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August 18, cialis prices walmart 2020 (TORONTO) — Canada Health Infoway (Infoway) and Loblaw Companies Limited (Loblaw) are pleased to announce that they have reached an agreement to advance e-prescribing in Canada. Under the agreement, Shoppers Drug Mart, Loblaw retail pharmacies and QHR Technologies’ AccuroEMR®, Canada’s largest single electronic medical record platform, will work towards connecting with PrescribeIT®, Infoway’s national e-prescribing service.As a first step in the initiative, Shoppers Drug Mart and Loblaw will begin to roll out PrescribeIT® in pharmacies already using software that is integrated with PrescribeIT®. “This agreement will accelerate the adoption of e-prescribing in Canada, bringing significant benefits to patients, prescribers and health care systems across the country,” said Ashesh Desai, Executive Vice President Pharmacy and Healthcare Businesses at Shoppers Drug Mart.“PrescribeIT® has shown tremendous momentum since it launched,” said Michael Green, President and CEO of cialis prices walmart Infoway. €œThis is an important expansion for PrescribeIT® and will help extend the benefits of the service more broadly.”Loblaw will continue to operate FreedomRx, the e-prescribing and messaging platform that is currently available predominantly to Loblaw and Shoppers Drug Mart pharmacies and physicians using AccuroEMR® as their electronic medical records system.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada.

Through our investments, we help deliver better quality and access cialis prices walmart to care and more efficient delivery of health services for patients and clinicians. Infoway is an independent, not-for-profit organization funded by the federal government. Visit www.infoway-inforoute.ca.About PrescribeIT®Canada Health Infoway is working with Health Canada, the provinces and territories, and industry stakeholders to develop, operate and maintain the national e-prescribing service known cialis prices walmart as PrescribeIT®. PrescribeIT® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriber’s electronic medical record (EMR) and the pharmacy management system (PMS) of a patient’s pharmacy of choice.

PrescribeIT® will protect Canadians’ personal health information from being cialis prices walmart sold or used for commercial activities. Visit www.PrescribeIT.ca.About Loblaw Companies LimitedLoblaw is Canada's food and pharmacy leader, and the nation's largest retailer. Loblaw provides Canadians with grocery, pharmacy, health and beauty, apparel, general merchandise, cialis prices walmart financial services and wireless mobile products and services. With more than 2,400 corporate, franchised and Associate-owned locations, Loblaw, its franchisees and associate-owners employ approximately 200,000 full- and part-time employees, making it one of Canada's largest private sector employers.Loblaw's purpose – Live Life Well® – puts first the needs and well-being of Canadians who make one billion transactions annually in the company's stores.

Loblaw is positioned to meet and exceed those needs in cialis prices walmart many ways. Convenient locations. More than 1,050 grocery stores that span the value spectrum cialis prices walmart from discount to specialty. Full-service pharmacies at nearly 1,400 Shoppers Drug Mart® and Pharmaprix® locations and close to 500 Loblaw locations.

PC Financial® services cialis prices walmart. Affordable Joe Fresh® fashion and family apparel. And three cialis prices walmart of Canada's top-consumer brands in Life Brand, no name® and President's Choice. For more information, visit Loblaw's website at www.loblaw.ca.-30-Media Inquiries Catherine ParrySenior Director, Marketing &.

CommunicationsCanada Health Infoway(647) 267-7013 Email UsFollow @InfowayCatherine ThomasSenior Director, External CommunicationLoblaw Companies Limited This cialis prices walmart email address is being protected from spambots. You need JavaScript enabled to view it.Inquiries about PrescribeIT®July 22, 2020 (Toronto) – Rexall Pharmacy Group Ltd. (Rexall) and Canada cialis prices walmart Health Infoway (Infoway) are pleased to announce that PrescribeIT®, Infoway’s national e-prescribing service, will soon become available in more than 250 Rexall pharmacies across Canada. PrescribeIT® enables prescribers and pharmacists to electronically create, receive, renew and cancel prescriptions, while improving overall patient care through secure clinician messaging.“Rexall is an important addition to the PrescribeIT® roster of partners and we are very pleased to have them on board,” noted Jamie Bruce, Executive Vice President, Canada Health Infoway.

€œTogether we can cialis prices walmart help improve patient care through more effective medication management.”“At Rexall, we strive to build partnerships aimed at providing our pharmacists with innovative solutions to help improve overall patient care,” said Nicolas Caprio, President, Rexall. €œPrescribeIT® is a great opportunity for us to continue strengthening our digital offering, allowing pharmacists and physicians to increase their communication and ultimately positively impact patient health.”In anticipation of the agreement, Rexall has already introduced the service in key locations in Ontario, Alberta and New Brunswick. Additional sites will start to offer PrescribeIT® starting in the next several weeks.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the cialis prices walmart development, adoption and effective use of digital health across Canada. Through our investments, we help deliver better quality and access to care and more efficient delivery of health services for patients and clinicians.

Infoway is an independent, not-for-profit organization funded by the federal government. Visit www.infoway.ca.About PrescribeIT®Canada Health Infoway is working with Health Canada, the provinces and territories, cialis prices walmart and industry stakeholders to develop, operate and maintain the national e-prescribing service known as PrescribeIT®. PrescribeIT® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriber’s electronic medical record (EMR) and the pharmacy management system (PMS) of a patient’s pharmacy of choice. PrescribeIT® will protect Canadians’ personal health information from being sold or used for commercial activities cialis prices walmart.

Visit www.prescribeit.ca.About Rexall Pharmacy Group Ltd.With a heritage dating back over a century, Rexall is a leading drugstore operator with a dynamic history of innovation and growth, dedicated to caring for Canadians’ health…one person at a time. Operating over 400 pharmacies across Canada, Rexall’s 8,500 employees provide cialis prices walmart exceptional patient care and customer service. Rexall is part of the Rexall Pharmacy Group Ltd. And a proud member of the cialis prices walmart global McKesson Corporation family.

For more information, visit rexall.ca. Follow us cialis prices walmart on Twitter. @RexallDrugstore, on Instagram at @RexallDrugstoreOfficial and on Facebook at @RexallDrugstore.-30-Media Inquiries Catherine ParrySenior Director, Marketing &. CommunicationsCanada Health cialis prices walmart Infoway(647) 267-7013 Email UsFollow @InfowayInquiries about PrescribeIT®Inquiries about McKesson CanadaAndrew ForgioneDirector, Media Relations and Public AffairsMcKesson Canada(905) 671-4586NEW YORK and SALT LAKE CITY, Aug.

12, 2020 /PRNewswire/ -- Northwell Health today joined Health Catalyst, Inc. ("Health Catalyst," cialis prices walmart Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, in announcing a long-term strategic partnership to transform the quality of patient care by using data and analytics to better anticipate and respond to the evolving needs of patients, providers and payers in today's rapidly evolving healthcare ecosystem. In this partnership, Health Catalyst will provide solutions to allow for increased cloud-based reliance on data and analytics, while sharing insights and best practices from a decade of support to hundreds of other cialis prices walmart healthcare clients.

This will accelerate greater efficiency in data mapping and data storage to/with the Electronic Medical Record (EMR) and the affordable emergence of an enterprise solution for meaningful and measurable clinical, financial and operational improvements. The solutions will be used across the Northwell Health enterprise, which includes the Feinstein Institute and Donald and Barbara Zucker School of Medicine at Hofstra cialis prices walmart. "Northwell Health's goal is a simple one that has not changed since our inception. Be better cialis prices walmart tomorrow than we are today.

Partnering with Health Catalyst will allow us to accelerate the generation of critical insights for one of the world's most diverse patient populations which includes more than 11 million individuals who will potentially turn to us for care," said Michael Dowling, President and CEO of Northwell Health. "Health Catalyst's Augmented Intelligence (AI) and data science experience and expertise, along with our shared cultural attributes and mission alignment, will allow us to use data-informed decision making to achieve our shared commitment of transforming healthcare for the communities we serve."Northwell Health is New York State's largest health care provider and private employer, with 23 hospitals, nearly 800 outpatient facilities and more than 18,500 affiliated physicians cialis prices walmart. More than 11,000 COVID-19 patients have received care from Northwell's 16,000-plus nurses and 4,000 employed doctors, including members of Northwell Health Physician Partners, and using 1,600 additional COVID-19 focused beds."We are honored to have the opportunity to join Northwell Health on its mission-driven journey to transform healthcare," said Dan Burton, CEO of Health Catalyst. "We have deep respect for our Northwell colleagues and are excited about combining cialis prices walmart our Solution with Northwell's team members' experience, knowledge and passion for improvement.

We are also honored to have Northwell's CEO Michael Dowling as a keynote speaker at Health Catalyst's upcoming Healthcare Analytics Summit (HAS), where we'll hear his important perspectives on the COVID-19 pandemic and the future of healthcare delivery." This partnership will be built using Health Catalyst's DOS™ technology, a data-first analytics and application platform, to capture and map raw data into meaningful, actionable insights. Northwell Health will also immediately have access to Health Catalyst's growing suite of COVID-19 solutions, including but not limited cialis prices walmart to a registry, staff and patient tracker and capacity planning tool. Broadly sharing Northwell Health's data driven insights from its COVID-19 work is another significant opportunity for transformational care."Health Catalyst will become our data and analytics backbone, as their Solutions will enable our organization to take our current data adoption and transformation to entirely new heights," said John Bosco, Senior Vice President and Chief Information Officer at Northwell Health. "We are looking forward to leaning on DOS to create an affordable, yet innovative enterprise solution that will further enable transformative care to the patients we serve."About Northwell HealthNorthwell Health is New York State's largest health care provider and private employer, with cialis prices walmart 23 hospitals, 665 outpatient facilities and more than 18,500 affiliated physicians.

We care for over two million people annually in the New York metro area and beyond, thanks to philanthropic support from our communities. Our 66,000 employees – 16,000-plus nurses and 4,000 employed doctors, including members of Northwell Health Physician Partners – are working to change health care for the better. We are making breakthroughs in medicine at the Feinstein Institute cialis prices walmart for Medical Research. We are training the next generation of medical professionals at the visionary Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and the Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies.

For information on our more than 100 medical specialties, visit Northwell.edu.About Health CatalystHealth Catalyst cialis prices walmart is a leading provider of data and analytics technology and services to healthcare organizations, and is committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial and operational improvements. Health Catalyst envisions a future in which cialis prices walmart all healthcare decisions are data informed. Northwell Health Media Contact:Michelle Pinto516-321-6708mpinto@northwell.edu Health Catalyst Media Contact:Kristen BerrySenior Vice President, Public Relations+1 (617) 234-4123+1 (774) 573-0455 (m)kberry@we-worldwide.com View original content to download multimedia:http://www.prnewswire.com/news-releases/health-catalyst-and-northwell-health-partner-to-transform-patient-care-with-cloud-based-data-and-analytics-enterprise-solution-301110803.htmlSOURCE Health CatalystSALT LAKE CITY, Aug.

11, 2020 (GLOBE NEWSWIRE) -- cialis prices walmart Health Catalyst, Inc. (“Health Catalyst,” Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today announced that it has entered into a definitive agreement to acquire Vitalware, LLC, a Yakima, Washington-based provider cialis prices walmart of revenue workflow optimization and analytics SaaS technology solutions to healthcare organizations.Vitalware’s flagship offering is a Best in KLAS chargemaster management solution that delivers results for the complex regulatory and compliance functions needed by all healthcare provider systems. Additionally, Vitalware brings to bear newer product suites in Revenue Integrity, to help health systems capture lost revenue, and Price Transparency, to support compliance with expanding pricing transparency regulation.

Importantly, Vitalware offers Health Catalyst a strategic anchor technology cialis prices walmart in the revenue space, expanding its CFO offering and value proposition. Vitalware’s solutions support all major EMRs and act as a key integration point for health systems with multiple EMRs.Health Catalyst CEO Dan Burton said, “We are excited to welcome the Vitalware team to support our shared mission to be the catalyst for massive, measurable improvements. In addition to adding a best in KLAS technology solution from Vitalware, this acquisition is another powerful example of Health Catalyst’s cialis prices walmart ability to integrate and scale software on top of our DOS™ platform. Ultimately, DOS, our cloud-based data platform, will further enhance the analytics insights made available by Vitalware’s technology by integrating charge and revenue data with claims, cost, and quality data.”“Vitalware, since inception, has been about delivering solutions that provide critical insights and better financial outcomes to health systems,” said Vitalware CEO and Co-founder, Kerry Martin.

€œWe have a cialis prices walmart great team committed to our clients and their success, and adding the expertise and solutions from the Health Catalyst team will allow Vitalware to deliver even more innovative solutions. Our number one priority continues to be to create positive outcomes for our clients, and we’re confident the combination of our resources with Health Catalyst will only accelerate that effort.”Health Catalyst expects to fund the transaction using a mix of stock and cash. The parties expect the transaction, which is subject to customary closing conditions, to close in the third or cialis prices walmart fourth quarter of 2020. Further details regarding the acquisition will be reported on a Form 8-K filing that will be filed with the Securities and Exchange Commission today.About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations, and is committed to being the catalyst for massive, measurable, data-informed healthcare improvement.

Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as cialis prices walmart its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.About VitalwareVitalware is the leading mid-cycle revenue SaaS solutions provider, specializing in Health-IT applications aimed at making the business of healthcare easier through its intuitive cloud-based technologies and regulatory content expertise. With nearly 1,000 hospitals on its client cialis prices walmart roster, Vitalware’s product portfolio is the healthcare industry’s best solution for providing visibility and continuity in chargemaster management, pricing transparency, charge capture, and regulatory code references. Beyond providing tools, and healthcare regulatory and compliance resources, Vitalware offers professional services designed to support organizations’ need of coding guidance, process improvement, education, and financial impact solutions.

Vitalware is recognized as a 2020 Best in KLAS software for its VitalCDM® cialis prices walmart platform. Visit our website, www.vitalware.com.Cautionary Note Regarding Forward-Looking StatementsThis press release contains forward-looking statements relating to expectations, plans, and prospects including expectations relating to our ability to close, and the timing of the closing of, this transaction and the benefits that will be derived from this transaction. These forward-looking statements are based upon the current expectations and beliefs of Health Catalyst’s management as of the date of this release, and are subject to certain risks and uncertainties that could cause actual results to differ materially from those described cialis prices walmart in the forward-looking statements including, without limitation, the risk of adverse and unpredictable macro-economic conditions and risks related to closing this transaction and integration of the companies. All forward-looking statements in this press release are based on information available to the Company as of the date hereof, and Health Catalyst disclaims any obligation to update these forward-looking statements.Health Catalyst Investor Relations Contact:Adam BrownSenior Vice President, Investor Relations+1 (855)-309-6800ir@healthcatalyst.comHealth Catalyst Media Contact:Kristen BerrySenior Vice President, Public Relations+1 (617) 234-4123+1 (774) 573-0455 (m)kberry@we-worldwide.com Source.

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Shutterstock Ohio Attorney General Dave Yost announced Thursday that one of the hospitals involved in a study that identifies whether genetics free sample pack of cialis plays a role in opioid addiction had reached a milestone taking half a cialis enrollment number. Yost’s Scientific Committee on Opioid Prevention and Education began work on the study last year with the recruitment of patients at the University of Cincinnati Medical Center (UCMC) and The Ohio State University Wexner Medical Center (OSUWMC). Yost said that UCMC had reached an initial milestone of 100 patients enrolled in the free sample pack of cialis study. Both medical centers began enrolling patients this summer. €œAn awful lot of the people who got addicted to opioids didn’t get that way on their own,” said Yost.

€œThey weren’t trying to use opioids as a free sample pack of cialis party drug. They went to their doctor and were given a prescription following a surgery or injury.”The study’s leaders discussed the project and its processes in a 13-minute online presentation. Drs. Jon Sprague and Carolina Freiermuth said their initial observations show a high participation rate among emergency room patients randomly approached and asked to participate. €œPeople truly want to help prevent others from going down the pathway of opioid addiction,” said Sprague.Yost said SCOPE’s genetic research team will enroll up to 1,500 participants over the next year before analyzing participants’ genetic and environmental data.

Patients recruited from emergency departments answer survey questions about their environment and then submit DNA via a cheek swab. Researchers will be looking for the presence of 180 genetic markers suspected to be associate with opioid addiction. Genetic samples of those with opioid addiction will then be compared to those without opioid addiction to determine if there are genetic markers associated with opioid use disorder. €œWhy is it that two people can take the same drug in the same dosage and only one becomes addicted?. € said Yost.

€œWe think genetics will help us understand why, and we want to get that powerful information into the hands of physicians to help stop opioid addiction before it starts,” he added.Shutterstock New York Attorney General Letitia James announced Thursday that her office, in coordination with other law enforcement agencies, had shut down a multi-county drug ring providing fentanyl, cocaine, and heroin and other drugs in the state’s capital area. The 303-count indictment covers individuals in Saratoga, Albany, Rensselaer, Schenectady, and Warren counties, as well as dealers located in New York City. The network was distributing heroin laced with fentanyl, straight fentanyl the dealers were calling heroin, cocaine, crack cocaine, and illegal prescription pills. The bust netted the recovery of approximately 7 kilograms of cocaine, 70 grams of heroin, 120 grams of fentanyl, dozens of narcotic pills, and the seizure of $40,000. €œWe will pursue and prosecute all those who peddle illicit drugs and put New Yorkers in harm’s way for personal profit,” said Attorney General James.

€œCommunities across New York are safer today for having shut down this vast network of distributors and traffickers of illicit drugs. My office will remain vigilant about bringing these offenders to justice, and we are grateful to our other partners in law enforcement for their assistance.”The year-long investigation, code-named “Operation Red Dawn,” was part of the Attorney General’s Suburban and Upstate Response to the Growing Epidemic (SURGE) Initiative to combat violent drug trafficking and included multiple state and local law enforcement agencies. Launched in 2017, the initiative has taken 554 alleged drug traffickers off the streets, James’ office said. €œDrug dealers do not limit their illegal activities to specific jurisdictions, and we have shown by this collaborative effort that law enforcement will rise to the challenge and protect our communities,” said City of Saratoga Springs Police Chief Shane Crooks. €œThis investigation is the direct result of the hard work done by members of the various agencies involved and shows just how effective law enforcement can be when working together.”The indictment leveled charges against 47 individuals, most of whom faced multiple charges from Operating as a Major Trafficker to Criminal Sale and Criminal Possession of a Controlled Substance and Conspiracy in the Second Degree..

Shutterstock Ohio Attorney General Dave Yost announced Thursday that one of the hospitals involved in cialis prices walmart a study that identifies whether genetics plays a role in opioid addiction had reached a milestone enrollment number. Yost’s Scientific Committee on Opioid Prevention and Education began work on the study last year with the recruitment of patients at the University of Cincinnati Medical Center (UCMC) and The Ohio State University Wexner Medical Center (OSUWMC). Yost said that UCMC cialis prices walmart had reached an initial milestone of 100 patients enrolled in the study. Both medical centers began enrolling patients this summer. €œAn awful lot of the people who got addicted to opioids didn’t get that way on their own,” said Yost.

€œThey weren’t trying to use opioids as cialis prices walmart a party drug. They went to their doctor and were given a prescription following a surgery or injury.”The study’s leaders discussed the project and its processes in a 13-minute online presentation. Drs. Jon Sprague and Carolina Freiermuth said their initial observations show a high participation rate among emergency room patients randomly approached and asked to participate. €œPeople truly want to help prevent others from going down the pathway of opioid addiction,” said Sprague.Yost said SCOPE’s genetic research team will enroll up to 1,500 participants over the next year before analyzing participants’ genetic and environmental data.

