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Customers spread their food on the hoods of their trucks and ate there while sharing news and commiserating kamagra oral jelly thailand price over the stresses http://tvandfilmtoys.com/kamagra-canada-wholesale/ of ranching during the kamagra. Keeping that community hub operating has been vital for the ranchers around Kiowa as the kamagra takes its toll on mental health in agricultural communities where health providers are scarce and a “pull yourself up by your own bootstraps” mentality is prevalent. Wheeler heads into Patty Ann’s Cafe for lunch. Ranchers often come to the kamagra oral jelly thailand price Kiowa, Colorado, cafe for breakfast or lunch, which Wheeler said is a way to connect with others experiencing similar stresses. €œThat’s your support group, because you have commonality, a common experience, common difficulty.” (Eli Imadali for KHN) Roberta Kusma (left) laughs with her old friend Betty Hood at Patty Ann’s Cafe.

The two worked in the same building when it was a grocery store years ago. (Eli Imadali for KHN) The kamagra kamagra oral jelly thailand price over the past year has been a surprising boon for many farms and ranches as higher consumer demand amid food shortages has boosted business. But coupled with everyday worries about weather and commodity prices, the kamagra also has led to mental health challenges, including serious stress, anxiety and depression among farmers and ranchers, health officials said. The American Farm Bureau Federation found that about 3 in 5 rural adults reported that the kamagra has affected mental health in their communities, while two-thirds of farmers and farmworkers said the kamagra has impacted their mental health. Treatment for mental health problems caused or worsened by the stress and isolation of the kamagra has obstacles particular to ranching and farming country kamagra oral jelly thailand price.

The stigma of acknowledging the need for mental health care can prevent people from seeking it. For those who overcome that obstacle and look for help, they are likely to find underfunded, understaffed and underequipped health providers who often don’t have the bandwidth or expertise for sufficient mental health support. €œI guess my kamagra oral jelly thailand price cows are my therapists,” joked Wheeler. The 54-year-old rancher said he has felt the stress of the added responsibility of providing meat to customers in a time of food shortages, particularly at the beginning of the kamagra. But he feels lucky to have a family that supports him.

Because drought has impeded hay production in Colorado, Wheeler has had to kamagra oral jelly thailand price have bales shipped in from South Dakota. Wheeler says the lack of rain has been his biggest stressor. (Eli Imadali for KHN) Similar to other Rocky Mountain states, Colorado has one of the highest suicide rates in the country. The rates are often worse in the state’s rural communities, a factor consistent with rural Americans’ kamagra oral jelly thailand price risks nationwide. A Centers for Disease Control and Prevention report examining 2001-15 data found the suicide rate in rural counties was more than 17 per 100,000 people, compared with about 15 per 100,000 in small and medium-sized metro counties and about 12 per 100,000 in large metro counties.

Kiowa is in Elbert County, whose 1,850 square miles of mostly dusty, flat plains start where the affluent bedroom communities of Denver end. The county has no urgent care center or hospital like its kamagra oral jelly thailand price suburban neighbors, just four clinics to serve a population of 27,000. A health care center in Elizabeth, Colorado, offers counseling, among other services. The few physical and mental health resources available in Elbert County are concentrated in the west, closer to Denver. (Eli Imadali for KHN) Dwayne Smith, Elbert County’s public health director, said that to help solve the problem kamagra oral jelly thailand price residents need to talk with their health providers as candidly about their mental health challenges as about skin cancer or heart disease.

€œIn a more conservative community, where historically mental health issues may not have been talked about as openly and as comfortably as in the [Denver] area, you have to work diligently to increase people’s comfort level,” Smith said. €œEven saying the words ‘anxiety,’ ‘depression,’ ‘mental health’ — all those things that in prior generations were very much a taboo subject.” Elbert County Public Health Director Dwayne Smith poses outside the Department of Health and Human Services, surrounded by prairie. (Eli Imadali for KHN) The public health crisis is just kamagra oral jelly thailand price an added burden to the already high stress on people in the agricultural industry. €œFarmers and ranchers are absorbing a lot of the shocks to the system for us. Hailstorms, pest outbreaks, drought, markets — they’re adjusting for all that to keep food production moving,” said Colorado’s agriculture commissioner, Kate Greenberg.

Unpredictable weather, a volatile commodity market kamagra oral jelly thailand price and a 700-acre grass fire cost Laura Negley, a rancher in the southeastern town of Eads, a lot of income around 2012. Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land. But she was devastated after those losses, followed by her youngest child’s departure for college. €œThat’s kind kamagra oral jelly thailand price of when the wheels fell off for me. And then I kind of spiraled down,” Negley said.

The kamagra exacerbated Laura Negley’s anxiety, isolating her from extended family and causing worry about her elderly parents.(Eli Imadali for KHN) Negley, now 59, said she initially didn’t recognize she needed help even though she was deep into her “dark place” of depression and anxiety, but her brother encouraged her to see a counselor near him in Greeley. So, when the cattle were done grazing for the season, Negley spent six kamagra oral jelly thailand price winter weeks getting counseling 200 miles north. Those visits eventually transitioned to phone counseling and an anti-anxiety medication. €œI do think you have to have a support group,” said Negley, who said her faith has helped her, too. Over the years, slashed kamagra oral jelly thailand price budgets to local health departments have cut to the bone.

In Elbert County, Smith is one of just three full-time employees in his department. About 15 years ago, it had at least six nurses. It now kamagra oral jelly thailand price has none. It is trying to hire one. €œWe have a lack of health providers” in rural America, Negley said.

€œThe ones we do have are doing their best — but they’re trying to wear multiple hats.” Negley kamagra oral jelly thailand price talks with son Jayce as he repairs a sweep plow on their family land in Eads, Colorado. (Eli Imadali for KHN) Negley’s and her husband’s families have been in agriculture since the late 1600s and early 1700s, and they are now the third generation on the same Colorado land. (Eli Imadali for KHN) Stressors like severe drought and exhaustion from unrelenting hard work can lead to mental health struggles for farmers and ranchers. Negley will likely not have cattle this year because drought impeded grass growth.(Eli Imadali for KHN) Agencies in Colorado recognize the need to improve mental health services offered to rural kamagra oral jelly thailand price residents. Colorado Crisis Services has a hotline and text-messaging number to refer people to free, confidential support.

And the state is working on tailored messaging campaigns to help farmers and ranchers understand those numbers are free and confidential to contact. These services kamagra oral jelly thailand price can help. According to the CDC, for every adult death by suicide, about 230 people think seriously about suicide. A bill introduced in Colorado’s legislature would boost funding for rural rehabilitation specialists and help provide vouchers for rural Coloradans to get behavioral health services. €œWe have to kamagra oral jelly thailand price be flexible.

What works in Denver does not work in La Junta” or the rest of rural Colorado, said Robert Werthwein, director of the state’s Office of Behavioral Health. But in tightknit small towns, ranchers say, even if the resources are there the stigma remains. €œThese are normal kamagra oral jelly thailand price people with normal problems. We’re just trying to, perhaps first and foremost, destigmatize mental health needs and resources,” Smith said. €œTimecards and schedules have had no meaning for the past year,” says Smith, one of three full-time employees in his department.

€œIt’s just been never-ending.” (Eli kamagra oral jelly thailand price Imadali for KHN) Stigmas are something 26-year-old Jacob Walter and his family want to help tackle. As Walter was growing up, a friend’s father and another friend’s mother died by suicide. Before Walter left the family’s ranch in southeastern Colorado to start his sophomore year in college, he lost his own father, Rusty, to suicide in 2016. Walter said kamagra oral jelly thailand price there were few local resources at the time to help people like his dad, and the nearest town was 45 minutes away. Rusty was involved in many community service organizations and gave a lot of his time to others, Walter said, but he suffered from depression.

€œThe day before he committed suicide, we had been talking at the kitchen table, and he was just talking about [his depression], and he said. €˜You know, you can always get help and stuff.’” That’s the message agricultural leaders like Ray Atkinson, communications director at the American Farm Bureau Federation, say should kamagra oral jelly thailand price be conveyed most. It’s OK to acknowledge when you need help. €œIf your tractor needed maintenance … you would stop what you’re doing and you’d get it working right before you go try and go out in the field,” Atkinson said. €œYou are kamagra oral jelly thailand price the most important piece of equipment on your farm.” Cattle eat hay on Rafter W Ranch near Simla, Colorado.

Drought hasn’t allowed grazing on grassy pastures. (Eli Imadali for KHN) [Editor’s note. If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline kamagra oral jelly thailand price at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting TALK to 741741. In Colorado, you can also contact Colorado Crisis Services at 1-844-493-TALK (8255) or text TALK to 38255.] Related Topics Contact Us Submit a Story TipStart Preamble Department of Veterans Affairs. Announcement for Public Meetings.

The Department of Veterans Affairs (VA) will be holding two public virtual listening sessions to seek kamagra oral jelly thailand price input on implementing the requirements of section 201 of the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019. The Act mandates VA to establish the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP) to reduce Veteran suicide through a 3-year community-based grant program that would provide financial Start Printed Page 25939assistance to eligible entities to provide or coordinate providing suicide prevention services to eligible Veterans and their families. VA is required to consult with certain entities related to administering this new grant program. VA previously published a request for information on April 1, 2021, seeking written comments from these entities to kamagra oral jelly thailand price help inform VA's development of the SSG Fox SPGP and its implementing regulations. These public virtual listening sessions serve as additional means for VA to consult with these same entities.

VA will hold the first public virtual listening session on May 25, 2021, and the second public virtual listening session on May 26, 2021. Each meeting will start at 10:00 a.m kamagra oral jelly thailand price. And conclude on or before 5:00 p.m. Eastern Standard Time (EST). There will kamagra oral jelly thailand price be limited space for participants to speak at the public virtual listening sessions.

To accommodate as many speakers as possible, participants will have no more than 20 minutes to provide oral comments, testimonies and/or technical remarks. More concise contributions are also welcome. The exact time allotted will kamagra oral jelly thailand price vary based on the number of participants registered and selected to speak. The sessions will be held virtually as a WebEx Event, and it will be open to the public to listen. Information about the meeting and registration to speak or listen can be obtained by emailing VASSGFoxGrants@va.gov.

Virtual attendance will kamagra oral jelly thailand price be limited to 1,000 registrants. Advanced registration for individuals and groups is strongly encouraged (see registration instructions below). Individuals or groups who seek to speak must pre-register by May 19, 2021, at 4:00 p.m. EST. Speakers must virtually check-in between 9:00 a.m.

And 9:45 a.m. EST to test their WebEx access and resolve any platform issues. Start Further Info Juliana Hallows, Associate Director for Policy and Planning—Suicide Prevention Program, Office of Mental Health and Suicide Prevention (OMHSP), 11MHSP, 810 Vermont Avenue NW, Washington, DC 20420, 202-266-4653. (This is not a toll-free telephone number.) End Further Info End Preamble Start Supplemental Information Background Section 201 of the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 (the Act), Public Law 116-171, enacted on October 17, 2020, requires VA to create a new community-based suicide prevention grant program to reduce Veteran suicide. Section 201 authorizes the award of grants for no more than $750,000 per grantee per fiscal year to eligible entities to provide or coordinate providing suicide prevention services to eligible individuals and their families.

An eligible individual is a person at risk of suicide who is a Veteran as defined in 38 U.S.C. 101, an individual described in 38 U.S.C. 1720I(b) or an individual described in 38 U.S.C. 1712A(a)(1)(C)(i)-(iv). Consultation With Interested Parties In administering the SSG Fox SPGP, VA is required to consult with certain entities to.

1. Establish the criteria for selecting eligible entities that have submitted applications. 2. Develop a framework for collecting and sharing information about eligible entities receiving grants. And 3.

Develop the measures and metrics eligible entities receiving grants will use to determine the effectiveness of programming provided to improve mental health status, well-being and reduce suicide risk and deaths by suicide. VA is also required to consult with entities in developing a plan for the design and implementing the provision of grants, including criteria for awarding such grants, and on non-traditional and innovative approaches and treatment practices. The Act requires VA to specifically consult with the following entities. (1) Veterans Service Organizations. (2) National organizations representing potential community partners in providing supportive services to address the needs of Veterans and their families, including national organizations that advocate for the needs of individuals with or at risk of behavioral health conditions as well as national organizations representing mayors, unions, first responders, chiefs of police and sheriffs, governors, a territory of the United States or representing a Tribal alliance.

(3) National organizations representing members of the Armed Forces. (4) National organizations representing counties. (5) Organizations with which VA has a current memorandum of agreement or understanding related to mental health or suicide prevention. (6) State Departments of Veterans Affairs. (7) National organizations representing members of the Reserve Components of the Armed Forces.

(8) National organizations representing members of the Coast Guard. (9) Organizations, including institutions of higher education, with experience in creating measurement tools for purposes of advising the Secretary on the most appropriate existing measurement tool or protocol for VA to utilize. (10) The National Alliance on Mental Illness. (11) a labor organization (as such term is defined in 5 U.S.C. 7103(a)(4)).

(12) The Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration and PREVENTS. And (13) Such other organizations as the Secretary deems appropriate. On April 1, 2021, VA published a request for information in the Federal Register seeking input from these groups and entities. See 86 FR 17268. These public virtual listening sessions serve as an additional means for VA to consult with these entities.

Responses will be used to inform development of the SSG Fox SPGP and its implementing regulations. Oral comment, testimonies and technical remarks are encouraged to be concise and directed toward specific virtual public listening session topics. Please note that VA will not respond to comments or other questions regarding policy plans, decisions or issues regarding this notice. Comments received in response to this notice will be evaluated and, as appropriate, incorporated into a proposed rulemaking for grants under this law. Registration Individual registration.

VA encourages individual registrations for those not affiliated with or representing a group, association or organization. Group registration. Identification of the name of the group, association or organization should be indicated in your registration request. Due to virtual platform meeting limitations of WebEx and the statutory mandate that VA consult with certain entities, VA may select certain entities to speak or may limit the size of a group's registration to allow receipt of testimonies and/or technical remarks from a broad, diverse group of stakeholders. Oral comments, testimonies and/or technical remarks may be limited from a group, association or organization to no more than two (2) individuals representing the same group, association or organization.

Efforts will be made to accommodate all attendees who wish to participate. However, VA will give priority to representatives of the stakeholders enumerated in the statute who request registration before May 19, 2021, 4:00 p.m. EST, and wish to provide oral comments, testimonies and/or technical remarks. The length of time allotted for participants to provide oral comments, testimonies and/or technical remarks during the meeting will be no more than 20 minutes and is Start Printed Page 25940subject to the total number of participants speaking, to ensure time is allotted to selected registered speakers. There will be no opportunity for audio-visual presentations during the meeting.

Audio (For listening purposes only). Limited to the first 200 participants, on a first-come, first-served basis. Advanced registration is not required. Audio attendees will not be allowed to offer oral comments, testimonies and/or technical remarks as the phone line will be muted. Note.

