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€œDespite a new wave which began on 25 July which Viet Nam is now also in the process of bringing under effective control, it is globally recognized that Viet Nam demonstrated one of the levitra online canada world’s most successful responses to the see it here erectile dysfunction treatment levitra between January and April 16. After that date, no cases of local transmission were recorded for 99 consecutive days.There were less than 400 cases of across the country during that period, most of them imported, and zero deaths, a remarkable accomplishment considering the country’s population of 96 million people and the fact that it shares a 1,450 km land border with China.Long-term planning pays offKamal Malhotra is the UN Resident Coordinator in Viet Nam. , by UN Viet Nam/Nguyen Duc HieuViet Nam’s success has drawn international attention because of levitra online canada its early, proactive, response, led by the government, and involving the whole political system, and all aspects of the society.

With the support of theWorld Health Organization (WHO) and other partners, Viet Nam had already put a long-term plan in place, to enable it to cope with public health emergencies, building on its experience dealing with previous disease outbreaks, such as SARS, which it also handled remarkably well.Viet Nam’s successful management of the erectile dysfunction treatment outbreak so far can, therefore, be at least partly put down to the its investment during “peacetime”. The country has now demonstrated that preparedness to deal with infectious disease is a levitra online canada key ingredient for protecting people and securing public health in times of levitras such as erectile dysfunction treatment.As early as January 2020, Viet Nam conducted its first risk assessment, immediately after the identification of a cluster of cases of “severe pneumonia with unknown etiology” in Wuhan, China. From the time that the first two erectile dysfunction treatment cases were confirmed in Viet Nam in the second half of January 2020, the government started to put precautionary measures into effect by strengthening entry-screening measures and extending the Tết (Lunar New Year) holiday for schools.

© UNICEFTeachers and students were able to return to school in Lao Cai, Viet Nam, in May.By 13 February 2020, the number of cases had climbed to 16 with limited local transmission detected in a village near the capital city, Hanoi. As this had the potential to cause a further spread levitra online canada of the levitra in Viet Nam, the country implemented a targeted three-week village-wide quarantine, affecting 11,000 people. There were then no further local cases for three weeks.But Viet Nam had simultaneously developed its broader quarantine and isolation policy to control erectile dysfunction treatment.

As the next wave began in early March, through an imported case from the UK, the government knew that it was crucial to contain levitra transmission as fast as possible, in order also to safeguard its economy.Viet Nam therefore closed its borders and suspended international flights from mainland China in February, extending this to levitra online canada UK, Europe, the US and then the rest of the world progressively in March, whilst requiring all travelers entering the country, including its nationals, to undergo 14-day mandatory quarantine on arrival.This helped the authorities keep track of imported cases of erectile dysfunction treatment and prevent further local transmission which could have then led to wider community transmission. Both the military and local governments were mobilized to provide testing, meals and amenity services to all quarantine facilities which remained free during this period.No lockdown requiredWhile there was never a nationwide lockdown, some restrictive physical distancing measures were implemented throughout the country. On 1 April 2020, the Prime Minister issued a nationwide two week physical levitra online canada distancing directive, which was extended by a week in major cities and hotspots.

People were advised to stay at home, non-essential businesses were requested to close, and public transportation was limited.Such measures were so successful that, by early May, following two weeks without a locally confirmed case, schools and businesses resumed their operations and people could return to regular routines. Green One UN House, the home of most UN agencies in Viet Nam, remained open throughout this period, with the Resident Coordinator, WHO Representative and approximately 200 UN staff and consultants physically in the office throughout this period, to provide vital support to the Government and people of Viet Nam.Notably, the Vietnamese public had been exceptionally compliant with government directives and advice, partly as a result of trust built up thanks to real time, transparent communication from the Ministry of Health, supported by the WHO and other UN agencies. Innovative methods were used to keep levitra online canada the public informed and safe.

For instance, regular text updates were sent by the Ministry of Health, on preventive measures and erectile dysfunction treatment’s symptoms. A erectile dysfunction treatment song was released, with lyrics raising public awareness of the disease, which later went viral on levitra online canada social media with a dance challenge on Tik Tok initiated by Quang Dang, a local celebrity.. UN Viet Nam/Nguyen Duc HieuYoung people in Viet Nam take part in International Youth Day 2020 festivities in June.

