County teenager who has not been seen since March.New York State Police in Monroe are attempting to track down propecia online Harriman resident Jessica Zagrobelny, who was reported missing on Wednesday, March 31, officials announced. Police said that Zagrobelny was last seen wearing a blue Northface sweatshirt and glasses driving a 2016 red Mazda MZ6 with the New York license plate JMG-3328. It is believed that Zagrobelny may be traveling to northeastern propecia online Pennsylvania.

Zagrobelny was described as being 5-foot-5 weighing approximately 115 pounds with black hair and blue eyes. Anyone with information regarding her whereabouts has been asked to contact the New York State Missing Persons Clearinghouse at 1-800-346-3543 or New York propecia online State Police in Monroe at (845) 782-8311. Click here to sign up for Daily Voice's free daily emails and news alerts.A Fairfield County man will take center stage on national television as he debuts on “American Ninja Warrior” on NBC. Ridgefield native propecia online will debut on the popular NBC program at 8 p.m.

On Monday, June 7 to kick off Season 13 of “American Ninja Warrior,” which showcases some of the country’s most talented athletes.The man, 33-year-old Zac Palazzo of Ridgefield, known locally as the “Zac of All Trades” carpenter, has trained for years at different gyms in Fairfield County and ramped up his efforts at various ninja gyms in advance of his American Ninja Warrior debut. A self-proclaimed “super dad,” Palazzo released his nomination video for the show, which showcases his athleticism, shows him juggling fire, skydiving, and propecia online training for the event at multiple area gyms.“One of the biggest reasons I’m here on this season to hit that buzzer is for a good friend of mine, Junior, AKA ‘Survivor Ninja,’” Palazzo said in his submission video. €œHe recently passed away so I’m here to press that button for him and his kids. Junior this propecia online one is for you.“I’m here for that next generation to get outside, be active, do things, get out of those TV screens unless you’re watching ‘American Ninja Warrior,” then I approve.

Click here to sign up for Daily Voice's free daily emails and news alerts.An 18-year-old man has been killed during a single-vehicle rollover crash in Northern Westchester.Jaylan P. Jaijairam, of the Bronx, was killed around 11:05 a.m., Sunday, June 6 on the Taconic State Parkway in Mount Pleasant, said Trooper AJ Hicks.According to Hicks, Jaijairam was driving a propecia online 2020 Dodge Challenger at a high rate of speed and was unable to negotiate a curve. The vehicle rotated 180-degrees before striking the guide rail and overturning, Hicks said.Jaijairam was transported to the Westchester Medical Center by Hawthorne EMS where he was pronounced dead. This investigation remains ongoing propecia online.

Click here to sign up for Daily Voice's free daily emails and news alerts..

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Public engagement propecia hair growth results and input are Read Full Report vital to ACIP’s work. Members of the public are invited to submit comments to ACIP in two ways. (1) written comments submitted via regulations.gov, and/or (2) in-person oral public comment at ACIP meetings.How to Submit a Written Public CommentAny member of the public can submit a written public comment to ACIP propecia hair growth results.

Written comments must be received by December 21, 2020. You may propecia hair growth results submit comments for the December 19 and 20, 2020 ACIP meetings, identified by Docket No. CDC-2020-0124, using the Federal eRulemaking Portalexternal iconexternal icon.

Follow the instructions propecia hair growth results for submitting comments. All submissions received must include the agency name and Docket Number.All relevant comments received will be posted without change to http://regulations.govexternal icon, including any personal information provided. For access to the docket or to read background documents or comments received, go to http://www.regulations.govexternal icon.How to Request to Make an Oral Public CommentThe December 19 propecia hair growth results and 20, 2020 ACIP meeting will be a virtual meeting and will include 30 minutes on December 19th and 60 minutes on December 20th for oral public comment for members of the public.

Oral public comment sessions will occur on both December 19 and 20, 2020. All individuals interested in making an oral public comment are strongly encouraged to submit a request no later than 11:59 p.m., EST, December 18, 2020 as there will be no opportunity to register for oral public comment later than December 18, 2020.If the number of persons requesting to speak is greater than can be reasonably accommodated during the propecia hair growth results scheduled time, CDC will conduct a lottery to determine the speakers for the scheduled public comment session. CDC staff will notify individuals regarding their request to speak by email by noon EST December 19, 2020.

To accommodate the significant interest in participation in the oral public comment session of ACIP meetings, each speaker will be limited to 3 minutes, and each speaker may only speak once per meetingPlease register for the date that corresponds with the propecia hair growth results day that you’d like to make a public comment. Please do not register for both days. Request to Make an Oral Public CommentOral Public Comment for December 19 or 20, 2020 MeetingThe Department of Health and Human Services (HHS) announces that the Centers for Disease Control and Prevention (CDC) will award $140 million for hair loss treatment preparedness and almost $87 million for tracking and testing to 64 jurisdictions, including all 50 states and propecia hair growth results U.S.

Territories. €œStates and other public health jurisdictions are vital propecia hair growth results partners in the hair loss treatment response and especially in the plans for distributing safe and effective hair loss treatments,” said HHS Secretary Alex Azar. €œThis new round of funding will help these awardees continue to plan for and implement their hair loss treatment programs, in collaboration with CDC, Operation Warp Speed, and the private-sector distribution and administration partners that we have enlisted.”hair loss treatment PreparednessThe hair loss Aid, Relief, and Economic Security Act (CARES) funding will provide critical infrastructure support to existing grantees through the Immunizations and treatments for Children cooperative agreement.

These funds, along with previous support of $200 million propecia hair growth results in September, will help awardees continue to prepare to distribute hair loss treatments.hair loss treatment Response Activities. Tracking and testingThe Paycheck Protection Program and Health Care Enhancement Act funding will provide critical support to existing CDC grantees through the agency’s Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) Cooperative Agreement. These efforts will complement treatment implementation activities and focus on three propecia hair growth results targeted areas of activity.

Increasing the use of Advanced Molecular Detection technologies, such as whole genome sequencing of hair loss. Strengthening public propecia hair growth results health laboratory preparedness. And ensuring safe travel through optimized data sharing and communication with international travelers.“These are critical investments at a critical time in the hair loss treatment propecia,” said CDC Director Robert R.

Redfield, M.D propecia hair growth results. €œtreatment is being distributed now, and this additional funding is an important step along the road to restoring some normalcy to our lives and to our country. These investments will also have lasting effects on our Nation’s public health infrastructure, including strengthened capabilities for public health labs across the country.”For more information about CDC’s ongoing support to these jurisdictions, please visit https://www.cdc.gov/hair loss/2019-ncov/downloads/php/funding-update.pdf.

Public engagement and propecia online input are vital to ACIP’s work. Members of the public are invited to submit comments to ACIP in two ways. (1) written comments submitted via regulations.gov, and/or (2) in-person oral public comment at propecia online ACIP meetings.How to Submit a Written Public CommentAny member of the public can submit a written public comment to ACIP. Written comments must be received by December 21, 2020. You may propecia online submit comments for the December 19 and 20, 2020 ACIP meetings, identified by Docket No.

CDC-2020-0124, using the Federal eRulemaking Portalexternal iconexternal icon. Follow the propecia online instructions for submitting comments. All submissions received must include the agency name and Docket Number.All relevant comments received will be posted without change to http://regulations.govexternal icon, including any personal information provided. For access to the docket or to read background documents or comments received, go to http://www.regulations.govexternal icon.How to Request to Make an Oral Public CommentThe December 19 and 20, 2020 propecia online ACIP meeting will be a virtual meeting and will include 30 minutes on December 19th and 60 minutes on December 20th for oral public comment for members of the public. Oral public comment sessions will occur on both December 19 and 20, 2020.

All individuals interested in making an oral public comment are strongly encouraged to submit a request no later than 11:59 p.m., EST, December 18, 2020 as there will be no opportunity to register for oral public comment later than December 18, 2020.If the number of persons requesting to speak is greater than can be reasonably accommodated during the scheduled time, CDC will conduct a lottery to determine the propecia online speakers for the scheduled public comment session. CDC staff will notify individuals regarding their request to speak by email by noon EST December 19, 2020. To accommodate the significant interest in participation in the oral public comment session of ACIP meetings, each speaker will be limited to 3 minutes, and each speaker may only speak once per meetingPlease register for the date that corresponds propecia online with the day that you’d like to make a public comment. Please do not register for both days. Request to Make an Oral Public CommentOral Public Comment for December 19 or 20, 2020 MeetingThe propecia online Department of Health and Human Services (HHS) announces that the Centers for Disease Control and Prevention (CDC) will award $140 million for hair loss treatment preparedness and almost $87 million for tracking and testing to 64 jurisdictions, including all 50 states and U.S.

Territories. €œStates and other public health jurisdictions are vital partners in the hair loss treatment response and especially in the plans for distributing safe and propecia online effective hair loss treatments,” said HHS Secretary Alex Azar. €œThis new round of funding will help these awardees continue to plan for and implement their hair loss treatment programs, in collaboration with CDC, Operation Warp Speed, and the private-sector distribution and administration partners that we have enlisted.”hair loss treatment PreparednessThe hair loss Aid, Relief, and Economic Security Act (CARES) funding will provide critical infrastructure support to existing grantees through the Immunizations and treatments for Children cooperative agreement. These funds, along with previous support of $200 million in September, will help awardees continue to prepare propecia online to distribute hair loss treatments.hair loss treatment Response Activities. Tracking and testingThe Paycheck Protection Program and Health Care Enhancement Act funding will provide critical support to existing CDC grantees through the agency’s Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) Cooperative Agreement.

These efforts will complement treatment implementation activities and propecia online focus on three targeted areas of activity. Increasing the use of Advanced Molecular Detection technologies, such as whole genome sequencing of hair loss. Strengthening public propecia online health laboratory preparedness. And ensuring safe travel through optimized data sharing and communication with international travelers.“These are critical investments at a critical time in the hair loss treatment propecia,” said CDC Director Robert R. Redfield, M.D propecia online.

€œtreatment is being distributed now, and this additional funding is an important step along the road to restoring some normalcy to our lives and to our country. These investments will also have lasting effects on our Nation’s public health infrastructure, including strengthened capabilities for public health labs across the country.”For more information about CDC’s ongoing support to these jurisdictions, please visit https://www.cdc.gov/hair loss/2019-ncov/downloads/php/funding-update.pdf.