Should it be necessary to cancel the meeting due to technical issues or other emergencies, VA will take available measures to notify registered participants. VA will conduct the public meeting informally, and technical rules of evidence will not apply. VA will arrange for a written transcript of the meeting and keep the official record open for 15 days after the meeting to allow submission of supplemental information. You may make arrangements for copies of the transcript directly with the reporter, and the transcript will also be posted in the docket of the rule as part of the official record when the rule is published. Each listening session will focus on specific virtual public listening session topics described in this notice and specified in the following Agenda.

Listening Session 1 Virtual Public Listening Session 1 Topics (May 25, 2021) A. Distribution and Selection of Grants B. Administration of Grant Program C. Training and Technical Assistance Agenda 09:00-10:00 Speaker Virtual Check-In 10:00-12:00 Morning Public Meeting Session 12:00-13:00 Break 13:00-17:00 Afternoon Public Meeting Session 17:00 Adjourn Listening Session 2 Virtual Public Listening Session 2 Topics (May 26, 2021) D. Referral for Care E.

Risk of Suicide F. Suicide Prevention Services Agenda 09:00-10:00 Arrival/Check-In 10:00-12:00 Morning Public Meeting Session 12:00-13:00 Break 13:00-17:00 Afternoon Public Meeting Session 17:00 Adjourn Virtual Public Listening Session Topics To design and implement the SSG Fox SPGP consistent with, and pursuant to, section 201 of the Act, the Secretary seeks information on the topics and issues listed below. Commenters do not need to address every question and should focus on those that relate to their expertise or perspectives. To the extent possible, please clearly indicate which topics and issues you address in your response. Virtual Public Listening Session 1.

May 25, 2021 A. Distribution and Selection of Grants (Section 201(d)(h)(1) of the Act) 1. What criteria should VA establish for the selection of eligible entities that have submitted applications under the SSG Fox SPGP?. 2. Pursuant to the Act, the Secretary shall give preference to eligible entities that have demonstrated the ability to provide or coordinate suicide prevention services.

How should VA weigh evidence of demonstrated ability to provide or coordinate suicide prevention services, in giving preference to eligible entities that have demonstrated such ability?. B. Administration of Grant Program. Development of Measures and Metrics (Section 201(h)(2) of the Act) 1. How should VA collect and share information about entities in receipt of grants under the SSG Fox SPGP?.

2. How can shared information about entities be used to improve the provision or coordination of suicide prevention services for eligible individuals and families?. 3. What measures and metrics should eligible entities, who are in receipt of grants under the SSG Fox SPGP, use to determine the effectiveness of the programs they are providing?. 4.

What existing measurements, tool or protocols are available to determine program effectiveness?. Which of these should be used for purposes of measuring effectiveness of programs provided through this grant program?. C. Training and Technical Assistance (Section 201(g) of the Act) Section 201(g) of the Act provides that the Secretary, in coordination with CDC, shall provide training and technical assistance to grant recipients. The required training and technical assistance will cover suicide risk identification and management, data required to be collected and shared with VA, the means of data collection and sharing, use of tools to be used to measure the effectiveness of the grants and the reporting requirements.

The Secretary may provide the training and technical assistance directly or through grants or contracts with appropriate public or nonprofit entities. 1. What training and technical assistance programs and tools currently exist for the specified subject areas described above that could be utilized by VA?. 2. What data collection tools and training currently exist for the specified subject areas that could be utilized by VA?.

3. What tools and training currently exist for measuring the effectiveness of grants that could be utilized by VA?. 4. What tools and training currently exist for managing reporting requirements that could be utilized by VA?. 5.

Should VA provide training and/or technical assistance directly, through grants or contracts with appropriate public or nonprofit entities, or a combination of both?. Virtual Public Listening Session 2. May 26, 2021 D. Referral for Care (Section 201(m) of the Act) Section 201(m) of the Act provides that if an eligible entity in receipt of a grant under the SSG Fox SPGP determines that an eligible individual is at risk of suicide or other mental or behavioral health condition pursuant to a baseline mental health screening conducted under subsection (q)(11)(A)(ii) of the Act with respect to the individual, the entity shall refer the eligible individual to VA for additional care under subsection (n) of the Act or any other provision of law. Section 201(m) of the Act also provides that if an eligible entity in receipt of a grant under the SSG Fox SPGP determines that an eligible individual furnished clinical services for emergency treatment under subsection (q)(11)(A)(iv) of the Act requires ongoing services, the entity shall refer the eligible individual to VA for additional care under subsection (n) of the Act or any other provision of law.

1. When an eligible entity in receipt of a grant under the SSG Fox SPGP determines that an eligible individual is at risk of suicide or other mental or behavioral health condition pursuant to a qualifying baseline mental health screening, by what mechanism should the eligible entity refer the eligible individual to VA for additional care?. 2. When an eligible entity in receipt of a grant under the SSG Fox SPGP determines that an eligible individual furnished clinical services for Start Printed Page 25941emergency treatment requires ongoing services, by what mechanism should the eligible entity refer the eligible individual to VA for additional care?. 3.

How should referrals to VA for additional care be tracked and reported by eligible entities?.

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SALT LAKE CITY, the kamagra store May 06, 2021 (GLOBE NEWSWIRE) -- sites Health Catalyst, Inc. ("Health Catalyst," Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today reported financial results for the quarter ended March 31, 2021. €œIn the first quarter of 2021, I am pleased the kamagra store to share that we achieved strong performance across our business, including exceeding the mid-point of our quarterly guidance for both revenue and Adjusted EBITDA,” said Dan Burton, CEO of Health Catalyst. €œI am also happy to report that in the most recent team member engagement and satisfaction survey, independently administered by the Gallup organization, team member satisfaction scores at Health Catalyst measured in the 96th percentile.

This latest engagement level continues a pattern that has been in place for many years, of industry-leading engagement, consistently ranked between the 95th and 99th percentile in overall team member satisfaction scores. This latest result is of particular significance given that the kamagra store it comes during a period where we were required to adapt to global kamagra necessitating a remote-only work environment, as well as having welcomed nearly two hundred new teammates who came to us primarily through multiple recent acquisitions.” Financial Highlights for the Three Months Ended March 31, 2021 Key Financial Metrics Three Months Ended March 31, Year over Year Change 2021 2020 GAAP Financial Data:(in thousands, except percentages, unaudited)Technology revenue$33,839 $24,699 37%Professional services revenue$22,007 $20,417 8%Total revenue$55,846 $45,116 24%Loss from operations$(24,317) $(18,105) (34)%Net loss$(28,370) $(17,490) (62)%Other Non-GAAP Financial Data:(1) Adjusted Technology Gross Profit$23,388 $16,969 38%Adjusted Technology Gross Margin69% 69% Adjusted Professional Services Gross Profit$6,929 $5,071 37%Adjusted Professional Services Gross Margin31% 25% Total Adjusted Gross Profit$30,317 $22,040 38%Total Adjusted Gross Margin54% 49% Adjusted EBITDA$(837) $(5,971) 86%________________________(1) These measures are not calculated in accordance with generally accepted accounting principles in the United States (GAAP). See the accompanying "Non-GAAP Financial Measures" section below for more information about these financial measures, including the limitations of such measures, and for a reconciliation of each measure to the most directly comparable measure calculated in accordance with GAAP. Financial Outlook Health Catalyst provides forward-looking guidance on total revenue, a GAAP measure, and Adjusted EBITDA, a non-GAAP measure. For the second the kamagra store quarter of 2021, we expect.

Total revenue between $55.1 million and $58.1 million, andAdjusted EBITDA between $(4.8) million and $(2.8) millionFor the full year of 2021, we expect. Total revenue between $228.1 million and $231.1 million, andAdjusted EBITDA between $(15.0) million and $(13.0) millionWe have not reconciled guidance for Adjusted EBITDA to net loss, the most directly comparable GAAP measure, and have not provided forward-looking guidance for net loss, because there are items that may impact net loss, including stock-based compensation, that are not within our control or cannot be reasonably predicted. Chair of the Board Transition On April the kamagra store 29, 2021, our board of directors (the board) accepted Dr. Tim Ferris's resignation from the board and all board committees, effective May 1, 2021. Dr.

Ferris's resignation is not the result of any disagreement with Health Catalyst, but rather as a result of the kamagra store his new role as the National Director of Transformation for England's National Health Service (NHS). NHS required Dr. Ferris to resign from our board in connection with his NHS appointment. €œDr. Ferris provided a unique perspective that will continue to impact our company for years to come.

We are grateful for the opportunity to have benefited from his wisdom and experience, and we congratulate him on his new role as National Director of Transformation at NHS,” said Dan Burton, CEO. Health Catalyst is thrilled to announce that John A. (Jack) Kane has accepted the invitation to serve as chair of the board effective May 1, 2021. Mr. Kane has been a director of the Company and has been the chair of the audit committee of the board since February 2016.

Mr. Kane has more than 30 years’ experience in healthcare technology, including as a director and chairperson of the audit committee of Merchants Bancshares, Inc. (MBVT) from 2005 until 2014 and athenahealth, Inc. From 2007 until February 2019. He previously occupied the position of CFO, Treasurer &.

Senior VP-Administration at IDX Systems Corp. €œJack has served on our board for many years. His valuable guidance and feedback often challenges us to think deeply about our solutions. I am grateful for Jack’s dedication to our mission and his depth of financial leadership experience in healthcare and technology, which make him uniquely qualified to serve as our chair,” said Burton. Quarterly Conference Call Details The company will host a conference call to review the results today, Thursday, May 6, 2021, at 5:00 p.m.

E.T. The conference call can be accessed by dialing 1-877-295-1104 for U.S. Participants, or 1-470-495-9486 for international participants, and referencing participant code 9183315. A live audio webcast will be available online at https://ir.healthcatalyst.com/. A replay of the call will be available via webcast for on-demand listening shortly after the completion of the call, at the same web link, and will remain available for approximately 90 days.

About Health Catalyst Health Catalyst is a leading provider of data and analytics technology and services to healthcare organizations 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 all healthcare decisions are data informed. Available Information Health Catalyst intends to use its Investor Relations website as a means of disclosing material non-public information and for complying with its disclosure obligations under Regulation FD. Forward-Looking Statements This release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended, and the Private Securities Litigation Reform Act of 1995, as amended.

These forward-looking statements include statements regarding our future growth and our financial outlook for Q2 and fiscal year 2021. Forward-looking statements are subject to risks and uncertainties and are based on potentially inaccurate assumptions that could cause actual results to differ materially from those expected or implied by the forward-looking statements. Actual results may differ materially from the results predicted, and reported results should not be considered as an indication of future performance. Important risks and uncertainties that could cause our actual results and financial condition to differ materially from those indicated in the forward-looking statements include, among others, the following. (i) changes in laws and regulations applicable to our business model.

(ii) changes in market or industry conditions, regulatory environment and receptivity to our technology and services. (iii) results of litigation or a security incident. (iv) the loss of one or more key customers or partners. (v) the impact of erectile dysfunction treatment on our business and results of operations. And (vi) changes to our abilities to recruit and retain qualified team members.

For a detailed discussion of the risk factors that could affect our actual results, please refer to the risk factors identified in our SEC reports, including, but not limited to the Annual Report on Form 10-K for the year ended December 31, 2020 filed with the SEC on or about February 25, 2021 buy kamagra gold and the Quarterly Report on Form 10-Q for the fiscal quarter ended March 31, 2021 expected to be filed with the SEC on or about May 7, 2021. All information provided in this release and in the attachments is as of the date hereof, and we undertake no duty to update or revise this information unless required by law. Condensed Consolidated Balance Sheets(in thousands, except share and per share data, unaudited) As ofMarch 31, As ofDecember 31, 2021 2020Assets Current assets. Cash and cash equivalents$132,627 $91,954 Short-term investments133,807 178,917 Accounts receivable, net45,905 48,296 Prepaid expenses and other assets12,404 10,632 Total current assets324,743 329,799 Property and equipment, net18,653 12,863 Intangible assets, net91,840 98,921 Operating lease right-of-use assets24,093 24,729 Goodwill107,822 107,822 Other assets4,068 3,606 Total assets$571,219 $577,740 Liabilities and stockholders’ equity Current liabilities. Accounts payable$4,626 $5,332 Accrued liabilities12,946 16,510 Acquisition-related consideration payable— 2,000 Deferred revenue51,634 47,145 Operating lease liabilities2,454 2,622 Contingent consideration liabilities15,902 14,427 Convertible senior notes, net171,864 — Total current liabilities259,426 88,036 Convertible senior notes, net of current portion— 168,994 Deferred revenue, net of current portion1,135 1,878 Operating lease liabilities, net of current portion23,083 23,669 Contingent consideration liabilities, net of current portion16,509 16837 Other liabilities2,230 2227 Total liabilities302,383 301,641 Commitments and contingencies Stockholders’ equity.

Common stock, $0.001 par value. 44,340,036 and 43,376,848 shares issued and outstanding as of March 31, 2021 and December 31, 2020, respectively44 43 Additional paid-in capital1,022,781 1,001,645 Accumulated deficit(754,020) (725,650)Accumulated other comprehensive income31 61 Total stockholders' equity268,836 276,099 Total liabilities and stockholders’ equity$571,219 $577,740 Condensed Consolidated Statements of Operations(in thousands, except per share data, unaudited) Three Months EndedMarch 31, 2021 2020Revenue. Technology$33,839 $24,699 Professional services22,007 20,417 Total revenue55,846 45,116 Cost of revenue, excluding depreciation and amortization. Technology(1)10,825 7,906 Professional services(1)16,513 16,162 Total cost of revenue, excluding depreciation and amortization27,338 24,068 Operating expenses. Sales and marketing(1)15,651 13,487 Research and development(1)14,345 13,088 General and administrative(1)(2)(3)15,015 9,701 Depreciation and amortization7,814 2,877 Total operating expenses52,825 39,153 Loss from operations(24,317) (18,105)Interest and other expense, net(3,952) (621)Loss before income taxes(28,269) (18,726)Income tax provision (benefit)101 (1,236)Net loss$(28,370) $(17,490)Net loss per share, basic and diluted$(0.65) $(0.47)Weighted-average shares outstanding used in calculating net loss per share, basic and diluted43,870 37,109 Adjusted net loss(4)$(2,753) $(6,083)Adjusted net loss per share, basic and diluted(4)$(0.06) $(0.16) _______________(1) Includes stock-based compensation expense as follows.

Three Months EndedMarch 31, 2021 2020 Stock-Based Compensation Expense:(in thousands)Cost of revenue, excluding depreciation and amortization. Technology$374 $176 Professional services1,435 816 Sales and marketing4,818 3,182 Research and development2,257 1,882 General and administrative4,626 2,685 Total$13,510 $8,741 (2) Includes acquisition transaction costs as follows. Three Months EndedMarch 31, 2021 2020 Acquisition transaction costs:(in thousands)General and administrative$— $875 (3) Includes the change in fair value of contingent consideration liabilities, as follows. Three Months EndedMarch 31, 2021 2020 Change in fair value of contingent consideration liabilities:(in thousands)General and administrative$2,156 $(359)(4) Includes non-GAAP adjustments to net loss. Refer to the "Non-GAAP Financial Measures—Adjusted Net Loss Per Share" section below for further details.