Protecting the vulnerableStill, challenges remain to ensure that the people across the country, especially the hardest hit people, from small and medium-sized enterprises (SMEs) and poor and vulnerable groups, are well levitra online canada served by an adequately resourced and effectively implemented social protection package. The UN in Viet Nam is keen to help the government support clean technology-based SMEs, with the cooperation of international financial institutions, which will need to do things differently from the past and embrace a new, more inclusive and sustainable, perspective on growth.Challenges remainAs I write, Viet Nam stands at a critical point with respect to erectile dysfunction treatment. On 25 July, 99 days after being erectile dysfunction treatment-free in terms of local transmission, a new case was confirmed in Da Nang, a well-known tourist destination.

Hundreds of thousands of people flocked to the city and surrounding region over the summer.The government is once again demonstrating its serious commitment to containing local levitra online canada levitra transmission. While there have been a few hundred new local transmission cases and 24 deaths, all centered in a major hospital in Danang (sadly, all the deaths were of people with multiple pre-conditions) aggressive contact tracing, proactive case management, extensive quarantining measures and comprehensive public communication activities are taking place.I am confident that the country will be successful in its efforts to once again successfully contain the levitra, once more over the next few weeks.”The Review Committee will advise whether any amendments to the International Health Regulations (IHR) are necessary to ensure it is as effective as possible, WHO Director General Tedros Adhanom Ghebreyesus told journalists. He said the erectile dysfunction treatment levitra has been “an levitra online canada acid test” for many countries, organizations and the treaty.

“Even before the levitra, I have spoken about how emergencies such as the Ebola outbreak in eastern DRC (the Democratic Republic of the Congo) have demonstrated that some elements of the IHR may need review, including the binary nature of the mechanism for declaring a public health emergency of international concern,” said Mr. Tedros. Interaction with levitra panel The IHR Review Committee will levitra online canada hold its first meeting on 8 and 9 September.

The committee will also interact with two other entities, exchanging information and sharing findings. They are the Independent Panel for levitra online canada levitra Preparedness and Response, established last month to evaluate global response to the erectile dysfunction treatment levitra, and the Independent Oversight Advisory Committee for the WHO Health Emergencies Programme. It is expected that the committee will present a progress report to the World Health Assembly, WHO’s decision-making body, at its resumed session in November.

The Assembly comprises delegations from WHO’s levitra online canada 194 member States who meet annually in May. A truncated virtual session was held this year due to the levitra. The committee will present its full report to the Assembly in 2021.

Committed to ending erectile dysfunction treatment The IHR levitra online canada was first adopted in 1969 and is legally-binding on 196 countries, including all WHO Member States. It was last revised in 2005. The treaty outlines rights and obligations for countries, including the requirement to levitra online canada report public health events, as well as the criteria to determine whether or not a particular event constitutes a “public health emergency of international concern”.

Mr. Tedros underscored WHO’s commitment to ending the levitra, “and to working with all countries to learn from it, and to ensure that together we build the healthier, safer, fairer world that we want.” Invest in mental health WHO is also shining light on the levitra’s impact on mental health at a time when services have levitra online canada suffered disruptions. For example, Mr.

Tedros said lack of social interaction has affected many people, while others have experienced anxiety and fear. Meanwhile, some mental health levitra online canada facilities have been closed and converted to erectile dysfunction treatment facilities. Globally, close to one billion people are living with a mental disorder.

In low- and middle-income countries, more than three-quarters of people with mental, neurological and levitra online canada substance use disorders do not receive treatment. World Mental Health Day is observed annually on 10 October, and WHO and partners are calling for a massive scale-up in investments. The UN agency also will host its first-ever levitra online canada global online advocacy event on mental health where experts, musicians and sports figures will discuss action to improve mental health, in addition to sharing their stories.

Global fight against polio continues The milestone eradication of wild poliolevitra in Africa does not mean the disease has been defeated globally, Mr. Tedros reminded journalists. WHO announced on Tuesday that the continent has been declared free of the levitra, which can cause paralysis, after no cases were reported for four years “We still have a lot of work to do to eradicate levitra online canada polio from the last two countries where it exists.

Afghanistan and Pakistan,” he said. Mr. Tedros also congratulated Togo, which on Wednesday celebrated the end of sleeping sickness as a public health problem.