Patients recruited from emergency departments answer survey questions about their environment and then submit DNA via a cheek swab. Researchers will be looking for the presence of 180 genetic markers suspected to be associate with opioid addiction. Genetic samples of those with opioid addiction will then be compared to those without opioid addiction to determine if there are genetic markers associated with opioid use disorder. €œWhy is it that two people can take the same drug in the same dosage and only one becomes addicted?. € said Yost.

€œWe think genetics will help us understand why, and we want to get that powerful information into the hands of physicians to help stop opioid addiction before it starts,” he added.Shutterstock New York Attorney General Letitia James announced Thursday that her office, in coordination with other law enforcement agencies, had shut down a multi-county drug ring providing fentanyl, cocaine, and heroin and other drugs in the state’s capital area. The 303-count indictment covers individuals in Saratoga, Albany, Rensselaer, Schenectady, and Warren counties, as well as dealers located in New York City. The network was distributing heroin laced with fentanyl, straight fentanyl the dealers were calling heroin, cocaine, crack cocaine, and illegal prescription pills. The bust netted the recovery of approximately 7 kilograms of cocaine, 70 grams of heroin, 120 grams of fentanyl, dozens of narcotic pills, and the seizure of $40,000. €œWe will pursue and prosecute all those who peddle illicit drugs and put New Yorkers in harm’s way for personal profit,” said Attorney General James.

€œCommunities across New York are safer today for having shut down this vast network of distributors and traffickers of illicit drugs. My office will remain vigilant about bringing these offenders to justice, and we are grateful to our other partners in law enforcement for their assistance.”The year-long investigation, code-named “Operation Red Dawn,” was part of the Attorney General’s Suburban and Upstate Response to the Growing Epidemic (SURGE) Initiative to combat violent drug trafficking and included multiple state and local law enforcement agencies. Launched in 2017, the initiative has taken 554 alleged drug traffickers off the streets, James’ office said. €œDrug dealers do not limit their illegal activities to specific jurisdictions, and we have shown by this collaborative effort that law enforcement will rise to the challenge and protect our communities,” said City of Saratoga Springs Police Chief Shane Crooks. €œThis investigation is the direct result of the hard work done by members of the various agencies involved and shows just how effective law enforcement can be when working together.”The indictment leveled charges against 47 individuals, most of whom faced multiple charges from Operating as a Major Trafficker to Criminal Sale and Criminal Possession of a Controlled Substance and Conspiracy in the Second Degree..

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SOBRE NOTICIAS EN ESPAÑOLNoticias en español es una sección de Kaiser Health News que contiene traducciones de artículos de gran interés para la comunidad hispanohablante, y contenido original enfocado en la what does a generic cialis pill look like población hispana que vive en los Estados Unidos. Use Nuestro Contenido Este contenido what does a generic cialis pill look like puede usarse de manera gratuita (detalles). El doctor Chris Kjolhede está enfocado en los niños del centro de Nueva York.Como codirector de los centros de salud escolares de Bassett Healthcare Network, el pediatra supervisa alrededor de 21 clínicas de salud escolares en toda la región, una zona rural pobre conocida por sus fábricas y paralizada por la epidemia de opioides. Desde un esguince de tobillo en el recreo hasta preguntas what does a generic cialis pill look like sobre el control de la natalidad, las clínicas sirven como proveedoras de atención primaria para muchos estudiantes, dentro y fuera del aula.La meta principal es asegurarse que los niños estén al día con las vacunas obligatorias, dijo Kjolhede.Pero, en marzo, COVID revocó el acuerdo cuando obligó a cerrar las escuelas.Lo primero que me pregunté, dijo Kjolhede, fue. €œÂ¿qué va a pasar ahora?.

€.Las escuelas juegan un what does a generic cialis pill look like papel fundamental en los esfuerzos de vacunación en los Estados Unidos. Las leyes requieren que los niños tengan ciertas vacunas para inscribirse y asistir a clases.Pero para evitar que COVID-19 no siguiera propagándose, muchos distritos escolares han optado por comenzar el año académico en internet.La decisión neutraliza en muchos casos el impulso de los padres por vacunar a sus hijos para el regreso a la escuela, dijo el doctor Nathaniel Beers, miembro del Consejo de Salud Escolar de la Academia Americana de Pediatría.Beers, quien también ocupó varios roles en el sistema de Escuelas Públicas del Distrito de Columbia, agregó que si la educación no es en persona, “es más difícil de hacer cumplir los requisitos”.Los funcionarios de salud pública han confiado en las escuelas como un medio para controlar las enfermedades prevenibles por vacunas durante más de un siglo. Las leyes de vacunación surgieron por primera vez en la década de 1850 en Massachusetts como un medio para controlar la viruela, según cuentan los Centros para el Control y Prevención de Enfermedades (CDC).Todos los estados requieren que los niños reciban ciertas vacunas contra enfermedades como la poliomielitis, las paperas y el sarampión antes de empezar el año escolar o al jardín de infantes, al menos que el niño tenga una exención médica.Algunos estados permiten a las personas optar por no vacunar a los niños por razones religiosas o filosóficas, aunque estas exenciones se han asociado con brotes de enfermedades que de otro modo estarían bien controladas, como por ejemplo el sarampión.“Cuando entran al sistema, en preescolar, es donde se detecta si están atrasados con sus vacunas”, dijo Claire Hannan, directora ejecutiva de la Asociación de Administradores de Inmunización.A nivel local, la responsabilidad de rastrear what does a generic cialis pill look like si los estudiantes cumplen con los requisitos de vacunación generalmente recae en la enfermera de la escuela. Si no, un oficinista o administrador hace el trabajo, dijo Linda Mendonca, presidenta electa de la Asociación Nacional de Enfermeras Escolares.Si no los cumplen, algunas escuelas trabajan con los padres para programar citas con un proveedor de salud. Otras aíslan what does a generic cialis pill look like a los niños en el aula, y otras son tan estrictas que “ni siquiera puedes cruzar la puerta a menos que estés debidamente inmunizado”, dijo Beers.La pandemia de COVID-19 ha provocado una baja dramática en la vacunación.

En mayo, un informe de los CDC mostró una fuerte caída en la cantidad de pedidos al programa Vaccines For Children, una iniciativa federal que compra vacunas para la mitad de los niños del país.Un segundo comunicado reveló tendencias similares. La cobertura de vacunación en Michigan disminuyó entre todas what does a generic cialis pill look like las edades, con la excepción de las vacunas que se administran al nacer, que generalmente se dan en el hospital.En Pennsylvania, por ejemplo, el Departamento de Salud estatal suspendió en julio los requisitos de vacunas durante dos meses después del inicio del año escolar.“El departamento no puede enfatizar más que hay que vacunarse lo antes posible”, dijo Nate Wardle, secretario de prensa del departamento de salud de ese estado, en una declaración escrita. Sin embargo, la orden de permanecer en casa por COVID hizo que durante meses los consultorios pediátricos no hicieran citas con niños sanos.Beers reconoció que el cierre de las escuelas, entre otras acciones como restringir los viajes y cerrar grandes espacios de reunión, hace que los niños sean menos propensos a contraer o propagar enfermedades que generalmente se incuban en las aulas. Por ejemplo, según los datos de los CDC, el sarampión prácticamente ha what does a generic cialis pill look like desaparecido. Se habían reportado 12 casos hasta el 19 de agosto de este año, en comparación con 1,282 en 2019.“Lo que sería una gran vergüenza es que las escuelas vuelvan a abrir en persona y los niños vuelvan a estar juntos y empecemos a tener brotes de otras enfermedades que se pueden prevenir con vacunas”, agregó.Los centros de salud de las escuelas de Nueva York se están comunicando activamente what does a generic cialis pill look like con los padres sobre las vacunas.

En Cooperstown, Kjolhede se acercó a todos los superintendentes poco después del cierre en marzo para preguntar si la clínica podía permanecer abierta. Todos menos uno dijeron que no.Luego, el personal concertó citas de telesalud y llamó a los estudiantes que necesitaban atención en persona para concertar visitas, incluidos aquellos que necesitaban una what does a generic cialis pill look like vacuna antes del comienzo de este año escolar, dijo. Afortunadamente, el centro de salud que permaneció abierto tenía una puerta que permitía a los pacientes ingresar a la clínica sin caminar por la escuela.A varias horas de distancia, la doctora Lisa Handwerker está lidiando con la forma de abordar el problema de que cientos de estudiantes en sus seis clínicas de salud en las escuelas de la ciudad de Nueva York no han recibido vacunas mandatorias.El departamento de salud de la ciudad le dio una lista de estudiantes bajo su cuidado que necesitaban vacunas adicionales, dijo. A más what does a generic cialis pill look like de 400 niños les faltaba la segunda dosis para prevenir la meningitis meningocócica, que generalmente se administra a adolescentes y adultos jóvenes de 16 a 23 años. Debido a que el departamento usó datos del último año académico para compilar la lista, Handwerker no tiene información sobre nuevos estudiantes.

Algunas familias abandonaron la ciudad por la falta de ingresos y recursos provocada por la pandemia.“Tuvimos dificultades con al menos la mitad de los niños en nuestra lista de vacunas”, dijo what does a generic cialis pill look like Handwerker. €œLuego, cuando hablamos a las familias, se mostraron reacias a salir de sus casas”.Ese no fue el caso de Tracey Wolf, una madre de dos hijos que visitó al médico recientemente para vacunar a su hijo Jordan contra el sarampión, las paperas, la rubéola y el VPH antes de comenzar el séptimo grado. Asistirá a la escuela secundaria en Dunedin, Florida, en persona, dijo Wolf, de 38 años.Parecía una tontería mantener a Jordan, de 13 años, alejado de sus compañeros what does a generic cialis pill look like de clase cuando ya juega béisbol y sale con sus amigos, dijo. Sus calificaciones también bajaron la primavera pasada cuando la amenaza COVID transformó su salón de clases en una computadora.También llevó a su hijo de 6 meses a recibir sus vacunas. Cuando se le preguntó si tenía miedo de ir al consultorio de what does a generic cialis pill look like su médico, respondió.

€œNo más que ir al supermercado”.Independientemente de si un niño comienza la escuela en casa o en el aula, los expertos en inmunización enfatizaron la importancia de vacunar siguiendo el calendario de inmunizaciones. Esas fechas tienen en cuenta la etapa de desarrollo what does a generic cialis pill look like del niño para maximizar la eficacia de la vacuna. Dicho esto, es preferible que los niños reciban las vacunas de su médico habitual para evitar la pérdida de los registros de vacunación y las vacunas adicionales, completó Beers.Sin embargo, el 19 de agosto, what does a generic cialis pill look like el Departamento de Salud y Servicios Humanos (HHS) emitió una declaración que permite a los farmacéuticos administrar vacunas infantiles a niños y adolescents de 3 a 18 años. Carmen Heredia Rodriguez. CarmenH@kff.org, @ByCHRodriguez Related Topics Noticias En Español Public Health Children's Health COVID-19 VaccinesAlthough what does a generic cialis pill look like the coronavirus pandemic shut down many organizations and businesses across the nation, KHN has never been busier ― and health coverage has never been more vital.

We’ve revamped our Behind the Byline YouTube series and brought it to Instagram TV.Journalists and producers from across KHN’s newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts — all while staying safe.Heidi de Marco — “At Least I Got the Shot” Photojournalist Heidi de Marco’s stunning images transport viewers to two California hospitals near the U.S.-Mexico border where the influx of patients with COVID-19 overwhelmed local intensive care units in late May. To capture these scenes at El Centro Regional Medical Center in Imperial County and Scripps Mercy Hospital Chula what does a generic cialis pill look like Vista in San Diego County, de Marco donned personal protective equipment and followed each facility’s safety guidelines. Still, she acknowledges, the work increased her risk of exposure to the coronavirus. She also risked what does a generic cialis pill look like bringing the virus home to her family. For her it was worth the risk, in order to give readers a window on health care in the midst of a pandemic — and to share her work with the world.

This KHN story first published on California Healthline, a what does a generic cialis pill look like service of the California Health Care Foundation. Heidi de Marco. heidid@kff.org, @Heidi_deMarco Related Topics California Multimedia Public Health States Behind The what does a generic cialis pill look like Byline COVID-19Can’t see the audio player?. Click here to listen. About This what does a generic cialis pill look like Podcast Health care — and how much it costs — is scary.

But you’re not alone with this stuff, and knowledge is power. €œAn Arm and a Leg” is a podcast about these issues, and its second what does a generic cialis pill look like season is co-produced by KHN. Barbara Faubion’s boss, an insurance what does a generic cialis pill look like broker, used to tell clients. €œListen, you don’t need to be on the phone for four hours with Blue Cross Blue Shield. Let us what does a generic cialis pill look like do that.

I have a person.”Faubion was that person. And she got up every day psyched to go to work, which she said what does a generic cialis pill look like puzzled her friends.“They’d go, ‘You love your job?. !. ?. You spend your whole day talking to an insurance company.

Are you kidding me?. €™â€She was not kidding. Faubion loved to win — and she was really, really good at untangling other people’s health insurance problems.Now she’s going to teach us some of what she knows.So why doesn’t every health insurance broker have someone like Faubion on staff?. ProPublica reporter Marshall Allen has that answer. There are big clues in his 2019 story about industry commissions and bonuses.“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.To keep in touch with “An Arm and a Leg,” subscribe to the newsletter.

You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.To hear all Kaiser Health News podcasts, click here.And subscribe to “An Arm and a Leg” on iTunes, Pocket Casts, Google Play or Spotify. Related Topics Cost and Quality Health Care Costs Health Industry Insurance Multimedia An Arm and a Leg PodcastsThis story also ran on USA Today. This story can be republished for free (details). Dr. Chris Kjolhede is focused on the children of central New York.As co-director of school-based health centers at Bassett Healthcare Network, the pediatrician oversees about 21 school-based health clinics across the region — a poor, rural area known for manufacturing and crippled by the opioid epidemic.From ankles sprained during recess to birth control questions, the clinics serve as the primary care provider for many children both in and out of the classroom. High on the to-do list is making sure kids are up to date on required vaccinations, said Kjolhede.But, in March, COVID upended the arrangement when it forced schools to close.“It was like, holy smokes,” he said, “what’s going to happen now?.

€ Email Sign-Up Subscribe to KHN’s free Morning Briefing. Schools play a pivotal role in U.S. Vaccination efforts. Laws require children to have certain immunizations to enroll and attend classes.But this academic year, to prevent COVID-19 from spreading, many school districts have opted to start classes online. The decision takes away much of the back-to-school leverage pushing parents to stay current on their children’s shots, said Dr.

Nathaniel Beers, member of the Council on School Health for the American Academy of Pediatrics. If schooling is not happening in person, said Beers, who also led multiple roles in the District of Columbia Public Schools system, “it is harder to enforce.”Public health officials have relied on schools as a means to control vaccine-preventable diseases for over a century. Vaccination laws that require immunizations to enter school first emerged in the 1850s in Massachusetts as a means to control smallpox, as the Centers for Disease Control and Prevention has noted.Every state requires children to receive certain vaccinations against illnesses like polio, mumps and measles before entering the classroom or a child care center, unless the child has a medical exemption. Some states allow people to opt children out of vaccinations for religious or philosophical reasons, although these exemptions have been associated with outbreaks of otherwise well-controlled diseases like measles.“If they get behind or they don’t get specific vaccines they need, kindergarten is a real catch point to get them up to speed and make sure they’re up to date,” said Claire Hannan, executive director of the Association of Immunization Managers.At the local level, the responsibility of tracking whether students are compliant generally falls on the school nurse. If one is not present, a clerical worker or administrator does the job, said Linda Mendonca, president-elect of the National Association of School Nurses.

Usually, school systems face a deadline for checking every child’s record and reporting compliance to government health officials, she said.How districts choose to hold noncompliant children accountable varies, Beers said. Some schools work with parents to set up appointments with a provider. Some isolate children in a classroom, he said, and some are so strict that “you can’t even walk through the door unless you are appropriately immunized.”The COVID-19 pandemic has resulted in steep declines in vaccinations. In May, a report from the CDC showed a sharp drop in the number of orders submitted to the Vaccines For Children program, a federal initiative that purchases vaccines for half the children in the U.S. A second release revealed similar trends — vaccination coverage in Michigan declined among all milestone ages, with the exception of immunizations given at birth, which are generally done in a hospital.Making Backup PlansIn Pennsylvania, for instance, the state health department in July suspended vaccine requirements for two months after the start of the school year.

In addition to causing delays in doctors’ offices, the state said, the pandemic may also prevent school and public health nurses from holding in-school “catch-up” vaccination clinics.“The department cannot stress enough that as soon as children can be vaccinated, they should be,” said Nate Wardle, press secretary for the state’s health department, in a written statement. However, the lockdown order prompted by COVID meant “that there was a several month period in some parts of the state where well-child visits were not occurring.”Members of the American Academy of Pediatrics, the National Association of School Nurses and the Association of Immunization Managers said the grace periods are a prudent step to account for the pandemic’s effect on pediatric care. The majority of children already have some protection from diseases from previous vaccines, they said.Additionally, Beers acknowledged that closing schools — among other actions like restricting travel and shuttering large gathering spaces — make children less likely to contract or spread illnesses that typically incubate in classrooms. For example, according to CDC data, measles has essentially disappeared — 12 cases had been reported as of Aug. 19 this year, compared with 1,282 throughout 2019.However, schooling will eventually resume in person, which will also bring back the risks of illnesses moving through classrooms, Beers said.

And school systems may be less forgiving of children who enter the classroom without the needed vaccinations.“What would be an immense shame is if schools reopen in person and children are back together and we start getting outbreaks of other diseases that are preventable based on immunizations,” he said.School-based health centers in New York are actively contacting parents about vaccinations. In Cooperstown, Kjolhede reached out to every superintendent soon after the lockdown in March to ask if the clinic could remain open. All but one said no.The staff then set up telehealth appointments and phoned students who needed in-person care to arrange visits — including those who needed a vaccine before the start of this school year, he said. Luckily, the health center that remained open had a door that allowed patients to enter the clinic without walking through the school.Several hours away, Dr. Lisa Handwerker is grappling with how to tackle the problem that hundreds of students across her six school-based health clinics in New York City have missed a required vaccine.The city’s health department gave her a list of students in her care who needed additional immunizations, she said.

Over 400 children were missing the second dose to prevent meningococcal meningitis, generally given to teens and young adults ages 16 to 23. Because the department used data from the last academic year to compile the list, Handwerker has no information about new students. Some families left the city because of the lack of income and resources caused by the pandemic.“We had difficulty with at least half of the kids on our vaccine list,” Handwerker said. €œThen when we reached families, they were reluctant to leave their houses.”A Shot at NormalcyThat wasn’t the case for Tracey Wolf, a mother of two who visited the doctor recently to get her son Jordan vaccinated for measles, mumps, rubella and HPV before starting the seventh grade. He will be attending middle school in Dunedin, Florida, in person, said Wolf, 38.It seemed nonsensical to keep Jordan, 13, from his classmates when he already plays baseball and hangs out with his friends, she said.

His grades also slipped last spring when the COVID threat transformed his classroom into a computer.She also took her 6-month-old Ethan for his immunizations. When asked whether she was afraid of going into her doctor’s office, she replied, “Not more than going to the grocery store.”Regardless of whether a child starts school at home or in the classroom, immunization experts stressed the importance of vaccinating a child on time. The schedules factor in a child’s stage of development to maximize the vaccine’s effectiveness. That said, it is preferable that children get their vaccines from their regular doctor to prevent lost immunization records and additional shots, said Beers.Yet on Aug. 19, the Department of Health and Human Services released a statement allowing pharmacists to provide childhood immunizations for children ages 3 to 18.