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Accidentally took 2 propecia

Ketoacidosis and fluidsThe debate around fluid resuscitation and maintenance in DKA has been smouldering for years, the recent, large PECARN FLUID trial providing some guidance, but, http://subwaycaterstampa.com/four-cols/ not drawing a line under all the issuesIn the light of the study, revisiting the arguments is useful and a group of three papers re-open the accidentally took 2 propecia discussion. The catalyst on this occasion has been the publication of new British Society of Paediatric Endocrinology (BSPED) guidance, recommendations which leave ultimate decision making to the individual clinician but in broad terms suggest an initial resuscitation bolus (of 10 mL/kg) to all children. Our first correspondent, John Lillie on behalf of the South Thames Retrieval Service whose policy has been restrictive since 2008 after three deaths from DKA associated cerebral oedema argues that degree of dehydration (an agreed moot point by all parties) is all too easily overestimated particularly when capillary refill time (prolonged by hypocapnoea inherent to accidentally took 2 propecia ketosis) is used to make the assessment.

Neil Wright on behalf of BPSED argues that once initial resuscitation is completed there is little difference philosophically between the two approachesThe physiology, science and moot points are weighed up in Robert Tasker’s editorial in which one bystander in recent debate, the rate of insulin infusion is also revisited, a lower exposure causing less rapid shifts in osmotic pressure and (theoretically) less risk of cerebral oedema. Here we come full circle in that the number of children developing this complication is so low that even a trial as large as FLUID is potentially underpowered. See pages 1019, 1020 and 917Perinatal encephalopathyThe dangers of over-diagnosis of a vague accidentally took 2 propecia entity are highlighted in Mustayev’s systematic review.

The term perinatal encephalopathy (PE) (sometimes also called the ‘syndrome of intracranial hypertension’) was coined by a Russian paediatrician Iurii Iakunin in the 1970s referring to a range of signs and symptoms thought to be attributable to a perinatal insult, mediated by a rise in intracranial pressure. The notion was admirable, but the accidentally took 2 propecia group of disorders inevitably heterogenous. As the term became more widely used in Eastern European countries, it was sometimes applied to infants and children with transient signs and no discernable pathology.

The nomenclature was (paradoxically) reinforced by the lack of a unifying diagnostic test. The label being at the discretion of the paediatrician or paediatric neuropathologist, to which many of these accidentally took 2 propecia infants were referred. Diagnoses result in treatments and wide range of agents had been used on occasions.

Anticonvulsants, mineral and metabolic supplements, diuretics, cattle-derived neuropeptides, vasoactive agents, psychostimulants, and physical therapies. The issue of the Perinatal Encephalopathy Syndrome has long been on the radar of the WHO, and was the subject of a meeting in St Petersburg in 2007, at which many positive signs of reform were accidentally took 2 propecia seen. This review shows further change, but some areas of continuing concern related to the diagnosis which still appears to be applied in some areas.

These potential harms are both direct and accidentally took 2 propecia indirect and include the failure to diagnose other disorders. Unnecessary follow-up appointments and diagnostic procedures. The development of the vulnerable child syndrome.

And even deferral accidentally took 2 propecia of vaccinations. See page 921After sudden infant deathSUDI is a rare event and a second death in a subsequent child extremely unusual, but to date there has been little data to quantify the recurrence risk and counsel parents. Garstang’s analysis of the Care of the Next Infant database from 2000 to 2015 provides some answers.

Over this period, 6608 live-born accidentally took 2 propecia infants were registered. 171 were first-born infants to mothers whose male partners had previously had an unexplained infant death. 29 unexpected infant deaths following the index death occurred in 26 families, 23 with 2 accidentally took 2 propecia deaths and 3 with three deaths.

The second SUDI rate was estimated as 3.93 per 1000 live births and the third as 115 per 1000 live births. The findings should not, though, engender complacency as there have in the past been convictions for homicide. The risk of repeat SUDI in a family is still 10 times that of the general population, a reflection of inherent genetic risks as well as accidentally took 2 propecia environmental factors such as maternal smoking and unsafe sleeping.

CONI cannot address intrinsic risk factors, but these are very vulnerable families who need comprehensive care and support packages to help them understand safe sleeping, address mental health problems and enhance their parenting capacity. See page 945Emergency steroids and asthma prophylaxisIn a neat and salutary reminder of the reason some children reach the stage of accidentally took 2 propecia requiring rescue oral corticosteroids (OCS) at routine clinic appointments, Willson reviews experience from a quarternary respiratory department with respect to adherence prescribed prophylaxis. In the series 25 children received 32 courses of OCS.

For those episodes with full data, uptake of prescriptions for inhaled corticosteroid prophylaxis, the median uptake over the previous 6 months was only 33% and in only 29% episodes was uptake ≥75% of that prescribed So, rather than just prescribe the emergency course and ascribe it to bad luck or bad asthma… maybe check on adherence. This and related themes are accidentally took 2 propecia explored in Ian Sinha’s Viewpoint exploration of the national respiratory audit database. See pages 993 and 910Monitoring inflammatory bowel diseaseEqually pragmatic is the issue with calprotectin stability described by Haisma.

Stool calprotectin is pivotal in the diagnosis, monitoring of and to treatment modifications in IBD. Often a sample will be taken in the home and dropped off at the lab or sent by post having spent time at room temperature in the accidentally took 2 propecia interim rather than the recommended 4 C. The fall in levels is so great (35% and 46% in Our site extraction buffer) that disease activity will inevitably be underestimated and treatment not increased appropriately.

So, before reducing immune modulating treatment immediately, check how the sample travelled before analysis and, if in any doubt, accidentally took 2 propecia recheck making any changes. See page 996Two letters in the journal focus on the volume of intravenous fluid to be used during resuscitation and early management of paediatric patients presenting with diabetic ketoacidosis (DKA).1 2 The correspondence encapsulates an important debate about intravenous fluids and risk of morbidities, such as cerebral oedema, and provides us with the range in contemporary opinions in the UK.Lillie et al1 use their insights from the South Thames Retrieval service (STRS) and its 20 referring district general hospitals to highlight a concern about the new British Society for Paediatric Endocrinology and Diabetes (BSPED) guideline3 and integrated care pathway4 for the management of DKA. The authors have a network of emergency practice, and they imply that the new emphasis by the BSPED on permissive rather than restrictive (ie, reduced volume rules) intravenous fluids will be disruptive to the measures that they have taken since dealing with three cerebral oedema deaths in their region.

Wright and Thomas2 have responded on behalf of the BSPED DKA interest group accidentally took 2 propecia. They emphasise the importance of adequate intravenous fluid resuscitation in limiting morbidity. They also provide an instructive table2 showing fluid resuscitation and rehydration volumes used in a number of protocols, including that of STRS and the new BSPED approach.

The main differences come down to the estimate of fluid deficit, the use of an intravenous fluid bolus at presentation and the calculation of maintenance fluid requirements.The STRS approach assumes a 10% fluid deficit in all patients with DKA at presentation, versus the new BSPED guideline’s accidentally took 2 propecia use of three levels in estimated fluid deficit based on severity of acidosis (ie, pH >7.2, 5%. PH 7.1 to 7.2, 7%. And pH accidentally took 2 propecia <7.1, 10%).

In the STRS approach, an intravenous fluid bolus of 10 mL/kg normal saline (NS) is reserved for patients in shock. In contrast, the new BSPED guideline recommends that all patients with DKA receive an intravenous bolus of 10 mL/kg NS, with an extra 10 mL/kg NS (20 mL/kg in total) for those in shock. Last, in the STRS protocol, the 10% fluid deficit is repaired over 48 hours by adding the accidentally took 2 propecia volume to restrictive or so-called reduced volume rules for maintenance intravenous requirements and for body weight (ie, up to 10 kg, 2 mL/kg/hour.

10–14 kg, 1 mL/kg/hour and >40 kg, fixed volume 40 mL/hr). The new BSPED guideline also recommends replacing the presumed fluid deficit over 48 hours, but this hourly volume is added to standard (and higher than reduced volume rules) maintenance intravenous fluids.4 5Now, add to this mixture of opinions, the UK National Institute for Health and Care accidentally took 2 propecia Excellence (NICE) latest updated pathway for DKA in children and young people.6 Like the new BSPED guideline, NICE also estimates fluid deficit based on severity of acidosis. However, severity of fluid deficit is dichotomised to 5% or 10% based on whether pH is above or below 7.1, respectively.

Like the STRS approach, there is no routine use of an intravenous NS fluid bolus in severe DKA. Last, like the STRS approach the estimated fluid deficit is repaired over 48 hours by adding accidentally took 2 propecia the hourly volume to maintenance requirement calculated using reduced volume rules.How can there be such variance in opinion and recommendations and what should we do?. To be fair, the new BSPED guideline3 was only ever ‘… an interim recommendation pending the publication of the future NICE review.’ But, more importantly, the BSPED website acknowledges that the onus for decision-making remains with the clinician.

A similar stance on responsibility of guideline users is also taken by NICE.The new information that seems to have influenced the BSPED and the NICE updates on DKA is the Pediatric Emergency Care Applied Research Network (PECARN) clinical trial of fluid infusion rates for paediatric DKA (FLUID trial).7 It is worth re-reading the paper and its protocol and supplementary appendix, in particular have a look at Figure S1 on compliance to assigned fluid rate. The bottom line of the FLUID trial is that neither the rate of administration (fast vs slow repair) nor the sodium chloride content (NS vs 0.45% saline) of intravenous fluids significantly influenced neurological accidentally took 2 propecia outcomes. Wright and Thomas2 show in their table that the difference between fast and slow repair in the trial was complex and not only included a difference in timing of fluid-deficit repair (ie, fast with 50% repair in first 12 hours followed by 50% repair in next 24 hours vs slow repair evenly distributed over 48 hours).

It also involved differences in presumed fluid deficit (10% vs 5%) and use of intravenous NS accidentally took 2 propecia boluses (20 mL/kg vs 10 mL/kg). Close review of the compliance to assigned fluid rate in the FLUID trial (see Supplemental Figure S17) shows that actual fluid received by patients in the fast and slow repair groups are similar to those suggested by the BSPED and STRS/NICE, respectively. If there is no difference in neurological outcome, does the difference in fluid strategy really matter, as each of our correspondents argue?.