The disease, officially known as human African Trypanosomiasis, is spread by tsetse flies and is fatal without treatment..

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The onset of the erectile dysfunction treatment levitra and blood pressure levitra affected all aspects of medical care, including the management of multiple sclerosis (MS)."There was some concern about the disease itself increasing the susceptibility, or http://cz.keimfarben.de/genuine-levitra-online/ the risk of complications, from erectile dysfunction treatment," Gabriel Pardo, MD, director of the Oklahoma Medical Research Foundation Multiple Sclerosis Center of Excellence, told MedPage Today. "And by extension there were concerns about levitra and blood pressure the different medications we use because they have an effect on the immune system.""So there were a lot of different recommendations given by institutions and organizations," said Pardo. However, as described in these guidelines published by the Consortium of Multiple Sclerosis Centers, the differences among these recommendations created some confusion.The problem, according to Joseph Berger, MD, an MS specialist at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, is "that we really had no hard data on how the disease itself would be affected by MS, and how MS would be affected by erectile dysfunction treatment. And more importantly, how people on disease-modifying therapies (DMTs) would respond to erectile dysfunction treatment, and whether it would increase the morbidity and mortality levitra and blood pressure of erectile dysfunction treatment."One response, Pardo explained, was a concerted effort on the part of the MS field to set up registries of patients living with MS who were infected with erectile dysfunction treatment.

For example, COViMS (erectile dysfunction treatment s in MS &. Related Diseases) is a joint effort by the National MS Society, Consortium of MS Centers, and Multiple Sclerosis Society of Canada to capture information on outcomes of people with MS and other central nervous system demyelinating diseases who have developed erectile dysfunction treatment."So far, and this is an evolving concept, levitra and blood pressure it has been very reassuring that we do not have clear evidence that our MS patients are at increased risk for developing the or developing complications," said Pardo. "They seem to have the same risk as the general population, with comorbidities playing levitra and blood pressure the same sort of role."In a study published in the Lancet Neurology, Italian researchers evaluated 232 MS patients who had either tested positive for erectile dysfunction treatment or were suspected of having the . Most of these patients (96%) had either mild or no pneumonia.The was considered severe in four people, and critical (defined as respiratory failure, septic shock, and multiple organ dysfunction or failure, and were hospitalized in an intensive care unit) in six patients.

Of those six critical levitra and blood pressure patients, one recovered and five (2%) died. Those patients tended to have comorbidities, higher disability, and/or were age 50 or older.And a French cohort study of 347 patients with MS published in JAMA Neurology found that risk factors for severe forms of erectile dysfunction treatment were neurological disability, age, and obesity (with patients with high Expanded Disability Status Scale (EDSS) and older age at highest risk of severe erectile dysfunction treatment), but that there was no association between DMT exposure and erectile dysfunction treatment severity.Berger, along with UPenn colleagues Rachel Brandstadter, MD, and Amit Bar-Or, MD, published a review of the current state of knowledge regarding the effect of MS DMTs on erectile dysfunction treatment illness.Anecdotal reports suggested that "patients with MS, including those on commonly used DMTs, are at no higher risk of contracting symptomatic erectile dysfunction viral , nor at a higher risk of severe erectile dysfunction treatment complications, compared with the population at large," the group wrote.Berger said that there was particular concern about drugs such as alemtuzumab (Lemtrada) or cladribine (Mavenclad), which are classified as immune reconstitution therapies. "But with respect to other [DMTs] we didn't think there was likely to be a significant problem," levitra and blood pressure Berger told MedPage Today. "And our own practice was not to change anything when managing these patients.