Carmen Heredia Rodriguez. CarmenH@kff.org, @ByCHRodriguez Related Topics Public Health Children's Health COVID-19 Vaccines.

SOBRE NOTICIAS EN ESPAÑOLNoticias en español es una sección de Kaiser Health News que contiene traducciones de artículos de gran interés cialis prices walmart para la comunidad hispanohablante, Go Here y contenido original enfocado en la población hispana que vive en los Estados Unidos. Use Nuestro Contenido Este contenido puede usarse de manera cialis prices walmart gratuita (detalles). El doctor Chris Kjolhede está enfocado en los niños del centro de Nueva York.Como codirector de los centros de salud escolares de Bassett Healthcare Network, el pediatra supervisa alrededor de 21 clínicas de salud escolares en toda la región, una zona rural pobre conocida por sus fábricas y paralizada por la epidemia de opioides. Desde un esguince de tobillo en el recreo hasta preguntas sobre el control de la natalidad, las clínicas sirven como proveedoras de atención primaria para muchos estudiantes, cialis prices walmart dentro y fuera del aula.La meta principal es asegurarse que los niños estén al día con las vacunas obligatorias, dijo Kjolhede.Pero, en marzo, COVID revocó el acuerdo cuando obligó a cerrar las escuelas.Lo primero que me pregunté, dijo Kjolhede, fue.

€œÂ¿qué va a pasar ahora?. €.Las escuelas juegan cialis prices walmart un papel fundamental en los esfuerzos de vacunación en los Estados Unidos. Las leyes requieren que los niños tengan ciertas vacunas para inscribirse y asistir a clases.Pero para evitar que COVID-19 no siguiera propagándose, muchos distritos escolares han optado por comenzar el año académico en internet.La decisión neutraliza en muchos casos el impulso de los padres por vacunar a sus hijos para el regreso a la escuela, dijo el doctor Nathaniel Beers, miembro del Consejo de Salud Escolar de la Academia Americana de Pediatría.Beers, quien también ocupó varios roles en el sistema de Escuelas Públicas del Distrito de Columbia, agregó que si la educación no es en persona, “es más difícil de hacer cumplir los requisitos”.Los funcionarios de salud pública han confiado en las escuelas como un medio para controlar las enfermedades prevenibles por vacunas durante más de un siglo. Las leyes de vacunación surgieron por primera vez en la década de 1850 en Massachusetts como un medio para controlar la viruela, según cuentan los Centros para el Control y Prevención de Enfermedades (CDC).Todos los estados requieren que los niños reciban ciertas vacunas contra enfermedades como la poliomielitis, las paperas y el sarampión antes de empezar el año escolar o al jardín de infantes, al menos que el niño tenga una exención médica.Algunos estados permiten a las personas optar por no vacunar a los cialis prices walmart niños por razones religiosas o filosóficas, aunque estas exenciones se han asociado con brotes de enfermedades que de otro modo estarían bien controladas, como por ejemplo el sarampión.“Cuando entran al sistema, en preescolar, es donde se detecta si están atrasados con sus vacunas”, dijo Claire Hannan, directora ejecutiva de la Asociación de Administradores de Inmunización.A nivel local, la responsabilidad de rastrear si los estudiantes cumplen con los requisitos de vacunación generalmente recae en la enfermera de la escuela.

Si no, un oficinista o administrador hace el trabajo, dijo Linda Mendonca, presidenta electa de la Asociación Nacional de Enfermeras Escolares.Si no los cumplen, algunas escuelas trabajan con los padres para programar citas con un proveedor de salud. Otras aíslan a los niños en el aula, y otras son tan estrictas que “ni siquiera puedes cruzar la puerta a menos que estés debidamente inmunizado”, dijo Beers.La pandemia de COVID-19 ha cialis prices walmart provocado una baja dramática en la vacunación. En mayo, un informe de los CDC mostró una fuerte caída en la cantidad de pedidos al programa Vaccines For Children, una iniciativa federal que compra vacunas para la mitad de los niños del país.Un segundo comunicado reveló tendencias similares. La cobertura de vacunación en Michigan disminuyó entre todas las edades, con la excepción de las vacunas que se administran al nacer, que generalmente se dan en el hospital.En Pennsylvania, por ejemplo, el Departamento cialis prices walmart de Salud estatal suspendió en julio los requisitos de vacunas durante dos meses después del inicio del año escolar.“El departamento no puede enfatizar más que hay que vacunarse lo antes posible”, dijo Nate Wardle, secretario de prensa del departamento de salud de ese estado, en una declaración escrita.

Sin embargo, la orden de permanecer en casa por COVID hizo que durante meses los consultorios pediátricos no hicieran citas con niños sanos.Beers reconoció que el cierre de las escuelas, entre otras acciones como restringir los viajes y cerrar grandes espacios de reunión, hace que los niños sean menos propensos a contraer o propagar enfermedades que generalmente se incuban en las aulas. Por ejemplo, cialis prices walmart según los datos de los CDC, el sarampión prácticamente ha desaparecido. Se habían reportado 12 casos hasta el 19 de agosto de este año, en comparación con 1,282 en 2019.“Lo que sería una gran vergüenza es que las escuelas vuelvan a abrir en persona y los niños vuelvan a estar juntos cialis prices walmart y empecemos a tener brotes de otras enfermedades que se pueden prevenir con vacunas”, agregó.Los centros de salud de las escuelas de Nueva York se están comunicando activamente con los padres sobre las vacunas. En Cooperstown, Kjolhede se acercó a todos los superintendentes poco después del cierre en marzo para preguntar si la clínica podía permanecer abierta.

Todos menos uno dijeron que no.Luego, cialis prices walmart el personal concertó citas de telesalud y llamó a los estudiantes que necesitaban atención en persona para concertar visitas, incluidos aquellos que necesitaban una vacuna antes del comienzo de este año escolar, dijo. Afortunadamente, el centro de salud que permaneció abierto tenía una puerta que permitía a los pacientes ingresar a la clínica sin caminar por la escuela.A varias horas de distancia, la doctora Lisa Handwerker está lidiando con la forma de abordar el problema de que cientos de estudiantes en sus seis clínicas de salud en las escuelas de la ciudad de Nueva York no han recibido vacunas mandatorias.El departamento de salud de la ciudad le dio una lista de estudiantes bajo su cuidado que necesitaban vacunas adicionales, dijo. A más de 400 niños les faltaba cialis prices walmart la segunda dosis para prevenir la meningitis meningocócica, que generalmente se administra a adolescentes y adultos jóvenes de 16 a 23 años. Debido a que el departamento usó datos del último año académico para compilar la lista, Handwerker no tiene información sobre nuevos estudiantes.

Algunas familias abandonaron la ciudad por la falta de ingresos y recursos provocada por la pandemia.“Tuvimos dificultades con al menos la mitad de los niños en nuestra lista cialis prices walmart de vacunas”, dijo Handwerker. €œLuego, cuando hablamos a las familias, se mostraron reacias a salir de sus casas”.Ese no fue el caso de Tracey Wolf, una madre de dos hijos que visitó al médico recientemente para vacunar a su hijo Jordan contra el sarampión, las paperas, la rubéola y el VPH antes de comenzar el séptimo grado. Asistirá a la escuela secundaria en Dunedin, Florida, en persona, dijo Wolf, de 38 años.Parecía una tontería mantener a Jordan, de 13 cialis prices walmart años, alejado de sus compañeros de clase cuando ya juega béisbol y sale con sus amigos, dijo. Sus calificaciones también bajaron la primavera pasada cuando la amenaza COVID transformó su salón de clases en una computadora.También llevó a su hijo de 6 meses a recibir sus vacunas.

Cuando se cialis prices walmart le preguntó si tenía miedo de ir al consultorio de su médico, respondió. €œNo más que ir al supermercado”.Independientemente de si un niño comienza la escuela en casa o en el aula, los expertos en inmunización enfatizaron la importancia de vacunar siguiendo el calendario de inmunizaciones. Esas fechas tienen en cuenta la etapa de desarrollo del niño para maximizar la eficacia de cialis prices walmart la vacuna. Dicho esto, es preferible que los niños reciban las vacunas de su médico habitual para evitar la pérdida cialis prices walmart de los registros de vacunación y las vacunas adicionales, completó Beers.Sin embargo, el 19 de agosto, el Departamento de Salud y Servicios Humanos (HHS) emitió una declaración que permite a los farmacéuticos administrar vacunas infantiles a niños y adolescents de 3 a 18 años.

Carmen Heredia Rodriguez. CarmenH@kff.org, @ByCHRodriguez Related Topics Noticias En Español Public Health Children's Health COVID-19 VaccinesAlthough the coronavirus cialis prices walmart pandemic shut down many organizations and businesses across the nation, KHN has never been busier ― and health coverage has never been more vital. We’ve revamped our Behind the Byline YouTube series and brought it to Instagram TV.Journalists and producers from across KHN’s newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts — all while staying safe.Heidi de Marco — “At Least I Got the Shot” Photojournalist Heidi de Marco’s stunning images transport viewers to two California hospitals near the U.S.-Mexico border where the influx of patients with COVID-19 overwhelmed local intensive care units in late May. To capture these scenes at El Centro Regional Medical Center in Imperial County and Scripps Mercy Hospital Chula Vista in San Diego County, de Marco donned personal protective equipment and followed each facility’s cialis prices walmart safety guidelines.

Still, she acknowledges, the work increased her risk of exposure to the coronavirus. She also risked cialis prices walmart bringing the virus home to her family. For her it was worth the risk, in order to give readers a window on health care in the midst of a pandemic — and to share her work with the world. This KHN story first published on California Healthline, a service of cialis prices walmart the California Health Care Foundation.

Heidi de Marco. heidid@kff.org, @Heidi_deMarco Related Topics California Multimedia Public Health States Behind The Byline COVID-19Can’t see the audio cialis prices walmart player?. Click here to listen. About This Podcast Health care — and cialis prices walmart how much it costs — is scary.

But you’re not alone with this stuff, and knowledge is power. €œAn Arm and a Leg” is a podcast about these issues, and its second cialis prices walmart season is co-produced by KHN. Barbara Faubion’s boss, an insurance broker, used to tell cialis prices walmart clients. €œListen, you don’t need to be on the phone for four hours with Blue Cross Blue Shield.

Let us cialis prices walmart do that. I have a person.”Faubion was that person. And she got up every day psyched to go to work, which she said puzzled her friends.“They’d cialis prices walmart go, ‘You love your job?. !.

? Your Domain Name cialis prices walmart. You spend your whole day talking to an insurance company. Are you kidding me? cialis prices walmart. €™â€She was not kidding.

Faubion loved to win — and she was really, really good at untangling other people’s health insurance problems.Now she’s going to teach us some of what she knows.So cialis prices walmart why doesn’t every health insurance broker have someone like Faubion on staff?. ProPublica reporter Marshall Allen has that answer. There are big cialis prices walmart clues in his 2019 story about industry commissions and bonuses.“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on cialis prices walmart Facebook and Twitter.

And if you’ve got stories to tell about the health care system, the producers would love to hear from you.To hear all Kaiser Health News podcasts, click here.And subscribe to “An Arm and a Leg” on iTunes, Pocket Casts, Google Play or Spotify. Related Topics Cost and Quality Health Care cialis prices walmart Costs Health Industry Insurance Multimedia An Arm and a Leg PodcastsThis story also ran on USA Today. This story can be republished for free (details). Dr. Chris Kjolhede is focused on the children of central New York.As co-director of school-based health centers at Bassett Healthcare Network, the pediatrician oversees about 21 school-based health clinics across the region — a poor, rural area known for manufacturing and crippled by the opioid epidemic.From ankles sprained during recess to birth control questions, the clinics serve as the primary care provider for many children both in and out of the classroom. High on the to-do list is making sure kids are up cialis prices walmart to date on required vaccinations, said Kjolhede.But, in March, COVID upended the arrangement when it forced schools to close.“It was like, holy smokes,” he said, “what’s going to happen now?.

€ Email Sign-Up Subscribe to KHN’s free Morning Briefing. Schools play a pivotal role in U.S cialis prices walmart. Vaccination efforts. Laws require children to have cialis prices walmart certain immunizations to enroll and attend classes.But this academic year, to prevent COVID-19 from spreading, many school districts have opted to start classes online.

The decision takes away much of the back-to-school leverage pushing parents to stay current on their children’s shots, said Dr. Nathaniel Beers, member cialis prices walmart of the Council on School Health for the American Academy of Pediatrics. If schooling is not happening in person, said Beers, who also led multiple roles in the District of Columbia Public Schools system, “it is harder to enforce.”Public health officials have relied on schools as a means to control vaccine-preventable diseases for over a century. Vaccination laws that require immunizations to enter school first emerged in the 1850s in Massachusetts as a means to control smallpox, as the Centers for cialis prices walmart Disease Control and Prevention has noted.Every state requires children to receive certain vaccinations against illnesses like polio, mumps and measles before entering the classroom or a child care center, unless the child has a medical exemption.

Some states allow people to opt children out of vaccinations for religious or philosophical reasons, although these exemptions have been associated with outbreaks of otherwise well-controlled diseases like measles.“If they get behind or they don’t get specific vaccines they need, kindergarten is a real catch point to get them up to speed and make sure they’re up to date,” said Claire Hannan, executive director of the Association of Immunization Managers.At the local level, the responsibility of tracking whether students are compliant generally falls on the school nurse. If one is not present, a clerical worker or administrator does the job, said cialis prices walmart Linda Mendonca, president-elect of the National Association of School Nurses. Usually, school systems face a deadline for checking every child’s record and reporting compliance to government health officials, she said.How cialis prices walmart districts choose to hold noncompliant children accountable varies, Beers said. Some schools work with parents to set up appointments with a provider.

Some isolate children in a classroom, he said, and some are so cialis prices walmart strict that “you can’t even walk through the door unless you are appropriately immunized.”The COVID-19 pandemic has resulted in steep declines in vaccinations. In May, a report from the CDC showed a sharp drop in the number of orders submitted to the Vaccines For Children program, a federal initiative that purchases vaccines for half the children in the U.S. A second release revealed similar trends — vaccination coverage in Michigan declined among all milestone ages, with the exception of immunizations given at birth, which are generally done in a hospital.Making Backup PlansIn Pennsylvania, for instance, the state health department in July suspended vaccine requirements cialis prices walmart for two months after the start of the school year. In addition to causing delays in doctors’ offices, the state said, the pandemic may also prevent school and public health nurses from holding in-school “catch-up” vaccination clinics.“The department cannot stress enough that as soon as children can be vaccinated, they should be,” said Nate Wardle, press secretary for the state’s health department, in a written statement.

However, the lockdown order prompted by COVID meant “that there was a several month period in some parts of the state where well-child visits were not occurring.”Members of the American Academy of Pediatrics, the National Association of School Nurses cialis prices walmart and the Association of Immunization Managers said the grace periods are a prudent step to account for the pandemic’s effect on pediatric care. The majority of children already have some protection from diseases from previous vaccines, they said.Additionally, Beers acknowledged that closing schools — among other actions like restricting travel and shuttering large gathering spaces — make children less likely to contract or spread illnesses that typically incubate in classrooms. For example, according to CDC data, measles has essentially disappeared cialis prices walmart — 12 cases had been reported as of Aug. 19 this year, compared with 1,282 throughout 2019.However, schooling will eventually resume in person, which will also bring back the risks of illnesses moving through classrooms, Beers said.

And school systems may be less forgiving of children who enter the classroom without the needed vaccinations.“What would be an immense shame is if schools reopen in cialis prices walmart person and children are back together and we start getting outbreaks of other diseases that are preventable based on immunizations,” he said.School-based health centers in New York are actively contacting parents about vaccinations. In Cooperstown, Kjolhede reached out to every superintendent soon after the lockdown in March to ask if the clinic could remain open. All but one said no.The staff then set up telehealth appointments and phoned students who needed in-person care to arrange visits — including those who cialis prices walmart needed a vaccine before the start of this school year, he said. Luckily, the health center that remained open had cialis prices walmart a door that allowed patients to enter the clinic without walking through the school.Several hours away, Dr.

Lisa Handwerker is grappling with how to tackle the problem that hundreds of students across her six school-based health clinics in New York City have missed a required vaccine.The city’s health department gave her a list of students in her care who needed additional immunizations, she said. Over 400 children were missing the second dose to cialis prices walmart prevent meningococcal meningitis, generally given to teens and young adults ages 16 to 23. Because the department used data from the last academic year to compile the list, Handwerker has no information about new students. Some families left the city because of the cialis prices walmart lack of income and resources caused by the pandemic.“We had difficulty with at least half of the kids on our vaccine list,” Handwerker said.

€œThen when we reached families, they were reluctant to leave their houses.”A Shot at NormalcyThat wasn’t the case for Tracey Wolf, a mother of two who visited the doctor recently to get her son Jordan vaccinated for measles, mumps, rubella and HPV before starting the seventh grade. He will be attending middle school in Dunedin, Florida, in person, said cialis prices walmart Wolf, 38.It seemed nonsensical to keep Jordan, 13, from his classmates when he already plays baseball and hangs out with his friends, she said. His grades also slipped last spring when the COVID threat transformed his classroom into a computer.She also took her 6-month-old Ethan for his immunizations. When asked whether she was afraid of going into her doctor’s office, she replied, “Not more than going to the grocery store.”Regardless of whether a child starts school at home or in the classroom, immunization experts stressed the importance of vaccinating a child on time.

The schedules factor in a child’s stage of development to maximize the vaccine’s effectiveness. That said, it is preferable that children get their vaccines from their regular doctor to prevent lost immunization records and additional shots, said Beers.Yet on Aug. 19, the Department of Health and Human Services released a statement allowing pharmacists to provide childhood immunizations for children ages 3 to 18. Carmen Heredia Rodriguez.

CarmenH@kff.org, @ByCHRodriguez Related Topics Public Health Children's Health COVID-19 Vaccines.

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Credit. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia in this population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries.

During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls.

Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the two conditions remains unclear,” she says. However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

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

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

These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer.

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

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. €œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says.

Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

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

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

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

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

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

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

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

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

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

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

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

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

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€‚For the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This Focus Issue on heart failure (HF) provides novel clinically relevant information on sodium–glucose co-transporter-2 (SGLT2) inhibitors which, initially proposed for the treatment of type 2 diabetes mellitus (T2D), have been found to improve the outcome of HF with reduced ejection fraction (HFrEF) when administered on the top cialis savings card of drugs known to improve the outcome of HF and are recommended in current European Guidelines.1,2Acording to modelling estimates, when compared with no neurohormonal blockade, the use of a broad-based combination of disease-modifying drugs at target doses cialis best price in patients with HF may reduce the risk of death by as much as 75%. It is surprising that in spite of this powerful therapeutic armamentarium, <1% of patients with chronic HF are currently receiving recommended drugs at doses that have been shown to prolong life.3 The issue opens with a Current Opinion article entitled ‘Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction. Implications for clinical practice’ by Milton Packer from the Baylor University cialis best price Medical Center at Dallas in Texas, USA and colleagues. The authors provide a perspective on the totality of evidence with SGLT2 inhibitors in patients with HFrEF.4 This paper is the first to issue a call for a major change in clinical practice based on the concordant results of DAPA-HF and EMPEROR-Reduced trials. The analyses and interpretations that are presented in this manuscript will undoubtedly generate considerable discussion and debate for a long time.Concern about hypotension often leads to withholding of beneficial therapy in patients with HFrEF.