To attempt to answer this question we have to look at two key details accidentally took 2 propecia of the FLUID trial. The first is that of the 1389 patients undergoing randomisation, 1263 (91%) had Glasgow Coma Scale (GCS) score 15, 99 (7%) had GCS score 14 and 28 (2%) had GCS score <14. In essence, the test of fast versus slow fluid strategy is strongly influenced by patients with DKA who are fully awake at presentation.

Both of our correspondents1 2 acknowledge that patients with altered mental state raise accidentally took 2 propecia concern, although their approaches differ—on this matter we have no answer from the FLUID trial. The other detail to consider is that the uniformly used standard insulin infusion rate (0.1 U/kg/hour) differs from the dosing range (0.05 to 0.1 U/kg/hour) used in UK practice.3 4 6 One theoretical aim of low-dose insulin (0.05 U/kg/hour)8 9 is to avoid too rapid decrease in serum glucose concentration (ie, >5.5 mmol/L/hour), with consequent too rapid change in serum osmolarity, which may increase the risk of cerebral oedema.10 11 Does this idea mean that the low-dose insulin strategy enables better tolerance of fast-fluid repair rate, with low risk of morbidity?. Impossible to answer accidentally took 2 propecia.

As we see from the FLUID trial, such a proposition—with an outcome of brain injury in less than 1% of DKA episodes—is likely untestable in a future sufficiently powered clinical trial.Taking all the above together, there is clearly a need to realign the variance in DKA fluid management reflected in the STRS,1 BSPED2–4 and NICE6 approaches. Even though we have gold standard clinical information from the PECARN DKA FLUID trial,7 the relevance of that information to all paediatric patients presenting with DKA needs careful consideration. Which means that clinicians still need accidentally took 2 propecia to exercise judgement in individual situations.

Finally, the letter by Lillie et al1 also reminds us of the value of systems of care. Their hub-and-spoke network for emergency DKA care is not just about adopting latest recommendations but is also tasked with bringing about any necessary knowledge-to-action change (see the table and figure 2 as responses to three cerebral oedema DKA deaths),1 a process called implementation science.12.

Ketoacidosis and fluidsThe debate around fluid resuscitation and maintenance in DKA has been smouldering for years, the recent, large PECARN FLUID trial providing buy propecia in canada some guidance, but, not drawing a line under propecia online all the issuesIn the light of the study, revisiting the arguments is useful and a group of three papers re-open the discussion. The catalyst on this occasion has been the publication of new British Society of Paediatric Endocrinology (BSPED) guidance, recommendations which leave ultimate decision making to the individual clinician but in broad terms suggest an initial resuscitation bolus (of 10 mL/kg) to all children. Our first correspondent, John Lillie on behalf of the South Thames Retrieval Service whose policy propecia online has been restrictive since 2008 after three deaths from DKA associated cerebral oedema argues that degree of dehydration (an agreed moot point by all parties) is all too easily overestimated particularly when capillary refill time (prolonged by hypocapnoea inherent to ketosis) is used to make the assessment. Neil Wright on behalf of BPSED argues that once initial resuscitation is completed there is little difference philosophically between the two approachesThe physiology, science and moot points are weighed up in Robert Tasker’s editorial in which one bystander in recent debate, the rate of insulin infusion is also revisited, a lower exposure causing less rapid shifts in osmotic pressure and (theoretically) less risk of cerebral oedema.

Here we come full circle in that the number of children developing this complication is so low that even a trial as large as FLUID is potentially underpowered. See pages 1019, 1020 and 917Perinatal encephalopathyThe dangers of over-diagnosis of a vague entity propecia online are highlighted in Mustayev’s systematic review. The term perinatal encephalopathy (PE) (sometimes also called the ‘syndrome of intracranial hypertension’) was coined by a Russian paediatrician Iurii Iakunin in the 1970s referring to a range of signs and symptoms thought to be attributable to a perinatal insult, mediated by a rise in intracranial pressure. The notion was admirable, propecia online but the group of disorders inevitably heterogenous.

As the term became more widely used in Eastern European countries, it was sometimes applied to infants and children with transient signs and no discernable pathology. The nomenclature was (paradoxically) reinforced by the lack of a unifying diagnostic test. The label propecia online being at the discretion of the paediatrician or paediatric neuropathologist, to which many of these infants were referred. Diagnoses result in treatments and wide range of agents had been used on occasions.

Anticonvulsants, mineral and metabolic supplements, diuretics, cattle-derived neuropeptides, vasoactive agents, psychostimulants, and physical therapies. The issue of the Perinatal Encephalopathy Syndrome has long been on the radar of the WHO, and was the subject of a meeting in St Petersburg in 2007, at which many positive signs propecia online of reform were seen. This review shows further change, but some areas of continuing concern related to the diagnosis which still appears to be applied in some areas. These potential harms are both direct and indirect and include the propecia online failure to diagnose other disorders.

Unnecessary follow-up appointments and diagnostic procedures. The development of the vulnerable child syndrome. And even deferral propecia online of vaccinations. See page 921After sudden infant deathSUDI is a rare event and a second death in a subsequent child extremely unusual, but to date there has been little data to quantify the recurrence risk and counsel parents.

Garstang’s analysis of the Care of the Next Infant database from 2000 to 2015 provides some answers. Over this propecia online period, 6608 live-born infants were registered. 171 were first-born infants to mothers whose male partners had previously had an unexplained infant death. 29 unexpected infant deaths following the index death occurred in 26 propecia online families, 23 with 2 deaths and 3 with three deaths.

The second SUDI rate was estimated as 3.93 per 1000 live births and the third as 115 per 1000 live births. The findings should not, though, engender complacency as there have in the past been convictions for homicide. The risk of repeat SUDI in a family is still 10 times that of the general population, a reflection of inherent genetic risks as well as propecia online environmental factors such as maternal smoking and unsafe sleeping. CONI cannot address intrinsic risk factors, but these are very vulnerable families who need comprehensive care and support packages to help them understand safe sleeping, address mental health problems and enhance their parenting capacity.

See page 945Emergency steroids and asthma prophylaxisIn a neat and salutary reminder of the reason some children reach the stage of requiring rescue oral corticosteroids propecia online (OCS) at routine clinic appointments, Willson reviews experience from a quarternary respiratory department with respect to adherence prescribed prophylaxis. In the series 25 children received 32 courses of OCS. For those episodes with full data, uptake of prescriptions for inhaled corticosteroid prophylaxis, the median uptake over the previous 6 months was only 33% and in only 29% episodes was uptake ≥75% of that prescribed So, rather than just prescribe the emergency course and ascribe it to bad luck or bad asthma… maybe check on adherence. This and related themes propecia online are explored in Ian Sinha’s Viewpoint exploration of the national respiratory audit database.

See pages 993 and 910Monitoring inflammatory bowel diseaseEqually pragmatic is the issue with calprotectin stability described by Haisma. Stool calprotectin is pivotal in the diagnosis, monitoring of and to treatment modifications in IBD. Often a sample will propecia online be taken in the home and dropped off at the lab or sent by post having spent time at room temperature in the interim rather than the recommended 4 C. The fall in levels is so great (35% and 46% in extraction buffer) that disease activity will inevitably be underestimated and treatment not increased appropriately.

So, before reducing immune modulating treatment propecia online immediately, check how the sample travelled before analysis and, if in any doubt, recheck making any changes. See page 996Two letters in the journal focus on the volume of intravenous fluid to be used during resuscitation and early management of paediatric patients presenting with diabetic ketoacidosis (DKA).1 2 The correspondence encapsulates an important debate about intravenous fluids and risk of morbidities, such as cerebral oedema, and provides us with the range in contemporary opinions in the UK.Lillie et al1 use their insights from the South Thames Retrieval service (STRS) and its 20 referring district general hospitals to highlight a concern about the new British Society for Paediatric Endocrinology and Diabetes (BSPED) guideline3 and integrated care pathway4 for the management of DKA. The authors have a network of emergency practice, and they imply that the new emphasis by the BSPED on permissive rather than restrictive (ie, reduced volume rules) intravenous fluids will be disruptive to the measures that they have taken since dealing with three cerebral oedema deaths in their region. Wright and Thomas2 have propecia online responded on behalf of the BSPED DKA interest group.

They emphasise the importance of adequate intravenous fluid resuscitation in limiting morbidity. They also provide an instructive table2 showing fluid resuscitation and rehydration volumes used in a number of protocols, including that of STRS and the new BSPED approach. The main differences come down to the estimate of fluid deficit, the use of an intravenous fluid bolus at presentation and the calculation of maintenance fluid requirements.The STRS approach assumes a 10% fluid deficit in all patients with DKA at presentation, versus the new BSPED guideline’s use of three levels in estimated fluid deficit based on severity of acidosis (ie, pH >7.2, 5% propecia online. PH 7.1 to 7.2, 7%.

And pH <7.1, 10%) propecia online. In the STRS approach, an intravenous fluid bolus of 10 mL/kg normal saline (NS) is reserved for patients in shock. In contrast, the new BSPED guideline recommends that all patients with DKA receive an intravenous bolus of 10 mL/kg NS, with an extra 10 mL/kg NS (20 mL/kg in total) for those in shock. Last, in the STRS protocol, the 10% fluid deficit is repaired over 48 hours by adding the volume to restrictive or so-called propecia online reduced volume rules for maintenance intravenous requirements and for body weight (ie, up to 10 kg, 2 mL/kg/hour.

10–14 kg, 1 mL/kg/hour and >40 kg, fixed volume 40 mL/hr). The new BSPED guideline also recommends replacing the presumed fluid deficit over 48 hours, but this hourly volume is added to standard (and higher than reduced volume rules) maintenance intravenous fluids.4 5Now, add to this mixture of opinions, the UK National Institute for Health propecia online and Care Excellence (NICE) latest updated pathway for DKA in children and young people.6 Like the new BSPED guideline, NICE also estimates fluid deficit based on severity of acidosis. However, severity of fluid deficit is dichotomised to 5% or 10% based on whether pH is above or below 7.1, respectively. Like the STRS approach, there is no routine use of an intravenous NS fluid bolus in severe DKA.