We have kept our own registry and our initial thoughts have been borne out, which is that there levitra and blood pressure does not appear to be a significant effect either on morbidity or mortality with respect to the disease-modifying therapies we employ -- and that includes cladribine. We have people that we have levitra and blood pressure started on cladribine, and have been on cladribine, and have developed erectile dysfunction treatment, and they've done well, and the large registries seem to bear this out.""The people who have had a significant problem with respect to erectile dysfunction treatment, and who have MS, are, for the most part, older individuals, with multiple how to make levitra more effective comorbidities that increase the risk of erectile dysfunction treatment morbidity and mortality, and quite often are not on any therapy whatsoever, and are disabled as a consequence of their disease," he added. Most have EDSS scores of 6 or more, he noted, meaning their ambulation is affected.Berger suggested that some of these DMTs could even have a "salutary" effect by limiting the aggressive immune response that causes the most severe complications associated with erectile dysfunction treatment. For example, fingolimod (Gilenya) is being tested as a treatment for acute respiratory distress in erectile dysfunction treatment patients.In their report, Berger and his colleagues recommended that most patients with MS continue on their DMT, "particularly those on platform therapy for whom the risk of erectile dysfunction and erectile dysfunction treatment is minimal." They levitra and blood pressure added that treatment decisions should be tailored to individual patients, particularly for those with increased risk of either acquiring or with serious erectile dysfunction treatment complications.In its treatment guidelines, the National Multiple Sclerosis Society recommended that DMT decisions should be individualized and made collaboratively between MS patients and their care providers.

That discussions between patient and provider should include a consideration of disease factors, risks and benefits of the DMT, and risks associated with erectile dysfunction treatment. And that persons with MS currently taking DMTs should continue treatment.One question that remains to be answered, said Pardo, is how patients with MS will respond to a levitra and blood pressure potential treatment. "Will the fact that they are on different medications affect the immune system and blunt the ability to mount an appropriate response to the treatment, or decrease it?. " he levitra and blood pressure said.

"We don't know that quite yet."Berger agreed that diminished treatment levitra and blood pressure response might occur "with some of the drugs we use like the anti-CD20 monoclonal antibodies, and perhaps with others as well. It may be that those in our MS population on these drugs might need more than one dose of the treatment, and that the antibody response will need to be monitored to ensure that it is adequate."He also noted that clinicians have traditionally advised MS patients on DMTs to avoid live levitra treatments of any kind. But, he said, levitra and blood pressure "it looks like there are very few live levitra treatments in development, and those under development in the U.S., to the best of my understanding, are not live levitra treatments. So any of those treatments should be fine in the MS population regardless of the disease-modifying therapy they are on." Disclosures Berger serves as a consultant and/or on the PML adjudication committees of Novartis and Takeda/Millennium.

He also serves on the scientific advisory board of Excision Bio levitra and blood pressure and Inhibikase. He is chair of the Data Safety Monitoring Board for MAPI.Pardo has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities for Alexion, Biogen, Celgene, EMD Serono, Roche/Genentech, Novartis, and Sanofi Genzyme..

The onset of levitra online canada the erectile dysfunction treatment levitra affected all aspects of medical care, including the management of multiple sclerosis (MS)."There was some concern about the disease itself increasing the susceptibility, or the risk of complications, from erectile dysfunction treatment," Gabriel Pardo, MD, director of the Oklahoma Medical Research Foundation Multiple Sclerosis Center of Excellence, told MedPage Today. "And by extension there were concerns about levitra online canada the different medications we use because they have an effect on the immune system.""So there were a lot of different recommendations given by institutions and organizations," said Pardo. However, as described in these guidelines published by the Consortium of Multiple Sclerosis Centers, the differences among these recommendations created some confusion.The problem, according to Joseph Berger, MD, an MS specialist at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, is "that we really had no hard data on how the disease itself would be affected by MS, and how MS would be affected by erectile dysfunction treatment.

And more importantly, how people on disease-modifying therapies (DMTs) would respond to erectile dysfunction treatment, and whether it would increase the morbidity and mortality of erectile dysfunction treatment."One response, Pardo explained, was a concerted effort on the part of the MS field to set up registries of levitra online canada patients living with MS who were infected with erectile dysfunction treatment. For example, COViMS (erectile dysfunction treatment s in MS &. Related Diseases) is a joint effort by the National MS Society, Consortium of MS Centers, and Multiple Sclerosis Society of Canada to capture information on outcomes of people with MS and other central nervous system demyelinating diseases who have developed erectile dysfunction treatment."So far, and this is an evolving concept, it has been very reassuring that we do not have clear evidence that our MS patients are levitra online canada at increased risk for developing the or developing complications," said Pardo.

"They seem to have the same risk as the general population, with comorbidities playing the same sort of levitra online canada role."In a study published in the Lancet Neurology, Italian researchers evaluated 232 MS patients who had either tested positive for erectile dysfunction treatment or were suspected of having the . Most of these patients (96%) had either mild or no pneumonia.The was considered severe in four people, and critical (defined as respiratory failure, septic shock, and multiple organ dysfunction or failure, and were hospitalized in an intensive care unit) in six patients. Of those six levitra online canada critical patients, one recovered and five (2%) died.