In a clinical research manuscript entitled ‘Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF)’ cialis best price John McMurray from the Western Infirmary in Glasgow, UK and colleagues on behalf of the DAPA-HF Investigators and Committees evaluated the efficacy and safety of dapagliflozin according to baseline systolic blood pressure (SBP) in DAPA-HF trial.5 Key inclusion criteria were. New York Heart Association (NYHA) class II–IV, left ventricular ejection fraction (LVEF) ≤40%, elevated N-terminal probrain natriuretic peptide (NT-proBNP) level, and SBP ≥95 mmHg. The primary outcome was a composite of worsening HF or cardiovascular death. The efficacy and safety of dapagliflozin was examined using SBP as both cialis best price a categorical and a continuous variable. The placebo-corrected reduction in SBP from baseline to 2 weeks with dapagliflozin was –2.54 mmHg.

The benefit and safety of dapagliflozin were consistent across cialis best price the range of SBP. Study drug discontinuation did not differ between dapagliflozin and placebo across the SBP categories examined.The authors conclude that dapagliflozin had a small effect on SBP in patients with HFrEF and was superior to placebo in improving outcomes, and well tolerated, across the range of SBP included in DAPA-HF. The manuscript is accompanied by an Editorial by Francesco Cosentino from the University Hospital Solna in Stockholm, Sweden who comments that altogether, the results of the current post-hoc analysis demonstrating efficacy and safety of dapagliflozin regardless of SBP values might significantly contribute to foster the implementation of dapagliflozin use in HF clinical practice by dissipating any potential safety concern linked with its hypotensive effects.6In a clinical research article entitled ‘A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial’, Chim Lang from the University of Dundee in the UK and colleagues tested the hypothesis that dapagliflozin may regress left ventricular hypertrophy (LVH) in people with T2D.7 The authors randomly assigned 66 patients with T2D, LVH, and controlled blood pressure to receive dapagliflozin 10 mg once daily or placebo for 12 months cialis best price. The primary endpoint was change in absolute left ventricular mass (LVM), assessed by cardiac magnetic resonance imaging (MRI).

In the intention-to-treat analysis, dapagliflozin significantly reduced LVM compared with placebo, with an absolute mean change of –2.82 g. Additional sensitivity analysis adjusting for baseline LVM, baseline blood pressure, weight, and SBP change showed the LVM change cialis best price to remain statistically significant. Dapagliflozin significantly reduced pre-specified secondary endpoints including ambulatory 24-h SBP, nocturnal SBP, body weight, visceral adipose tissue, subcutaneous adipose tissue, insulin resistance, and high-sensitivity C-reactive protein. Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with cialis best price type two diabetes.

The DAPA-LVH trial. See pages 3421–3432).Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment cialis best price compared to placebo (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial. See pages 3421–3432).Lang and colleagues conclude that dapagliflozin treatment significantly cialis best price reduced LVM in patients with T2D and LVH.

The regression of LVM suggests that dapagliflozin can initiate reverse remodelling and changes in left ventricular structure that may partly contribute to cardioprotective effects of dapagliflozin. This manuscript is accompanied by an Editorial by Francesco Paneni from the University of Zurich in Switzerland and colleagues.8 They note that the above-mentioned effects of SGLT2 inhibitors set the ground for a possible beneficial effect of these drugs in patients with HFpEF, where microvascular dysfunction, cardiomyocyte inflammation, and cardiometabolic alterations take centre stage.While several landmark studies have long established that implantable cardioverter-defibrillator (ICD) therapy improves survival for primary prevention of sudden cardiac death ,9 risk stratification parameters and methods for this purpose are clinically underused. In a clinical research article entitled ‘Clinical effectiveness of primary cialis best price prevention implantable cardioverter-defibrillators. Results of the EU-CERT-ICD controlled multicentre cohort study’ Markus Zabel from the Universitätsmedizin Göttingen in Germany and colleagues from the EU-CERT-ICD Study Investigators assessed the current clinical effectiveness of primary prevention by ICD therapy in a prospective investigator-initiated, controlled cohort study, conducted in 44 centres and 15 European countries. The study sought to assess current clinical effectiveness of primary prophylactic ICD implantation.10 The authors recruited 2327 patients with ischaemic or dilated cardiomyopathy cialis best price and guideline indications for prophylactic ICD implantation.

The primary endpoint was all-cause mortality. Baseline and follow-up data from 2247 patients were analysable. 1516 patients with first ICD implantation (ICD cialis best price group) and 731 patients without ICD serving as controls. Multivariable models and propensity scoring for adjustment were used to compare the two groups for mortality. Adjusted mortality associated with ICD vs.

Control was cialis best price significantly lower (hazard ratio 0.731). Subgroup analyses indicated no ICD benefit in diabetics or in those aged ≥75 years. Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and placebo at 6 months. Change in (A) left ventricular end-diastolic cialis best price volume. (B) left ventricular end-systolic volume.

And (C) cialis best price N-terminal pro b-type natriuretic peptide levels. At 6 months. CDC, cardiosphere-derived cell. LVEDV, left ventricular end-diastolic cialis best price volume. LVESV, left ventricular end-systolic volume.

NT-proBNP, N-terminal pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cialis best price cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial. See pages 3451--3458).Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and placebo at 6 months. Change in (A) cialis best price left ventricular end-diastolic volume.

(B) left ventricular end-systolic volume. And (C) cialis best price N-terminal pro b-type natriuretic peptide levels. At 6 months. CDC, cardiosphere-derived cell. LVEDV, left ventricular cialis best price end-diastolic volume.

LVESV, left ventricular end-systolic volume. NT-proBNP, N-terminal pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic cialis best price heart STem cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial. See pages 3451--3458).The authors conclude that in contemporary ischaemic/dilated cardiomyopathy patients (LVEF ≤35%, narrow QRS), primary prophylactic ICD treatment was associated with cialis best price a substantial reduction in mortality, although this improvement was not consistent across the whole population.

The manuscript is accompanied by an Editorial by N.A. Mark Estes III from the Heart and Vascular Institute UPMC in Pittsburgh, Pennsylvania, USA.11 The authors note that clinicians should be mindful of available risk stratification models and subgroup analyses from the EU-CERT-ICD and other studies. It follows that the process of shared decision-making should include careful consideration of the patient’s wishes and values, with an individualized assessment of potential cialis best price benefit and risks of primary prevention of sudden death by ICD implantation.Cardiosphere-derived cells (CDCs) are cardiac progenitor cells which exhibit disease-modifying bioactivity in various models of cardiomyopathy and in previous clinical studies of acute myocardial infarction (MI), dilated cardiomyopathy, and Duchenne muscular dystrophy.12,13 In a clinical research article entitled ‘Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial’, Raj Makkar from the Cedars-Sinai Heart Institute in Los Angeles, California, USA and colleagues assessed the safety and efficacy of intracoronary administration of allogeneic CDCs in the multicentre, randomized, double-blind, placebo-controlled, intracoronary ALLogeneic Heart STem Cells to Achieve Myocardial Regeneration (ALLSTAR) trial.14 The authors enrolled patients 4 weeks to 12 months after MI, with LVEF ≤45% and left ventricular LV scar size ≥15% of LVM by MRI. A pre-specified interim analysis was performed when 6-month MRI data were available.

The trial was subsequently stopped due to the low probability of detecting a significant treatment effect of CDCs cialis best price based on the primary endpoint. Patients were randomly allocated in a 2:1 ratio to receive CDCs or placebo in the infarct-related artery by the stop–flow technique. The primary safety endpoint was the occurrence, during 1-month post-intracoronary infusion, of acute myocarditis attributable to allogeneic CDCs, ventricular tachycardia- or ventricular fibrillation-related death, sudden unexpected death, or a major adverse cardiac event (death or hospitalization for HF or non-fatal MI). The primary efficacy endpoint cialis best price was the relative percentage change in infarct size at 12 months post-infusion as assessed by contrast-enhanced cardiac MRI. Makkar and colleagues randomly allocated 90 patients to the CDC group and 44 to the placebo group.

The mean baseline LVEF was 40% and cialis best price the mean scar size was 22% of the LVM. No primary safety endpoint events occurred. There was no difference in the percentage change from baseline in scar size between CDC and placebo groups at 6 months. Compared with placebo, there were significant reductions in LV end-diastolic volume, cialis best price LV end-systolic volume, and NT-proBNP at 6 months in CDC-treated patients.The authors conclude that intracoronary infusion of allogeneic CDCs in patients with post-MI left ventricular dysfunction was safe but did not reduce scar size relative to placebo at 6 months. The manuscript is accompanied by an Editorial by Francisco Fernandez-Aviles from the Hospital General Universitario Gregorio Marañón in Madrid, Spain and colleagues.15 The authors feel that various points need to be better addressed before proceeding again to clinical trials, if we want to move the field of cardiovascular regenerative and reparative medicine forward, for the sake of the cardiovascular health of millions of patients.Treatment of pathological cardiac remodelling and subsequent HF represents an unmet clinical need.

Long non-coding RNAs (lncRNAs) are emerging as crucial molecular orchestrators of disease processes including that of heart diseases.16,17 In a Basic Science article entitled ‘Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac hypertrophy’, Thomas Thum from the Hannover Medical School in Germany, and colleagues report on the powerful therapeutic potential of the conserved lncRNA H19 in the treatment of pathological cardiac hypertrophy.18 Pressure overload-induced left ventricular cardiac remodelling revealed an up-regulation of H19 in the early phase, but a strong sustained repression upon reaching the decompensated phase of HF. The translational potential of H19 was highlighted by its repression in a cialis best price large animal (pig) model of LVH, in diseased human heart samples, in human stem cell-derived cardiomyocytes, and in human engineered heart tissue in response to afterload enhancement. Pressure overload-induced cardiac hypertrophy in H19 knockout mice was aggravated compared with wild-type mice. In contrast, vector-based, cardiomyocyte-directed gene therapy using murine but also human H19 strongly attenuated HF even when cardiac hypertrophy was already established cialis best price. Mechanistically, using microarray, gene set enrichment analyses, and chromatin immunoprecipitation-DNA sequencing, the authors identified a link between H19 and prohypertrophic nuclear factor of activated T cells (NFAT) signalling.

H19 physically interacts with the polycomb repressive complex 2 to suppress H3K27 tri-methylation of the antihypertrophic Tescalcin locus which in turn leads to reduced NFAT expression and activity.Thum and colleagues conclude that H19 is highly conserved and down-regulated in failing hearts from mice, pigs, and humans. H19 gene therapy prevents cialis best price and reverses experimental pressure overload-induced HF. H19 acts as an antihypertrophic lncRNA and represents a promising therapeutic target to combat pathological cardiac remodelling. The manuscript is accompanied by an Editorial by Gianluigi Condorelli from the Humanitas University in Rozzano, Italy and colleagues. The authors cialis best price note that dysregulation of epigenetic mechanisms leading to aberrant loss of cardiomyocyte homeostasis is a critical point to consider in understanding the onset of cardiovascular pathologies.

Thus exploiting lncRNAs as therapeutic agents in myocardial disease could pave the way for efficaciously combatting one of the greatest healthcare burdens worldwide.19With the advent of omics, an innovative inductive method has provided researchers with possible ways new to monitor health and disease. This approach incorporates data from studies of the genome, transcriptome, proteome, and metabolome to focus on the assessment of a varied range of biomolecules.20 In a clinical review article entitled ‘Omics phenotyping in heart failure. The next cialis best price frontier’ Antoni Bayes-Genis from the Cardiology Service, Hospital Universitari Germans Trias i Pujol in Badalona, Spain and colleagues provide a state-of-the-art review aiming to provide an up-to-date look at breakthrough omic technologies that are helping to unravel HF disease mechanisms and heterogeneity.21 Genomics, transcriptomics, proteomics, and metabolomics in HF are reviewed in depth. In addition, there is a thorough, expert discussion regarding the value of omics in identifying novel disease pathways, advancing understanding of disease mechanisms, differentiating HF phenotypes, yielding biomarkers for diagnosis or prognosis, or identifying new therapeutic targets in HF. The combination of multiple omics technologies may create a more comprehensive picture of the factors and pathophysiology involved in HF than achieved by either one alone, cialis best price and provides a rich resource for predictive phenotype modelling.

However, the successful translation of omics tools as solutions to clinical HF requires that the observations are robust and reproducible, and can be validated across multiple independent populations to ensure confidence in clinical decision-making.This issue is also complemented by a Discussion Forum contribution. In a contribution entitled ‘Heart failure development in obesity. Mechanistic pathways’ Kristjan Karason from the Sahlgrenska University Hospital in Gothenburg, Sweden and colleagues cialis best price provide a reply to a recent comment entitled ‘Incident heart failure risk after bariatric surgery. The role of epicardial fat’.22,23The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Hugger, and Martin Meyer for help with compilation of this article. References1Docherty KF, Jhund PS, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, DeMets DL, Sabatine MS, Bengtsson O, Sjöstrand M, Langkilde AM, Desai AS, Diez M, Howlett JG, Katova T, Ljungman CEA, O’Meara E, Petrie MC, Schou M, Verma S, Vinh PN, Solomon SD, McMurray JJV.

Effects of dapagliflozin in DAPA-HF according to cialis best price background heart failure therapy. Eur Heart J 2020;41:2379–2392.2Ponikowski P, Voors AA,, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of cialis best price Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

Eur Heart J 2016;37:2129–2200.3Packer M cialis best price. Are the benefits of SGLT2 inhibitors in heart failure and a reduced ejection fraction influenced by background therapy?. Expectations and realities of a new standard of care. Eur Heart J 2020;41:2393–2396.4Butler J, Zannad F, Filippatos G, Anker SD, Packer cialis best price M. Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction.

Implications for clinical practice. Eur Heart J 2020;41:3398–3401.5Serenelli M, Böhm M, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P,, Sabatine MS, Solomon SD, DeMets DL, Bengtsson O, Sjöstrand M, Langkilde AM, Anand IS, Chiang CE, Chopra VK, de Boer RA, Diez M, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, cialis best price Verma S,, Docherty KF, Jhund PS, McMurray JJV. Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF). Eur Heart cialis best price J 2020;41:3402–3418.6Savarese G, Cosentino F. The interaction between dapagliflozin and blood pressure in heart failure.

New evidence dissipating concerns. Eur Heart J 2020;41:3419–3420.7Brown AJM, Gandy S, cialis best price McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial. Eur Heart cialis best price J 2020;41:3421–3432.8Paneni F, Costantino S, Hamdani N.

Regression of left ventricular hypertrophy with SGLT2 inhibitors. Eur Heart J 2020;41:3433–3436.9Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekvål TM, Spaulding C, Van Veldhuisen DJ. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias cialis best price and the prevention of sudden cardiac death. The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by cialis best price.

Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015;36:2793–2867.10Zabel M, Willems R, Lubinski A, Bauer A, Brugada J, Conen D, Flevari P, Hasenfuß G, Svetlosak M, Huikuri HV, Malik M, Pavlović N, Schmidt G, Sritharan R, Schlögl S, Szavits-Nossan J, Traykov V, Tuinenburg AE, Willich SN, Harden M, Friede T, Svendsen JH, Sticherling C, Merkely B. Clinical effectiveness of primary prevention implantable cialis best price cardioverter-defibrillators. Results of the EU-CERT-ICD controlled multicentre cohort study. Eur Heart J 2020;41:3437–3447.11Estes MNA, Saba S.

Primary prevention cialis best price of sudden death with the implantable cardioverter defibrillator. Bridging the evidence gap. Eur Heart J 2020;41:3448–3450.12Aminzadeh MA, Tseliou E, Sun B, Cheng K, Malliaras K, Makkar RR, Marbán E. Therapeutic efficacy of cardiosphere-derived cells in a transgenic mouse model of cialis best price non-ischaemic dilated cardiomyopathy. Eur Heart J 2015;36:751–762.13Fadini GP, Mehta A, Dhindsa DS, Bonora BM, Sreejit G, Nagareddy P, Quyyumi AA.

Circulating stem cells and cardiovascular outcomes cialis best price. From basic science to the clinic. Eur Heart J 2020. Doi:10.1093/eurheartj/ehz923.14Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, cialis best price Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR).

A randomized, placebo-controlled, double-blinded trial. Eur Heart cialis best price J 2020;41:3451–3458.15Sanz-Ruiz R, Fernández-Avilés F. Cardiovascular regenerative and reparative medicine. Is myocardial cialis best price infarction the model?. Eur Heart J 2020;41:3459–3461.16Ounzain S, Micheletti R, Beckmann T, Schroen B, Alexanian M, Pezzuto I, Crippa S, Nemir M, Sarre A, Johnson R, Dauvillier J, Burdet F, Ibberson M, Guigó R, Xenarios I, Heymans S, Pedrazzini T.

Genome-wide profiling of the cardiac transcriptome after myocardial infarction identifies novel heart-specific long non-coding RNAs. Eur Heart J 2015;36:353–368.17Lüscher cialis best price TF. Novel molecular mechanisms of vascular disease. Non-coding RNAs, inflammation, and radiation. Eur Heart cialis best price J.

2020;40:2467–2470.18Viereck J, Bührke A, Foinquinos A, Chatterjee S, Kleeberger JA, Xiao K, Janssen-Peters H, Batkai S, Ramanujam D, Kraft T, Cebotari S, Gueler F, Beyer AM, Schmitz J, Bräsen JH, Schmitto JD, Gyöngyösi M, Löser A, Hirt MN, Eschenhagen T, Engelhardt S, Bär C, Thum T. Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac hypertrophy. Eur Heart J 2020;41:3462–3474.19Pagiatakis C, cialis best price Hall IF, Condorelli G. Long non-coding RNA H19. A new cialis best price avenue for RNA therapeutics in cardiac hypertrophy?.

Eur Heart J 2020;41:3475–3476.20Hoogeveen RM, Pereira JPB, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw KT, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk prediction using targeted plasma proteomics in primary prevention. Eur Heart J cialis best price 2020;ehaa648. 21Bayes-Genis A, Liu PP, Lanfear DE, de Boer RA, González A, Thum T, Emdin M, Januzzi JL. Omics phenotyping in heart failure.

The next frontier cialis best price. Eur Heart J 2020;41:3477–3484.22Karason K, Jamaly S. Heart failure development in obesity cialis best price. Mechanistic pathways. Eur Heart J 2020;41:3485.23van Woerden G, van Veldhuisen SL, Rienstra M.

Incident heart cialis best price failure risk after bariatric surgery. The role of epicardial fat. Eur Heart J 2020;41:1775. Published cialis best price on behalf of the European Society of Cardiology. All rights reserved.

© The Author(s) 2020. For permissions, cialis best price please email. Journals.permissions@oup.com. For the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This Focus Issue on heart failure (HF) provides novel clinically relevant information on sodium–glucose co-transporter-2 (SGLT2) inhibitors which, initially proposed for the treatment of type 2 diabetes mellitus (T2D), have been found to improve the outcome of HF with cialis 5mg daily how long before it works reduced ejection fraction (HFrEF) when administered on the top of drugs known to improve the outcome of HF and are recommended in current European Guidelines.1,2Acording to modelling estimates, when compared with no neurohormonal blockade, the use of a broad-based combination of disease-modifying drugs at target doses in patients with HF may reduce the risk of death by as much as 75%. It is surprising that in spite of cialis best price this powerful therapeutic armamentarium, <1% of patients with chronic HF are currently receiving recommended drugs at doses that have been shown to prolong life.3 The issue opens with a Current Opinion article entitled ‘Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction. Implications for clinical practice’ by Milton Packer from the Baylor University Medical Center at Dallas in Texas, USA and colleagues.