Last, like the STRS approach the propecia online estimated fluid deficit is repaired over 48 hours by adding the hourly volume to maintenance requirement calculated using reduced volume rules.How can there be such variance in opinion and recommendations and what should we do?. To be fair, the new BSPED guideline3 was only ever ‘… an interim recommendation pending the publication of the future NICE review.’ But, more importantly, the BSPED website acknowledges that the onus for decision-making remains with the clinician. A similar stance on responsibility of guideline users is also taken by NICE.The new information that seems to have influenced the BSPED and the NICE updates on DKA is the Pediatric Emergency Care Applied Research Network (PECARN) clinical trial of fluid infusion rates for paediatric DKA (FLUID trial).7 It is worth re-reading the paper and its protocol and supplementary appendix, in particular have a look at Figure S1 on compliance to assigned fluid rate. The bottom line of the FLUID trial is that neither the rate of administration (fast vs slow repair) nor the propecia online sodium chloride content (NS vs 0.45% saline) of intravenous fluids significantly influenced neurological outcomes.

Wright and Thomas2 show in their table that the difference between fast and slow repair in the trial was complex and not only included a difference in timing of fluid-deficit repair (ie, fast with 50% repair in first 12 hours followed by 50% repair in next 24 hours vs slow repair evenly distributed over 48 hours). It also involved differences in presumed fluid deficit (10% vs 5%) and use of intravenous NS boluses propecia online (20 mL/kg vs 10 mL/kg). Close review of the compliance to assigned fluid rate in the FLUID trial (see Supplemental Figure S17) shows that actual fluid received by patients in the fast and slow repair groups are similar to those suggested by the BSPED and STRS/NICE, respectively. If there is no difference in neurological outcome, does the difference in fluid strategy really matter, as each of our correspondents argue?.

To attempt to answer this question we have to look at two key details of propecia online the FLUID trial. The first is that of the 1389 patients undergoing randomisation, 1263 (91%) had Glasgow Coma Scale (GCS) score 15, 99 (7%) had GCS score 14 and 28 (2%) had GCS score <14. In essence, the test of fast versus slow fluid strategy is strongly influenced by patients with DKA who are fully awake at presentation. Both of our correspondents1 propecia online 2 acknowledge that patients with altered mental state raise concern, although their approaches differ—on this matter we have no answer from the FLUID trial.

The other detail to consider is that the uniformly used standard insulin infusion rate (0.1 U/kg/hour) differs from the dosing range (0.05 to 0.1 U/kg/hour) used in UK practice.3 4 6 One theoretical aim of low-dose insulin (0.05 U/kg/hour)8 9 is to avoid too rapid decrease in serum glucose concentration (ie, >5.5 mmol/L/hour), with consequent too rapid change in serum osmolarity, which may increase the risk of cerebral oedema.10 11 Does this idea mean that the low-dose insulin strategy enables better tolerance of fast-fluid repair rate, with low risk of morbidity?. Impossible propecia online to answer. As we see from the FLUID trial, such a proposition—with an outcome of brain injury in less than 1% of DKA episodes—is likely untestable in a future sufficiently powered clinical trial.Taking all the above together, there is clearly a need to realign the variance in DKA fluid management reflected in the STRS,1 BSPED2–4 and NICE6 approaches. Even though we have gold standard clinical information from the PECARN DKA FLUID trial,7 the relevance of that information to all paediatric patients presenting with DKA needs careful consideration.

Which means propecia online that clinicians still need to exercise judgement in individual situations. Finally, the letter by Lillie et al1 also reminds us of the value of systems of care. Their hub-and-spoke network for emergency DKA care is not just about adopting latest recommendations but is also tasked with bringing about any necessary knowledge-to-action change (see the table and figure 2 as responses to three cerebral oedema DKA deaths),1 a process called implementation science.12.

Buy propecia online

Clear evidence for a weekend effect was first demonstrated buy propecia online by Bell and Redelmeier1 who examined 3.8 million emergency admissions between 1988 and 1997 in an http://agilexperts.co.uk/can-you-buy-over-the-counter-levitra/ acute care hospital in Ontario. They had noted that staffing levels were lower buy propecia online in acute care hospitals at weekends and hypothesised that this might lead to poorer care and higher mortality. To test this hypothesis, they identified three conditions (ruptured abdominal aortic aneurysm, acute epiglottitis and pulmonary embolism) for which lower staffing on admission was expected to have consequences in outcomes, as well as three control conditions for which this would not be the case. In addition, they conducted an analysis without a prespecified hypothesis, examining the 100 conditions responsible for buy propecia online most deaths.

After adjustment for illness severity, they found higher mortality for conditions expected to be affected by lower staffing and no increase for control conditions. From the 100 medical conditions examined, 23 had significantly increased mortality risk for buy propecia online weekend admissions. These two sets of findings provided strong evidence for a weekend effect, suggesting that for some conditions lower staffing on admission affected standards of care and thereby patient outcomes.Since then, dozens of studies of the weekend effect have been conducted, mostly in the UK and the USA.2 In Britain, the issue became much more high profile after an intervention in 2015 by the Secretary of State who suggested that 11 000 patients were unnecessarily dying at the weekend.3 4 This claim was challenged at the time,5 and many pointed out that the National Health Service (NHS) was already a 7-day service.6 7 However, concern about the weekend led eventually to the introduction of ‘7 day services’ in the NHS in England. A new set of 10 clinical standards was introduced to reduce differences between weekend and weekday services, including increased involvement of consultants in the first 24 buy propecia online hours of admission.8 9 A cross-sectional analysis covering the period before introduction showed no association between specialist intensity and weekend admission mortality.10 Nevertheless, the programme did lead to many NHS hospital trusts reorganising services to reduce differences in care delivery across the 7-day week.

The reorganisation of services did not affect clinical outcomes11 nor was adoption of the clinical standards associated with any significant change in the magnitude of the weekend effect.12Possible underlying mechanisms. The weekend as proxy variableRecent systematic reviews have concluded that the weekend effect does exist, but the explanation for the finding is unclear.2 4 13–17 Patients admitted to hospital at the weekend are more likely to die than those during weekdays with ORs of buy propecia online 1.16 (all studies)2 and 1.07 (UK studies),4 with reviews for some specific disease categories reporting higher ORs.2 13 The quality of studies is highly variable, with findings being influenced by methodological, clinical and service configuration factors2 with ongoing debate about likely mechanisms. Why has it been so difficult to elucidate possible mechanisms?. To go more deeply into this, we need to consider what role the weekend is playing in the design of all buy propecia online these studies.Bell and Redelmeier1 used two distinct designs in their original investigation, which might best be defined as an investigation of staffing levels and mortality.

In their first analysis, the weekend is used as a proxy measure for differences in staffing. They targeted specific conditions such buy propecia online as ruptured abdominal aortic aneurysm for which staffing on admission was deemed likely to have an important impact on patient outcomes. Their second analysis took the opposite approach, by examining overall outcomes at the weekend and then speculating about which factors might explain any observed differences. Most subsequent studies have used the second approach, which has made it difficult to make progress buy propecia online on identifying the relevant factors driving any effect.

If we do not define the questions and hypothesised relationships precisely, then we will not be able to identify how care delivered to patients is affected and which factors are responsible for poorer outcomes. Critically, if we cannot identify the factors, then we cannot intelligently propose interventions to improve patient care.We therefore need to examine how the weekend as a proxy variable for staffing buy propecia online levels fits into the conceptual model. Is the proxy only associated with the determinant, often assumed to be staffing levels, or also with other possible confounders or factors that affect the outcome in question?. We recognise there are multiple possible sets of relationships, but examining three of buy propecia online them is sufficient to make the general argument.

Figure 1 displays three possible sets of relationships, which correspond with three broad hypotheses about potential mechanisms and hence the interpretation of the weekend effect.Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing." data-icon-position data-hide-link-title="0">Figure 1 Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing.Levels of staffing on admission is the dominant influence on quality of care and mortality (panel A)This shows the ‘ideal’ and simplest situation when the proxy weekend/weekday variable is primarily associated with staffing in the first hours or days. The implied mechanism is that lower numbers of staff, buy propecia online particularly senior staff, lead to poorer care and increased mortality. In that situation, weekend–weekday mortality differences, after adjustment for patient mix, can be presumed to be due to staffing differences. Bell and Redelmeier specifically tested this scenario by selecting those conditions for which the first few days of admission are critical, that are buy propecia online treatable and where death may be rapid.

For these conditions, insufficient staffing levels at admission (determinant) might cause delay in care processes (intermediate variable) and higher mortality (outcome).Patients at weekends are sicker and more likely to die (panel B)As many studies have shown, the weekend is associated with confounding variables. Patients admitted buy propecia online at the weekend are known to be sicker18 19 and are less likely to be admitted from emergency departments despite attendance rates being similar.16 20 Studies attempt to control for severity of condition and other confounders, but there is general agreement that it is simply not possible to control for all potential factors (and confounding by indication). There is always the possibility that, even after adjustment for severity of buy propecia online illness and other patient variables, that differences in outcome are due to other patient factors that, for whatever reason, could not be included in the calculations. So for many conditions, this is an important alternative pathway to consider.Multiple factors affect care at the weekend, which in turn increases mortality (panel C)This model underlies the second approach by Bell and Redelmeier and many subsequent studies.

The basic hypothesis is buy propecia online that patient outcomes differ between weekend and weekday, but this may be due to multiple relationships and multiple interrelated variables. For instance, the average seniority or specialty level may differ between the groups of nurses and medical staff working during weekdays and weekends, and such differences in skill-mix may affect patient outcomes.21–23 Access to diagnostic tests or other ancillary services might also differ between weekends and weekdays, or there may be factors further along the patient pathway (in subsequent days after admission) such as how quickly any deterioration on the ward is detected. In this buy propecia online scenario, uncertainty about the mechanisms of the weekend effect makes it very difficult to identify targeted interventions to improve outcomes for patients admitted at the weekend.The assumed intermediate variable of worse quality of careHypotheses 1 and 3 have the same intermediate variable, that quality of care is poorer at the weekend—although for different reasons—and that this is the reason for higher mortality. Investigating this particular proposal requires, as many have noted, ‘painstaking detective work’,24 but few studies have directly examined the quality of care provided during weekdays and at weekends.