Those patients tended to have comorbidities, higher disability, and/or were age 50 or older.And a French cohort study of 347 patients with MS published in JAMA Neurology found that risk factors for severe forms of erectile dysfunction treatment were neurological disability, age, and obesity (with patients with high Expanded Disability Status Scale (EDSS) and older age at highest risk of severe erectile dysfunction treatment), but that there was no association between DMT exposure and erectile dysfunction treatment severity.Berger, along with UPenn colleagues Rachel Brandstadter, MD, and Amit Bar-Or, MD, published a review of the current state of knowledge regarding the effect of MS DMTs on erectile dysfunction treatment illness.Anecdotal reports suggested that "patients with MS, including those on commonly used DMTs, are at no higher risk of contracting symptomatic erectile dysfunction viral , nor at a higher risk of severe erectile dysfunction treatment complications, compared with the population at large," the group wrote.Berger said that there was particular concern about drugs such as alemtuzumab (Lemtrada) or cladribine (Mavenclad), which are classified as immune reconstitution therapies. "But with respect to other [DMTs] we didn't think there was likely levitra online canada to be a significant problem," Berger told MedPage Today. "And our own practice was not to change anything when managing these patients.

We have kept our own registry and our initial thoughts have been borne out, which is that there does not appear to be a significant effect either on morbidity or mortality with respect to the disease-modifying therapies we employ -- and that levitra online canada includes cladribine. We have people that we have started on cladribine, and have been on cladribine, and have developed erectile dysfunction treatment, and they've done well, and the large registries seem to bear this out.""The people who have had a significant problem with respect to erectile dysfunction treatment, and who have MS, are, for the most part, older individuals, with multiple comorbidities that increase the risk of erectile dysfunction treatment morbidity and mortality, and quite often are not on levitra online canada any therapy whatsoever, and are disabled as a consequence of their disease," he added. Most have EDSS scores of 6 or more, he noted, meaning their ambulation is affected.Berger suggested that some of these DMTs could even have a "salutary" effect by limiting the aggressive immune response that causes the most severe complications associated with erectile dysfunction treatment.

For example, fingolimod (Gilenya) levitra online canada is being tested as a treatment for acute respiratory distress in erectile dysfunction treatment patients.In their report, Berger and his colleagues recommended that most patients with MS continue on their DMT, "particularly those on platform therapy for whom the risk of erectile dysfunction and erectile dysfunction treatment is minimal." They added that treatment decisions should be tailored to individual patients, particularly for those with increased risk of either acquiring or with serious erectile dysfunction treatment complications.In its treatment guidelines, the National Multiple Sclerosis Society recommended that DMT decisions should be individualized and made collaboratively between MS patients and their care providers. That discussions between patient and provider should include a consideration of disease factors, risks and benefits of the DMT, and risks associated with erectile dysfunction treatment. And that persons with MS currently taking DMTs should continue treatment.One question that remains to be answered, said Pardo, is how levitra online canada patients with MS will respond to a potential treatment.

"Will the fact that they are on different medications affect the immune system and blunt the ability to mount an appropriate response to the treatment, or decrease it?. " he said levitra online canada. "We don't levitra online canada know that quite yet."Berger agreed that diminished treatment response might occur "with some of the drugs we use like the anti-CD20 monoclonal antibodies, and perhaps with others as well.

It may be that those in our MS population on these drugs might need more than one dose of the treatment, and that the antibody response will need to be monitored to ensure that it is adequate."He also noted that clinicians have traditionally advised MS patients on DMTs to avoid live levitra treatments of any kind. But, he said, "it looks like there are very few live levitra treatments levitra online canada in development, and those under development in the U.S., to the best of my understanding, are not live levitra treatments. So any of those treatments should be fine in the MS population regardless of the disease-modifying therapy they are on." Disclosures Berger serves as a consultant and/or on the PML adjudication committees of Novartis and Takeda/Millennium.

He also serves on the scientific advisory board of Excision levitra online canada Bio and Inhibikase. He is chair of the Data Safety Monitoring Board for MAPI.Pardo has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities for Alexion, Biogen, Celgene, EMD Serono, Roche/Genentech, Novartis, and Sanofi Genzyme..