The authors provide a perspective on the totality of evidence with SGLT2 inhibitors in patients with HFrEF.4 This paper is the first to issue a call for a major change in clinical practice based on the concordant results of DAPA-HF and EMPEROR-Reduced trials. The analyses and interpretations cialis best price that are presented in this manuscript will undoubtedly generate considerable discussion and debate for a long time.Concern about hypotension often leads to withholding of beneficial therapy in patients with HFrEF. In a clinical research manuscript entitled ‘Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF)’ John McMurray from the Western Infirmary in Glasgow, UK and colleagues on behalf of the DAPA-HF Investigators and Committees evaluated the efficacy and safety of dapagliflozin according to baseline systolic blood pressure (SBP) in DAPA-HF trial.5 Key inclusion criteria were. New York Heart Association (NYHA) class II–IV, left ventricular ejection fraction (LVEF) ≤40%, elevated N-terminal probrain natriuretic peptide (NT-proBNP) level, and SBP ≥95 mmHg. The primary cialis best price outcome was a composite of worsening HF or cardiovascular death.

The efficacy and safety of dapagliflozin was examined using SBP as both a categorical and a continuous variable. The placebo-corrected reduction in SBP from baseline to 2 weeks with dapagliflozin was –2.54 mmHg. The benefit and safety of dapagliflozin were consistent cialis best price across the range of SBP. Study drug discontinuation did not differ between dapagliflozin and placebo across the SBP categories examined.The authors conclude that dapagliflozin had a small effect on SBP in patients with HFrEF and was superior to placebo in improving outcomes, and well tolerated, across the range of SBP included in DAPA-HF. The manuscript is accompanied by an Editorial by Francesco Cosentino from the University Hospital Solna in Stockholm, Sweden who comments that altogether, the results of the current post-hoc analysis demonstrating efficacy and safety of dapagliflozin regardless of SBP values might significantly contribute to foster the implementation of dapagliflozin use in HF clinical practice by dissipating any potential cialis best price safety concern linked with its hypotensive effects.6In a clinical research article entitled ‘A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes.

The DAPA-LVH trial’, Chim Lang from the University of Dundee in the UK and colleagues tested the hypothesis that dapagliflozin may regress left ventricular hypertrophy (LVH) in people with T2D.7 The authors randomly assigned 66 patients with T2D, LVH, and controlled blood pressure to receive dapagliflozin 10 mg once daily or placebo for 12 months. The primary endpoint was change in absolute left ventricular mass (LVM), assessed by cardiac magnetic resonance imaging (MRI). In the intention-to-treat analysis, dapagliflozin significantly reduced LVM compared with placebo, with an absolute mean change of –2.82 g cialis best price. Additional sensitivity analysis adjusting for baseline LVM, baseline blood pressure, weight, and SBP change showed the LVM change to remain statistically significant. Dapagliflozin significantly reduced pre-specified secondary endpoints including ambulatory 24-h SBP, nocturnal SBP, body weight, visceral adipose tissue, subcutaneous adipose tissue, insulin resistance, and high-sensitivity C-reactive protein.

Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo cialis best price (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH cialis best price trial. See pages 3421–3432).Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes.

The DAPA-LVH trial cialis best price. See pages 3421–3432).Lang and colleagues conclude that dapagliflozin treatment significantly reduced LVM in patients with T2D and LVH. The regression of LVM suggests that dapagliflozin can initiate reverse remodelling and changes in left ventricular structure that may partly contribute to cardioprotective effects of dapagliflozin. This manuscript is accompanied by an Editorial by Francesco Paneni from the University of Zurich in Switzerland and colleagues.8 They note that the above-mentioned effects of SGLT2 inhibitors set the ground for a possible beneficial effect of these drugs in patients with HFpEF, where microvascular dysfunction, cardiomyocyte inflammation, and cardiometabolic alterations cialis best price take centre stage.While several landmark studies have long established that implantable cardioverter-defibrillator (ICD) therapy improves survival for primary prevention of sudden cardiac death ,9 risk stratification parameters and methods for this purpose are clinically underused. In a clinical research article entitled ‘Clinical effectiveness of primary prevention implantable cardioverter-defibrillators.

Results of the EU-CERT-ICD controlled multicentre cohort study’ Markus Zabel from the Universitätsmedizin Göttingen in Germany and colleagues from the EU-CERT-ICD Study Investigators assessed the current clinical effectiveness of primary prevention by ICD therapy in a prospective investigator-initiated, controlled cohort study, conducted in 44 centres and 15 European countries. The study sought to assess current clinical effectiveness of primary prophylactic ICD implantation.10 The authors recruited 2327 patients with ischaemic or dilated cardiomyopathy and guideline indications for prophylactic ICD cialis best price implantation. The primary endpoint was all-cause mortality. Baseline and follow-up data from 2247 patients were analysable cialis best price. 1516 patients with first ICD implantation (ICD group) and 731 patients without ICD serving as controls.

Multivariable models and propensity scoring for adjustment were used to compare the two groups for mortality. Adjusted mortality cialis best price associated with ICD vs. Control was significantly lower (hazard ratio 0.731). Subgroup analyses indicated no ICD benefit in diabetics or in those aged ≥75 years. Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and cialis best price placebo at 6 months.

Change in (A) left ventricular end-diastolic volume. (B) left ventricular end-systolic cialis best price volume. And (C) N-terminal pro b-type natriuretic peptide levels. At 6 months. CDC, cardiosphere-derived cialis best price cell.

LVEDV, left ventricular end-diastolic volume. LVESV, left ventricular end-systolic volume. NT-proBNP, N-terminal pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, cialis best price Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial.

See pages 3451--3458).Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and cialis best price placebo at 6 months. Change in (A) left ventricular end-diastolic volume. (B) left ventricular end-systolic cialis best price volume. And (C) N-terminal pro b-type natriuretic peptide levels. At 6 months.

CDC, cardiosphere-derived cialis best price cell. LVEDV, left ventricular end-diastolic volume. LVESV, left ventricular end-systolic volume. NT-proBNP, N-terminal cialis best price pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR).

A randomized, placebo-controlled, double-blinded trial. See pages 3451--3458).The authors conclude that in contemporary ischaemic/dilated cardiomyopathy patients (LVEF ≤35%, narrow QRS), primary prophylactic ICD treatment cialis best price was associated with a substantial reduction in mortality, although this improvement was not consistent across the whole population. The manuscript is accompanied by an Editorial by N.A. Mark Estes III from the Heart and Vascular Institute UPMC in Pittsburgh, Pennsylvania, USA.11 The authors note that clinicians should be mindful cialis best price of available risk stratification models and subgroup analyses from the EU-CERT-ICD and other studies. It follows that the process of shared decision-making should include careful consideration of the patient’s wishes and values, with an individualized assessment of potential benefit and risks of primary prevention of sudden death by ICD implantation.Cardiosphere-derived cells (CDCs) are cardiac progenitor cells which exhibit disease-modifying bioactivity in various models of cardiomyopathy and in previous clinical studies of acute myocardial infarction (MI), dilated cardiomyopathy, and Duchenne muscular dystrophy.12,13 In a clinical research article entitled ‘Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR).

A randomized, placebo-controlled, double-blinded trial’, Raj Makkar from the Cedars-Sinai Heart Institute in Los Angeles, California, USA and colleagues assessed the safety and efficacy of intracoronary administration of allogeneic CDCs in the multicentre, randomized, double-blind, placebo-controlled, intracoronary ALLogeneic Heart STem Cells to Achieve Myocardial Regeneration (ALLSTAR) trial.14 The authors enrolled patients 4 weeks to 12 months after MI, with LVEF ≤45% and left ventricular LV scar size ≥15% of LVM by MRI. A pre-specified interim analysis was performed cialis best price when 6-month MRI data were available. The trial was subsequently stopped due to the low probability of detecting a significant treatment effect of CDCs based on the primary endpoint. Patients were randomly allocated in a 2:1 ratio to receive CDCs or placebo in the infarct-related artery by the stop–flow technique. The primary safety endpoint was the occurrence, during 1-month post-intracoronary infusion, of acute myocarditis attributable to allogeneic CDCs, ventricular tachycardia- or cialis best price ventricular fibrillation-related death, sudden unexpected death, or a major adverse cardiac event (death or hospitalization for HF or non-fatal MI).

The primary efficacy endpoint was the relative percentage change in infarct size at 12 months post-infusion as assessed by contrast-enhanced cardiac MRI. Makkar and colleagues randomly allocated cialis best price 90 patients to the CDC group and 44 to the placebo group. The mean baseline LVEF was 40% and the mean scar size was 22% of the LVM. No primary safety endpoint events occurred. There was no difference in the cialis best price percentage change from baseline in scar size between CDC and placebo groups at 6 months.

Compared with placebo, there were significant reductions in LV end-diastolic volume, LV end-systolic volume, and NT-proBNP at 6 months in CDC-treated patients.The authors conclude that intracoronary infusion of allogeneic CDCs in patients with post-MI left ventricular dysfunction was safe but did not reduce scar size relative to placebo at 6 months. The manuscript is accompanied by an Editorial by Francisco Fernandez-Aviles from the Hospital General Universitario Gregorio Marañón in Madrid, Spain and colleagues.15 The authors feel that various points need to be better addressed before proceeding again to clinical trials, if we want to move the field of cardiovascular regenerative and reparative medicine forward, for the sake of the cardiovascular health of millions of patients.Treatment of pathological cardiac remodelling and subsequent HF represents an unmet clinical need. Long non-coding RNAs (lncRNAs) are emerging as crucial molecular orchestrators of disease processes including that of heart diseases.16,17 In a Basic Science article entitled ‘Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac hypertrophy’, Thomas Thum from the Hannover Medical School in Germany, and cialis best price colleagues report on the powerful therapeutic potential of the conserved lncRNA H19 in the treatment of pathological cardiac hypertrophy.18 Pressure overload-induced left ventricular cardiac remodelling revealed an up-regulation of H19 in the early phase, but a strong sustained repression upon reaching the decompensated phase of HF. The translational potential of H19 was highlighted by its repression in a large animal (pig) model of LVH, in diseased human heart samples, in human stem cell-derived cardiomyocytes, and in human engineered heart tissue in response to afterload enhancement. Pressure overload-induced cardiac hypertrophy in H19 knockout mice was aggravated compared with wild-type mice.

In contrast, vector-based, cardiomyocyte-directed gene therapy using murine cialis best price but also human H19 strongly attenuated HF even when cardiac hypertrophy was already established. Mechanistically, using microarray, gene set enrichment analyses, and chromatin immunoprecipitation-DNA sequencing, the authors identified a link between H19 and prohypertrophic nuclear factor of activated T cells (NFAT) signalling. H19 physically interacts with the polycomb repressive complex 2 to suppress H3K27 tri-methylation of the antihypertrophic Tescalcin cialis best price locus which in turn leads to reduced NFAT expression and activity.Thum and colleagues conclude that H19 is highly conserved and down-regulated in failing hearts from mice, pigs, and humans. H19 gene therapy prevents and reverses experimental pressure overload-induced HF. H19 acts as an antihypertrophic lncRNA and represents a promising therapeutic target to combat pathological cardiac remodelling.

The manuscript is accompanied by an Editorial by Gianluigi Condorelli from the Humanitas University in Rozzano, cialis best price Italy and colleagues. The authors note that dysregulation of epigenetic mechanisms leading to aberrant loss of cardiomyocyte homeostasis is a critical point to consider in understanding the onset of cardiovascular pathologies. Thus exploiting lncRNAs as therapeutic agents in myocardial disease could pave the way for efficaciously combatting one of the greatest healthcare burdens worldwide.19With the advent of omics, an innovative inductive method has provided researchers with possible ways new to monitor health and disease. This approach incorporates data from studies of the genome, transcriptome, proteome, and metabolome to focus on the cialis best price assessment of a varied range of biomolecules.20 In a clinical review article entitled ‘Omics phenotyping in heart failure. The next frontier’ Antoni Bayes-Genis from the Cardiology Service, Hospital Universitari Germans Trias i Pujol in Badalona, Spain and colleagues provide a state-of-the-art review aiming to provide an up-to-date look at breakthrough omic technologies that are helping to unravel HF disease mechanisms and heterogeneity.21 Genomics, transcriptomics, proteomics, and metabolomics in HF are reviewed in depth.

In addition, there is a thorough, expert discussion regarding the value of omics in identifying novel disease pathways, advancing understanding of disease mechanisms, differentiating HF phenotypes, yielding biomarkers for diagnosis or prognosis, or identifying new therapeutic targets in HF. The combination of multiple omics technologies may create a more comprehensive picture of the factors and pathophysiology cialis best price involved in HF than achieved by either one alone, and provides a rich resource for predictive phenotype modelling. However, the successful translation of omics tools as solutions to clinical HF requires that the observations are robust and reproducible, and can be validated across multiple independent populations to ensure confidence in clinical decision-making.This issue is also complemented by a Discussion Forum contribution. In a contribution entitled ‘Heart failure development in obesity cialis best price. Mechanistic pathways’ Kristjan Karason from the Sahlgrenska University Hospital in Gothenburg, Sweden and colleagues provide a reply to a recent comment entitled ‘Incident heart failure risk after bariatric surgery.

The role of epicardial fat’.22,23The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Hugger, and Martin Meyer for help with compilation of this article. References1Docherty KF, cialis best price Jhund PS, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, DeMets DL, Sabatine MS, Bengtsson O, Sjöstrand M, Langkilde AM, Desai AS, Diez M, Howlett JG, Katova T, Ljungman CEA, O’Meara E, Petrie MC, Schou M, Verma S, Vinh PN, Solomon SD, McMurray JJV. Effects of dapagliflozin in DAPA-HF according to background heart failure therapy. Eur Heart J 2020;41:2379–2392.2Ponikowski P, Voors AA,, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC cialis best price Guidelines for the diagnosis and treatment of acute and chronic heart failure.

The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the cialis best price ESC. Eur Heart J 2016;37:2129–2200.3Packer M. Are the benefits of SGLT2 inhibitors in heart failure and a reduced ejection fraction influenced by background therapy?. Expectations and realities of a cialis best price new standard of care.

Eur Heart J 2020;41:2393–2396.4Butler J, Zannad F, Filippatos G, Anker SD, Packer M. Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction. Implications for clinical cialis best price practice. Eur Heart J 2020;41:3398–3401.5Serenelli M, Böhm M, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P,, Sabatine MS, Solomon SD, DeMets DL, Bengtsson O, Sjöstrand M, Langkilde AM, Anand IS, Chiang CE, Chopra VK, de Boer RA, Diez M, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Verma S,, Docherty KF, Jhund PS, McMurray JJV. Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF).

Eur Heart J 2020;41:3402–3418.6Savarese G, Cosentino cialis best price F. The interaction between dapagliflozin and blood pressure in heart failure. New evidence cialis best price dissipating concerns. Eur Heart J 2020;41:3419–3420.7Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes.

The DAPA-LVH cialis best price trial. Eur Heart J 2020;41:3421–3432.8Paneni F, Costantino S, Hamdani N. Regression of left ventricular hypertrophy with SGLT2 inhibitors. Eur Heart J 2020;41:3433–3436.9Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck cialis best price KH, Hernandez-Madrid A, Nikolaou N, Norekvål TM, Spaulding C, Van Veldhuisen DJ. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.

The Task Force for the Management of Patients with cialis best price Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by. Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015;36:2793–2867.10Zabel M, Willems R, Lubinski A, Bauer A, Brugada J, cialis best price Conen D, Flevari P, Hasenfuß G, Svetlosak M, Huikuri HV, Malik M, Pavlović N, Schmidt G, Sritharan R, Schlögl S, Szavits-Nossan J, Traykov V, Tuinenburg AE, Willich SN, Harden M, Friede T, Svendsen JH, Sticherling C, Merkely B. Clinical effectiveness of primary prevention implantable cardioverter-defibrillators.

Results of the EU-CERT-ICD controlled multicentre cohort study. Eur Heart J cialis best price 2020;41:3437–3447.11Estes MNA, Saba S. Primary prevention of sudden death with the implantable cardioverter defibrillator. Bridging the evidence gap. Eur Heart J 2020;41:3448–3450.12Aminzadeh MA, Tseliou E, Sun B, Cheng K, cialis best price Malliaras K, Makkar RR, Marbán E.

Therapeutic efficacy of cardiosphere-derived cells in a transgenic mouse model of non-ischaemic dilated cardiomyopathy. Eur Heart J 2015;36:751–762.13Fadini GP, Mehta A, Dhindsa DS, Bonora BM, Sreejit cialis best price G, Nagareddy P, Quyyumi AA. Circulating stem cells and cardiovascular outcomes. From basic science to the clinic. Eur Heart cialis best price J 2020.

Doi:10.1093/eurheartj/ehz923.14Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, cialis best price placebo-controlled, double-blinded trial. Eur Heart J 2020;41:3451–3458.15Sanz-Ruiz R, Fernández-Avilés F. Cardiovascular regenerative and reparative medicine.

Is myocardial cialis best price infarction the model?. Eur Heart J 2020;41:3459–3461.16Ounzain S, Micheletti R, Beckmann T, Schroen B, Alexanian M, Pezzuto I, Crippa S, Nemir M, Sarre A, Johnson R, Dauvillier J, Burdet F, Ibberson M, Guigó R, Xenarios I, Heymans S, Pedrazzini T. Genome-wide profiling cialis best price of the cardiac transcriptome after myocardial infarction identifies novel heart-specific long non-coding RNAs. Eur Heart J 2015;36:353–368.17Lüscher TF. Novel molecular mechanisms of vascular disease.

Non-coding RNAs, inflammation, and radiation cialis best price. Eur Heart J. 2020;40:2467–2470.18Viereck J, Bührke A, Foinquinos A, Chatterjee S, Kleeberger JA, Xiao K, Janssen-Peters H, Batkai S, Ramanujam D, Kraft T, Cebotari S, Gueler F, Beyer AM, Schmitz J, Bräsen JH, Schmitto JD, Gyöngyösi M, Löser A, Hirt MN, Eschenhagen T, Engelhardt S, Bär C, Thum T. Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac cialis best price hypertrophy. Eur Heart J 2020;41:3462–3474.19Pagiatakis C, Hall IF, Condorelli G.

Long non-coding RNA cialis best price H19. A new avenue for RNA therapeutics in cardiac hypertrophy?. Eur Heart J 2020;41:3475–3476.20Hoogeveen RM, Pereira JPB, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw KT, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk prediction cialis best price using targeted plasma proteomics in primary prevention. Eur Heart J 2020;ehaa648.

21Bayes-Genis A, Liu PP, Lanfear DE, de Boer RA, González A, Thum T, Emdin M, Januzzi JL. Omics phenotyping cialis best price in heart failure. The next frontier. Eur Heart J 2020;41:3477–3484.22Karason K, Jamaly S. Heart failure development in obesity cialis best price.

Mechanistic pathways. Eur Heart J 2020;41:3485.23van Woerden G, van Veldhuisen SL, Rienstra cialis best price M. Incident heart failure risk after bariatric surgery. The role of epicardial fat. Eur Heart cialis best price J 2020;41:1775.

Published on behalf of the European Society of Cardiology. All rights reserved. © The cialis best price Author(s) 2020. For permissions, please email. Journals.permissions@oup.com..