Condensed Consolidated Statements of Cash Flows(in thousands, unaudited) Three Months Ended March 31,Cash flows from operating activities2021 2020Net loss$(28,370) $(17,490)Adjustments to reconcile net loss to net cash used in operating activities. Depreciation and amortization7,814 2,877 Amortization of debt discount and issuance costs2,870 285 Non-cash operating lease expense965 741 Investment discount and premium amortization417 (6)Provision for expected credit losses300 51 Stock-based compensation expense13,510 8,741 Deferred tax (benefit) provision2 (1,280)Change in fair value of contingent consideration liabilities2,156 (359)Other(34) (4)Change in operating assets and liabilities. Accounts receivable, net2,090 (7,335)Deferred costs— 444 Prepaid expenses and other assets(2,173) (2,244)Accounts payable, accrued liabilities, and other liabilities(5,352) (4,283)Deferred revenue3,745 3,936 Operating lease liabilities(1,083) (843)Net cash used in operating activities(3,143) (16,769) Cash flows from investing activities Purchase of short-term investments(8,621) — Proceeds from the sale and maturity of short-term investments53,240 66,653 Acquisition of businesses, net of cash acquired— (15,249)Purchase of property and equipment(5,882) (428)Capitalization of internal use software(887) (78)Purchase of intangible assets(480) (758)Proceeds from sale of property and equipment6 6 Net cash provided by investing activities37,376 50,146 Cash flows from financing activities Proceeds from exercise of stock options6,488 9,046 Proceeds from employee stock purchase plan1,349 1,289 Payments of acquisition-related consideration(1,391) (748)Net cash provided by financing activities6,446 9,587 Effect of exchange rate on cash and cash equivalents(6) (31)Net increase in cash and cash equivalents40,673 42,933 Cash and cash equivalents at beginning of period91,954 18,032 Cash and cash equivalents at end of period$132,627 $60,965 Non-GAAP Financial Measures To supplement our financial information presented in accordance with GAAP, we believe certain non-GAAP measures, including Adjusted Gross Profit, Adjusted Gross Margin, Adjusted EBITDA, Adjusted Net Loss, and Adjusted Net Loss per share, basic and diluted, are useful in evaluating our operating performance. For example, we exclude stock-based compensation expense because it is non-cash in nature and excluding this expense provides meaningful supplemental information regarding our operational performance and allows investors the ability to make more meaningful comparisons between our operating results and those of other companies. We use this non-GAAP financial information to evaluate our ongoing operations, as a component in determining employee bonus compensation, and for internal planning and forecasting purposes.

We believe that non-GAAP financial information, when taken collectively, may be helpful to investors because it provides consistency and comparability with past financial performance. However, non-GAAP financial information is presented for supplemental informational purposes only, has limitations as an analytical tool and should not be considered in isolation or as a substitute for financial information presented in accordance with GAAP. In addition, other companies, including companies in our industry, may calculate similarly-titled non-GAAP measures differently or may use other measures to evaluate their performance. A reconciliation is provided below for each non-GAAP financial measure to the most directly comparable financial measure stated in accordance with GAAP. Investors are encouraged to review the related GAAP financial measures and the reconciliation of these non-GAAP financial measures to their most directly comparable GAAP financial measures, and not to rely on any single financial measure to evaluate our business.

Adjusted Gross Profit and Adjusted Gross Margin Adjusted Gross Profit is a non-GAAP financial measure that we define as revenue less cost of revenue, excluding depreciation and amortization and excluding stock-based compensation. We define Adjusted Gross Margin as our Adjusted Gross Profit divided by our revenue. We believe Adjusted Gross Profit and Adjusted Gross Margin are useful to investors as they eliminate the impact of certain non-cash expenses and allow a direct comparison of these measures between periods without the impact of non-cash expenses and certain other non-recurring operating expenses. The following is a reconciliation of revenue, the most directly comparable GAAP financial measure, to Adjusted Gross Profit, for the three months ended March 31, 2021 and 2020. Three Months Ended March 31, 2021 (in thousands, except percentages) Technology Professional Services TotalRevenue$33,839 $22,007 $55,846 Cost of revenue, excluding depreciation and amortization(10,825) (16,513) (27,338)Gross profit, excluding depreciation and amortization23,014 5,494 28,508 Add.

Stock-based compensation374 1,435 1,809 Adjusted Gross Profit$23,388 $6,929 $30,317 Gross margin, excluding depreciation and amortization68% 25% 51%Adjusted Gross Margin69% 31% 54% Three Months Ended March 31, 2020 (in thousands, except percentages) Technology Professional Services TotalRevenue$24,699 $20,417 $45,116 Cost of revenue, excluding depreciation and amortization(7,906) (16,162) (24,068)Gross profit, excluding depreciation and amortization16,793 4,255 21,048 Add. Stock-based compensation176 816 992 Adjusted Gross Profit$16,969 $5,071 $22,040 Gross margin, excluding depreciation and amortization68% 21% 47%Adjusted Gross Margin69% 25% 49% Adjusted EBITDA Adjusted EBITDA is a non-GAAP financial measure that we define as net loss adjusted for (i) interest and other expense, net, (ii) income tax (benefit) provision, (iii) depreciation and amortization, (iv) stock-based compensation, (v) acquisition transaction costs, and (vi) change in fair value of contingent consideration liabilities when they are incurred. We view acquisition-related expenses when applicable, such as transaction costs and changes in the fair value of contingent consideration liabilities that are directly related to business combinations as events that are not necessarily reflective of operational performance during a period. We believe Adjusted EBITDA provides investors with useful information on period-to-period performance as evaluated by management and comparison with our past financial performance and is useful in evaluating our operating performance compared to that of other companies in our industry, as this metric generally eliminates the effects of certain items that may vary from company to company for reasons unrelated to overall operating performance. The following is a reconciliation of our net loss, the most directly comparable GAAP financial measure, to Adjusted EBITDA, for the three months ended March 31, 2021 and 2020.

Three Months EndedMarch 31, 2021 2020 (in thousands)Net loss$(28,370) $(17,490)Add. Interest and other expense, net3,952 621 Income tax (benefit) provision101 (1,236)Depreciation and amortization7,814 2,877 Stock-based compensation13,510 8,741 Acquisition transaction costs— 875 Change in fair value of contingent consideration liabilities2,156 (359)Adjusted EBITDA$(837) $(5,971) Adjusted Net Loss Per Share Adjusted Net Loss is a non-GAAP financial measure that we define as net loss attributable to common stockholders adjusted for (i) stock-based compensation, (ii) amortization of acquired intangibles, (iii) acquisition transaction costs, (iv) change in fair value of contingent consideration liabilities, and (v) non-cash interest expense related to our convertible senior notes. We believe Adjusted Net Loss provides investors with useful information on period-to-period performance as evaluated by management and comparison with our past financial performance and is useful in evaluating our operating performance compared to that of other companies in our industry, as this metric generally eliminates the effects of certain items that may vary from company to company for reasons unrelated to overall operating performance. Three Months Ended March 31, 2021 2020 Numerator:(in thousands, except share and per share amounts)Net loss attributable to common stockholders$(28,370) $(17,490)Add. Stock-based compensation13,510 8,741 Amortization of acquired intangibles7,081 2,150 Acquisition transaction costs— 875 Change in fair value of contingent consideration liabilities2,156 (359)Non-cash interest expense related to convertible senior notes2,870 — Adjusted Net Loss$(2,753) $(6,083)Denominator.

Weighted-average number of shares used in calculating net loss, basic and diluted43,870,288 37,108,998 Adjusted net loss per share, basic and diluted$(0.06) $(0.16) Health Catalyst Investor Relations Contact:Adam BrownSenior Vice President, Investor Relations and FP&A+1 (855)-309-6800ir@healthcatalyst.com Health Catalyst Media Contact:Amanda HundtVice President, Corporate Communicationsamanda.hundt@healthcatalyst.com+1 (575) 491-0974SALT LAKE CITY, April 20, 2021 (GLOBE NEWSWIRE) -- Health Catalyst, Inc. ("Health Catalyst", Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, will release its 2021 first quarter operating results on Thursday, May 6, 2021, after market close. In conjunction, the company will host a conference call to review the results at 5 p.m. E.T.

On the same day. Conference Call Details The conference call can be accessed by dialing 1-877-295-1104 for U.S. Participants, or 1-470-495-9486 for international participants, and referencing participant code 9183315. A live audio webcast will be available online at https://ir.healthcatalyst.com/. A replay of the call will be available via webcast for on-demand listening shortly after the completion of the call, at the same web link, and will remain available for approximately 90 days.

About Health Catalyst Health Catalyst is a leading provider of data and analytics technology and services to healthcare organizations 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 all healthcare decisions are data informed. Health Catalyst Investor Relations Contact. Adam BrownSenior Vice President, Investor Relations and FP&A+1 (855)-309-6800ir@healthcatalyst.com Health Catalyst Media Contact:Amanda Hundt+1 (575)-491-0974amanda.hundt@healthcatalyst.com.

SALT LAKE CITY, May 06, 2021 http://neocapital.com.ec/?p=1 (GLOBE NEWSWIRE) kamagra oral jelly thailand price -- Health Catalyst, Inc. ("Health Catalyst," Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today reported financial results for the quarter ended March 31, 2021. €œIn the first quarter of 2021, I am pleased to share that we achieved strong performance across our business, kamagra oral jelly thailand price including exceeding the mid-point of our quarterly guidance for both revenue and Adjusted EBITDA,” said Dan Burton, CEO of Health Catalyst.

€œI am also happy to report that in the most recent team member engagement and satisfaction survey, independently administered by the Gallup organization, team member satisfaction scores at Health Catalyst measured in the 96th percentile. This latest engagement level continues a pattern that has been in place for many years, of industry-leading engagement, consistently ranked between the 95th and 99th percentile in overall team member satisfaction scores. This latest result is of particular significance given that it comes during a period where we were required to adapt to global kamagra necessitating a remote-only work environment, as well as having welcomed nearly two hundred new teammates who came to us primarily through multiple recent acquisitions.” Financial Highlights for the Three Months Ended March 31, 2021 Key Financial kamagra oral jelly thailand price Metrics Three Months Ended March 31, Year over Year Change 2021 2020 GAAP Financial Data:(in thousands, except percentages, unaudited)Technology revenue$33,839 $24,699 37%Professional services revenue$22,007 $20,417 8%Total revenue$55,846 $45,116 24%Loss from operations$(24,317) $(18,105) (34)%Net loss$(28,370) $(17,490) (62)%Other Non-GAAP Financial Data:(1) Adjusted Technology Gross Profit$23,388 $16,969 38%Adjusted Technology Gross Margin69% 69% Adjusted Professional Services Gross Profit$6,929 $5,071 37%Adjusted Professional Services Gross Margin31% 25% Total Adjusted Gross Profit$30,317 $22,040 38%Total Adjusted Gross Margin54% 49% Adjusted EBITDA$(837) $(5,971) 86%________________________(1) These measures are not calculated in accordance with generally accepted accounting principles in the United States (GAAP). See the accompanying "Non-GAAP Financial Measures" section below for more information about these financial measures, including the limitations of such measures, and for a reconciliation of each measure to the most directly comparable measure calculated in accordance with GAAP.

Financial Outlook Health Catalyst provides forward-looking guidance on total revenue, a GAAP measure, and Adjusted EBITDA, a non-GAAP measure. For the second quarter of 2021, we kamagra oral jelly thailand price expect. Total revenue between $55.1 million and $58.1 million, andAdjusted EBITDA between $(4.8) million and $(2.8) millionFor the full year of 2021, we expect. Total revenue between $228.1 million and $231.1 million, andAdjusted EBITDA between $(15.0) million and $(13.0) millionWe have not reconciled guidance for Adjusted EBITDA to net loss, the most directly comparable GAAP measure, and have not provided forward-looking guidance for net loss, because there are items that may impact net loss, including stock-based compensation, that are not within our control or cannot be reasonably predicted.

Chair of kamagra oral jelly thailand price the Board Transition On April 29, 2021, our board of directors (the board) accepted Dr. Tim Ferris's resignation from the board and all board committees, effective May 1, 2021. Dr. Ferris's resignation is not the result of any disagreement with Health Catalyst, but rather as a result of his new role as the National Director of Transformation for England's National Health kamagra oral jelly thailand price Service (NHS).

NHS required Dr. Ferris to resign from our board in connection with his NHS appointment. €œDr. Ferris provided a unique perspective that will continue to impact our company for years to come.

We are grateful for the opportunity to have benefited from his wisdom and experience, and we congratulate him on his new role as National Director of Transformation at NHS,” said Dan Burton, CEO. Health Catalyst is thrilled to announce that John A. (Jack) Kane has accepted the invitation to serve as chair of the board effective May 1, 2021. Mr.

Kane has been a director of the Company and has been the chair of the audit committee of the board since February 2016. Mr. Kane has more than 30 years’ experience in healthcare technology, including as a director and chairperson of the audit committee of Merchants Bancshares, Inc. (MBVT) from 2005 until 2014 and athenahealth, Inc.

From 2007 until February 2019. He previously occupied the position of CFO, Treasurer &. Senior VP-Administration at IDX Systems Corp. €œJack has served on our board for many years.

His valuable guidance and feedback often challenges us to think deeply about our solutions. I am grateful for Jack’s dedication to our mission and his depth of financial leadership experience in healthcare and technology, which make him uniquely qualified to serve as our chair,” said Burton. Quarterly Conference Call Details The company will host a conference call to review the results today, Thursday, May 6, 2021, at 5:00 p.m. E.T.

The conference call can be accessed by dialing 1-877-295-1104 for U.S. Participants, or 1-470-495-9486 for international participants, and referencing participant code 9183315. A live audio webcast will be available online at https://ir.healthcatalyst.com/. A replay of the call will be available via webcast for on-demand listening shortly after the completion of the call, at the same web link, and will remain available for approximately 90 days.

About Health Catalyst Health Catalyst is a leading provider of data and analytics technology and services to healthcare organizations 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 all healthcare decisions are data informed. Available Information Health Catalyst intends to use its Investor Relations website as a means of disclosing material non-public information and for complying with its disclosure obligations under Regulation FD.

Forward-Looking Statements This release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended, and the Private Securities Litigation Reform Act of 1995, as amended. These forward-looking statements include statements regarding our future growth and our financial outlook for Q2 and fiscal year 2021. Forward-looking statements are subject to risks and uncertainties and are based on potentially inaccurate assumptions that could cause actual results to differ materially from those expected or implied by the forward-looking statements. Actual results may differ materially from the results predicted, and reported results should not be considered as an indication of future performance.