Where can I keep Levitra?

Keep out of the reach of children. Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F). Throw away any unused medicine after the expiration date.

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The past week http://cz.keimfarben.de/genuine-levitra-online/ has seen an explosion of media commentary about whether children in the levitra 20mg canada UK should go back to school. Since ‘lockdown’ (23 March 2020) began schools have been open levitra 20mg canada to vulnerable children and young people, and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools.

Viner et al1 produced levitra 20mg canada a rapid systematic review that concludes that school closures have less impact on rate and mortality than other social distancing measures. Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’. This was conveyed to the population of the levitra 20mg canada UK on 10 May by the UK prime minister, Boris Johnson.

He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken by various groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson announced that there would be levitra 20mg canada a phased return (in England) of some children to school from 1 June. There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools.

In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a vital part of restarting the UK economy, but they have concerns about the safety and levitra 20mg canada welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision. Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there are children out there that have not spoken or levitra 20mg canada played with another child their own age for the last two months.

They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest children will be the ones who fall further behind levitra 20mg canada if we keep school gates closed. This phased return is in line with what other European countries are doing.There ensued an at levitra 20mg canada times ill-tempered debate and a flurry of tweets and news articles identifying problems in enacting the government plan and the illogical nature of Williamson’s statement.

The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school. This has caused concern about the attainment gap, but as Quinn6 points out fewer children from disadvantaged backgrounds are likely to return to school than those from more levitra 20mg canada affluent backgrounds.Government ministers and spokespeople reiterated that scientific evidence and observation of other European countries where schools had reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit.

Is that levitra 20mg canada correct?. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’. This provoked a levitra 20mg canada great deal of disquiet.

Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the risk to children of developing erectile dysfunction levitra 20mg canada disease. The second is the risk to others of children transmitting erectile dysfunction disease, either while being symptomatic or asymptomatic.

Here are some of the available evidence.Morbidity and mortality in children levitra 20mg canada from erectile dysfunction diseaseChildren appear to be less likely to acquire erectile dysfunction disease in various nations.9–11 Barton et al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications). Of these 8113 paediatric cases, 14% required hospital admission. The admission rate to critical care was 2.2% of levitra 20mg canada confirmed cases (7.2% of admitted children).

Death was reported in 15 levitra 20mg canada cases (0.18%). This adds to other evidence suggesting that children are at a relatively low risk from the levitra, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the levitra.15There are concerns that children who have been infected with the levitra can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for erectile dysfunction treatment, and in the absence of effective community testing it will be impossible to know if they are carrying the levitra. Children also can have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In short, it is difficult to determine without much more extensive testing if a child can transmit the .Arav et al18 found that the contact route was much levitra 20mg canada more important than the airborne route, which they concluded had a negligible contribution.

They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is a case for reopening schools to limited numbers of pupils—the levitra 20mg canada risk to pupils and the adults they come into contact with seems to be small, and the potential gains for children may outweigh them. There is a big proviso with this however, and that is that the overall incidence of erectile dysfunction treatment has fallen below specified threshold.

This is levitra 20mg canada quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of decreasing to manageable levels.Ensuring that personal protective equipment supply can meet demand.Being confident that any adjustments would not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy. Decisions about whether to reopen schools are taken on a levitra 20mg canada national level with a distance from personal concerns and fears.

Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is levitra 20mg canada a difficult path to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation.

Parents were being asked levitra 20mg canada to believe that MMR was a safe treatment in the face of a massive and emotive campaign that promoted the ‘risk’ of having the treatment above all else. This situation is even more complex than that levitra 20mg canada as we have increased access to opinion and difficulty in look at here understanding if or how much that information is biased. It is no wonder that decision-making is difficult.

It is likely that evidence levitra 20mg canada will continue to emerge and gradually the choice will become easier to make. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach. By working to identify a consensus position, researchers can report findings on a specific question (or set of questions) that levitra 20mg canada are based on the knowledge and experience of experts in their field.However, there are challenges to this approach.

For example, what should be done when consensus cannot be reached?. How can experts be engaged in a way that allows them to consider objectively the views of others and—where appropriate—change their own opinions in levitra 20mg canada response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus.

Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, levitra 20mg canada so that the methods employed “…appear to be more conducive to independent thought on the part of the experts and to aid them in the gradual formation of a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline. First, the overarching approach is levitra 20mg canada based on a series of ‘rounds’, where a set of experts are asked their opinions on a particular issue.

The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses. Finally, the findings levitra 20mg canada of each round are always shared with the broader group anonymously. This avoids any bias that might result from participants being concerned about their levitra 20mg canada own views being viewed negatively or from their own opinions being biased by personal factors.

This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged. For example, a study of human factors that contributed to nursing errors used levitra 20mg canada only two rounds. The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could.

Analysis of responses resulted in a list of 28 potential reasons—this list was sent back to the same group of experts for levitra 20mg canada the second round, asking them to score each one for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round 1, draft competencies were developed from the levitra 20mg canada findings of a survey of NP beliefs, knowledge and level of implementation of advance care planning.

Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made based on the original feedback, and a third round was conducted where 15 of the original NP participants confirmed their levitra 20mg canada consensus with the final document. The final document includes four competencies, each with several elements.

Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and levitra 20mg canada weaknesses of Delphi studiesThe Delphi technique offers a flexible approach to gathering the views of experts on an area of interest. The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups. The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and levitra 20mg canada reduces the risk of the ‘halo effect’ where views from dominant or high-profile members of the group are given extra credence.5However, Delphi studies can—by their very nature—be complex and time consuming.

The need levitra 20mg canada for participants to complete multiple rounds can lead to high drop-out rates which impacts on validity of the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword. It provides those taking part with the opportunity to reflect and reconsider their position in response to additional information, levitra 20mg canada which is an important part of nursing practice.

Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’. Even with the level of flexibility and reflexivity present in Delphi studies, it is still unlikely that a group of experts will demonstrate 100% agreement on levitra 20mg canada issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached.

This is where there is inconsistency across studies and levitra 20mg canada authors, with the suggested level of consensus ranging from 51% to 100%.2 In addition, it has been identified that in some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore related to the levitra 20mg canada quality of evidence, with expert opinion viewed as providing a poor basis for making judgements on healthcare interventions.7 This does not mean that the findings of Delphi studies are intrinsically unreliable or invalid.

It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts. It allows for reflection among levitra 20mg canada participants, who are able to nuance and reconsider their opinion based on the anonymised opinions of others. However, researchers must take steps to enhance robustness of the studies.

It is important to try and prevent participants from simply resorting levitra 20mg canada to agreeing with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

The past visit this website week has seen an explosion of media commentary about levitra online canada whether children in the UK should go back to school. Since ‘lockdown’ (23 March 2020) began schools have been open to vulnerable children and young levitra online canada people, and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools. Viner et al1 produced a rapid systematic review that concludes that school closures have less impact on rate and mortality than other social distancing levitra online canada measures.

Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’. This was conveyed to the population of the UK on 10 May by the UK prime minister, levitra online canada Boris Johnson. He announced a range of measures to gradually reduce the level of lockdown. This is in levitra online canada keeping with modelling undertaken by various groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson announced that there would be a phased return (in England) of some children to school from 1 June.

There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools. In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a vital part of restarting the UK economy, but they have concerns about the safety and welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press levitra online canada conference on 16 May stating that scientific evidence backed their decision. Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there are children out there that have not spoken or played with another child their own age levitra online canada for the last two months.

They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest children will be the ones who fall further behind if we keep school gates levitra online canada closed. This phased return levitra online canada is in line with what other European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets and news articles identifying problems in enacting the government plan and the illogical nature of Williamson’s statement. The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school.

This has caused concern about the attainment gap, but as Quinn6 points out fewer children from disadvantaged backgrounds are likely to return to school than those from levitra online canada more affluent backgrounds.Government ministers and spokespeople reiterated that scientific evidence and observation of other European countries where schools had reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit. Is that levitra online canada correct?. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’.

This provoked a great deal of levitra online canada disquiet. Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the risk to children levitra online canada of developing erectile dysfunction disease. The second is the risk to others of children transmitting erectile dysfunction disease, either while being symptomatic or asymptomatic.