In this issue of buy propecia online BMJ Quality &. Safety, Bion and colleagues therefore add crucial evidence with their impressive and comprehensive study.25 They reviewed the quality of care delivered by examining case records from 4000 non-operative medical emergency admissions in 20 acute hospital trusts before and after introduction of the ‘7-day services’ in England. Records were randomly sampled from each trust, equally divided between the two time periods and weekend versus weekday admissions buy propecia online. They found that rates of errors and adverse events were not significantly different between weekdays and weekends and that this was the case both before and after introduction of the ‘7-day services’.

They also made a direct assessment of intensity of senior medical staffing buy propecia online by comparing hours of consultant time per 10 emergency admissions between Sundays and Wednesdays. This specialist intensity ratio was much lower at weekends (0.51 overall) and improved slightly (from 0.47 to 0.58) across periods. Their study therefore does not offer support for quality of care being worse at the weekend or that senior staff involvement at buy propecia online an early point in the patient’s admission is significantly associated with overall quality of care. We should note, however, that operative patients were excluded, so it remains possible that care is poorer for some other groups of patients.The implicit assumption in many previous studies, and most political discourse, is that the weekend is simply a reflection and proxy for lower levels of skilled staff, particularly medical staff.

Proxy variables are of course used all the time in research and can be very helpful if they are ‘close’ to the variable buy propecia online of interest. For instance, we might use the prescription record of a medication as a proxy for the actual medication administered to the patient. We are then confident of what the proxy means and how it relates to buy propecia online the actual variable of interest. Even though some patients may decide not to collect their medication or be non-adherent in taking it, interpreting the proxy is relatively straightforward.In contrast, the weekend/weekday comparison is a distant and complex proxy.

Care could potentially be different for a whole buy propecia online variety of reasons, which are only partly dependent on levels of skilled medical staff. Diagnostic tests and investigations may not be readily available. Coordination between different specialties may be problematic within the hospital or between buy propecia online primary and secondary care and so on. Each of these may cause delay in a care process that may (in combination) affect patient outcomes.

In addition, conditions vary in the extent to which delays in the first few days are critical buy propecia online in preventing death. Some primarily require skilled staff on admission, while others are more vulnerable to buy propecia online later deterioration on wards and need care from experienced nurses in the days following admission.Should we continue studying the weekend effect?. We do not doubt that studies of the weekend effect have been worthwhile. Clearly, the higher mortality at buy propecia online weekends originally identified 20 years ago merited investigation.

The question is whether it is worthwhile to continue to conduct similar studies in the future given the limited funding and research time available. What avenues of inquiry are most likely to benefit patients? buy propecia online. The ultimate aim of all concerned is to improve care given to patients. The weekend effect is only important as a buy propecia online potential marker of other problems.

Local reviews of mortality or other indices of quality should always be alert to variations in the quality of care over the week, and consider whether care is poorer at weekends or indeed at any particular time of the day, week or year. However, we consider that there is no buy propecia online reason to carry out further studies that simply demonstrate a weekend effect. We need instead to turn our attention to the factors directly influencing quality of care for which the weekend has been a proxy.Bion and colleagues provide a valuable illustration of research that examines the presumed causal relationships, looking at the actual care processes and so give a clearer indication of what kind of intervention might most benefit patients. Their study found that care had improved over time but that about 15% buy propecia online of patients received partial care and a small percentage received very poor care.25 These problems occurred throughout the week, affecting the larger volume of patients treated on weekdays.

Following the example of the study by Bion et al, future studies could directly assess standards of care and the factors that most powerfully influence quality. A notable example is the study by Jayawardana and colleagues,26 showing that the increased mortality for out-of-hours admissions buy propecia online with ST-elevation acute myocardial infarction was explained by differences in door-to-needle time, identifying the specific care process on which interventions should be targeted. To improve clinical practice, we need evidence that will help us design targeted interventions to influence the quality of care delivered and thereby patient outcomes.The ‘7-day services’ initiative was introduced in England without a clear understanding of the causes of the weekend effect. The intervention, while well intentioned, was therefore buy propecia online poorly targeted.

Rather than a one-size-fits all initiative to increase consultant intensity, we should consider the much harder question on how to spend the same money to maximum effect. Consultant time is scarce and so should be tailored to the time, place buy propecia online and particular conditions where it is most beneficial over the week as a whole. For some patients though, more rapid access to diagnostic tests or the increased use of skilled nurses during recovery may be much more critical to improving outcomes. Studies of the weekend effect drew attention to potentially dangerous levels buy propecia online of staffing that undoubtedly posed risks to patients.

At this point, however, we need more precise studies that directly examine standards of care and the factors that influence the care delivered. We can then define and target interventions effectively and make best use of scarce resources.Ethics statementsPatient consent for publicationNot required.The Harvard Medical Practice Study brought the issue of patient safety into the public buy propecia online eye and demonstrated that patients are often harmed by the care they receive.1 It used retrospective chart review to identify adverse events. Since its publication in 1991, considerable focus has been placed on trying to improve the methods for understanding the prevalence of harm in hospitals. These efforts have led to deeper understanding of the relative strengths buy propecia online and weaknesses of the tools we currently have for adverse event identification.

Still, most organisations do not have robust approaches for tracking all types of harm routinely. Other efforts buy propecia online have sought to assess safety not just in hospitals but across national health systems, and at one point in time, and to track and trend.Developing better approaches for measuring safety routinely is critical if we are to understand how many patients are being harmed, what the primary causes are and whether care is getting safer or less safe. However, it is also work that needs to be contextualised and the limitations of our tools must be appreciated.2 3The Irish National Adverse Event Study 2 buy propecia online (INAES-2) is presented in this issue.4 In this study, Connolly and colleagues used retrospective chart review to find adverse events at eight Irish hospitals in 2015 and compare these to previously reported data from 2009. Retrospective chart review was the first method used in this space5 6 and is still a mainstay for national studies assessing rates of adverse events,7–12 although approaches using claims data are also used widely and are much less expensive though much less sensitive.13 The original approach using retrospective chart review relied on information exclusively gathered from retrospective review of randomly selected medical records, but it has since been bolstered by the creation of standardised triggers,14 and more rigorous methods for chart review which make it more sensitive for finding adverse events, and more reliable.

Despite this, retrospective chart buy propecia online review has many limitations, most notably the level of agreement between abstractors and its reliance on the completeness of documentation in medical charts.15The issue of reliance on documentation is especially important. There have been well-conceived critiques that have raised concern related to underdocumentation of errors that occur in hospitals, as well as those that have raised concern that the findings from longitudinal studies looking at trends may be confounded by improved documentation resulting in an overestimation of the true (comparative) incidence of events. These are buy propecia online both legitimate concerns. The INAES-2 study, as in prior similar work looking at multi-institution adverse event rates over time,16 17 showed an increase in events over time but no change in preventable harm.

We are left not knowing if this represents a change in safety or a change in buy propecia online documentation.These concerns have led other investigators to develop adverse event identification approaches to enable more real-time identification, leveraging a broader set of data for the interpretation of the preventability and impact of these events.18 19 Prospective event identification, or the near real-time application of triggers, can also incorporate the perspectives of staff in the clinical environment around the time of the event to provide additional insights. Even with this more comprehensive, contemporaneous collection of data however, agreement continues to be variable between reviewers.20–22Looking to spontaneous reporting from front-line staff, rather than retrospectively or prospectively monitoring for triggers, is another method that has been proposed as a mechanism for identifying the prevalence of adverse events over time. Similar to documentation, however, concerns exist about the under-reporting of events by buy propecia online front-line staff in safety reporting systems.23 24 Moreover, spontaneous reporting routinely underestimates the incidence of adverse events for some types of events by a factor of 20.25The inverse is also likely true that advances in safety culture may increase reporting, without any change in the frequency of actual events. Indeed, in the INAES-2 study, the researchers found that although safety reports increased threefold, adverse event rates did not change.

This highlights the challenge of using safety buy propecia online reports alone as a proxy for adverse events. Instead, the insights from safety reporting may hold promise for other uses in the safety space, such as providing a signal for the degree of staff engagement in safety, enabling the identification of near misses and facilitating the identification of significant events that require root cause analysis.Because of the variability that exists in the methods mentioned, many investigators have attempted to identify more reliable ways to identify adverse events. Several studies have employed reimbursement codes (in the USA, International Classification of Diseases Ninth Revision codes) as a mechanism to screen for adverse events.26–28 These systems, which aim to identify complications of medical care by looking for codes that are highly associated with adverse events, have largely been shown to be ineffective.29 30 This is likely to be multifactorial, buy propecia online with an inability to identify which conditions predated the current healthcare encounter, a lack of incentives to use coding to identify adverse events and their limited ability to accurately capture the full clinical picture all contributing to their limited efficacy.31Other approaches have leveraged information systems to screen for adverse events, which is almost certainly how this will be done in the future.32 This works better for some categories of events than for others. Identification for some events is relatively straightforward, for example, for the development of acute kidney injury in which there is a biomarker to track (rise in creatinine), which routinely appears when the event is present.

However, the identification buy propecia online of newly altered mental status, for example, is much more challenging. For events such as falls, which are almost always documented in electronic health record (EHR) systems, this also works well. Commercial products buy propecia online that sift through data from the EHR are available to find adverse events for inpatients, while the situation regarding adverse event detection is much less advanced in the ambulatory setting, even though EHR use is widespread in developed countries. Among the main types of inpatient adverse events, hospital-acquired s, adverse drug events and falls can readily be detected in inpatients, while the situation is more complex for deep venous thromboses/pulmonary emboli, surgical injuries, specific types of pressure ulcers and missed diagnoses.32 Novel approaches that are highly effective for identifying wrong patient errors have been developed, such as ‘retract and reorder’ detection, which identifies these errors effectively.33 This has led to interventions such as showing the photograph of a patient to the ordering clinician, which reduced the likelihood of a wrong patient order by 43% in one study.34 Still, most organisations do not have a robust sense of how often their patients experience adverse events across the spectrum of care.The challenge of adverse event identification is multiplied by the importance of understanding one moment in time and, as the authors in the INAES-2 study aim to do, trying to look at trends.