Important risks and uncertainties that could cause our actual results and financial condition to differ materially from those indicated in the forward-looking statements include, among others, the following. (i) changes in laws and regulations applicable to our business model. (ii) changes in market or industry conditions, regulatory environment and receptivity to our technology and services. (iii) results of litigation or a security incident.

(iv) the loss of one or more key customers or partners. (v) the impact of erectile dysfunction treatment on our business and results of operations. And (vi) changes to our abilities to recruit and retain qualified team members. For a detailed discussion of the risk factors that could affect our actual results, please refer to the risk factors identified in our SEC reports, including, but not limited to the Annual Report on Form 10-K for the year ended December 31, 2020 filed with the SEC on or about February 25, 2021 and the Quarterly Report on Form 10-Q for the fiscal quarter ended March 31, 2021 expected to be filed with the SEC on or about May 7, 2021.

All information provided in this release and in the attachments is as of the date hereof, and we undertake no duty to update or revise this information unless required by law. Condensed Consolidated Balance Sheets(in thousands, except share and per share data, unaudited) As ofMarch 31, As ofDecember 31, 2021 2020Assets Current assets. Cash and cash equivalents$132,627 $91,954 Short-term investments133,807 178,917 Accounts receivable, net45,905 48,296 Prepaid expenses and other assets12,404 10,632 Total current assets324,743 329,799 Property and equipment, net18,653 12,863 Intangible assets, net91,840 98,921 Operating lease right-of-use assets24,093 24,729 Goodwill107,822 107,822 Other assets4,068 3,606 Total assets$571,219 $577,740 Liabilities and stockholders’ equity Current liabilities. Accounts payable$4,626 $5,332 Accrued liabilities12,946 16,510 Acquisition-related consideration payable— 2,000 Deferred revenue51,634 47,145 Operating lease liabilities2,454 2,622 Contingent consideration liabilities15,902 14,427 Convertible senior notes, net171,864 — Total current liabilities259,426 88,036 Convertible senior notes, net of current portion— 168,994 Deferred revenue, net of current portion1,135 1,878 Operating lease liabilities, net of current portion23,083 23,669 Contingent consideration liabilities, net of current portion16,509 16837 Other liabilities2,230 2227 Total liabilities302,383 301,641 Commitments and contingencies Stockholders’ equity.

Common stock, $0.001 par value. 44,340,036 and 43,376,848 shares issued and outstanding as of March 31, 2021 and December 31, 2020, respectively44 43 Additional paid-in capital1,022,781 1,001,645 Accumulated deficit(754,020) (725,650)Accumulated other comprehensive income31 61 Total stockholders' equity268,836 276,099 Total liabilities and stockholders’ equity$571,219 $577,740 Condensed Consolidated Statements of Operations(in thousands, except per share data, unaudited) Three Months EndedMarch 31, 2021 2020Revenue. Technology$33,839 $24,699 Professional services22,007 20,417 Total revenue55,846 45,116 Cost of revenue, excluding depreciation and amortization. Technology(1)10,825 7,906 Professional services(1)16,513 16,162 Total cost of revenue, excluding depreciation and amortization27,338 24,068 Operating expenses.

Sales and marketing(1)15,651 13,487 Research and development(1)14,345 13,088 General and administrative(1)(2)(3)15,015 9,701 Depreciation and amortization7,814 2,877 Total operating expenses52,825 39,153 Loss from operations(24,317) (18,105)Interest and other expense, net(3,952) (621)Loss before income taxes(28,269) (18,726)Income tax provision (benefit)101 (1,236)Net loss$(28,370) $(17,490)Net loss per share, basic and diluted$(0.65) $(0.47)Weighted-average shares outstanding used in calculating net loss per share, basic and diluted43,870 37,109 Adjusted net loss(4)$(2,753) $(6,083)Adjusted net loss per share, basic and diluted(4)$(0.06) $(0.16) _______________(1) Includes stock-based compensation expense as follows. Three Months EndedMarch 31, 2021 2020 Stock-Based Compensation Expense:(in thousands)Cost of revenue, excluding depreciation and amortization. Technology$374 $176 Professional services1,435 816 Sales and marketing4,818 3,182 Research and development2,257 1,882 General and administrative4,626 2,685 Total$13,510 $8,741 (2) Includes acquisition transaction costs as follows. Three Months EndedMarch 31, 2021 2020 Acquisition transaction costs:(in thousands)General and administrative$— $875 (3) Includes the change in fair value of contingent consideration liabilities, as follows.

Three Months EndedMarch 31, 2021 2020 Change in fair value of contingent consideration liabilities:(in thousands)General and administrative$2,156 $(359)(4) Includes non-GAAP adjustments to net loss. Refer to the "Non-GAAP Financial Measures—Adjusted Net Loss Per Share" section below for further details. Condensed Consolidated Statements of Cash Flows(in thousands, unaudited) Three Months Ended March 31,Cash flows from operating activities2021 2020Net loss$(28,370) $(17,490)Adjustments to reconcile net loss to net cash used in operating activities. Depreciation and amortization7,814 2,877 Amortization of debt discount and issuance costs2,870 285 Non-cash operating lease expense965 741 Investment discount and premium amortization417 (6)Provision for expected credit losses300 51 Stock-based compensation expense13,510 8,741 Deferred tax (benefit) provision2 (1,280)Change in fair value of contingent consideration liabilities2,156 (359)Other(34) (4)Change in operating assets and liabilities.

Accounts receivable, net2,090 (7,335)Deferred costs— 444 Prepaid expenses and other assets(2,173) (2,244)Accounts payable, accrued liabilities, and other liabilities(5,352) (4,283)Deferred revenue3,745 3,936 Operating lease liabilities(1,083) (843)Net cash used in operating activities(3,143) (16,769) Cash flows from investing activities Purchase of short-term investments(8,621) — Proceeds from the sale and maturity of short-term investments53,240 66,653 Acquisition of businesses, net of cash acquired— (15,249)Purchase of property and equipment(5,882) (428)Capitalization of internal use software(887) (78)Purchase of intangible assets(480) (758)Proceeds from sale of property and equipment6 6 Net cash provided by investing activities37,376 50,146 Cash flows from financing activities Proceeds from exercise of stock options6,488 9,046 Proceeds from employee stock purchase plan1,349 1,289 Payments of acquisition-related consideration(1,391) (748)Net cash provided by financing activities6,446 9,587 Effect of exchange rate on cash and cash equivalents(6) (31)Net increase in cash and cash equivalents40,673 42,933 Cash and cash equivalents at beginning of period91,954 18,032 Cash and cash equivalents at end of period$132,627 $60,965 Non-GAAP Financial Measures To supplement our financial information presented in accordance with GAAP, we believe certain non-GAAP measures, including Adjusted Gross Profit, Adjusted Gross Margin, Adjusted EBITDA, Adjusted Net Loss, and Adjusted Net Loss per share, basic and diluted, are useful in evaluating our operating performance. For example, we exclude stock-based compensation expense because it is non-cash in nature and excluding this expense provides meaningful supplemental information regarding our operational performance and allows investors the ability to make more meaningful comparisons between our operating results and those of other companies. We use this non-GAAP financial information to evaluate our ongoing operations, as a component in determining employee bonus compensation, and for internal planning and forecasting purposes. We believe that non-GAAP financial information, when taken collectively, may be helpful to investors because it provides consistency and comparability with past financial performance.

However, non-GAAP financial information is presented for supplemental informational purposes only, has limitations as an analytical tool and should not be considered in isolation or as a substitute for financial information presented in accordance with GAAP. In addition, other companies, including companies in our industry, may calculate similarly-titled non-GAAP measures differently or may use other measures to evaluate their performance. A reconciliation is provided below for each non-GAAP financial measure to the most directly comparable financial measure stated in accordance with GAAP. Investors are encouraged to review the related GAAP financial measures and the reconciliation of these non-GAAP financial measures to their most directly comparable GAAP financial measures, and not to rely on any single financial measure to evaluate our business.

Adjusted Gross Profit and Adjusted Gross Margin Adjusted Gross Profit is a non-GAAP financial measure that we define as revenue less cost of revenue, excluding depreciation and amortization and excluding stock-based compensation. We define Adjusted Gross Margin as our Adjusted Gross Profit divided by our revenue. We believe Adjusted Gross Profit and Adjusted Gross Margin are useful to investors as they eliminate the impact of certain non-cash expenses and allow a direct comparison of these measures between periods without the impact of non-cash expenses and certain other non-recurring operating expenses. The following is a reconciliation of revenue, the most directly comparable GAAP financial measure, to Adjusted Gross Profit, for the three months ended March 31, 2021 and 2020.

Three Months Ended March 31, 2021 (in thousands, except percentages) Technology Professional Services TotalRevenue$33,839 $22,007 $55,846 Cost of revenue, excluding depreciation and amortization(10,825) (16,513) (27,338)Gross profit, excluding depreciation and amortization23,014 5,494 28,508 Add. Stock-based compensation374 1,435 1,809 Adjusted Gross Profit$23,388 $6,929 $30,317 Gross margin, excluding depreciation and amortization68% 25% 51%Adjusted Gross Margin69% 31% 54% Three Months Ended March 31, 2020 (in thousands, except percentages) Technology Professional Services TotalRevenue$24,699 $20,417 $45,116 Cost of revenue, excluding depreciation and amortization(7,906) (16,162) (24,068)Gross profit, excluding depreciation and amortization16,793 4,255 21,048 Add. Stock-based compensation176 816 992 Adjusted Gross Profit$16,969 $5,071 $22,040 Gross margin, excluding depreciation and amortization68% 21% 47%Adjusted Gross Margin69% 25% 49% Adjusted EBITDA Adjusted EBITDA is a non-GAAP financial measure that we define as net loss adjusted for (i) interest and other expense, net, (ii) income tax (benefit) provision, (iii) depreciation and amortization, (iv) stock-based compensation, (v) acquisition transaction costs, and (vi) change in fair value of contingent consideration liabilities when they are incurred. We view acquisition-related expenses when applicable, such as transaction costs and changes in the fair value of contingent consideration liabilities that are directly related to business combinations as events that are not necessarily reflective of operational performance during a period.

We believe Adjusted EBITDA provides investors with useful information on period-to-period performance as evaluated by management and comparison with our past financial performance and is useful in evaluating our operating performance compared to that of other companies in our industry, as this metric generally eliminates the effects of certain items that may vary from company to company for reasons unrelated to overall operating performance. The following is a reconciliation of our net loss, the most directly comparable GAAP financial measure, to Adjusted EBITDA, for the three months ended March 31, 2021 and 2020. Three Months EndedMarch 31, 2021 2020 (in thousands)Net loss$(28,370) $(17,490)Add. Interest and other expense, net3,952 621 Income tax (benefit) provision101 (1,236)Depreciation and amortization7,814 2,877 Stock-based compensation13,510 8,741 Acquisition transaction costs— 875 Change in fair value of contingent consideration liabilities2,156 (359)Adjusted EBITDA$(837) $(5,971) Adjusted Net Loss Per Share Adjusted Net Loss is a non-GAAP financial measure that we define as net loss attributable to common stockholders adjusted for (i) stock-based compensation, (ii) amortization of acquired intangibles, (iii) acquisition transaction costs, (iv) change in fair value of contingent consideration liabilities, and (v) non-cash interest expense related to our convertible senior notes.

We believe Adjusted Net Loss provides investors with useful information on period-to-period performance as evaluated by management and comparison with our past financial performance and is useful in evaluating our operating performance compared to that of other companies in our industry, as this metric generally eliminates the effects of certain items that may vary from company to company for reasons unrelated to overall operating performance. Three Months Ended March 31, 2021 2020 Numerator:(in thousands, except share and per share amounts)Net loss attributable to common stockholders$(28,370) $(17,490)Add. Stock-based compensation13,510 8,741 Amortization of acquired intangibles7,081 2,150 Acquisition transaction costs— 875 Change in fair value of contingent consideration liabilities2,156 (359)Non-cash interest expense related to convertible senior notes2,870 — Adjusted Net Loss$(2,753) $(6,083)Denominator. Weighted-average number of shares used in calculating net loss, basic and diluted43,870,288 37,108,998 Adjusted net loss per share, basic and diluted$(0.06) $(0.16) Health Catalyst Investor Relations Contact:Adam BrownSenior Vice President, Investor Relations and FP&A+1 (855)-309-6800ir@healthcatalyst.com Health Catalyst Media Contact:Amanda HundtVice President, Corporate Communicationsamanda.hundt@healthcatalyst.com+1 (575) 491-0974SALT LAKE CITY, April 20, 2021 (GLOBE NEWSWIRE) -- Health Catalyst, Inc.

("Health Catalyst", Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, will release its 2021 first quarter operating results on Thursday, May 6, 2021, after market close. In conjunction, the company will host a conference call to review the results at 5 p.m. E.T.

On the same day. Conference Call Details The conference call can be accessed by dialing 1-877-295-1104 for U.S. Participants, or 1-470-495-9486 for international participants, and referencing participant code 9183315. A live audio webcast will be available online at https://ir.healthcatalyst.com/.

A replay of the call will be available via webcast for on-demand listening shortly after the completion of the call, at the same web link, and will remain available for approximately 90 days. About Health Catalyst Health Catalyst is a leading provider of data and analytics technology and services to healthcare organizations 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 all healthcare decisions are data informed.

Health Catalyst Investor Relations Contact. Adam BrownSenior Vice President, Investor Relations and FP&A+1 (855)-309-6800ir@healthcatalyst.com Health Catalyst Media Contact:Amanda Hundt+1 (575)-491-0974amanda.hundt@healthcatalyst.com.

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During her kamagra for sale online three-year battle with breast cancer, my wife, Leslie, graciously endured multiple rounds of horrifically toxic treatment to eke out more time Can you buy flagyl over the counter with our two young children. But after 18 cancer-free months, the disease returned with a vengeance in June 2003. It fractured her bones and invaded her kamagra for sale online spinal canal, bathing her brain in malignancy. During the final six months, as she lay on her home hospice bed in constant pain, attached to a morphine drip around-the-clock while losing her eyesight and withering to a skeleton, the idea of ending her suffering by ending her life didn’t even enter into our conversations. I’ve been thinking a lot about those bleak days while looking into California’s End of Life Option Act, which allows terminally ill patients with a life expectancy of less than six months to end their lives by taking medications prescribed by a physician.

In October, kamagra for sale online Gov. Gavin Newsom signed a revised version of the law, extending it to January 2031 and loosening some restrictions in the 2015 version that proponents say have become barriers to dying people who wish to avail themselves of the law. The original law, which remains in effect until Jan. 1, contains numerous safeguards meant kamagra for sale online to ensure that patients are not being coerced by family members who view them as a burden or a potential financial bonanza. Under the current law, patients who want to die must make two oral requests for the medications at least 15 days apart.