€‚For the cialis interactions podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This Focus Issue on cialis prices walmart heart failure (HF) provides novel clinically relevant information on sodium–glucose co-transporter-2 (SGLT2) inhibitors which, initially proposed for the treatment of type 2 diabetes mellitus (T2D), have been found to improve the outcome of HF with reduced ejection fraction (HFrEF) when administered on the top of drugs known to improve the outcome of HF and are recommended in current European Guidelines.1,2Acording to modelling estimates, when compared with no neurohormonal blockade, the use of a broad-based combination of disease-modifying drugs at target doses in patients with HF may reduce the risk of death by as much as 75%. It is surprising that in spite of this powerful therapeutic armamentarium, <1% of patients with chronic HF are currently receiving recommended drugs at doses that have been shown to prolong life.3 The issue opens with a Current Opinion article entitled ‘Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction. Implications for clinical practice’ by Milton Packer from the Baylor cialis prices walmart University Medical Center at Dallas in Texas, USA and colleagues. The authors provide a perspective on the totality of evidence with SGLT2 inhibitors in patients with HFrEF.4 This paper is the first to issue a call for a major change in clinical practice based on the concordant results of DAPA-HF and EMPEROR-Reduced trials. The analyses and interpretations that are presented in this manuscript will undoubtedly generate considerable discussion and debate for a long time.Concern about hypotension often leads to withholding of beneficial therapy in patients with HFrEF.

In a clinical research manuscript entitled ‘Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF)’ John McMurray from the Western Infirmary in Glasgow, UK and colleagues on behalf of the DAPA-HF Investigators and cialis prices walmart Committees evaluated the efficacy and safety of dapagliflozin according to baseline systolic blood pressure (SBP) in DAPA-HF trial.5 Key inclusion criteria were. New York Heart Association (NYHA) class II–IV, left ventricular ejection fraction (LVEF) ≤40%, elevated N-terminal probrain natriuretic peptide (NT-proBNP) level, and SBP ≥95 mmHg. The primary outcome was a composite of worsening HF or cardiovascular death. The efficacy and safety of dapagliflozin was examined using SBP as both a cialis prices walmart categorical and a continuous variable. The placebo-corrected reduction in SBP from baseline to 2 weeks with dapagliflozin was –2.54 mmHg.

The benefit and safety of cialis prices walmart dapagliflozin were consistent across the range of SBP. Study drug discontinuation did not differ between dapagliflozin and placebo across the SBP categories examined.The authors conclude that dapagliflozin had a small effect on SBP in patients with HFrEF and was superior to placebo in improving outcomes, and well tolerated, across the range of SBP included in DAPA-HF. The manuscript is accompanied by an Editorial by Francesco Cosentino from the University Hospital Solna in Stockholm, Sweden who comments that altogether, the results of the current post-hoc analysis demonstrating efficacy and safety of dapagliflozin regardless of SBP values might significantly contribute to foster the implementation of dapagliflozin use in HF clinical practice by dissipating any potential safety concern linked with its hypotensive effects.6In a clinical research article entitled ‘A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial’, Chim Lang from the University of Dundee in the UK and colleagues tested the hypothesis that dapagliflozin may regress left ventricular hypertrophy (LVH) in people with T2D.7 The authors randomly assigned 66 patients with T2D, LVH, and controlled blood pressure to receive dapagliflozin 10 mg once daily cialis prices walmart or placebo for 12 months. The primary endpoint was change in absolute left ventricular mass (LVM), assessed by cardiac magnetic resonance imaging (MRI).

In the intention-to-treat analysis, dapagliflozin significantly reduced LVM compared with placebo, with an absolute mean change of –2.82 g. Additional sensitivity analysis adjusting for baseline LVM, baseline blood pressure, weight, and SBP change showed cialis prices walmart the LVM change to remain statistically significant. Dapagliflozin significantly reduced pre-specified secondary endpoints including ambulatory 24-h SBP, nocturnal SBP, body weight, visceral adipose tissue, subcutaneous adipose tissue, insulin resistance, and high-sensitivity C-reactive protein. Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular cialis prices walmart hypertrophy in people with type two diabetes.

The DAPA-LVH trial. See pages 3421–3432).Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo (from Brown AJM, Gandy S, cialis prices walmart McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial. See pages 3421–3432).Lang and colleagues conclude that dapagliflozin treatment significantly reduced LVM cialis prices walmart in patients with T2D and LVH.

The regression of LVM suggests that dapagliflozin can initiate reverse remodelling and changes in left ventricular structure that may partly contribute to cardioprotective effects of dapagliflozin. This manuscript is accompanied by an Editorial by Francesco Paneni from the University of Zurich in Switzerland and colleagues.8 They note that the above-mentioned effects of SGLT2 inhibitors set the ground for a possible beneficial effect of these drugs in patients with HFpEF, where microvascular dysfunction, cardiomyocyte inflammation, and cardiometabolic alterations take centre stage.While several landmark studies have long established that implantable cardioverter-defibrillator (ICD) therapy improves survival for primary prevention of sudden cardiac death ,9 risk stratification parameters and methods for this purpose are clinically underused. In a clinical research article entitled ‘Clinical effectiveness cialis prices walmart of primary prevention implantable cardioverter-defibrillators. Results of the EU-CERT-ICD controlled multicentre cohort study’ Markus Zabel from the Universitätsmedizin Göttingen in Germany and colleagues from the EU-CERT-ICD Study Investigators assessed the current clinical effectiveness of primary prevention by ICD therapy in a prospective investigator-initiated, controlled cohort study, conducted in 44 centres and 15 European countries. The study sought to assess current clinical effectiveness of primary prophylactic ICD implantation.10 The authors recruited 2327 patients with ischaemic or dilated cialis prices walmart cardiomyopathy and guideline indications for prophylactic ICD implantation.

The primary endpoint was all-cause mortality. Baseline and follow-up data from 2247 patients were analysable. 1516 patients with first ICD implantation (ICD group) cialis prices walmart and 731 patients without ICD serving as controls. Multivariable models and propensity scoring for adjustment were used to compare the two groups for mortality. Adjusted mortality associated with ICD vs.

Control was cialis prices walmart significantly lower (hazard ratio 0.731). Subgroup analyses indicated no ICD benefit in diabetics or in those aged ≥75 years. Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and placebo at 6 months. Change in cialis prices walmart (A) left ventricular end-diastolic volume. (B) left ventricular end-systolic volume.

And (C) N-terminal pro cialis prices walmart b-type natriuretic peptide levels. At 6 months. CDC, cardiosphere-derived cell. LVEDV, left ventricular end-diastolic volume cialis prices walmart. LVESV, left ventricular end-systolic volume.

NT-proBNP, N-terminal pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve cialis prices walmart myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial. See pages 3451--3458).Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and placebo at 6 months. Change in cialis prices walmart (A) left ventricular end-diastolic volume.

(B) left ventricular end-systolic volume. And (C) N-terminal cialis prices walmart pro b-type natriuretic peptide levels. At 6 months. CDC, cardiosphere-derived cell. LVEDV, left ventricular end-diastolic volume cialis prices walmart.

LVESV, left ventricular end-systolic volume. NT-proBNP, N-terminal pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic cialis prices walmart heart STem cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial. See pages cialis prices walmart 3451--3458).The authors conclude that in contemporary ischaemic/dilated cardiomyopathy patients (LVEF ≤35%, narrow QRS), primary prophylactic ICD treatment was associated with a substantial reduction in mortality, although this improvement was not consistent across the whole population.

The manuscript is accompanied by an Editorial by N.A. Mark Estes III from the Heart and Vascular Institute UPMC in Pittsburgh, Pennsylvania, USA.11 The authors note that clinicians should be mindful of available risk stratification models and subgroup analyses from the EU-CERT-ICD and other studies. It follows that the process of shared decision-making should include careful consideration of the patient’s wishes and values, with an individualized assessment of potential benefit and risks of primary prevention of sudden death by ICD implantation.Cardiosphere-derived cells (CDCs) are cardiac progenitor cells which exhibit disease-modifying bioactivity in various models of cardiomyopathy and in previous clinical studies of acute myocardial infarction (MI), dilated cardiomyopathy, and Duchenne muscular dystrophy.12,13 In a clinical research article entitled ‘Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration cialis prices walmart (ALLSTAR). A randomized, placebo-controlled, double-blinded trial’, Raj Makkar from the Cedars-Sinai Heart Institute in Los Angeles, California, USA and colleagues assessed the safety and efficacy of intracoronary administration of allogeneic CDCs in the multicentre, randomized, double-blind, placebo-controlled, intracoronary ALLogeneic Heart STem Cells to Achieve Myocardial Regeneration (ALLSTAR) trial.14 The authors enrolled patients 4 weeks to 12 months after MI, with LVEF ≤45% and left ventricular LV scar size ≥15% of LVM by MRI. A pre-specified interim analysis was performed when 6-month MRI data were available.

The trial was subsequently stopped due cialis prices walmart to the low probability of detecting a significant treatment effect of CDCs based on the primary endpoint. Patients were randomly allocated in a 2:1 ratio to receive CDCs or placebo in the infarct-related artery by the stop–flow technique. The primary safety endpoint was the occurrence, during 1-month post-intracoronary infusion, of acute myocarditis attributable to allogeneic CDCs, ventricular tachycardia- or ventricular fibrillation-related death, sudden unexpected death, or a major adverse cardiac event (death or hospitalization for HF or non-fatal MI). The primary efficacy endpoint was the relative percentage change in infarct size at 12 months post-infusion as assessed by contrast-enhanced cardiac MRI cialis prices walmart. Makkar and colleagues randomly allocated 90 patients to the CDC group and 44 to the placebo group.

The mean baseline LVEF was 40% cialis prices walmart and the mean scar size was 22% of the LVM. No primary safety endpoint events occurred. There was no difference in the percentage change from baseline in scar size between CDC and placebo groups at 6 months. Compared with placebo, there were significant reductions in LV end-diastolic volume, LV end-systolic volume, and NT-proBNP at 6 months in cialis prices walmart CDC-treated patients.The authors conclude that intracoronary infusion of allogeneic CDCs in patients with post-MI left ventricular dysfunction was safe but did not reduce scar size relative to placebo at 6 months. The manuscript is accompanied by an Editorial by Francisco Fernandez-Aviles from the Hospital General Universitario Gregorio Marañón in Madrid, Spain and colleagues.15 The authors feel that various points need to be better addressed before proceeding again to clinical trials, if we want to move the field of cardiovascular regenerative and reparative medicine forward, for the sake of the cardiovascular health of millions of patients.Treatment of pathological cardiac remodelling and subsequent HF represents an unmet clinical need.

Long non-coding RNAs (lncRNAs) are emerging as crucial molecular orchestrators of disease processes including that of heart diseases.16,17 In a Basic Science article entitled ‘Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac hypertrophy’, Thomas Thum from the Hannover Medical School in Germany, and colleagues report on the powerful therapeutic potential of the conserved lncRNA H19 in the treatment of pathological cardiac hypertrophy.18 Pressure overload-induced left ventricular cardiac remodelling revealed an up-regulation of H19 in the early phase, but a strong sustained repression upon reaching the decompensated phase of HF. The translational potential of H19 was highlighted by its repression in a large animal (pig) model of LVH, in diseased human heart samples, in human stem cell-derived cardiomyocytes, and in human engineered heart cialis prices walmart tissue in response to afterload enhancement. Pressure overload-induced cardiac hypertrophy in H19 knockout mice was aggravated compared with wild-type mice. In contrast, vector-based, cardiomyocyte-directed gene therapy using murine but also human H19 strongly attenuated HF even when cialis prices walmart cardiac hypertrophy was already established. Mechanistically, using microarray, gene set enrichment analyses, and chromatin immunoprecipitation-DNA sequencing, the authors identified a link between H19 and prohypertrophic nuclear factor of activated T cells (NFAT) signalling.

H19 physically interacts with the polycomb repressive complex 2 to suppress H3K27 tri-methylation of the antihypertrophic Tescalcin locus which in turn leads to reduced NFAT expression and activity.Thum and colleagues conclude that H19 is highly conserved and down-regulated in failing hearts from mice, pigs, and humans. H19 gene therapy prevents cialis prices walmart and reverses experimental pressure overload-induced HF. H19 acts as an antihypertrophic lncRNA and represents a promising therapeutic target to combat pathological cardiac remodelling. The manuscript is accompanied by an Editorial by Gianluigi Condorelli from the Humanitas University in Rozzano, Italy and colleagues. The authors note that dysregulation of epigenetic mechanisms cialis prices walmart leading to aberrant loss of cardiomyocyte homeostasis is a critical point to consider in understanding the onset of cardiovascular pathologies.

Thus exploiting lncRNAs as therapeutic agents in myocardial disease could pave the way for efficaciously combatting one of the greatest healthcare burdens worldwide.19With the advent of omics, an innovative inductive method has provided researchers with possible ways new to monitor health and disease. This approach incorporates data from studies of the genome, transcriptome, proteome, and metabolome to focus on the assessment of a varied range of biomolecules.20 In a clinical review article entitled ‘Omics phenotyping in heart failure. The next frontier’ Antoni Bayes-Genis from the Cardiology Service, Hospital Universitari Germans Trias i Pujol in Badalona, Spain and colleagues provide a state-of-the-art review aiming to provide an up-to-date look at breakthrough omic technologies cialis prices walmart that are helping to unravel HF disease mechanisms and heterogeneity.21 Genomics, transcriptomics, proteomics, and metabolomics in HF are reviewed in depth. In addition, there is a thorough, expert discussion regarding the value of omics in identifying novel disease pathways, advancing understanding of disease mechanisms, differentiating HF phenotypes, yielding biomarkers for diagnosis or prognosis, or identifying new therapeutic targets in HF. The combination of multiple cialis prices walmart omics technologies may create a more comprehensive picture of the factors and pathophysiology involved in HF than achieved by either one alone, and provides a rich resource for predictive phenotype modelling.

However, the successful translation of omics tools as solutions to clinical HF requires that the observations are robust and reproducible, and can be validated across multiple independent populations to ensure confidence in clinical decision-making.This issue is also complemented by a Discussion Forum contribution. In a contribution entitled ‘Heart failure development in obesity. Mechanistic pathways’ Kristjan Karason from the Sahlgrenska cialis prices walmart University Hospital in Gothenburg, Sweden and colleagues provide a reply to a recent comment entitled ‘Incident heart failure risk after bariatric surgery. The role of epicardial fat’.22,23The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Hugger, and Martin Meyer for help with compilation of this article. References1Docherty KF, Jhund PS, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, DeMets DL, Sabatine MS, Bengtsson O, Sjöstrand M, Langkilde AM, Desai AS, Diez M, Howlett JG, Katova T, Ljungman CEA, O’Meara E, Petrie MC, Schou M, Verma S, Vinh PN, Solomon SD, McMurray JJV.

Effects of dapagliflozin in cialis prices walmart DAPA-HF according to background heart failure therapy. Eur Heart J 2020;41:2379–2392.2Ponikowski P, Voors AA,, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. The Task Force for the diagnosis and cialis prices walmart treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

Eur Heart J cialis prices walmart 2016;37:2129–2200.3Packer M. Are the benefits of SGLT2 inhibitors in heart failure and a reduced ejection fraction influenced by background therapy?. Expectations and realities of a new standard of care. Eur Heart J 2020;41:2393–2396.4Butler J, Zannad cialis prices walmart F, Filippatos G, Anker SD, Packer M. Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction.

Implications for clinical practice. Eur Heart J 2020;41:3398–3401.5Serenelli M, Böhm M, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P,, Sabatine MS, Solomon SD, DeMets DL, cialis prices walmart Bengtsson O, Sjöstrand M, Langkilde AM, Anand IS, Chiang CE, Chopra VK, de Boer RA, Diez M, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Verma S,, Docherty KF, Jhund PS, McMurray JJV. Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF). Eur Heart J 2020;41:3402–3418.6Savarese G, Cosentino cialis prices walmart F. The interaction between dapagliflozin and blood pressure in heart failure.

New evidence dissipating concerns. Eur Heart cialis prices walmart J 2020;41:3419–3420.7Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial. Eur Heart J 2020;41:3421–3432.8Paneni F, Costantino cialis prices walmart S, Hamdani N.

Regression of left ventricular hypertrophy with SGLT2 inhibitors. Eur Heart J 2020;41:3433–3436.9Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekvål TM, Spaulding C, Van Veldhuisen DJ. 2015 ESC Guidelines cialis prices walmart for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by cialis prices walmart.

Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2015;36:2793–2867.10Zabel M, Willems R, Lubinski A, Bauer A, Brugada J, Conen D, Flevari P, Hasenfuß G, Svetlosak M, Huikuri HV, Malik M, Pavlović N, Schmidt G, Sritharan R, Schlögl S, Szavits-Nossan J, Traykov V, Tuinenburg AE, Willich SN, Harden M, Friede T, Svendsen JH, Sticherling C, Merkely B. Clinical effectiveness of primary prevention implantable cialis prices walmart cardioverter-defibrillators. Results of the EU-CERT-ICD controlled multicentre cohort study. Eur Heart J 2020;41:3437–3447.11Estes MNA, Saba S.

Primary prevention of sudden death with the implantable cardioverter defibrillator cialis prices walmart. Bridging the evidence gap. Eur Heart J 2020;41:3448–3450.12Aminzadeh MA, Tseliou E, Sun B, Cheng K, Malliaras K, Makkar RR, Marbán E. Therapeutic efficacy of cardiosphere-derived cells in a cialis prices walmart transgenic mouse model of non-ischaemic dilated cardiomyopathy. Eur Heart J 2015;36:751–762.13Fadini GP, Mehta A, Dhindsa DS, Bonora BM, Sreejit G, Nagareddy P, Quyyumi AA.

Circulating stem cells and cialis prices walmart cardiovascular outcomes. From basic science to the clinic. Eur Heart J 2020. Doi:10.1093/eurheartj/ehz923.14Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, cialis prices walmart Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR).

A randomized, placebo-controlled, double-blinded trial. Eur Heart cialis prices walmart J 2020;41:3451–3458.15Sanz-Ruiz R, Fernández-Avilés F. Cardiovascular regenerative and reparative medicine. Is myocardial cialis prices walmart infarction the model?. Eur Heart J 2020;41:3459–3461.16Ounzain S, Micheletti R, Beckmann T, Schroen B, Alexanian M, Pezzuto I, Crippa S, Nemir M, Sarre A, Johnson R, Dauvillier J, Burdet F, Ibberson M, Guigó R, Xenarios I, Heymans S, Pedrazzini T.

Genome-wide profiling of the cardiac transcriptome after myocardial infarction identifies novel heart-specific long non-coding RNAs. Eur Heart J cialis prices walmart 2015;36:353–368.17Lüscher TF. Novel molecular mechanisms of vascular disease. Non-coding RNAs, inflammation, and radiation. Eur Heart J cialis prices walmart.

2020;40:2467–2470.18Viereck J, Bührke A, Foinquinos A, Chatterjee S, Kleeberger JA, Xiao K, Janssen-Peters H, Batkai S, Ramanujam D, Kraft T, Cebotari S, Gueler F, Beyer AM, Schmitz J, Bräsen JH, Schmitto JD, Gyöngyösi M, Löser A, Hirt MN, Eschenhagen T, Engelhardt S, Bär C, Thum T. Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac hypertrophy. Eur Heart J 2020;41:3462–3474.19Pagiatakis cialis prices walmart C, Hall IF, Condorelli G. Long non-coding RNA H19. A new cialis prices walmart avenue for RNA therapeutics in cardiac hypertrophy?.