This will be essential as we continue to buy propecia online mobilise large efforts to improve safety and as these compete with other priorities. As with all work in quality, having robust metrics is vital. In safety, buy propecia online however, we have in many ways been ‘flying blind’—initiating large-scale efforts to decrease the rate of adverse events without having reliable ways to measure their prevalence over time.It is important to emphasise that this lack of insight into performance is not equally distributed across all categories of adverse events.3 In fact, as proposed recently by Shojania and Marang-van de Mheen, the incidence of adverse events may be best understood as a composite measure—with all of the limitations that come with looking at a measure with many composite parts.35 When broken apart, what we come to understand is that some of our mechanisms for identifying certain types of events are likely much more reliable than others. In the USA, for example, where the Agency for Healthcare Research and Quality has leveraged standardised methods for collecting and reporting national performance on a set of specific healthcare-associated s, we have much better insight into performance over time related to such healthcare-associated s than we do, for instance, with diagnostic error.Lastly, the challenge of interpreting national adverse event data over time is complicated by the nuances associated with the interfaces between politics and science.

In our personal experience, we have encountered challenges reporting results of safety studies that are tied to ministries of health.36 Related to the INAES-2 study specifically, Ireland has a long history of sensationalised media coverage of data pointing to opportunities for improved care, further complicating buy propecia online researchers’ ability to conduct this work free of influence.37Ultimately, the work presented by Connolly and colleagues is critically important work and we suggest that all health systems should be monitoring adverse event rates over time. The mechanisms for doing this, though, should rapidly evolve. With hospitals increasingly buy propecia online leveraging EHRs, data being collected in more uniform ways and advances in natural language processing and artificial intelligence, a future in which we have reliable measures of adverse events that are stable over time is likely within our reach. To get from here to there, an ongoing investment in research with evaluation including leveraging artificial intelligence and natural language processing, and a commitment to transparent data reporting and enabling collaboration between organisations and governments focused on this work is essential.38 If we can achieve this, we could reasonably expect a future in which we have access to publicly available meaningful data on how many people are being harmed, and in what context, which could in turn transform safety.Ethics statementsPatient consent for publicationNot required..

Clear evidence for a weekend effect propecia online was first demonstrated by Bell and Redelmeier1 who examined 3.8 million emergency admissions between 1988 and 1997 in an acute care Can you buy over the counter levitra hospital in Ontario. They had noted that staffing levels were lower in acute care hospitals at weekends and hypothesised that this might lead propecia online to poorer care and higher mortality. To test this hypothesis, they identified three conditions (ruptured abdominal aortic aneurysm, acute epiglottitis and pulmonary embolism) for which lower staffing on admission was expected to have consequences in outcomes, as well as three control conditions for which this would not be the case. In addition, they conducted an analysis without a propecia online prespecified hypothesis, examining the 100 conditions responsible for most deaths. After adjustment for illness severity, they found higher mortality for conditions expected to be affected by lower staffing and no increase for control conditions.

From the 100 medical conditions propecia online examined, 23 had significantly increased mortality risk for weekend admissions. These two sets of findings provided strong evidence for a weekend effect, suggesting that for some conditions lower staffing on admission affected standards of care and thereby patient outcomes.Since then, dozens of studies of the weekend effect have been conducted, mostly in the UK and the USA.2 In Britain, the issue became much more high profile after an intervention in 2015 by the Secretary of State who suggested that 11 000 patients were unnecessarily dying at the weekend.3 4 This claim was challenged at the time,5 and many pointed out that the National Health Service (NHS) was already a 7-day service.6 7 However, concern about the weekend led eventually to the introduction of ‘7 day services’ in the NHS in England. A new set of 10 clinical standards was introduced to reduce differences between weekend and weekday services, including increased involvement of consultants in the first 24 hours of admission.8 9 A cross-sectional analysis covering the period before introduction showed no association between propecia online specialist intensity and weekend admission mortality.10 Nevertheless, the programme did lead to many NHS hospital trusts reorganising services to reduce differences in care delivery across the 7-day week. The reorganisation of services did not affect clinical outcomes11 nor was adoption of the clinical standards associated with any significant change in the magnitude of the weekend effect.12Possible underlying mechanisms. The weekend as proxy variableRecent systematic reviews have concluded that the weekend effect does exist, but the explanation for the finding is unclear.2 4 13–17 Patients admitted to hospital at the weekend are more likely to die than those during weekdays with ORs of propecia online 1.16 (all studies)2 and 1.07 (UK studies),4 with reviews for some specific disease categories reporting higher ORs.2 13 The quality of studies is highly variable, with findings being influenced by methodological, clinical and service configuration factors2 with ongoing debate about likely mechanisms.

Why has it been so difficult to elucidate possible mechanisms?. To go more deeply into this, we need to consider what role the weekend is playing in the design of all these studies.Bell propecia online and Redelmeier1 used two distinct designs in their original investigation, which might best be defined as an investigation of staffing levels and mortality. In their first analysis, the weekend is used as a proxy measure for differences in staffing. They targeted specific propecia online conditions such as ruptured abdominal aortic aneurysm for which staffing on admission was deemed likely to have an important impact on patient outcomes. Their second analysis took the opposite approach, by examining overall outcomes at the weekend and then speculating about which factors might explain any observed differences.

Most subsequent propecia online studies have used the second approach, which has made it difficult to make progress on identifying the relevant factors driving any effect. If we do not define the questions and hypothesised relationships precisely, then we will not be able to identify how care delivered to patients is affected and which factors are responsible for poorer outcomes. Critically, if we cannot identify the factors, then we cannot intelligently propose interventions propecia online to improve patient care.We therefore need to examine how the weekend as a proxy variable for staffing levels fits into the conceptual model. Is the proxy only associated with the determinant, often assumed to be staffing levels, or also with other possible confounders or factors that affect the outcome in question?. We propecia online recognise there are multiple possible sets of relationships, but examining three of them is sufficient to make the general argument.

Figure 1 displays three possible sets of relationships, which correspond with three broad hypotheses about potential mechanisms and hence the interpretation of the weekend effect.Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing." data-icon-position data-hide-link-title="0">Figure 1 Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing.Levels of staffing on admission is the dominant influence on quality of care and mortality (panel A)This shows the ‘ideal’ and simplest situation when the proxy weekend/weekday variable is primarily associated with staffing in the first hours or days. The implied mechanism is that lower numbers of staff, particularly senior propecia online staff, lead to poorer care and increased mortality. In that situation, weekend–weekday mortality differences, after adjustment for patient mix, can be presumed to be due to staffing differences. Bell and Redelmeier propecia online specifically tested this scenario by selecting those conditions for which the first few days of admission are critical, that are treatable and where death may be rapid. For these conditions, insufficient staffing levels at admission (determinant) might cause delay in care processes (intermediate variable) and higher mortality (outcome).Patients at weekends are sicker and more likely to die (panel B)As many studies have shown, the weekend is associated with confounding variables.

Patients admitted at the weekend are known to be sicker18 19 and are less likely to be admitted from emergency departments propecia online despite attendance rates being similar.16 20 Studies attempt to control for severity of condition and other confounders, but there is general agreement that it is simply not possible to control for all potential factors (and confounding by indication). There is always the propecia online possibility that, even after adjustment for severity of illness and other patient variables, that differences in outcome are due to other patient factors that, for whatever reason, could not be included in the calculations. So for many conditions, this is an important alternative pathway to consider.Multiple factors affect care at the weekend, which in turn increases mortality (panel C)This model underlies the second approach by Bell and Redelmeier and many subsequent studies. The basic hypothesis is that patient outcomes differ between weekend and weekday, but this may propecia online be due to multiple relationships and multiple interrelated variables. For instance, the average seniority or specialty level may differ between the groups of nurses and medical staff working during weekdays and weekends, and such differences in skill-mix may affect patient outcomes.21–23 Access to diagnostic tests or other ancillary services might also differ between weekends and weekdays, or there may be factors further along the patient pathway (in subsequent days after admission) such as how quickly any deterioration on the ward is detected.

In this scenario, uncertainty about the mechanisms of the weekend effect makes it very difficult to identify targeted interventions to improve outcomes for patients admitted at the weekend.The assumed intermediate variable of worse quality of careHypotheses 1 and 3 have the same intermediate variable, that quality of care is poorer at the weekend—although for different reasons—and that this is the reason propecia online for higher mortality. Investigating this particular proposal requires, as many have noted, ‘painstaking detective work’,24 but few studies have directly examined the quality of care provided during weekdays and at weekends. In this propecia online issue of BMJ Quality &. Safety, Bion and colleagues therefore add crucial evidence with their impressive and comprehensive study.25 They reviewed the quality of care delivered by examining case records from 4000 non-operative medical emergency admissions in 20 acute hospital trusts before and after introduction of the ‘7-day services’ in England. Records were randomly sampled from each trust, equally divided between the two time propecia online periods and weekend versus weekday admissions.

They found that rates of errors and adverse events were not significantly different between weekdays and weekends and that this was the case both before and after introduction of the ‘7-day services’. They also made a direct assessment of intensity of senior propecia online medical staffing by comparing hours of consultant time per 10 emergency admissions between Sundays and Wednesdays. This specialist intensity ratio was much lower at weekends (0.51 overall) and improved slightly (from 0.47 to 0.58) across periods. Their study therefore does not offer support for quality of care being worse at the weekend or that senior staff involvement at an early point in the patient’s admission is significantly associated with overall quality of propecia online care. We should note, however, that operative patients were excluded, so it remains possible that care is poorer for some other groups of patients.The implicit assumption in many previous studies, and most political discourse, is that the weekend is simply a reflection and proxy for lower levels of skilled staff, particularly medical staff.

Proxy variables are of course used all the time in research and can be propecia online very helpful if they are ‘close’ to the variable of interest. For instance, we might use the prescription record of a medication as a proxy for the actual medication administered to the patient. We are then confident of what the proxy means and how it propecia online relates to the actual variable of interest. Even though some patients may decide not to collect their medication or be non-adherent in taking it, interpreting the proxy is relatively straightforward.In contrast, the weekend/weekday comparison is a distant and complex proxy. Care could potentially be different for a whole variety of reasons, which are only partly dependent on levels of skilled propecia online medical staff.