They also must request the drugs in writing, and two doctors must agree the patients are legally eligible. After receiving the medications, patients must confirm their intention to die by signing a form 48 hours before ingesting them kamagra for sale online. The patients must take the drugs without assistance, either by swallowing them in a drink or pushing a plunger attached to an IV or a feeding tube. And physicians can decline to prescribe the death-inducing drugs. After the law had been in effect for a while, its proponents and practitioners concluded that some safeguards made kamagra for sale online the option unavailable to certain patients.

Some patients were so sick they died during the 15 days they were required to wait between their first and second requests for the medications. Others were too weak or disoriented to sign the final attestation. The revised law reduces the 15-day waiting kamagra for sale online period to just two days and eliminates the final attestation. It also requires health care facilities to post their aid-in-dying policies online. Doctors who decline to prescribe the drugs — whether on principle or because they don’t feel qualified — are obliged to document the patient’s request and transfer the record to any other doctor the patient designates.

The most important part of the new law, advocates say, kamagra for sale online is the shortening of the waiting period. Dr. Chandana Banerjee, an assistant clinical professor specializing in palliative medicine at City of Hope National Medical Center in Duarte, California, says she’s seen many patients who were afraid to broach the subject of their own death until they were very close to the end. €œBy the time kamagra for sale online they made that first request and then had to wait for those 15 days, they either became completely nondecisional or went into a coma or passed away,” Banerjee says. Amanda Villegas, 30, of Ontario, California, became an outspoken advocate for updating the law after watching her husband, Chris, die an agonizing death from metastatic bladder cancer in 2019.

When the couple asked about the possibility of a physician-assisted death, Villegas says, staff at the Seventh-day Adventist hospital where Chris was being treated told them, inaccurately, that it was illegal. When he finally made a request for kamagra for sale online death-inducing drugs, it was too late. He died before the 15-day waiting period was up. The new law “will open doors for people who might … experience the same roadblocks,” Villegas says. €œWhen you are dying, the last thing kamagra for sale online you need is to go through bureaucratic barriers to access peace.” Medical aid in dying straddles the same political fault line as abortion and has long been opposed by many religious institutions and anti-abortion groups.

It has also encountered resistance from some disability rights organizations that claim it belittles the lives of those who are physically dependent on others. €œWe object to the whole idea of a state providing a vehicle for people to kill themselves,” says Alexandra Snyder, CEO of the Life Legal Defense Foundation, an anti-abortion nonprofit law firm. The 15-day waiting period, she says, provided an important cooling-off period for patients to reflect on a decision kamagra for sale online that is irreversible. €œNow, any safeguards that were in the law are gone.” Proponents of the law say they haven’t seen evidence that a patient’s decision to take the life-ending medications has ever been anything other than voluntary. Though neither version of the law requires a medical professional to be present when a patient takes the drugs, medical standards encourage professional participation in the dying process, kamagra for sale online says Dr.

Lonny Shavelson, chair of the American Clinicians Academy on Medical Aid in Dying. The drugs should be kept at the pharmacy until the patient is ready to ingest them, he says — though that doesn’t always happen. From the time the aid-in-dying law took effect in June 2016 through Dec kamagra for sale online. 31, 2020, just under two-thirds of the 2,858 people who received prescriptions actually took the medications and died, according to the most recent data from the California Department of Public Health. The rest died before they could take the drugs or found other ways to manage their pain and emotional distress.

Most major commercial health plans — including Kaiser Permanente, Anthem Blue Cross, Blue Shield of California and Health Net kamagra for sale online — cover aid-in-dying drugs and the related doctor visits, as does Medi-Cal, the government-run health insurance program for people with low incomes. However, more than 60% of those who take the drugs are on Medicare, which does not cover them. Effective life-ending drug combinations are available for as little as $400. If you are contemplating aid in dying, here are some resources to learn kamagra for sale online more about it. Talk to your doctor sooner rather than later if you are considering medically assisted death, in case you’ll need to seek a different physician’s help.

If your doctor agrees to help, the law requires that he or she discuss other end-of-life options with you, including hospice and palliative care. Whatever choice a patient makes, kamagra for sale online being more open about our mortality is important, says state Sen. Susan Eggman (D-Stockton), the author of the revised aid-in-dying law. €œWe should all have more conversations about life and death and what we want and don’t want and what is a peaceful death,” she says. €œWe are all going to die.” Leslie and I had plenty of those conversations, until the cancer kamagra for sale online ultimately robbed her of her mind.

In her final months, she would often sink into a semiconscious state, far out of our reach for days on end. Then, just when we thought she wasn’t coming back, she would suddenly open her eyes and ask for the children. She’d get into her wheelchair and kamagra for sale online join us at the dinner table. Those periods, which we called “awakenings,” were a source of great comfort to everyone who loved Leslie — but especially to the kids, who were relieved and overjoyed to have their mommy back. Though I’ll never know for sure, I suspect Leslie would not have wanted to foreclose on such moments.

This story kamagra for sale online was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Bernard J. Wolfson. bwolfson@kff.org, @bjwolfson Related Topics Contact Us kamagra for sale online Submit a Story TipCan’t see the audio player?. Click here to listen on Acast.

You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts. Judging by oral arguments this week, the Supreme Court appears ready to uphold a Mississippi law kamagra for sale online barring most abortions after 15 weeks of pregnancy — and possibly to overrule Roe v. Wade in the process, which has guaranteed American women the right to an abortion for nearly a half-century. Meanwhile, Congress is struggling to keep the lights kamagra for sale online on for the federal government, with a small group of Republicans threatening to block further spending unless the Biden administration agrees to drop its treatment mandates. This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet and Shefali Luthra of The 19th.

Among the takeaways from this week’s episode. During Supreme kamagra for sale online Court arguments over the Mississippi abortion law, some liberal justices questioned whether anything had changed in the country that should cause the court to reverse the long-standing precedent. One historic event, however, did play a key role in the case. The September 2020 death of Justice Ruth Bader Ginsburg, who was a staunch defender of the right to abortion, and her subsequent replacement by Justice Amy Coney Barrett, who has written about her concerns with the Roe opinion. In fact, the court delayed for months a decision on whether to take the Mississippi case, doing so only after Ginsburg’s death.When Mississippi initially petitioned for relief from the Supreme Court — after its abortion law had been overturned by lower federal courts — the state said it sought only kamagra for sale online the ability to reduce the time frame for permissible abortions from the current standard of roughly 24 weeks to 15 weeks.

But once the case was accepted, Mississippi changed its arguments and asked the court to overturn the full effect of the Roe decision.The attorney representing Mississippi’s abortion clinic and the U.S. Solicitor general argued to the court that if Mississippi is allowed to ban most abortions after 15 weeks, there will be nothing to stop other states from establishing even tighter time frames.The justices just last month rushed to hear a case in which Texas is seeking to ban abortions after six weeks. Those arguments had more to do with the legal process for appealing the law and the unusual enforcement of that law, so a decision kamagra for sale online in the Texas case won’t necessarily indicate much about the justices’ thinking on the Mississippi law or abortion rights in general.Nonetheless, the Texas situation is affecting Mississippi’s sole abortion clinic. The court allowed the Texas law to go forward during the legal review, effectively shutting down most abortion services in the state. Many Texas residents seeking abortions must now travel to get the procedure, and many are heading to Mississippi’s clinic.Congress has a long to-do list before heading home at the end of the year.

It has not yet resolved kamagra for sale online spending bills or extended the debt ceiling. Those priorities could force Senate Majority Leader Chuck Schumer to push back final votes until 2022 on the Build Back Better legislation, which would fund President Joe Biden’s social policy agenda.The Senate parliamentarian is going through that massive bill to make sure each provision is primarily about federal spending. Otherwise, the legislation could be subject to a filibuster.The emergence of a new erectile dysfunction treatment variant is raising questions, but public health officials say it is too early to know whether the omicron mutation will prove more virulent or transmissible. Concerns, however, might jump-start efforts to get vaccinated people to seek a booster shot.One thing public kamagra for sale online health officials are sure of is the need to bolster testing. The Biden administration is set to announce that, starting in January, it will require insurers to cover the cost of at-home tests for plan members.

Excluded from that mandate. Medicare and Medicaid beneficiaries.That insurance mandate kamagra for sale online would help many people given the tests’ significant costs in the U.S. But a bigger problem seems to be getting access to the tests. At this point, they are not in adequate supply. Also this kamagra for sale online week, Rovner interviews Blake Farmer of Nashville Public Radio, who reported and wrote the latest KHN-NPR “Bill of the Month episode” about a couple and their very different emergency room bills.

If you have an outrageous medical bill you’d like to send us, you can do that here. Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too. Julie Rovner kamagra for sale online. KHN and PBS NewsHour’s “How Unresolved Grief Could Haunt Children Who Lost a Parent or Caregiver to erectile dysfunction treatment,” by Sarah Varney and Jason Kane. Alice Miranda Ollstein.

The Washington Post’s “Long Overstretched, Abortion kamagra for sale online Funds in D.C., Maryland and Virginia Mobilize for an Uncertain Future,” by Rebecca Tan. Sarah Karlin-Smith. Axios’ “The Push to Revive an Industry-Backed Medical Device Rule,” by Bob Herman. Shefali Luthra kamagra for sale online. The 19th’s “‘Am I Even Fit to Be a Mom?.

€™ Diaper Need Is an Invisible Part of Poverty in America,” by kamagra for sale online Chabeli Carrazana. To hear all our podcasts, click here. And subscribe to KHN’s What the Health?. on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you kamagra for sale online listen to podcasts. Related Topics Contact Us Submit a Story TipWhile growing up in the ’90s in Johnson County, Kansas, in a suburb of Kansas City, I had a friend, Kevin Aaron, who was a dedicated environmentalist.

To strangers, Kevin appeared to be a laid-back punk-rock music fan with a dry and slightly mischievous sense of humor, but those of us who knew him best saw his passion for sustainability blossom during high school. In his barbecue-obsessed kamagra for sale online part of the country, he became the rare vegetarian, driven by witnessing large-scale meat production’s damage to the environment. As he grew into a young man, he eagerly researched and then adopted alternative practices — like driving a hybrid car — that he thought might reduce carbon emissions, if only by tiny measures. Kevin Aaron of Overland Park, Kansas, dedicated himself to finding solutions for climate change years before its dramatic effects became widely apparent. During his kamagra for sale online graduate studies, Aaron grew overwhelmed by a sense of hopelessness about the climate and died by suicide in 2003, at age 27.

(Sami Aaron) In the early 2000s, Kevin was living in the Bay Area and preparing for a career in climate advocacy, enrolled in a master’s program in city and regional planning while studying for a law degree. During his graduate studies, he became overwhelmed by a sense of hopelessness about the climate. He died by suicide in kamagra for sale online 2003, at age 27. Kevin had been living with a feeling that his efforts — combined with those of other environmental activists — just wouldn’t be enough to turn the tide on global warming. It added to the depression he was already struggling with, said his mother, Sami Aaron.

Environmental worries can motivate kamagra for sale online but also overwhelm people. Polling from September 2020 showed that more than half of adults in the U.S. Were anxious about how climate change affects their mental health. And nearly 40% of surveyed Gen Z Americans, born after 1996, said addressing climate change is kamagra for sale online their top personal concern. The loss of Kevin remains a shock for me, and for others who cared about him — especially his mother, who has become increasingly involved in environmental advocacy.

Aaron often turns to nature for comfort, and she picked a former Superfund site in Olathe, Kansas, that has been converted to a flower-filled sanctuary as the spot for us to talk about her son. She said that the more deeply Kevin became involved in environmental activism, the more his kamagra for sale online thinking about the future turned pessimistic — his mind and mood overtaken by despairing thoughts, like an invasive species. €œThere was one little seed that was planted where he couldn’t then quit thinking about it,” she said. After Kevin died, Aaron found some solace in yoga and meditation, but continued to see her grief as a private struggle — until a few years ago, when she met some environmentalists in the Flint Hills of Kansas who also struggled with mental health issues. Aaron wanted to teach kamagra for sale online them the coping strategies she had learned after her son’s death, so she created a Kansas City-based nonprofit, the Resilient Activist.

The organization’s website explains that Kevin’s death occurred “when eco-anxiety (fear about the ecology of the planet) and solastalgia (grief over loss of beloved places in nature) combined with his own inner demons and he took his own life.” The Resilient Activist offers mental health resources, community-building programs, consulting and other psychological resources for the environmental community. At 19, Kevin Aaron relaxes with the family’s dog, Sprite, at his childhood home in Overland Park, Kansas. His T-shirt reads “Student Insurgent,” the name of a campus group he led at the University of kamagra for sale online Oregon. (Sami Aaron) “We need activists who have the resilience to see us through these difficult times,” Aaron said. €œThat’s what I wanted to give.

It’s like, what would have helped him and others like kamagra for sale online him.” In eastern Kansas, the college town of Lawrence is steeped in environmental activism and, on Aug. 31, dozens of protesters gathered before the start of a city meeting, chanting slogans and carrying signs. €œTime Is Running kamagra for sale online Out!. € As the evening rush-hour traffic roared past, activists demanded Lawrence leaders follow through on their sustainability pledges. Many of the protesters were University of Kansas students, like undergraduate Marc Veloz.

He moved to Lawrence from Texas, where he became concerned about how flooding was disproportionately affecting communities of color in kamagra for sale online Dallas. He said taking part in local activism helps get him through what he calls “dark days.” “There are those days that I just have to lean on the little wins we’ve had to keep me going,” Veloz said. €œBecause I know that being in that space of despair and anger and sadness, it isn’t sustainable.” Another student, Kai Hamilton, grew up in the Kansas farming town of Hesston. She recalled kamagra for sale online that even though her neighbors suffered droughts year after year, the words “climate change” were never said out loud. €œI have vivid memories of being alone in my room in high school and just being so overwhelmed and deeply sad about my lack of control over it and also the lack of action in the world,” Hamilton said.

Young activists rallied in front of the Lawrence, Kansas, City Hall on Aug. 31, 2021 to urge city leaders kamagra for sale online to follow through on their commitment to sustainability. (Carlos Moreno / KCUR) Another protester, Agustina Carvallo Vazquez, came to KU from Paraguay, where she said she witnessed destructive and exploitative agricultural practices. She planned to study economics and music but started focusing on environmental activism after she grew frustrated by the inaction she found in the United States. Some amount of anxiety is a natural response to climate change, said Susan Clayton, kamagra for sale online a professor of psychology at the College of Wooster and a board member of the American Psychological Association.

She said getting involved in activism or environmental groups can help relieve feelings of helplessness, but, paradoxically, advocacy carries the risk added stress — sometimes leading to a diagnosis of mental illness. Clayton said that anxiety crosses the line to becoming a true concern when it causes activists to turn away or give up on the problem. “We have to find that common kamagra for sale online ground, where we can accept that there are some really serious things going on, but it doesn’t lead us to despair,” Clayton said. For decades, though, many environmentalists resisted prioritizing their own mental health. In 2018, Greenpeace International signaled a shift when it launched a major study on why so many of its activists were working themselves past their healthy limits.