Eur Heart J 2020;41:3475–3476.20Hoogeveen RM, Pereira JPB, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw KT, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk prediction using targeted plasma proteomics in primary prevention. Eur Heart J 2020;ehaa648 cialis prices walmart. 21Bayes-Genis A, Liu PP, Lanfear DE, de Boer RA, González A, Thum T, Emdin M, Januzzi JL. Omics phenotyping in heart failure.

The next cialis prices walmart frontier. Eur Heart J 2020;41:3477–3484.22Karason K, Jamaly S. Heart failure cialis prices walmart development in obesity. Mechanistic pathways. Eur Heart J 2020;41:3485.23van Woerden G, van Veldhuisen SL, Rienstra M.

Incident heart failure risk after bariatric surgery cialis prices walmart. The role of epicardial fat. Eur Heart J 2020;41:1775. Published on behalf of the European Society cialis prices walmart of Cardiology. All rights reserved.

© The Author(s) 2020. For permissions, please email cialis prices walmart. Journals.permissions@oup.com. For the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts.This Focus Issue on heart failure (HF) provides novel clinically relevant information on sodium–glucose co-transporter-2 (SGLT2) inhibitors which, initially proposed for the treatment of type 2 diabetes mellitus (T2D), have been found to improve the outcome of HF with reduced ejection fraction (HFrEF) when administered on the top of drugs known to improve the outcome of HF and are recommended in current European Guidelines.1,2Acording to modelling estimates, when compared with no neurohormonal blockade, the use of a broad-based combination of disease-modifying drugs at target doses in patients with HF may reduce the risk of death by as much dr oz this works better than viagra and cialis as 75%. It is surprising that in spite cialis prices walmart of this powerful therapeutic armamentarium, <1% of patients with chronic HF are currently receiving recommended drugs at doses that have been shown to prolong life.3 The issue opens with a Current Opinion article entitled ‘Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction. Implications for clinical practice’ by Milton Packer from the Baylor University Medical Center at Dallas in Texas, USA and colleagues.

The authors provide a perspective on the totality of evidence with SGLT2 inhibitors in patients with HFrEF.4 This paper is the first to issue a call for a major change in clinical practice based on the concordant results of DAPA-HF and EMPEROR-Reduced trials. The analyses and interpretations that cialis prices walmart are presented in this manuscript will undoubtedly generate considerable discussion and debate for a long time.Concern about hypotension often leads to withholding of beneficial therapy in patients with HFrEF. In a clinical research manuscript entitled ‘Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF)’ John McMurray from the Western Infirmary in Glasgow, UK and colleagues on behalf of the DAPA-HF Investigators and Committees evaluated the efficacy and safety of dapagliflozin according to baseline systolic blood pressure (SBP) in DAPA-HF trial.5 Key inclusion criteria were. New York Heart Association (NYHA) class II–IV, left ventricular ejection fraction (LVEF) ≤40%, elevated N-terminal probrain natriuretic peptide (NT-proBNP) level, and SBP ≥95 mmHg. The primary outcome was a cialis prices walmart composite of worsening HF or cardiovascular death.

The efficacy and safety of dapagliflozin was examined using SBP as both a categorical and a continuous variable. The placebo-corrected reduction in SBP from baseline to 2 weeks with dapagliflozin was –2.54 mmHg. The benefit and safety of dapagliflozin were cialis prices walmart consistent across the range of SBP. Study drug discontinuation did not differ between dapagliflozin and placebo across the SBP categories examined.The authors conclude that dapagliflozin had a small effect on SBP in patients with HFrEF and was superior to placebo in improving outcomes, and well tolerated, across the range of SBP included in DAPA-HF. The manuscript is accompanied by an Editorial by Francesco Cosentino from the University Hospital Solna in Stockholm, Sweden who comments that altogether, the results of the current post-hoc analysis demonstrating efficacy and safety of dapagliflozin regardless of SBP values might significantly contribute to foster the implementation of dapagliflozin use in HF clinical practice by dissipating any potential safety concern linked with its hypotensive effects.6In a clinical research article entitled ‘A randomized controlled cialis prices walmart trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes.

The DAPA-LVH trial’, Chim Lang from the University of Dundee in the UK and colleagues tested the hypothesis that dapagliflozin may regress left ventricular hypertrophy (LVH) in people with T2D.7 The authors randomly assigned 66 patients with T2D, LVH, and controlled blood pressure to receive dapagliflozin 10 mg once daily or placebo for 12 months. The primary endpoint was change in absolute left ventricular mass (LVM), assessed by cardiac magnetic resonance imaging (MRI). In the intention-to-treat analysis, dapagliflozin significantly reduced LVM compared with placebo, with cialis prices walmart an absolute mean change of –2.82 g. Additional sensitivity analysis adjusting for baseline LVM, baseline blood pressure, weight, and SBP change showed the LVM change to remain statistically significant. Dapagliflozin significantly reduced pre-specified secondary endpoints including ambulatory 24-h SBP, nocturnal SBP, body weight, visceral adipose tissue, subcutaneous adipose tissue, insulin resistance, and high-sensitivity C-reactive protein.

Figure 1Column cialis prices walmart bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes. The DAPA-LVH trial cialis prices walmart. See pages 3421–3432).Figure 1Column bar charts showing the mean regression of left ventricular mass following dapagliflozin treatment compared to placebo (from Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes.

The DAPA-LVH cialis prices walmart trial. See pages 3421–3432).Lang and colleagues conclude that dapagliflozin treatment significantly reduced LVM in patients with T2D and LVH. The regression of LVM suggests that dapagliflozin can initiate reverse remodelling and changes in left ventricular structure that may partly contribute to cardioprotective effects of dapagliflozin. This manuscript is accompanied by an Editorial by Francesco Paneni from the University of Zurich in Switzerland and colleagues.8 They note that the above-mentioned effects of SGLT2 inhibitors set the ground for a possible beneficial effect of these drugs in cialis prices walmart patients with HFpEF, where microvascular dysfunction, cardiomyocyte inflammation, and cardiometabolic alterations take centre stage.While several landmark studies have long established that implantable cardioverter-defibrillator (ICD) therapy improves survival for primary prevention of sudden cardiac death ,9 risk stratification parameters and methods for this purpose are clinically underused. In a clinical research article entitled ‘Clinical effectiveness of primary prevention implantable cardioverter-defibrillators.

Results of the EU-CERT-ICD controlled multicentre cohort study’ Markus Zabel from the Universitätsmedizin Göttingen in Germany and colleagues from the EU-CERT-ICD Study Investigators assessed the current clinical effectiveness of primary prevention by ICD therapy in a prospective investigator-initiated, controlled cohort study, conducted in 44 centres and 15 European countries. The study sought to assess current clinical effectiveness of primary prophylactic ICD cialis prices walmart implantation.10 The authors recruited 2327 patients with ischaemic or dilated cardiomyopathy and guideline indications for prophylactic ICD implantation. The primary endpoint was all-cause mortality. Baseline and follow-up data from 2247 cialis prices walmart patients were analysable. 1516 patients with first ICD implantation (ICD group) and 731 patients without ICD serving as controls.

Multivariable models and propensity scoring for adjustment were used to compare the two groups for mortality. Adjusted mortality cialis prices walmart associated with ICD vs. Control was significantly lower (hazard ratio 0.731). Subgroup analyses indicated no ICD benefit in diabetics or in those aged ≥75 years. Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cialis prices walmart cells and placebo at 6 months.

Change in (A) left ventricular end-diastolic volume. (B) left cialis prices walmart ventricular end-systolic volume. And (C) N-terminal pro b-type natriuretic peptide levels. At 6 months. CDC, cardiosphere-derived cialis prices walmart cell.

LVEDV, left ventricular end-diastolic volume. LVESV, left ventricular end-systolic volume. NT-proBNP, N-terminal pro b-type natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse cialis prices walmart JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial.

See pages cialis prices walmart 3451--3458).Figure 2Secondary efficacy endpoints comparing cardiosphere-derived cells and placebo at 6 months. Change in (A) left ventricular end-diastolic volume. (B) left ventricular end-systolic cialis prices walmart volume. And (C) N-terminal pro b-type natriuretic peptide levels. At 6 months.

CDC, cardiosphere-derived cialis prices walmart cell. LVEDV, left ventricular end-diastolic volume. LVESV, left ventricular end-systolic volume. NT-proBNP, N-terminal pro b-type cialis prices walmart natriuretic peptide (from Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR).

A randomized, placebo-controlled, double-blinded trial. See pages 3451--3458).The authors conclude that in contemporary ischaemic/dilated cardiomyopathy patients (LVEF ≤35%, narrow QRS), primary prophylactic ICD treatment was associated cialis prices walmart with a substantial reduction in mortality, although this improvement was not consistent across the whole population. The manuscript is accompanied by an Editorial by N.A. Mark Estes III from the cialis prices walmart Heart and Vascular Institute UPMC in Pittsburgh, Pennsylvania, USA.11 The authors note that clinicians should be mindful of available risk stratification models and subgroup analyses from the EU-CERT-ICD and other studies. It follows that the process of shared decision-making should include careful consideration of the patient’s wishes and values, with an individualized assessment of potential benefit and risks of primary prevention of sudden death by ICD implantation.Cardiosphere-derived cells (CDCs) are cardiac progenitor cells which exhibit disease-modifying bioactivity in various models of cardiomyopathy and in previous clinical studies of acute myocardial infarction (MI), dilated cardiomyopathy, and Duchenne muscular dystrophy.12,13 In a clinical research article entitled ‘Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR).

A randomized, placebo-controlled, double-blinded trial’, Raj Makkar from the Cedars-Sinai Heart Institute in Los Angeles, California, USA and colleagues assessed the safety and efficacy of intracoronary administration of allogeneic CDCs in the multicentre, randomized, double-blind, placebo-controlled, intracoronary ALLogeneic Heart STem Cells to Achieve Myocardial Regeneration (ALLSTAR) trial.14 The authors enrolled patients 4 weeks to 12 months after MI, with LVEF ≤45% and left ventricular LV scar size ≥15% of LVM by MRI. A pre-specified interim analysis was performed cialis prices walmart when 6-month MRI data were available. The trial was subsequently stopped due to the low probability of detecting a significant treatment effect of CDCs based on the primary endpoint. Patients were randomly allocated in a 2:1 ratio to receive CDCs or placebo in the infarct-related artery by the stop–flow technique. The primary safety endpoint was the occurrence, during 1-month post-intracoronary infusion, of acute myocarditis attributable to allogeneic CDCs, ventricular tachycardia- or ventricular fibrillation-related death, sudden unexpected death, or a major cialis prices walmart adverse cardiac event (death or hospitalization for HF or non-fatal MI).

The primary efficacy endpoint was the relative percentage change in infarct size at 12 months post-infusion as assessed by contrast-enhanced cardiac MRI. Makkar and colleagues randomly allocated 90 patients to the CDC group and 44 to the cialis prices walmart placebo group. The mean baseline LVEF was 40% and the mean scar size was 22% of the LVM. No primary safety endpoint events occurred. There was no difference in the percentage change from baseline in scar size between cialis prices walmart CDC and placebo groups at 6 months.

Compared with placebo, there were significant reductions in LV end-diastolic volume, LV end-systolic volume, and NT-proBNP at 6 months in CDC-treated patients.The authors conclude that intracoronary infusion of allogeneic CDCs in patients with post-MI left ventricular dysfunction was safe but did not reduce scar size relative to placebo at 6 months. The manuscript is accompanied by an Editorial by Francisco Fernandez-Aviles from the Hospital General Universitario Gregorio Marañón in Madrid, Spain and colleagues.15 The authors feel that various points need to be better addressed before proceeding again to clinical trials, if we want to move the field of cardiovascular regenerative and reparative medicine forward, for the sake of the cardiovascular health of millions of patients.Treatment of pathological cardiac remodelling and subsequent HF represents an unmet clinical need. Long non-coding cialis prices walmart RNAs (lncRNAs) are emerging as crucial molecular orchestrators of disease processes including that of heart diseases.16,17 In a Basic Science article entitled ‘Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac hypertrophy’, Thomas Thum from the Hannover Medical School in Germany, and colleagues report on the powerful therapeutic potential of the conserved lncRNA H19 in the treatment of pathological cardiac hypertrophy.18 Pressure overload-induced left ventricular cardiac remodelling revealed an up-regulation of H19 in the early phase, but a strong sustained repression upon reaching the decompensated phase of HF. The translational potential of H19 was highlighted by its repression in a large animal (pig) model of LVH, in diseased human heart samples, in human stem cell-derived cardiomyocytes, and in human engineered heart tissue in response to afterload enhancement. Pressure overload-induced cardiac hypertrophy in H19 knockout mice was aggravated compared with wild-type mice.

In contrast, vector-based, cardiomyocyte-directed gene therapy using murine but also human H19 strongly attenuated HF even when cardiac hypertrophy cialis prices walmart was already established. Mechanistically, using microarray, gene set enrichment analyses, and chromatin immunoprecipitation-DNA sequencing, the authors identified a link between H19 and prohypertrophic nuclear factor of activated T cells (NFAT) signalling. H19 physically interacts with the polycomb repressive complex 2 to suppress H3K27 tri-methylation of the antihypertrophic Tescalcin locus which in cialis prices walmart turn leads to reduced NFAT expression and activity.Thum and colleagues conclude that H19 is highly conserved and down-regulated in failing hearts from mice, pigs, and humans. H19 gene therapy prevents and reverses experimental pressure overload-induced HF. H19 acts as an antihypertrophic lncRNA and represents a promising therapeutic target to combat pathological cardiac remodelling.

The manuscript is accompanied by an Editorial by Gianluigi Condorelli from the Humanitas University in Rozzano, Italy and cialis prices walmart colleagues. The authors note that dysregulation of epigenetic mechanisms leading to aberrant loss of cardiomyocyte homeostasis is a critical point to consider in understanding the onset of cardiovascular pathologies. Thus exploiting lncRNAs as therapeutic agents in myocardial disease could pave the way for efficaciously combatting one of the greatest healthcare burdens worldwide.19With the advent of omics, an innovative inductive method has provided researchers with possible ways new to monitor health and disease. This approach incorporates data from studies of the genome, transcriptome, proteome, and metabolome to focus on the assessment of a varied range of biomolecules.20 In a clinical review article entitled ‘Omics phenotyping in cialis prices walmart heart failure. The next frontier’ Antoni Bayes-Genis from the Cardiology Service, Hospital Universitari Germans Trias i Pujol in Badalona, Spain and colleagues provide a state-of-the-art review aiming to provide an up-to-date look at breakthrough omic technologies that are helping to unravel HF disease mechanisms and heterogeneity.21 Genomics, transcriptomics, proteomics, and metabolomics in HF are reviewed in depth.

In addition, there is a thorough, expert discussion regarding the value of omics in identifying novel disease pathways, advancing understanding of disease mechanisms, differentiating HF phenotypes, yielding biomarkers for diagnosis or prognosis, or identifying new therapeutic targets in HF. The combination of multiple omics technologies may create a more comprehensive picture of the factors and pathophysiology involved in HF cialis prices walmart than achieved by either one alone, and provides a rich resource for predictive phenotype modelling. However, the successful translation of omics tools as solutions to clinical HF requires that the observations are robust and reproducible, and can be validated across multiple independent populations to ensure confidence in clinical decision-making.This issue is also complemented by a Discussion Forum contribution. In a contribution cialis prices walmart entitled ‘Heart failure development in obesity. Mechanistic pathways’ Kristjan Karason from the Sahlgrenska University Hospital in Gothenburg, Sweden and colleagues provide a reply to a recent comment entitled ‘Incident heart failure risk after bariatric surgery.

The role of epicardial fat’.22,23The editors hope that this issue of the European Heart Journal will be of interest to its readers.With thanks to Amelia Meier-Batschelet, Johanna Hugger, and Martin Meyer for help with compilation of this article. References1Docherty KF, Jhund PS, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, DeMets DL, Sabatine MS, Bengtsson O, Sjöstrand cialis prices walmart M, Langkilde AM, Desai AS, Diez M, Howlett JG, Katova T, Ljungman CEA, O’Meara E, Petrie MC, Schou M, Verma S, Vinh PN, Solomon SD, McMurray JJV. Effects of dapagliflozin in DAPA-HF according to background heart failure therapy. Eur Heart J 2020;41:2379–2392.2Ponikowski P, Voors AA,, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P. 2016 ESC Guidelines for the diagnosis cialis prices walmart and treatment of acute and chronic heart failure.

The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of cialis prices walmart the ESC. Eur Heart J 2016;37:2129–2200.3Packer M. Are the benefits of SGLT2 inhibitors in heart failure and a reduced ejection fraction influenced by background therapy?. Expectations and realities of cialis prices walmart a new standard of care.

Eur Heart J 2020;41:2393–2396.4Butler J, Zannad F, Filippatos G, Anker SD, Packer M. Totality of evidence in trials of sodium–glucose co-transporter-2 inhibitors in the patients with heart failure with reduced ejection fraction. Implications for cialis prices walmart clinical practice. Eur Heart J 2020;41:3398–3401.5Serenelli M, Böhm M, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P,, Sabatine MS, Solomon SD, DeMets DL, Bengtsson O, Sjöstrand M, Langkilde AM, Anand IS, Chiang CE, Chopra VK, de Boer RA, Diez M, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Verma S,, Docherty KF, Jhund PS, McMurray JJV. Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF).

Eur Heart J 2020;41:3402–3418.6Savarese G, Cosentino F cialis prices walmart. The interaction between dapagliflozin and blood pressure in heart failure. New evidence dissipating concerns cialis prices walmart. Eur Heart J 2020;41:3419–3420.7Brown AJM, Gandy S, McCrimmon R, Houston JG, Struthers AD, Lang CC. A randomized controlled trial of dapagliflozin on left ventricular hypertrophy in people with type two diabetes.

The DAPA-LVH cialis prices walmart trial. Eur Heart J 2020;41:3421–3432.8Paneni F, Costantino S, Hamdani N. Regression of left ventricular hypertrophy with SGLT2 inhibitors. Eur Heart J 2020;41:3433–3436.9Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, cialis prices walmart Hatala R, Hindricks G, Kirchhof P, Kjeldsen K, Kuck KH, Hernandez-Madrid A, Nikolaou N, Norekvål TM, Spaulding C, Van Veldhuisen DJ. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.

The Task Force cialis prices walmart for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by. Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart cialis prices walmart J 2015;36:2793–2867.10Zabel M, Willems R, Lubinski A, Bauer A, Brugada J, Conen D, Flevari P, Hasenfuß G, Svetlosak M, Huikuri HV, Malik M, Pavlović N, Schmidt G, Sritharan R, Schlögl S, Szavits-Nossan J, Traykov V, Tuinenburg AE, Willich SN, Harden M, Friede T, Svendsen JH, Sticherling C, Merkely B. Clinical effectiveness of primary prevention implantable cardioverter-defibrillators.

Results of the EU-CERT-ICD controlled multicentre cohort study. Eur Heart J 2020;41:3437–3447.11Estes MNA, Saba cialis prices walmart S. Primary prevention of sudden death with the implantable cardioverter defibrillator. Bridging the evidence gap. Eur Heart J 2020;41:3448–3450.12Aminzadeh MA, Tseliou cialis prices walmart E, Sun B, Cheng K, Malliaras K, Makkar RR, Marbán E.