Diagnostic tests and investigations may not be readily available. Coordination between different specialties may be problematic within the hospital or between primary and secondary care and so on propecia online. Each of these may cause delay in a care process that may (in combination) affect patient outcomes. In addition, conditions vary in the extent to propecia online which delays in the first few days are critical in preventing death. Some primarily require skilled staff on admission, while others are more vulnerable to later deterioration on propecia online wards and need care from experienced nurses in the days following admission.Should we continue studying the weekend effect?.

We do not doubt that studies of the weekend effect have been worthwhile. Clearly, the higher mortality propecia online at weekends originally identified 20 years ago merited investigation. The question is whether it is worthwhile to continue to conduct similar studies in the future given the limited funding and research time available. What avenues of inquiry are most likely to benefit patients? propecia online. The ultimate aim of all concerned is to improve care given to patients.

The weekend effect is only important as a propecia online potential marker of other problems. Local reviews of mortality or other indices of quality should always be alert to variations in the quality of care over the week, and consider whether care is poorer at weekends or indeed at any particular time of the day, week or year. However, we consider that propecia online there is no reason to carry out further studies that simply demonstrate a weekend effect. We need instead to turn our attention to the factors directly influencing quality of care for which the weekend has been a proxy.Bion and colleagues provide a valuable illustration of research that examines the presumed causal relationships, looking at the actual care processes and so give a clearer indication of what kind of intervention might most benefit patients. Their study propecia online found that care had improved over time but that about 15% of patients received partial care and a small percentage received very poor care.25 These problems occurred throughout the week, affecting the larger volume of patients treated on weekdays.

Following the example of the study by Bion et al, future studies could directly assess standards of care and the factors that most powerfully influence quality. A notable example is the study by Jayawardana and colleagues,26 showing that the increased mortality for out-of-hours admissions with ST-elevation acute myocardial infarction was explained by differences in door-to-needle time, identifying the specific care process on which interventions should propecia online be targeted. To improve clinical practice, we need evidence that will help us design targeted interventions to influence the quality of care delivered and thereby patient outcomes.The ‘7-day services’ initiative was introduced in England without a clear understanding of the causes of the weekend effect. The intervention, while well propecia online intentioned, was therefore poorly targeted. Rather than a one-size-fits all initiative to increase consultant intensity, we should consider the much harder question on how to spend the same money to maximum effect.

Consultant time is scarce and so should be tailored to the time, place and particular conditions where it is most beneficial over the propecia online week as a whole. For some patients though, more rapid access to diagnostic tests or the increased use of skilled nurses during recovery may be much more critical to improving outcomes. Studies of propecia online the weekend effect drew attention to potentially dangerous levels of staffing that undoubtedly posed risks to patients. At this point, however, we need more precise studies that directly examine standards of care and the factors that influence the care delivered. We can then define and target interventions effectively and make best use of scarce resources.Ethics statementsPatient consent for publicationNot required.The Harvard Medical Practice Study brought the issue of patient safety into the public eye and demonstrated that patients are often harmed by the care they receive.1 It used retrospective chart review to identify adverse events propecia online.

Since its publication in 1991, considerable focus has been placed on trying to improve the methods for understanding the prevalence of harm in hospitals. These efforts have led to deeper propecia online understanding of the relative strengths and weaknesses of the tools we currently have for adverse event identification. Still, most organisations do not have robust approaches for tracking all types of harm routinely. Other efforts have sought to assess safety not just in hospitals but across national health propecia online systems, and at one point in time, and to track and trend.Developing better approaches for measuring safety routinely is critical if we are to understand how many patients are being harmed, what the primary causes are and whether care is getting safer or less safe. However, it is also work that needs to be contextualised and the limitations of our tools must be appreciated.2 3The Irish National Adverse Event Study 2 (INAES-2) is presented in this issue.4 In this study, Connolly and colleagues used retrospective chart review to find adverse events at eight Irish hospitals in 2015 and compare these to previously propecia online reported data from 2009.

Retrospective chart review was the first method used in this space5 6 and is still a mainstay for national studies assessing rates of adverse events,7–12 although approaches using claims data are also used widely and are much less expensive though much less sensitive.13 The original approach using retrospective chart review relied on information exclusively gathered from retrospective review of randomly selected medical records, but it has since been bolstered by the creation of standardised triggers,14 and more rigorous methods for chart review which make it more sensitive for finding adverse events, and more reliable. Despite this, retrospective chart review has many limitations, most notably the level propecia online of agreement between abstractors and its reliance on the completeness of documentation in medical charts.15The issue of reliance on documentation is especially important. There have been well-conceived critiques that have raised concern related to underdocumentation of errors that occur in hospitals, as well as those that have raised concern that the findings from longitudinal studies looking at trends may be confounded by improved documentation resulting in an overestimation of the true (comparative) incidence of events. These are both propecia online legitimate concerns. The INAES-2 study, as in prior similar work looking at multi-institution adverse event rates over time,16 17 showed an increase in events over time but no change in preventable harm.

We are left not knowing if this represents a change in safety or a change in documentation.These concerns have led other investigators to develop adverse event identification approaches to enable more real-time identification, leveraging a broader set of propecia online data for the interpretation of the preventability and impact of these events.18 19 Prospective event identification, or the near real-time application of triggers, can also incorporate the perspectives of staff in the clinical environment around the time of the event to provide additional insights. Even with this more comprehensive, contemporaneous collection of data however, agreement continues to be variable between reviewers.20–22Looking to spontaneous reporting from front-line staff, rather than retrospectively or prospectively monitoring for triggers, is another method that has been proposed as a mechanism for identifying the prevalence of adverse events over time. Similar to documentation, however, concerns exist about the under-reporting of events by front-line staff in safety reporting systems.23 24 Moreover, spontaneous reporting routinely underestimates the incidence of adverse events for some types of events by a factor of 20.25The inverse is also likely true that advances in safety culture may increase reporting, without any change in the frequency of actual propecia online events. Indeed, in the INAES-2 study, the researchers found that although safety reports increased threefold, adverse event rates did not change. This highlights the challenge of using safety reports alone as a proxy for propecia online adverse events.

Instead, the insights from safety reporting may hold promise for other uses in the safety space, such as providing a signal for the degree of staff engagement in safety, enabling the identification of near misses and facilitating the identification of significant events that require root cause analysis.Because of the variability that exists in the methods mentioned, many investigators have attempted to identify more reliable ways to identify adverse events. Several studies have employed reimbursement codes (in the USA, International Classification of Diseases Ninth Revision codes) as a mechanism to screen for adverse events.26–28 These systems, which aim to identify complications of medical care by looking for codes that are highly associated with adverse events, have largely been shown to be ineffective.29 30 This is likely to be multifactorial, with an inability to identify which conditions propecia online predated the current healthcare encounter, a lack of incentives to use coding to identify adverse events and their limited ability to accurately capture the full clinical picture all contributing to their limited efficacy.31Other approaches have leveraged information systems to screen for adverse events, which is almost certainly how this will be done in the future.32 This works better for some categories of events than for others. Identification for some events is relatively straightforward, for example, for the development of acute kidney injury in which there is a biomarker to track (rise in creatinine), which routinely appears when the event is present. However, the identification of newly altered propecia online mental status, for example, is much more challenging. For events such as falls, which are almost always documented in electronic health record (EHR) systems, this also works well.

Commercial products that sift through data from the EHR are available to find adverse events for inpatients, while the situation regarding adverse event detection is much less advanced in the ambulatory setting, even though propecia online EHR use is widespread in developed countries. Among the main types of inpatient adverse events, hospital-acquired s, adverse drug events and falls can readily be detected in inpatients, while the situation is more complex for deep venous thromboses/pulmonary emboli, surgical injuries, specific types of pressure ulcers and missed diagnoses.32 Novel approaches that are highly effective for identifying wrong patient errors have been developed, such as ‘retract and reorder’ detection, which identifies these errors effectively.33 This has led to interventions such as showing the photograph of a patient to the ordering clinician, which reduced the likelihood of a wrong patient order by 43% in one study.34 Still, most organisations do not have a robust sense of how often their patients experience adverse events across the spectrum of care.The challenge of adverse event identification is multiplied by the importance of understanding one moment in time and, as the authors in the INAES-2 study aim to do, trying to look at trends. This will propecia online be essential as we continue to mobilise large efforts to improve safety and as these compete with other priorities. As with all work in quality, having robust metrics is vital. In safety, however, propecia online we have in many ways been ‘flying blind’—initiating large-scale efforts to decrease the rate of adverse events without having reliable ways to measure their prevalence over time.It is important to emphasise that this lack of insight into performance is not equally distributed across all categories of adverse events.3 In fact, as proposed recently by Shojania and Marang-van de Mheen, the incidence of adverse events may be best understood as a composite measure—with all of the limitations that come with looking at a measure with many composite parts.35 When broken apart, what we come to understand is that some of our mechanisms for identifying certain types of events are likely much more reliable than others.

In the USA, for example, where the Agency for Healthcare Research and Quality has leveraged standardised methods for collecting and reporting national performance on a set of specific healthcare-associated s, we have much better insight into performance over time related to such healthcare-associated s than we do, for instance, with diagnostic error.Lastly, the challenge of interpreting national adverse event data over time is complicated by the nuances associated with the interfaces between politics and science. In our personal experience, we have encountered challenges reporting results of safety studies that are tied to ministries of health.36 Related to the INAES-2 study specifically, Ireland has a long history of sensationalised media coverage of data pointing to opportunities for improved care, further complicating researchers’ ability to conduct this work free of influence.37Ultimately, the work presented by Connolly and colleagues is critically important work and we suggest that all health systems propecia online should be monitoring adverse event rates over time. The mechanisms for doing this, though, should rapidly evolve. With hospitals increasingly leveraging EHRs, data being collected in more uniform ways and advances in natural language processing and artificial intelligence, a future in which we have reliable propecia online measures of adverse events that are stable over time is likely within our reach. To get from here to there, an ongoing investment in research with evaluation including leveraging artificial intelligence and natural language processing, and a commitment to transparent data reporting and enabling collaboration between organisations and governments focused on this work is essential.38 If we can achieve this, we could reasonably expect a future in which we have access to publicly available meaningful data on how many people are being harmed, and in what context, which could in turn transform safety.Ethics statementsPatient consent for publicationNot required..