Here are some of the available evidence.Morbidity and mortality in children from erectile dysfunction diseaseChildren appear to be less levitra online canada likely to acquire erectile dysfunction disease in various nations.9–11 Barton et al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications). Of these 8113 paediatric cases, 14% required hospital admission. The admission levitra online canada rate to critical care was 2.2% of confirmed cases (7.2% of admitted children). Death was reported in levitra online canada 15 cases (0.18%).

This adds to other evidence suggesting that children are at a relatively low risk from the levitra, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the levitra.15There are concerns that children who have been infected with the levitra can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for erectile dysfunction treatment, and in the absence of effective community testing it will be impossible to know if they are carrying the levitra. Children also can have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In short, it is difficult to determine without much more extensive testing if a child can transmit the .Arav et al18 found levitra online canada that the contact route was much more important than the airborne route, which they concluded had a negligible contribution. They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is a case for reopening schools to limited numbers of pupils—the risk to pupils and the adults levitra online canada they come into contact with seems to be small, and the potential gains for children may outweigh them.

There is a big proviso with this however, and that is that the overall incidence of erectile dysfunction treatment has fallen below specified threshold. This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of decreasing to manageable levels.Ensuring that personal protective equipment supply can meet levitra online canada demand.Being confident that any adjustments would not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy. Decisions about whether to reopen schools are taken on a national level levitra online canada with a distance from personal concerns and fears.

Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is levitra online canada a difficult path to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation. Parents were being asked to believe that MMR was a safe treatment in the face of a massive and emotive campaign that promoted the ‘risk’ of having the treatment above all else levitra online canada.

This situation is even more complex than that as we have increased access to opinion and difficulty in understanding if levitra online canada or how much that information is biased. It is no wonder that decision-making is difficult. It is likely that evidence will continue to emerge and gradually the choice will become easier levitra online canada to make. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach.

By working to identify a consensus position, researchers can report findings on a specific question (or set of questions) that are based on the levitra online canada knowledge and experience of experts in their field.However, there are challenges to this approach. For example, what should be done when consensus cannot be reached?. How can experts be engaged in a way that allows them to consider objectively the views of levitra online canada others and—where appropriate—change their own opinions in response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus.

Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, so that the methods levitra online canada employed “…appear to be more conducive to independent thought on the part of the experts and to aid them in the gradual formation of a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline. First, the levitra online canada overarching approach is based on a series of ‘rounds’, where a set of experts are asked their opinions on a particular issue. The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses.

Finally, the findings of each round are always levitra online canada shared with the broader group anonymously. This avoids any bias that might result from participants being levitra online canada concerned about their own views being viewed negatively or from their own opinions being biased by personal factors. This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged. For example, a study of human factors that contributed levitra online canada to nursing errors used only two rounds.

The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could. Analysis of responses resulted in a list of 28 potential reasons—this list was sent back to the same group of experts for the second levitra online canada round, asking them to score each one for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round 1, draft competencies levitra online canada were developed from the findings of a survey of NP beliefs, knowledge and level of implementation of advance care planning.

Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made based on the original feedback, and a levitra online canada third round was conducted where 15 of the original NP participants confirmed their consensus with the final document. The final document includes four competencies, each with several elements. Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses of Delphi studiesThe Delphi levitra online canada technique offers a flexible approach to gathering the views of experts on an area of interest.

The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups. The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from levitra online canada dominant or high-profile members of the group are given extra credence.5However, Delphi studies can—by their very nature—be complex and time consuming. The need for participants to complete levitra online canada multiple rounds can lead to high drop-out rates which impacts on validity of the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword.

It provides those taking part with the opportunity to reflect and reconsider their position in response to levitra online canada additional information, which is an important part of nursing practice. Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’. Even with the level of flexibility and reflexivity present in Delphi studies, it is still unlikely that a group of levitra online canada experts will demonstrate 100% agreement on issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached.

This is where there is inconsistency across studies and authors, with the suggested level levitra online canada of consensus ranging from 51% to 100%.2 In addition, it has been identified that in some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore levitra online canada related to the quality of evidence, with expert opinion viewed as providing a poor basis for making judgements on healthcare interventions.7 This does not mean that the findings of Delphi studies are intrinsically unreliable or invalid. It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts.

It allows for reflection among participants, who are able to nuance and reconsider their opinion based on the anonymised opinions of others levitra online canada. However, researchers must take steps to enhance robustness of the studies. It is important to levitra online canada try and prevent participants from simply resorting to agreeing with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..