Therapeutic efficacy of cardiosphere-derived cells in a transgenic mouse model of non-ischaemic dilated cardiomyopathy. Eur Heart J 2015;36:751–762.13Fadini GP, Mehta A, Dhindsa DS, Bonora cialis prices walmart BM, Sreejit G, Nagareddy P, Quyyumi AA. Circulating stem cells and cardiovascular outcomes. From basic science to the clinic. Eur Heart J 2020 cialis prices walmart.

Doi:10.1093/eurheartj/ehz923.14Makkar RR, Kereiakes DJ, Aguirre F, Kowalchuk G, Chakravarty T, Malliaras K, Francis GS, Povsic TJ, Schatz R, Traverse JH, Pogoda JM, Smith RR, Marbán L, Ascheim DD, Ostovaneh MR, Lima JAC, DeMaria A, Marbán E, Henry TD. Intracoronary ALLogeneic heart STem cells to Achieve myocardial Regeneration (ALLSTAR). A randomized, placebo-controlled, double-blinded trial cialis prices walmart. Eur Heart J 2020;41:3451–3458.15Sanz-Ruiz R, Fernández-Avilés F. Cardiovascular regenerative and reparative medicine.

Is myocardial infarction the cialis prices walmart model?. Eur Heart J 2020;41:3459–3461.16Ounzain S, Micheletti R, Beckmann T, Schroen B, Alexanian M, Pezzuto I, Crippa S, Nemir M, Sarre A, Johnson R, Dauvillier J, Burdet F, Ibberson M, Guigó R, Xenarios I, Heymans S, Pedrazzini T. Genome-wide profiling of the cardiac transcriptome after myocardial infarction identifies novel heart-specific long non-coding cialis prices walmart RNAs. Eur Heart J 2015;36:353–368.17Lüscher TF. Novel molecular mechanisms of vascular disease.

Non-coding RNAs, inflammation, cialis prices walmart and radiation. Eur Heart J. 2020;40:2467–2470.18Viereck J, Bührke A, Foinquinos A, Chatterjee S, Kleeberger JA, Xiao K, Janssen-Peters H, Batkai S, Ramanujam D, Kraft T, Cebotari S, Gueler F, Beyer AM, Schmitz J, Bräsen JH, Schmitto JD, Gyöngyösi M, Löser A, Hirt MN, Eschenhagen T, Engelhardt S, Bär C, Thum T. Targeting muscle-enriched long non-coding RNA H19 reverses pathological cardiac cialis prices walmart hypertrophy. Eur Heart J 2020;41:3462–3474.19Pagiatakis C, Hall IF, Condorelli G.

Long non-coding cialis prices walmart RNA H19. A new avenue for RNA therapeutics in cardiac hypertrophy?. Eur Heart J 2020;41:3475–3476.20Hoogeveen RM, Pereira JPB, Nurmohamed NS, Zampoleri V, Bom MJ, Baragetti A, Boekholdt SM, Knaapen P, Khaw KT, Wareham NJ, Groen AK, Catapano AL, Koenig W, Levin E, Stroes ESG. Improved cardiovascular risk cialis prices walmart prediction using targeted plasma proteomics in primary prevention. Eur Heart J 2020;ehaa648.

21Bayes-Genis A, Liu PP, Lanfear DE, de Boer RA, González A, Thum T, Emdin M, Januzzi JL. Omics phenotyping in heart cialis prices walmart failure. The next frontier. Eur Heart J 2020;41:3477–3484.22Karason K, Jamaly S. Heart failure cialis prices walmart development in obesity.

Mechanistic pathways. Eur Heart J cialis prices walmart 2020;41:3485.23van Woerden G, van Veldhuisen SL, Rienstra M. Incident heart failure risk after bariatric surgery. The role of epicardial fat. Eur Heart J cialis prices walmart 2020;41:1775.

Published on behalf of the European Society of Cardiology. All rights reserved. © The cialis prices walmart Author(s) 2020. For permissions, please email. Journals.permissions@oup.com..

Cialis prescription

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We live in cialis prescription unprecedented times http://cz.keimfarben.de/cialis-discount-coupon/. But what makes them without parallel is not the current pandemic crisis nor the continued problems facing minorities in our institutions. Rather, it’s that for the cialis prescription first time, the problems of accessibility, rights and freedoms are now invading privileged spaces. There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals. For many, the world is not suddenly on fire.

€¦IntroductionMinecraft is a computer game with no specific cialis prescription goals to accomplish. The gameworld consists of three-dimensional (3D) cubes and objects which the player (Steve) can mine and build into infinitely complex (and logically impossible) structures. Steve sometimes encounters other characters (‘mobs’), such as cialis prescription animals and hostile creatures. He can ‘spawn’ and destroy them. While it looks like a harmless game of logical construction, it conveys some worryingly delusive ideas about the real world.

The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification in mental health has had cialis prescription various forms throughout history. Mack and colleagues set out a history of psychiatric classification beginning in 2600 BC with Egyptian references to melancholia and hysteria. Through the Ancient cialis prescription Greeks with Hippocrates’ phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease. Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some common trends such as the labels ‘melancholia’ and ‘hysteria’ which have survived millennia, the label ‘depression’ is relatively new.

The earliest usage noted cialis prescription by Snaith is from 1899. €˜in simple pathological depression…the patient exhibits a growing indifference to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge. This did not happen until the middle of the 20th cialis prescription century. With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate. In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical quarrels around categorisation of mental disorders.

DSM I and DSM II have been described as products of an American Psychiatric cialis prescription Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories. €˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state. Zimbardo, who described psychiatric care as a cialis prescription controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’. Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science.

In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are cialis prescription opposing stances in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility. The nominalism–realism debate is illustrated using as metaphor three different stances a cricket umpire might take on calling strikes and balls. The discussion sets out two cialis prescription of these as extreme views. €˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who is characterised as holding particularly extreme views, is named as an archetypal solipsist.

There is implied to be a degree of arrogance associated with this view in the illustrative example in which the umpire states ‘there are no balls and there are no cialis prescription strikes until I call them’. Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than to focus on its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’. The natural conclusion the reader is invited to reach is that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without cialis prescription specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’. Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’. The prototypical approach is again put forward as a clinically useful middle ground.

Illustrations are drawn from natural science cialis prescription. €˜a triangle and a square are never the same’, inciting the reader to consider science as value-free. The prototypical approach emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves cialis prescription the issues posed by the two alternatives, nor how a prototype can be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification. Doing so is more like playing Minecraft than cricket.

The National Institute for Health and Care Excellence (NICE) guideline for depression is taken as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, cialis prescription specifically subcategories of persistent forms of depression. As well as serving a clinical purpose, diagnosis in medicine is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service. The consequences for cialis prescription recipients of healthcare are therefore significant. Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression. €˜further-line’ treatment of depression (equivalent to TRD), CD and ‘depression with co-morbidities’.

The latter is cialis prescription subdivided into treatments for ‘complex depression’ and ‘psychotic depression’. These categories and subcategories introduce an unfortunate sense of certainty as though these labels represent real things. An analysis follows of cialis prescription how these definitions play out in terms of grouping of randomised controlled trials in the NICE evidence review. Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years. Dysthymia and double depression (MDD superimposed on dysthymia) were included.

If 75% of the trial population met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) cialis prescription required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point. If 80% of the trial participants met these criteria, it was reviewed in the TRD category.13 Complex depression was defined as ‘depression co-existing with personality disorder’. To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there cialis prescription is a potential problem with attempting to categorise trial populations into just one of these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information. The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the category of further-line treatments (TRD), 64 trials were reviewed.

Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’ cialis prescription. In drilling down by way of illustration, this analysis considers the 51 trials in the augmentation strategy evidence review. Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs. Fonagy 2015 cialis prescription and Kocsis 200915). About half of the trials (23/51) did not report the mean duration of episode, meaning that it is not possible to know what percentage of participants also met the criteria for CD.

Of trials that did cialis prescription report episode duration, 17 reported a mean duration longer than 24 months. While the standard deviations varied in size or were unreported, the mean indicates a good likelihood that a significant proportion of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE. For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations. Only 14 of 51 trials report employment cialis prescription data. Of those that do, unemployment ranges from 12% to 56% across trial samples.

None of the trials cialis prescription report trauma history. About half of the trials (26/51) excluded people who were considered a suicide risk. The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity. Of these, cialis prescription 18 did not exclude any diagnoses, while 12 excluded some (but not all) disorders. The most common diagnoses excluded were psychotic disorders, substance or alcohol abuse, and bipolar disorder (excluded in 26, 25 and 23 trials, respectively).

Only 7 of 51 trials clearly stated that all axis 1 diagnoses were excluded cialis prescription. This leaves only 13 studies providing any data about comorbidity. Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD. Many stated PD as an exclusion cialis prescription criterion but without defining a threshold for exclusion. For example, PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’.

Some excluded certain PDs (such as antisocial cialis prescription or borderline) and not others but without reporting the prevalence of those not excluded. In the five trials where prevalence was clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample (Town 201715). Two studies reported the mean number of PDs. 2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The cialis prescription majority of trials (43/51) did not report the prevalence of physical illness. Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be interpreted in different ways.

For example, illness could be excluded if it was ‘unstable’, ‘serious’, ‘significant’, ‘relevant’, or would ‘contraindicate’ or ‘impact’ the medication cialis prescription. Of the eight trials reporting information about physical health, there was a wide variation. Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used cialis prescription scales of physical health. Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners.

NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to cialis prescription generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials which use more than one of these measures reveals problems in the algorithm. Of the 51 trials, there are 6 instances in which the study population falls into NICE’s more severe category according to one measure and into the less severe category according to another. In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715). The other two trials were designated more severe (Barbee 2011, cialis prescription Dunner 200715). Only 17 of 51 trials reported two or more depression scale measures, leaving much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?.

A key philosophical error in science is to confuse an cialis prescription absence of knowledge with knowledge of absence. It is likely that some of the study populations deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity. Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm). The information may be non-existent cialis prescription as it was not collected. It may be somewhere in the publication pipeline.

Or it may be sitting in a database cialis prescription with a research team that has run out of funds for supplementary analyses. Wherever those data are or are not, their absence from published articles does not define the phenomenology of depression for the patients who took part. As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial cialis prescription also meets the guideline criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published cut-off scores). NICE categorised this population as less severe TRD, not CD and not complex.Notes1.

Avram H cialis prescription. Mack et al. (1994), “A Brief History of Psychiatric Classification. From the Ancients to DSM-IV,” Psychiatric Clinics 17, cialis prescription no. 3.

515–9.2. R. P. Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no. 3.

387.3. Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &. Medicine 62, no. 1. 52–7.4.

Gerald N. Grob (1991), “Origins of DSM-I. A Study in Appearance and Reality,” The American Journal of Psychiatry. 421–31.5. Wilson M.

Compton and Samuel B. Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no. 4. 198–9.6. Gerald L.

Klerman (1984), “A Debate on DSM-III. The Advantages of DSM-III,” The American Journal of Psychiatry. 539–42.7. Thomas E. Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist.

513–5.8. Daniel F. Hartner and Kari L. Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no. 4.

189–204.9. Sami Timimi (2014), “No More Psychiatric Labels. Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no. 3. 208–15.10.

Allen Frances et al. (1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy. A Forum for Bioethics and Philosophy of Medicine 19, no. 3. 207–18.11.

Andrea Jobst et al. (2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33. 20.12. National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management.

Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13. Ibid., 351–62.14. Ibid., 597.15. Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used. See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16.

National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management. Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17. National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18. Peter Fonagy et al.

(2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression. The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no. 3. 312–21.19. American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults.

Draft.20. Jacqui Thornton (2018), “Depression in Adults. Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361. K2681..

We live in cialis prices walmart unprecedented times. But what makes them without parallel is not the current pandemic crisis nor the continued problems facing minorities in our institutions. Rather, it’s that for the first time, the problems of accessibility, rights and freedoms cialis prices walmart are now invading privileged spaces.

There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals. For many, the world is not suddenly on fire. €¦IntroductionMinecraft is a computer game with no specific goals cialis prices walmart to accomplish.

The gameworld consists of three-dimensional (3D) cubes and objects which the player (Steve) can mine and build into infinitely complex (and logically impossible) structures. Steve sometimes encounters other characters (‘mobs’), such as cialis prices walmart animals and hostile creatures. He can ‘spawn’ and destroy them.

While it looks like a harmless game of logical construction, it conveys some worryingly delusive ideas about the real world. The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification cialis prices walmart in mental health has had various forms throughout history. Mack and colleagues set out a history of psychiatric classification beginning in 2600 BC with Egyptian references to melancholia and hysteria.

Through the Ancient Greeks with Hippocrates’ cialis prices walmart phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease. Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some common trends such as the labels ‘melancholia’ and ‘hysteria’ which have survived millennia, the label ‘depression’ is relatively new.

The earliest usage noted by cialis prices walmart Snaith is from 1899. €˜in simple pathological depression…the patient exhibits a growing indifference to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge. This did cialis prices walmart not happen until the middle of the 20th century.

With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate. In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical quarrels around categorisation of mental disorders. DSM I and DSM II have been described as products of an American Psychiatric Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the cialis prices walmart observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories.

€˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state. Zimbardo, who described psychiatric care as a cialis prices walmart controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’.

Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science. In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are opposing stances in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism cialis prices walmart in the service of clinical utility. The nominalism–realism debate is illustrated using as metaphor three different stances a cricket umpire might take on calling strikes and balls.

The discussion sets out two of cialis prices walmart these as extreme views. €˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who is characterised as holding particularly extreme views, is named as an archetypal solipsist.

There is implied to be a degree of arrogance associated with this view in the illustrative example in cialis prices walmart which the umpire states ‘there are no balls and there are no strikes until I call them’. Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than to focus on its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’. The natural conclusion the reader is invited to reach is that a middle ground of a heuristic concept is naturally right cialis prices walmart because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’.

Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’. The prototypical approach is again put forward as a clinically useful middle ground. Illustrations are drawn from natural science cialis prices walmart.

€˜a triangle and a square are never the same’, inciting the reader to consider science as value-free. The prototypical approach emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can cialis prices walmart be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification.

Doing so is more like playing Minecraft than cricket. The National Institute for Health and Care Excellence (NICE) guideline for depression is taken as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, specifically subcategories of cialis prices walmart persistent forms of depression. As well as serving a clinical purpose, diagnosis in medicine is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service.

The consequences for recipients of healthcare are cialis prices walmart therefore significant. Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression. €˜further-line’ treatment of depression (equivalent to TRD), CD and ‘depression with co-morbidities’.

The latter is subdivided cialis prices walmart into treatments for ‘complex depression’ and ‘psychotic depression’. These categories and subcategories introduce an unfortunate sense of certainty as though these labels represent real things. An analysis follows of how these definitions play out in terms of grouping of randomised controlled trials in the cialis prices walmart NICE evidence review.

Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years. Dysthymia and double depression (MDD superimposed on dysthymia) were included. If 75% cialis prices walmart of the trial population met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point.

If 80% of the trial participants met these criteria, it was reviewed in the TRD category.13 Complex depression was defined as ‘depression co-existing with personality disorder’. To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there is a potential problem with attempting to categorise trial populations into just one of cialis prices walmart these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information.

The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the category of further-line treatments (TRD), 64 trials were reviewed. Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’ cialis prices walmart. In drilling down by way of illustration, this analysis considers the 51 trials in the augmentation strategy evidence review.

Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs. Fonagy 2015 cialis prices walmart and Kocsis 200915). About half of the trials (23/51) did not report the mean duration of episode, meaning that it is not possible to know what percentage of participants also met the criteria for CD.

Of trials that did report cialis prices walmart episode duration, 17 reported a mean duration longer than 24 months. While the standard deviations varied in size or were unreported, the mean indicates a good likelihood that a significant proportion of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE. For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations.

Only 14 of 51 cialis prices walmart trials report employment data. Of those that do, unemployment ranges from 12% to 56% across trial samples. None of cialis prices walmart the trials report trauma history.

About half of the trials (26/51) excluded people who were considered a suicide risk. The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity. Of these, 18 did not exclude any diagnoses, while 12 excluded some (but not all) disorders cialis prices walmart.

The most common diagnoses excluded were psychotic disorders, substance or alcohol abuse, and bipolar disorder (excluded in 26, 25 and 23 trials, respectively). Only 7 of 51 trials clearly stated cialis prices walmart that all axis 1 diagnoses were excluded. This leaves only 13 studies providing any data about comorbidity.

Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD. Many stated PD as an exclusion criterion but without defining a threshold cialis prices walmart for exclusion. For example, PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’.

Some excluded certain PDs (such as antisocial or borderline) and not others cialis prices walmart but without reporting the prevalence of those not excluded. In the five trials where prevalence was clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample (Town 201715). Two studies reported the mean number of PDs.

2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The majority of trials (43/51) did not cialis prices walmart report the prevalence of physical illness. Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be interpreted in different ways. For example, illness could be excluded if it was ‘unstable’, cialis prices walmart ‘serious’, ‘significant’, ‘relevant’, or would ‘contraindicate’ or ‘impact’ the medication.

Of the eight trials reporting information about physical health, there was a wide variation. Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used scales of cialis prices walmart physical health.

Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners. NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ cialis prices walmart different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials which use more than one of these measures reveals problems in the algorithm. Of the 51 trials, there are 6 instances in which the study population falls into NICE’s more severe category according to one measure and into the less severe category according to another.

In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715). The other two trials were cialis prices walmart designated more severe (Barbee 2011, Dunner 200715). Only 17 of 51 trials reported two or more depression scale measures, leaving much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?.

A key philosophical error in science is to confuse an absence of knowledge cialis prices walmart with knowledge of absence. It is likely that some of the study populations deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity. Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm).

The information cialis prices walmart may be non-existent as it was not collected. It may be somewhere in the publication pipeline. Or it may be sitting in a database with a research team that has run out of funds for supplementary cialis prices walmart analyses.

Wherever those data are or are not, their absence from published articles does not define the phenomenology of depression for the patients who took part. As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial also meets the guideline criteria for CD according to the guideline’s own appendices.17 cialis prices walmart Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published cut-off scores).

NICE categorised this population as less severe TRD, not CD and not complex.Notes1. Avram H cialis prices walmart. Mack et al.

(1994), “A Brief History of Psychiatric Classification. From the Ancients cialis prices walmart to DSM-IV,” Psychiatric Clinics 17, no. 3.

Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no. 3. 387.3.

Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &. Medicine 62, no. 1.

52–7.4. Gerald N. Grob (1991), “Origins of DSM-I.

A Study in Appearance and Reality,” The American Journal of Psychiatry. 421–31.5. Wilson M.

Compton and Samuel B. Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no. 4.

198–9.6. Gerald L. Klerman (1984), “A Debate on DSM-III.

The Advantages of DSM-III,” The American Journal of Psychiatry. 539–42.7. Thomas E.

Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist. 513–5.8. Daniel F.

Hartner and Kari L. Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no. 4.

189–204.9. Sami Timimi (2014), “No More Psychiatric Labels. Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no.

(1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy. A Forum for Bioethics and Philosophy of Medicine 19, no. 3.

207–18.11. Andrea Jobst et al. (2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33.

20.12. National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management.

Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13. Ibid., 351–62.14. Ibid., 597.15.

Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used. See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16. National Institute for Health and Care Excellence (2018), Depression in Adults.

Treatment and Management. Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17. National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18.

Peter Fonagy et al. (2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression. The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no.

3. 312–21.19. American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults.

Draft.20. Jacqui Thornton (2018), “Depression in Adults. Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361.