Propecia not working

Finally, do the calcium and magnesium in seawater Best place to buy flagyl online also react with CO2, especially at the higher pressures propecia not working and temperatures at depth?. And if so, might this tend to “plug up” the veins, natural or induced, before the solution could migrate very far?. Gary McKown West Chester, Pa.

Fox describes a natural process that permanently petrifies CO2 as propecia not working magnesium carbonate (MgCO3) or calcite (CaCO3) in mantle rock in Oman. Each CO2 molecule has two oxygen atoms, whereas there are three in each molecule of MgCO3 or CaCO3. If the described process was greatly intensified to rid the atmosphere of CO2, is there a possibility that we would permanently “lose” too much oxygen?.

Would we exchange one evil propecia not working for another?. URSULA GARTENMANN Zurich FOX REPLIES. In response to McKown’s letter.

Injection of CO2 could indeed potentially be enhanced with propecia not working artificial fracking using seawater. Pressurized “supercritical” CO2 could also be a possible fracking fluid. The calcium and magnesium naturally present in seawater should not increase the tendency of pores in the rock to be clogged with precipitating carbonates.

This is because fluids in the water underground already contain propecia not working calcium and magnesium. The natural carbonation reactions actually involve an initial step in which these elements in the rock dissolve in the CO2-rich water (which is acidic). Ions of calcium and magnesium then react with the CO2 and precipitate back into solid minerals.

Gartenmann asks an propecia not working interesting question. Fortunately, the reactions that convert CO2 into CO3 do not consume oxygen gas (O2). Instead they consume oxygen atoms that are already present in the water and in minerals such as olivines (including Mg2SiO4 and Fe2SiO4), serpentine [Mg3Si2O5(OH)4] and brucite [Mg(OH)2].

Because of propecia not working the oxygen contents of such minerals, very roughly, Earth’s crust and mantle contain more than a million times more oxygen than the atmosphere!. But even if we were to assume that all of the extra oxygen atoms needed to sequester carbon in rock came from the air, we would lose only a minuscule amount of them. Mineralizing a billion metric tons of CO2 would consume about 0.00003 percent of the estimated 1.2 quadrillion metric tons of O2 in Earth’s atmosphere.

And mineralizing a trillion metric tons of CO2 would consume only about 0.03 percent propecia not working of that oxygen. SCIENCE AND “TRUTH” In “Is Science Actually ‘Right’?. € [Observatory], Naomi Oreskes argues that it offers a process of discovery rather than providing absolute truth.

Science is not really about “right,” “wrong,” “true” or “false.” My work studying Earth’s interior, where observations are always incomplete and often not very accurate, has led me to the idea that theories should be evaluated as more or less “useful within a certain propecia not working context.” I find this avoids much confusion about what science provides. For example, Isaac Newton’s theory of gravity was superseded by Albert Einstein’s, but that did not make Newton’s theory “wrong” or make Einstein’s “right.” Newton’s theory is still extremely useful in many contexts. Einstein’s theory is useful in a much broader range of them.

It can do a better job of propecia not working explaining Mercury’s orbit and black holes. If someday a better idea than Einstein’s general theory of relativity comes along, or observations are found that are inconsistent with that theory, then Einstein will not have been “wrong” either. A physician with a good scientific background will probably be more useful to your health than a typical politician, however prominent.

And a climate scientist’s projections into the future are likely propecia not working to be more useful than those of an ill-informed coal executive. On the other hand, your average shopkeeper may have a better understanding of economies than most neoclassical economists, whose theories bear no useful resemblance to observable economies. GEOFF DAVIES retired senior fellow, Australian National University BETTER GUN SAFETY In “Patient Care Must Include a Gun Talk” [Forum], Chethan Sathya and Sandeep Kapoor argue that doctors should talk to their patients about firearm safety.

Doctors are well equipped for good discussions with their patients about exercise, smoking, drug propecia not working and alcohol consumption, and diet as they relate to health. But few of them, including my doctors, own firearms, and most know little about appropriate firearm safety courses. I own a firearm and have taken in-person safety courses, which have been invaluable.

Doctors would be more effective and propecia not working trustworthy on this subject if they were better informed about safe gun ownership resources, including local safety courses. For those millions of citizens who are going to own firearms, nothing improves gun safety practices better than a well-taught training course. ANDREW GOLDSTEIN Portland, Ore.

NEW ERA OF propecia not working PROTEINS Your July issue was outstanding. I have never enjoyed reading so many of the articles in any one edition of Scientific American. All of them had important information.

I especially liked “Life, New and Improved,” Rowan Jacobsen’s feature on the creation of artificial proteins and the use of propecia not working the technology in the development of a new hair loss treatment. I’ve recommended it to my four granddaughters as must reading. One is a research biologist doing work in neuroscience.

Two just completed their sophomore years in different colleges, and the fourth will be a senior in propecia not working high school next year. J. P.

UTTLEY via propecia not working e-mail This is, without a doubt, the most intriguing article I have read in this magazine, and I am a long-time subscriber. I’m looking forward to follow-ups because this is obviously the dawn of a new era. I hate the overuse of hyperbolic descriptions, but the superlative fits well here.

As a physical chemist who picked up the rudiments of geology and geochemistry during environmental investigations, I was intrigued propecia online by the article, which discussed various mechanisms that might be used to enhance the process or lower costs, including both in situ and ex situ concepts. Would it be possible to use standard petroleum methods such as fracking with high-pressure liquids to improve the permeability of the mantle rocks?. And would seawater—which would already be used to sequester CO2 in Kelemen’s plan—be a candidate for such fracking?.

Finally, propecia online do the calcium and magnesium in seawater also react with CO2, especially at the higher pressures and temperatures at depth?. And if so, might this tend to “plug up” the veins, natural or induced, before the solution could migrate very far?. Gary McKown West Chester, Pa.

Fox describes a natural propecia online process that permanently petrifies CO2 as magnesium carbonate (MgCO3) or calcite (CaCO3) in mantle rock in Oman. Each CO2 molecule has two oxygen atoms, whereas there are three in each molecule of MgCO3 or CaCO3. If the described process was greatly intensified to rid the atmosphere of CO2, is there a possibility that we would permanently “lose” too much oxygen?.

Would we exchange one evil for another? propecia online. URSULA GARTENMANN Zurich FOX REPLIES. In response to McKown’s letter.

Injection of CO2 could indeed potentially be enhanced with artificial fracking using seawater propecia online. Pressurized “supercritical” CO2 could also be a possible fracking fluid. The calcium and magnesium naturally present in seawater should not increase the tendency of pores in the rock to be clogged with precipitating carbonates.

This is because fluids in the water propecia online underground already contain calcium and magnesium. The natural carbonation reactions actually involve an initial step in which these elements in the rock dissolve in the CO2-rich water (which is acidic). Ions of calcium and magnesium then react with the CO2 and precipitate back into solid minerals.

Gartenmann asks propecia online an interesting question. Fortunately, the reactions that convert CO2 into CO3 do not consume oxygen gas (O2). Instead they consume oxygen atoms that are already present in the water and in minerals such as olivines (including Mg2SiO4 and Fe2SiO4), serpentine [Mg3Si2O5(OH)4] and brucite [Mg(OH)2].

Because of the oxygen contents of such minerals, very roughly, Earth’s crust and mantle contain propecia online more than a million times more oxygen than the atmosphere!. But even if we were to assume that all of the extra oxygen atoms needed to sequester carbon in rock came from the air, we would lose only a minuscule amount of them. Mineralizing a billion metric tons of CO2 would consume about 0.00003 percent of the estimated 1.2 quadrillion metric tons of O2 in Earth’s atmosphere.

And mineralizing a trillion metric tons of CO2 would consume only about 0.03 propecia online percent of that oxygen. SCIENCE AND “TRUTH” In “Is Science Actually ‘Right’?. € [Observatory], Naomi Oreskes argues that it offers a process of discovery rather than providing absolute truth.

Science is not really about “right,” “wrong,” “true” or “false.” My work studying Earth’s interior, where observations propecia online are always incomplete and often not very accurate, has led me to the idea that theories should be evaluated as more or less “useful within a certain context.” I find this avoids much confusion about what science provides. For example, Isaac Newton’s theory of gravity was superseded by Albert Einstein’s, but that did not make Newton’s theory “wrong” or make Einstein’s “right.” Newton’s theory is still extremely useful in many contexts. Einstein’s theory is useful in a much broader range of them.

It can do a better job of explaining Mercury’s propecia online orbit and black holes. If someday a better idea than Einstein’s general theory of relativity comes along, or observations are found that are inconsistent with that theory, then Einstein will not have been “wrong” either. A physician with a good scientific background will probably be more useful to your health than a typical politician, however prominent.

And a climate scientist’s projections into the future are likely to be more useful than those of an ill-informed coal propecia online executive. On the other hand, your average shopkeeper may have a better understanding of economies than most neoclassical economists, whose theories bear no useful resemblance to observable economies. GEOFF DAVIES retired senior fellow, Australian National University BETTER GUN SAFETY In “Patient Care Must Include a Gun Talk” [Forum], Chethan Sathya and Sandeep Kapoor argue that doctors should talk to their patients about firearm safety.

Doctors are well equipped for good discussions with their patients about exercise, smoking, drug and alcohol consumption, and diet propecia online as they relate to health. But few of them, including my doctors, own firearms, and most know little about appropriate firearm safety courses. I own a firearm and have taken in-person safety courses, which have been invaluable.

Doctors would be more effective and propecia online trustworthy on this subject if they were better informed about safe gun ownership resources, including local safety courses. For those millions of citizens who are going to own firearms, nothing improves gun safety practices better than a well-taught training course. ANDREW GOLDSTEIN Portland, Ore.

NEW ERA propecia online OF PROTEINS Your July issue was outstanding. I have never enjoyed reading so many of the articles in any one edition of Scientific American. All of them had important information.

I especially liked “Life, New and Improved,” Rowan Jacobsen’s feature on the creation of artificial proteins and the use of the technology in the development of a propecia online new hair loss treatment. I’ve recommended it to my four granddaughters as must reading. One is a research biologist doing work in neuroscience.

Two just propecia online completed their sophomore years in different colleges, and the fourth will be a senior in high school next year. J. P.