Agustin Maggio, a campaign manager for Greenpeace, explains that many local volunteers and leaders had bought into a kind of “martyr culture.” “Burning yourself out is kamagra for sale online almost like a badge of honor,” Maggio said. Greenpeace and other leading environmental groups, including the Sierra Club, have begun urging volunteers and staff members to take breaks, unplug or even limit the scope of their activism for the sake of mental health. Ward Lyles, an associate professor of urban planning at the University of Kansas and an environmental activist since the ’90s, said he has changed the way he talks with students about the climate. Kevin Aaron kamagra for sale online on a hike in the mid-’90s in Oregon, where he attended college as an undergrad. (Sami Aaron) “When I first started, I thought it was my job to scare people into action,” Lyles said.

Now, Lyles said, he recognizes that students enter his classes already terrified about what’s happening to the planet — and desperate to do something about it. In class, Lyles welcomes discussions about environmental anxiety and grief, so that emerging activists understand they are not alone kamagra for sale online in having those feelings. €œIn classes where you acknowledge this is hard — this is hard work to do, but we’re here to support each other — then it’s really amazing to watch students come together and talk about finding solutions,” Lyles said. During the kamagra, Sami Aaron has been leading yoga and meditations to help activists relax and reduce narrow, negative thinking patterns that feed anxiety and depression. Reaching a sustainable future, Aaron explained, will require people to remain optimistic and open to new possibilities kamagra for sale online.

The goal is “to kind of shift you out of that fight-or-flight mode,” she said. €œSo that now you’re in a place where you have all different ways of thinking. You have all other options for what can happen and what you can do.” This story is from a partnership that includes NPR, KCUR and KHN. Alex Smith, KCUR. @AlexSmithKCUR Related Topics Contact Us Submit a Story Tip.

During her three-year battle with breast cancer, my wife, Leslie, graciously endured multiple rounds of horrifically toxic treatment to eke kamagra oral jelly thailand price out more time with our two young children. But after 18 cancer-free months, the disease returned with a vengeance in June 2003. It fractured her bones and invaded her kamagra oral jelly thailand price spinal canal, bathing her brain in malignancy. During the final six months, as she lay on her home hospice bed in constant pain, attached to a morphine drip around-the-clock while losing her eyesight and withering to a skeleton, the idea of ending her suffering by ending her life didn’t even enter into our conversations.

I’ve been thinking a lot about those bleak days while looking into California’s End of Life Option Act, which allows terminally ill patients with a life expectancy of less than six months to end their lives by taking medications prescribed by a physician. In October, Gov kamagra oral jelly thailand price. Gavin Newsom signed a revised version of the law, extending it to January 2031 and loosening some restrictions in the 2015 version that proponents say have become barriers to dying people who wish to avail themselves of the law. The original law, which remains in effect until Jan.

1, contains kamagra oral jelly thailand price numerous safeguards meant to ensure that patients are not being coerced by family members who view them as a burden or a potential financial bonanza. Under the current law, patients who want to die must make two oral requests for the medications at least 15 days apart. They also must request the drugs in writing, and two doctors must agree the patients are legally eligible. After receiving the kamagra oral jelly thailand price medications, patients must confirm their intention to die by signing a form 48 hours before ingesting them.

The patients must take the drugs without assistance, either by swallowing them in a drink or pushing a plunger attached to an IV or a feeding tube. And physicians can decline to prescribe the death-inducing drugs. After the law had been in effect for a while, its proponents and practitioners concluded that some safeguards made the option kamagra oral jelly thailand price unavailable to certain patients. Some patients were so sick they died during the 15 days they were required to wait between their first and second requests for the medications.

Others were too weak or disoriented to sign the final attestation. The revised law reduces the 15-day waiting period to just kamagra oral jelly thailand price two days and eliminates the final attestation. It also requires health care facilities to post their aid-in-dying policies online. Doctors who decline to prescribe the drugs — whether on principle or because they don’t feel qualified — are obliged to document the patient’s request and transfer the record to any other doctor the patient designates.

The most important part of the new law, advocates say, kamagra oral jelly thailand price is the shortening of the waiting period. Dr. Chandana Banerjee, an assistant clinical professor specializing in palliative medicine at City of Hope National Medical Center in Duarte, California, says she’s seen many patients who were afraid to broach the subject of their own death until they were very close to the end. €œBy the time they made that first request and then had to wait for those 15 days, they either became completely nondecisional or went into a coma or passed away,” Banerjee says kamagra oral jelly thailand price.

Amanda Villegas, 30, of Ontario, California, became an outspoken advocate for updating the law after watching her husband, Chris, die an agonizing death from metastatic bladder cancer in 2019. When the couple asked about the possibility of a physician-assisted death, Villegas says, staff at the Seventh-day Adventist hospital where Chris was being treated told them, inaccurately, that it was illegal. When he finally made a request for death-inducing drugs, it kamagra oral jelly thailand price was too late. He died before the 15-day waiting period was up.

The new law “will open doors for people who might … experience the same roadblocks,” Villegas says. €œWhen you are dying, the last thing you need is to go through bureaucratic barriers to access peace.” Medical aid in dying straddles the same political fault line as abortion and has long kamagra oral jelly thailand price been opposed by many religious institutions and anti-abortion groups. It has also encountered resistance from some disability rights organizations that claim it belittles the lives of those who are physically dependent on others. €œWe object to the whole idea of a state providing a vehicle for people to kill themselves,” says Alexandra Snyder, CEO of the Life Legal Defense Foundation, an anti-abortion nonprofit law firm.

The 15-day waiting period, she says, provided an important cooling-off period for patients to reflect on a decision that is irreversible kamagra oral jelly thailand price. €œNow, any safeguards that were in the law are gone.” Proponents of the law say they haven’t seen evidence that a patient’s decision to take the life-ending medications has ever been anything other than voluntary. Though neither version of the law requires a medical kamagra oral jelly thailand price professional to be present when a patient takes the drugs, medical standards encourage professional participation in the dying process, says Dr. Lonny Shavelson, chair of the American Clinicians Academy on Medical Aid in Dying.

The drugs should be kept at the pharmacy until the patient is ready to ingest them, he says — though that doesn’t always happen. From the time the aid-in-dying law took effect in June 2016 through kamagra oral jelly thailand price Dec. 31, 2020, just under two-thirds of the 2,858 people who received prescriptions actually took the medications and died, according to the most recent data from the California Department of Public Health. The rest died before they could take the drugs or found other ways to manage their pain and emotional distress.

Most major commercial health plans — including Kaiser Permanente, Anthem Blue Cross, Blue kamagra oral jelly thailand price Shield of California and Health Net — cover aid-in-dying drugs and the related doctor visits, as does Medi-Cal, the government-run health insurance program for people with low incomes. However, more than 60% of those who take the drugs are on Medicare, which does not cover them. Effective life-ending drug combinations are available for as little as $400. If you are contemplating aid in dying, here kamagra oral jelly thailand price are some resources to learn more about it.

Talk to your doctor sooner rather than later if you are considering medically assisted death, in case you’ll need to seek a different physician’s help. If your doctor agrees to help, the law requires that he or she discuss other end-of-life options with you, including hospice and palliative care. Whatever choice a patient makes, being more open about our mortality is important, says kamagra oral jelly thailand price state Sen. Susan Eggman (D-Stockton), the author of the revised aid-in-dying law.

€œWe should all have more conversations about life and death and what we want and don’t want and what is a peaceful death,” she says. €œWe are all going to die.” Leslie and I had plenty of those conversations, until the kamagra oral jelly thailand price cancer ultimately robbed her of her mind. In her final months, she would often sink into a semiconscious state, far out of our reach for days on end. Then, just when we thought she wasn’t coming back, she would suddenly open her eyes and ask for the children.

She’d get into her wheelchair and join kamagra oral jelly thailand price us at the dinner table. Those periods, which we called “awakenings,” were a source of great comfort to everyone who loved Leslie — but especially to the kids, who were relieved and overjoyed to have their mommy back. Though I’ll never know for sure, I suspect Leslie would not have wanted to foreclose on such moments. This story was produced by kamagra oral jelly thailand price KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Bernard J. Wolfson. bwolfson@kff.org, @bjwolfson Related Topics Contact Us Submit a Story TipCan’t see the audio kamagra oral jelly thailand price player?. Click here to listen on Acast.

You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts. Judging by oral arguments this week, the Supreme Court appears ready to uphold a Mississippi law barring most abortions kamagra oral jelly thailand price after 15 weeks of pregnancy — and possibly to overrule Roe v. Wade in the process, which has guaranteed American women the right to an abortion for nearly a half-century. Meanwhile, Congress kamagra oral jelly thailand price is struggling to keep the lights on for the federal government, with a small group of Republicans threatening to block further spending unless the Biden administration agrees to drop its treatment mandates.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sarah Karlin-Smith of the Pink Sheet and Shefali Luthra of The 19th. Among the takeaways from this week’s episode. During Supreme Court arguments over the Mississippi abortion law, some liberal justices questioned whether anything had changed in the country kamagra oral jelly thailand price that should cause the court to reverse the long-standing precedent. One historic event, however, did play a key role in the case.

The September 2020 death of Justice Ruth Bader Ginsburg, who was a staunch defender of the right to abortion, and her subsequent replacement by Justice Amy Coney Barrett, who has written about her concerns with the Roe opinion. In fact, the court delayed for months a decision on whether to take the Mississippi case, doing so only after Ginsburg’s death.When Mississippi initially petitioned for relief from the Supreme Court — after its abortion law had been overturned by lower federal courts — the state said it sought only the ability to reduce the time frame for permissible abortions from the current standard of roughly 24 weeks to 15 kamagra oral jelly thailand price weeks. But once the case was accepted, Mississippi changed its arguments and asked the court to overturn the full effect of the Roe decision.The attorney representing Mississippi’s abortion clinic and the U.S. Solicitor general argued to the court that if Mississippi is allowed to ban most abortions after 15 weeks, there will be nothing to stop other states from establishing even tighter time frames.The justices just last month rushed to hear a case in which Texas is seeking to ban abortions after six weeks.

Those arguments had more to do with the legal process for appealing the law and the unusual enforcement of that law, so a decision in the Texas case won’t necessarily indicate much about kamagra oral jelly thailand price the justices’ thinking on the Mississippi law or abortion rights in general.Nonetheless, the Texas situation is affecting Mississippi’s sole abortion clinic. The court allowed the Texas law to go forward during the legal review, effectively shutting down most abortion services in the state. Many Texas residents seeking abortions must now travel to get the procedure, and many are heading to Mississippi’s clinic.Congress has a long to-do list before heading home at the end of the year. It has not yet resolved kamagra oral jelly thailand price spending bills or extended the debt ceiling.

Those priorities could force Senate Majority Leader Chuck Schumer to push back final votes until 2022 on the Build Back Better legislation, which would fund President Joe Biden’s social policy agenda.The Senate parliamentarian is going through that massive bill to make sure each provision is primarily about federal spending. Otherwise, the legislation could be subject to a filibuster.The emergence of a new erectile dysfunction treatment variant is raising questions, but public health officials say it is too early to know whether the omicron mutation will prove more virulent or transmissible. Concerns, however, might jump-start kamagra oral jelly thailand price efforts to get vaccinated people to seek a booster shot.One thing public health officials are sure of is the need to bolster testing. The Biden administration is set to announce that, starting in January, it will require insurers to cover the cost of at-home tests for plan members.

Excluded from that mandate. Medicare and Medicaid kamagra oral jelly thailand price beneficiaries.That insurance mandate would help many people given the tests’ significant costs in the U.S. But a bigger problem seems to be getting access to the tests. At this point, they are not in adequate supply.

Also this week, Rovner interviews kamagra oral jelly thailand price Blake Farmer of Nashville Public Radio, who reported and wrote the latest KHN-NPR “Bill of the Month episode” about a couple and their very different emergency room bills. If you have an outrageous medical bill you’d like to send us, you can do that here. Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too. Julie Rovner kamagra oral jelly thailand price.

KHN and PBS NewsHour’s “How Unresolved Grief Could Haunt Children Who Lost a Parent or Caregiver to erectile dysfunction treatment,” by Sarah Varney and Jason Kane. Alice Miranda Ollstein. The Washington Post’s kamagra oral jelly thailand price “Long Overstretched, Abortion Funds in D.C., Maryland and Virginia Mobilize for an Uncertain Future,” by Rebecca Tan. Sarah Karlin-Smith.

Axios’ “The Push to Revive an Industry-Backed Medical Device Rule,” by Bob Herman. Shefali Luthra kamagra oral jelly thailand price. The 19th’s “‘Am I Even Fit to Be a Mom?. €™ Diaper Need Is an Invisible Part kamagra oral jelly thailand price of Poverty in America,” by Chabeli Carrazana.

To hear all our podcasts, click here. And subscribe to KHN’s What the Health?. on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen kamagra oral jelly thailand price to podcasts. Related Topics Contact Us Submit a Story TipWhile growing up in the ’90s in Johnson County, Kansas, in a suburb of Kansas City, I had a friend, Kevin Aaron, who was a dedicated environmentalist.

To strangers, Kevin appeared to be a laid-back punk-rock music fan with a dry and slightly mischievous sense of humor, but those of us who knew him best saw his passion for sustainability blossom during high school. In his barbecue-obsessed part kamagra oral jelly thailand price of the country, he became the rare vegetarian, driven by witnessing large-scale meat production’s damage to the environment. As he grew into a young man, he eagerly researched and then adopted alternative practices — like driving a hybrid car — that he thought might reduce carbon emissions, if only by tiny measures. Kevin Aaron of Overland Park, Kansas, dedicated himself to finding solutions for climate change years before its dramatic effects became widely apparent.

During his graduate studies, Aaron grew overwhelmed by a sense of hopelessness about the climate and died by suicide in 2003, at age 27 kamagra oral jelly thailand price. (Sami Aaron) In the early 2000s, Kevin was living in the Bay Area and preparing for a career in climate advocacy, enrolled in a master’s program in city and regional planning while studying for a law degree. During his graduate studies, he became overwhelmed by a sense of hopelessness about the climate. He died by suicide in 2003, kamagra oral jelly thailand price at age 27.

Kevin had been living with a feeling that his efforts — combined with those of other environmental activists — just wouldn’t be enough to turn the tide on global warming. It added to the depression he was already struggling with, said his mother, Sami Aaron. Environmental worries kamagra oral jelly thailand price can motivate but also overwhelm people. Polling from September 2020 showed that more than half of adults in the U.S.

Were anxious about how climate change affects their mental health. And nearly 40% of kamagra oral jelly thailand price surveyed Gen Z Americans, born after 1996, said addressing climate change is their top personal concern. The loss of Kevin remains a shock for me, and for others who cared about him — especially his mother, who has become increasingly involved in environmental advocacy. Aaron often turns to nature for comfort, and she picked a former Superfund site in Olathe, Kansas, that has been converted to a flower-filled sanctuary as the spot for us to talk about her son.

She said that the more kamagra oral jelly thailand price deeply Kevin became involved in environmental activism, the more his thinking about the future turned pessimistic — his mind and mood overtaken by despairing thoughts, like an invasive species. €œThere was one little seed that was planted where he couldn’t then quit thinking about it,” she said. After Kevin died, Aaron found some solace in yoga and meditation, but continued to see her grief as a private struggle — until a few years ago, when she met some environmentalists in the Flint Hills of Kansas who also struggled with mental health issues. Aaron wanted to teach them the coping strategies she had kamagra oral jelly thailand price learned after her son’s death, so she created a Kansas City-based nonprofit, the Resilient Activist.

The organization’s website explains that Kevin’s death occurred “when eco-anxiety (fear about the ecology of the planet) and solastalgia (grief over loss of beloved places in nature) combined with his own inner demons and he took his own life.” The Resilient Activist offers mental health resources, community-building programs, consulting and other psychological resources for the environmental community. At 19, Kevin Aaron relaxes with the family’s dog, Sprite, at his childhood home in Overland Park, Kansas. His T-shirt kamagra oral jelly thailand price reads “Student Insurgent,” the name of a campus group he led at the University of Oregon. (Sami Aaron) “We need activists who have the resilience to see us through these difficult times,” Aaron said.

€œThat’s what I wanted to give. It’s like, what would have helped him and others like him.” In eastern Kansas, the college town of Lawrence is steeped in environmental activism and, kamagra oral jelly thailand price on Aug. 31, dozens of protesters gathered before the start of a city meeting, chanting slogans and carrying signs. €œTime Is kamagra oral jelly thailand price Running Out!.

€ As the evening rush-hour traffic roared past, activists demanded Lawrence leaders follow through on their sustainability pledges. Many of the protesters were University of Kansas students, like undergraduate Marc Veloz. He moved to Lawrence from Texas, where he kamagra oral jelly thailand price became concerned about how flooding was disproportionately affecting communities of color in Dallas. He said taking part in local activism helps get him through what he calls “dark days.” “There are those days that I just have to lean on the little wins we’ve had to keep me going,” Veloz said.

€œBecause I know that being in that space of despair and anger and sadness, it isn’t sustainable.” Another student, Kai Hamilton, grew up in the Kansas farming town of Hesston. She recalled that even though her neighbors suffered kamagra oral jelly thailand price droughts year after year, the words “climate change” were never said out loud. €œI have vivid memories of being alone in my room in high school and just being so overwhelmed and deeply sad about my lack of control over it and also the lack of action in the world,” Hamilton said. Young activists rallied in front of the Lawrence, Kansas, City Hall on Aug.

31, 2021 to kamagra oral jelly thailand price urge city leaders to follow through on their commitment to sustainability. (Carlos Moreno / KCUR) Another protester, Agustina Carvallo Vazquez, came to KU from Paraguay, where she said she witnessed destructive and exploitative agricultural practices. She planned to study economics and music but started focusing on environmental activism after she grew frustrated by the inaction she found in the United States. Some amount kamagra oral jelly thailand price of anxiety is a natural response to climate change, said Susan Clayton, a professor of psychology at the College of Wooster and a board member of the American Psychological Association.

She said getting involved in activism or environmental groups can help relieve feelings of helplessness, but, paradoxically, advocacy carries the risk added stress — sometimes leading to a diagnosis of mental illness. Clayton said that anxiety crosses the line to becoming a true concern when it causes activists to turn away or give up on the problem. “We have to find that common ground, where we can accept that there are some really serious things going on, but it doesn’t lead us to kamagra oral jelly thailand price despair,” Clayton said. For decades, though, many environmentalists resisted prioritizing their own mental health.

In 2018, Greenpeace International signaled a shift when it launched a major study on why so many of its activists were working themselves past their healthy limits. Agustin Maggio, a campaign manager for Greenpeace, explains that many local volunteers and leaders had bought kamagra oral jelly thailand price into a kind of “martyr culture.” “Burning yourself out is almost like a badge of honor,” Maggio said. Greenpeace and other leading environmental groups, including the Sierra Club, have begun urging volunteers and staff members to take breaks, unplug or even limit the scope of their activism for the sake of mental health. Ward Lyles, an associate professor of urban planning at the University of Kansas and an environmental activist since the ’90s, said he has changed the way he talks with students about the climate.

Kevin Aaron on a hike in the mid-’90s in Oregon, where he attended college as an kamagra oral jelly thailand price undergrad. (Sami Aaron) “When I first started, I thought it was my job to scare people into action,” Lyles said. Now, Lyles said, he recognizes that students enter his classes already terrified about what’s happening to the planet — and desperate to do something about it. In class, Lyles welcomes discussions about environmental anxiety and grief, so that kamagra oral jelly thailand price emerging activists understand they are not alone in having those feelings.

€œIn classes where you acknowledge this is hard — this is hard work to do, but we’re here to support each other — then it’s really amazing to watch students come together and talk about finding solutions,” Lyles said. During the kamagra, Sami Aaron has been leading yoga and meditations to help activists relax and reduce narrow, negative thinking patterns that feed anxiety and depression. Reaching a sustainable future, Aaron explained, will require people kamagra oral jelly thailand price to remain optimistic and open to new possibilities. The goal is “to kind of shift you out of that fight-or-flight mode,” she said.

€œSo that now you’re in a place where you have all different ways of thinking. You have all other options for what can happen and what you can do.” This story kamagra oral jelly thailand price is from a partnership that includes NPR, KCUR and KHN. Alex Smith, KCUR. @AlexSmithKCUR Related Topics Contact Us Submit a Story Tip.

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When we took the editorship of Evidence-Based Mental Health buy cheap kamagra jelly online uk (EBMH) at the end of 2013, we set two main objectives http://simplifymgmt.com/best-online-viagra. To promote and embed an evidence-based medicine (EBM) approach into daily mental buy cheap kamagra jelly online uk health clinical practice, and to get an impact factor (IF) for EBMH. Both aims buy cheap kamagra jelly online uk have been big challenges and we have learnt a lot.EBM has been around for about 30 years now, shaping and changing the way we practice medicine. When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains. The best available evidence, the clinical state and circumstances, and patient’s preferences buy cheap kamagra jelly online uk and values.

EBM and EBMH have since continuously evolved to deepen our understanding of these three domains.The best available evidenceWe keep complaining about buy cheap kamagra jelly online uk the poor quality of studies in mental health. To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily …IntroductionQuality-adjusted life years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality buy cheap kamagra jelly online uk of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse than death). QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure of health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by buy cheap kamagra jelly online uk the National Institute of Health and Care Excellence in the UK. While the responsiveness of such generic measures to various mental conditions, especially severe mental illnesses, has been questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional buy cheap kamagra jelly online uk focus of measurements in mental health has centred mainly on symptoms.

Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 buy cheap kamagra jelly online uk 10We have been collecting individual participant-level data from randomised controlled trials of internet cognitive-behavioural therapies (iCBT) for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously. This study, therefore, attempts to link the depression-specific measure onto the generic measure buy cheap kamagra jelly online uk of health in order to enable estimation of QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if they had missing data in either of the two scales at baseline or at endpoint buy cheap kamagra jelly online uk.

We excluded studies that focused on patients with general medical disorders buy cheap kamagra jelly online uk (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do. This produces 3ˆ5=243 different health states, ranging from no problem at all in any dimension (11111) to buy cheap kamagra jelly online uk severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population. In TTO, respondents are asked to give the relative length of time in full health that they would be willing to buy cheap kamagra jelly online uk sacrifice for the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health and 0=death to minus values=worse than buy cheap kamagra jelly online uk death bounded by −1.

The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults. Over the years, value sets for EQ-5D-3L have been produced for many countries/regions.2 3 7Depression severity scalesWe included buy cheap kamagra jelly online uk any validated depression severity measures. The scale scores were converted into the most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck buy cheap kamagra jelly online uk Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness. The cut-offs have been buy cheap kamagra jelly online uk proposed as 0–4, 5–9, 10–14, 15–19 and 20- for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their changes, to establish if the linking is justified.

Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then applied the equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from PHQ-9 to EQ-5D buy cheap kamagra jelly online uk by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in buy cheap kamagra jelly online uk 2008. Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1). Three studies included only patients with major depressive disorder (MDD), one only patients buy cheap kamagra jelly online uk with subthreshold depression and the remaining three included both. All the studies administered buy cheap kamagra jelly online uk EQ-5D-3L.

PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at buy cheap kamagra jelly online uk baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint. Figure 2 shows the same between their change buy cheap kamagra jelly online uk scores. Table 1 summarises the correspondences between the two scales.PHQ-9 and buy cheap kamagra jelly online uk EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions.

PHQ-9, PatientHealth Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 1 PHQ-9 and EQ-5D total scores at buy cheap kamagra jelly online uk baseline and endpoint. EQ-5D,Euro-Qol Five buy cheap kamagra jelly online uk Dimensions. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol buy cheap kamagra jelly online uk Five Dimensions. PHQ-9, Patient Health Questionnaire-9." buy cheap kamagra jelly online uk data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 change scores and EQ-5D change scores.

EQ-5D,Euro-Qol Five buy cheap kamagra jelly online uk Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores. To summarise, subthreshold depression buy cheap kamagra jelly online uk corresponded with EQ-5D-3L index values of 0.9–0.8, mild major depression with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index buy cheap kamagra jelly online uk values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean (SD) utilities based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression. The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression.

One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies (IAPT) cohort7 buy cheap kamagra jelly online uk 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these buy cheap kamagra jelly online uk aforementioned studies.There was a consistent difference of about 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer. It is, therefore, reasonable to use the conversion table at baseline for relatively new cases of depression and that at end of buy cheap kamagra jelly online uk treatment for more chronic cases (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the average SD of buy cheap kamagra jelly online uk PHQ-9 in the studies was about 6, an effect size of 0.3 corresponds to a difference by two points on PHQ-9.

The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 and 0.13, producing an approximate average of 0.1 EQ-5D scores buy cheap kamagra jelly online uk. If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY buy cheap kamagra jelly online uk. (See figure 3 for a schematic drawing to help understand the calculation of QALYs based buy cheap kamagra jelly online uk on changing EQ-5D scores. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less.

If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 sessions of psychotherapy cost US$1600–3200 dollars, both therapies would be deemed buy cheap kamagra jelly online uk largely cost-effective. An individual’s decision, by contrast, will and should be more variable and no one can categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies buy cheap kamagra jelly online uk. A patient may start with PHQ-9 of buy cheap kamagra jelly online uk 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we buy cheap kamagra jelly online uk assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements buy cheap kamagra jelly online uk to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes buy cheap kamagra jelly online uk will be more smoothly curvilinear but the calculation will be similar. EQ-5D, Euro-Qol buy cheap kamagra jelly online uk Five Dimensions. PHQ-9, Patient buy cheap kamagra jelly online uk Health Questionnaire-9.

QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of 20, corresponding with EQ-5D index buy cheap kamagra jelly online uk value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid buy cheap kamagra jelly online uk line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the buy cheap kamagra jelly online uk course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY.

Please note that this is a schematic drawing for buy cheap kamagra jelly online uk illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar. EQ-5D,Euro-Qol Five buy cheap kamagra jelly online uk Dimensions. PHQ-9, PatientHealth buy cheap kamagra jelly online uk Questionnaire-9. QALY, quality-adjustedlife years.Several caveats buy cheap kamagra jelly online uk should be considered when interpreting the results.

First, our sample was limited to participants of trials of iCBT. It may be argued that the results, therefore, would not apply to patients with depression undergoing other therapies or in buy cheap kamagra jelly online uk other settings. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, buy cheap kamagra jelly online uk probably due to limited variability in PHQ-9 scores at baseline because some studies required minimum depression scores. However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we buy cheap kamagra jelly online uk were able to compare PHQ-9 to EQ-5D-3L only.

The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more buy cheap kamagra jelly online uk sensitive to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion values.Our study also has several important strengths. First, our sample included patients with subthreshold depression and major depression and from buy cheap kamagra jelly online uk the community or workplace and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in buy cheap kamagra jelly online uk our sample received iCBT or control interventions including care as usual. Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken buy cheap kamagra jelly online uk into consideration when evaluating their impacts, but our estimates, arguably independent of major side effects, can better inform such considerations.

Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees of improvement at the expense of buy cheap kamagra jelly online uk some potential side effects.Data availability statementData are available upon reasonable request. The overall database used for this IPD is restricted due to buy cheap kamagra jelly online uk data sharing agreements with the research institutes where the studies were conducted. IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

When we took the editorship kamagra oral jelly thailand price of Evidence-Based http://simplifymgmt.com/best-online-viagra Mental Health (EBMH) at the end of 2013, we set two main objectives. To promote and kamagra oral jelly thailand price embed an evidence-based medicine (EBM) approach into daily mental health clinical practice, and to get an impact factor (IF) for EBMH. Both aims have been big challenges and we have learnt a lot.EBM has been around for kamagra oral jelly thailand price about 30 years now, shaping and changing the way we practice medicine. When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains. The best available evidence, the clinical state and circumstances, and patient’s kamagra oral jelly thailand price preferences and values.

EBM and EBMH have since continuously evolved to deepen our understanding of kamagra oral jelly thailand price these three domains.The best available evidenceWe keep complaining about the poor quality of studies in mental health. To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily …IntroductionQuality-adjusted life years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse kamagra oral jelly thailand price than death). QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure of kamagra oral jelly thailand price health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the UK. While the responsiveness of kamagra oral jelly thailand price such generic measures to various mental conditions, especially severe mental illnesses, has been questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms.

Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled kamagra oral jelly thailand price trials of internet cognitive-behavioural therapies (iCBT) for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously. This study, therefore, attempts to link the depression-specific measure onto the generic measure of health in order to enable estimation of QALYs for depressive states and their changes kamagra oral jelly thailand price. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded kamagra oral jelly thailand price patients if they had missing data in either of the two scales at baseline or at endpoint.

We excluded studies that focused on patients with general medical disorders (eg, diabetes, glioma) and kamagra oral jelly thailand price depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do. This produces 3ˆ5=243 different health kamagra oral jelly thailand price states, ranging from no problem at all in any dimension (11111) to severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population. In TTO, respondents are asked to give the relative length of time in full health kamagra oral jelly thailand price that they would be willing to sacrifice for the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health kamagra oral jelly thailand price and 0=death to minus values=worse than death bounded by −1.

The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults. Over the years, value sets for EQ-5D-3L have been produced for many countries/regions.2 3 7Depression severity scalesWe included any validated depression kamagra oral jelly thailand price severity measures. The scale scores were converted into the most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion kamagra oral jelly thailand price algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness. The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 and 20- for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their kamagra oral jelly thailand price changes, to establish if the linking is justified.

Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then applied the equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from kamagra oral jelly thailand price PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted kamagra oral jelly thailand price a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1). Three studies included only patients with major depressive disorder (MDD), one kamagra oral jelly thailand price only patients with subthreshold depression and the remaining three included both. All the kamagra oral jelly thailand price studies administered EQ-5D-3L.

PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and kamagra oral jelly thailand price 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint. Figure 2 shows the kamagra oral jelly thailand price same between their change scores. Table 1 summarises the correspondences between the two scales.PHQ-9 and EQ-5D total scores at kamagra oral jelly thailand price baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions.

PHQ-9, PatientHealth kamagra oral jelly thailand price Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 1 PHQ-9 and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions kamagra oral jelly thailand price. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol Five Dimensions kamagra oral jelly thailand price. PHQ-9, Patient kamagra oral jelly thailand price Health Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 change scores and EQ-5D change scores.

EQ-5D,Euro-Qol Five Dimensions kamagra oral jelly thailand price. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores. To summarise, subthreshold depression corresponded with kamagra oral jelly thailand price EQ-5D-3L index values of 0.9–0.8, mild major depression with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean (SD) utilities based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) kamagra oral jelly thailand price for moderate and 0.27 (0.26) for severe major depression. The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression.

One recent study regressed PHQ-9 on SF-6D scores among 394 kamagra oral jelly thailand price patients in theimproving Access to Psychological Therapies (IAPT) cohort7 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these aforementioned studies.There was a consistent difference kamagra oral jelly thailand price of about 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer. It is, therefore, reasonable to use the kamagra oral jelly thailand price conversion table at baseline for relatively new cases of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the average SD of PHQ-9 in the studies was about 6, an effect size of 0.3 corresponds to a difference by two points on kamagra oral jelly thailand price PHQ-9.

The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 and 0.13, producing kamagra oral jelly thailand price an approximate average of 0.1 EQ-5D scores. If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements kamagra oral jelly thailand price to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. (See figure 3 for a schematic drawing to help kamagra oral jelly thailand price understand the calculation of QALYs based on changing EQ-5D scores. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less.

If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 sessions of psychotherapy cost US$1600–3200 dollars, both therapies would be kamagra oral jelly thailand price deemed largely cost-effective. An individual’s decision, by contrast, will and should be more variable and no one can kamagra oral jelly thailand price categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of 20, corresponding with EQ-5D kamagra oral jelly thailand price index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the kamagra oral jelly thailand price gain in QALY per year would be equal to 0.09 QALY.

If we kamagra oral jelly thailand price assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear kamagra oral jelly thailand price but the calculation will be similar. EQ-5D, Euro-Qol kamagra oral jelly thailand price Five Dimensions. PHQ-9, Patient kamagra oral jelly thailand price Health Questionnaire-9.

QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of kamagra oral jelly thailand price 20, corresponding with EQ-5D index value of 0.5. Then they may improve after kamagra oral jelly thailand price 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY. If we assume kamagra oral jelly thailand price that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY.

Please note that this is a schematic drawing for kamagra oral jelly thailand price illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar. EQ-5D,Euro-Qol Five kamagra oral jelly thailand price Dimensions. PHQ-9, PatientHealth kamagra oral jelly thailand price Questionnaire-9. QALY, quality-adjustedlife years.Several kamagra oral jelly thailand price caveats should be considered when interpreting the results.

First, our sample was limited to participants of trials of iCBT. It may be argued that the results, therefore, would not apply to patients with depression undergoing other therapies or in other settings kamagra oral jelly thailand price. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in PHQ-9 scores at baseline because some kamagra oral jelly thailand price studies required minimum depression scores. However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were able kamagra oral jelly thailand price to compare PHQ-9 to EQ-5D-3L only.

The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion kamagra oral jelly thailand price values.Our study also has several important strengths. First, our sample included patients with subthreshold depression and major depression and from the community or workplace and kamagra oral jelly thailand price the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in our sample kamagra oral jelly thailand price received iCBT or control interventions including care as usual. Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken into consideration when evaluating their impacts, but our estimates, arguably independent of kamagra oral jelly thailand price major side effects, can better inform such considerations.

Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table kamagra oral jelly thailand price will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request. The overall database used for this IPD kamagra oral jelly thailand price is restricted due to data sharing agreements with the research institutes where the studies were conducted. IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

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SACRAMENTO — kamagra green pills Gov kamagra online. Gavin Newsom routinely boasts that California has “one of the highest vaccination rates in the United States of America.” But Newsom, facing a recall election this fall, rarely mentions that the state’s erectile dysfunction treatment uptake has largely stagnated in Black and Latino neighborhoods hardest hit by the erectile dysfunction, and in rural outposts where opposition to treatments runs rampant. In these communities, deep distrust of government kamagra green pills and the U.S.

Health care system has collided with the state’s high-stakes effort to finish vaccinating its 34 million treatment-eligible residents. These are places where state health officials believe they can change a significant number of minds. But the Newsom administration is struggling to do so, public health experts say, hampered by its inconsistent and hastily developed public messaging and outreach campaign that relies too heavily on private advertising firms and companies such kamagra green pills as Google and Blue Shield of California.

€œMany people don’t trust information being put out about treatments because it’s coming from private companies that have profit-seeking motives,” said Dr. Tony Iton, a senior vice president at the California Endowment, which kamagra green pills focuses on expanding health care access for Californians. Iton served as Alameda County’s public health officer from 2003 to 2009.

What actually works, Iton and other public health experts say, are well-funded, locally designed operations led by organizations that have built trust with residents and are capable of going door to door to dispel treatment mythology, such as local nonprofits, county health departments and community clinics. EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. But California’s 61 local public health departments have been stunted by kamagra green pills years of declining revenue, budget cuts and staff reductions that have stymied their ability to conduct the expensive and time-consuming public health outreach campaigns necessary to combat treatment skepticism and hesitancy. €œWhen something like erectile dysfunction treatment comes along, local knowledge is absolutely invaluable in reaching every pocket of that community, particularly in building trust in vulnerable populations,” Iton said.

€œThe state doesn’t have that, Google doesn’t have that, and certainly Blue Shield doesn’t have that.” Even the Newsom administration’s internal polling shows its efforts are faltering. €œThe resounding barrier to vaccination,” state officials wrote in the latest survey published in June, “has been confusion as a result of inconsistent, contradictory or insufficient kamagra green pills messaging from government and public health officials.” Statewide, nearly 60% of Californians are fully vaccinated, but progress is uneven. Just 39% of eligible Black residents and 40% of Latinos had been vaccinated as of Friday, and local public health officials are intensely worried about regions like the Central Valley, where vaccination rates have stalled, especially given the threat of erectile dysfunction treatment’s dangerous delta variant.

Similar disparities exist by geography, across regions kamagra green pills and even among neighborhoods. The state’s treatment holdouts make up a cohort that cuts across political and geographic ideologies and is dominated by Latinos, African Americans, rural residents and young people. Unlike outright treatment “rejecters,” who lean Republican, undecideds align with Democrats, according to state polling.

State officials are trying to change the minds of both “undecideds” and “rejecters,” and kamagra green pills are relying primarily on treatment lotteries with giveaways totaling $116.5 million or vacation packages, and glitzy advertising campaigns featuring paid social media influencers. The state has awarded two $40 million contracts to high-dollar ad agencies for treatment outreach and education. Companies including Facebook, Google, Comcast and TikTok are providing free advertising on social media, radio and TV, and making kamagra green pills charitable contributions to help the state fund its public education campaigns, state records show.

Lackluster vaccination uptake drove the Newsom administration to pursue the more personal approach that public health experts favor, but the still-nascent campaign leaves out large swaths of the state. The administration launched its “Get Out the Vax” campaign in April, enlisting 70 community-based organizations and 2,000 community canvassers, now focused on Los Angeles and Central Valley neighborhoods where vaccinations have plateaued or declined. But county public health officials say the campaign isn’t big enough to combat kamagra green pills the treatment misinformation that has infiated regions such as California’s rural north.

€œIt’s terrible,” said Placer County’s health officer, Dr. Rob Oldham, who said misinformation is driving treatments down. €œUnfortunately, the lottery didn’t really help us kamagra green pills.

We’re working so much harder to get a dozen people vaccinated, whereas before we were doing close to 1,500 shots a day.” State Health and Human Services Secretary Mark Ghaly acknowledged that the state must boost its presence on the ground and said it “needs to do better and more.” At the same time, he and other state officials argue that the treatment lottery is working and that they are seeing progress in hard-hit neighborhoods. This month the state debuted pop-up treatment clinics at McDonald’s restaurants in 11 counties, kamagra green pills and state-funded outreach workers have fanned out in neighborhoods such as South Los Angeles to sign people up for appointments or vaccinate takers from a roving van. treatment canvassers report that the people who don’t want the treatments say they’re concerned about safety or repeat sometimes outrageous rumors, such as the false assertion that treatments turn people into zombies.

€œWe’re seeing lots of disinformation and lack of a sense of urgency,” said Yolanda Richardson, secretary of the California Government Operations Agency and Newsom’s “vaccination czar.” “The work that we have left to do is really finding out what each individual person needs to make that jump.” Carnella Marks of Oroville, in Butte County, offers a telling case of how hard public health officials must work to cut through the thick swamp of misinformation and confusion. Carnella Marks of Oroville, kamagra green pills California, pictured with Albert Smith, her late father-in-law, doesn’t believe erectile dysfunction treatments are safe. She says she wants someone to explain how the treatments work but “nobody’s knocking on my door to talk to me or answer my questions.” (Carnella Marks) Marks, 51, who is Black, has deep misgivings about the safety of the treatments that are rooted in the country’s racist history and her personal experience.

When she was pregnant with her second child, her doctor suggested she get a hysterectomy even though she wasn’t ready to stop having kids and had no health complications. She wonders kamagra green pills if the U.S. Government is experimenting on Black people, as it did on African American men in the Tuskegee syphilis study from the 1930s into the 1970s.

€œWhy do they kamagra green pills want us to take the treatment so bad?. € Marks asked. €œWe’ve never been first in line for anything, but now all of a sudden you want to make sure that the African American community gets the treatment?.

€ She had considered getting vaccinated because she thought it might be required for work — kamagra green pills until government officials paused the single-dose Johnson &. Johnson shot over concerns it caused blood clots. €œI don’t care what kind of money the governor is kamagra green pills shelling out to get me to take the treatment,” said Marks, who wants to discuss the safety of the treatments with someone who knows.

But “nobody’s knocking on my door to talk to me or answer my questions.” Public health experts say it could be possible to change the minds of people like Marks with targeted and relentless outreach by trusted members of the community who acknowledge their fears and mistrust of the medical system. A knock on the door or phone call from an epidemiologist who can explain the science behind vaccinations couldn’t hurt, they added. €œSo many of kamagra green pills these people really aren’t treatment hesitant.

They’re just trying to figure out the facts for themselves and get their questions answered,” said Oldham of Placer County. But the county can’t afford its own campaign, so Oldham said it “Placerizes” state material, adapting messaging for its residents. €œWhat we’ve seen from the state, frankly, is a lack of investment and interest in public health,” kamagra green pills he said.

€œI think it builds trust when you have the resources to call people back and tailor a message, but honestly we don’t really have that capacity.” Santa Clara County has created advertising to persuade residents to get vaccinated.(Santa Clara County Public Health) Some counties have committed scarce funds to develop ads targeting populations among whom distrust runs rampant, an effort they say has helped boost vaccination rates. Santa Clara County, for instance, has plowed at least $8.6 million into an outreach campaign and public service announcements related to erectile dysfunction treatment since March 2020, including Spanish-language kamagra green pills ads targeting the county’s large Latino population. Health officer Dr.

Sara Cody said the county has also enlisted the help of local health clinics, nonprofit groups and county employees of various ethnicities to develop messages that might persuade people to get vaccinated. €œWe are extraordinarily fortunate,” kamagra green pills Cody said. €œThat investment turned out to be one of the most useful.

People do have fears, and kamagra green pills we want to hear them.” About 73% of the county’s population is fully vaccinated, while other counties with fewer public health resources, like Placer, have struggled to mount effective campaigns. There, about 48% of residents are fully vaccinated. treatment canvassers say they are making progress by using personal stories and discussing the science behind the treatments.

Ricardo Márquez, kamagra green pills a state-funded treatment outreach worker in South Los Angeles, said he has changed minds. €œSometimes facts and science work, but sometimes people who don’t believe change their minds when I tell them people are dying, like my sweet grandma,” Márquez said. Angela Hart.

ahart@kff.org, @ahartreports Related Topics Contact Us kamagra green pills Submit a Story TipThe week before Brian Colvin was scheduled for shoulder surgery in November, he tested positive for erectile dysfunction treatment. What he thought at first was a head cold had morphed into shortness of breath and chest congestion coupled with profound fatigue and loss of balance. Now, seven months have passed and Colvin, 44, is still kamagra green pills waiting to feel well enough for surgery.

His surgeon is concerned about risking anesthesia with his ongoing respiratory problems, while Colvin worries he’ll lose his balance and fall on his shoulder before it heals. €œWhen I last spoke with the surgeon, he said to let him know when I’m ready,” Colvin said. €œBut with all the symptoms, I’ve never kamagra green pills felt ready for surgery.” As the number of people who have had erectile dysfunction treatment grows, medical experts are trying to determine when it’s safe for them to have elective surgery.

In addition to concerns about respiratory complications from anesthesia, erectile dysfunction treatment may affect multiple organs and systems, and clinicians are still learning the implications for surgery. A recent study compared the mortality rate in the 30 days following surgery in patients who had a erectile dysfunction treatment and in those who did not. It found that waiting to undergo surgery for at least seven weeks after a erectile dysfunction treatment reduced the risk of death to that of kamagra green pills people who hadn’t been infected in the first place.

Patients with lingering erectile dysfunction treatment symptoms should wait even longer, the study suggested. But, as Colvin’s experience illustrates, such guideposts may be of limited use kamagra green pills with a kamagra whose effect on individual patients is so unpredictable. €œWe know that erectile dysfunction treatment has lingering effects even in people who had relatively mild disease,” said Dr.

Don Goldmann, a professor at Harvard Medical School who is a senior fellow and chief scientific officer emeritus at the Institute for Healthcare Improvement. €œWe don’t know why kamagra green pills that is. But it’s reasonable to assume, when we decide how long we should wait before performing elective surgery, that someone’s respiratory or other systems may still be affected.” The study, published in the journal Anaesthesia in March, examined the 30-day postoperative mortality rate of more than 140,000 patients in 116 countries who had elective or emergency surgery in October.

Researchers found that patients who had surgery within two weeks of their erectile dysfunction treatment diagnosis had a 4.1% adjusted mortality rate at 30 days kamagra green pills. The rate decreased to 3.9% in those diagnosed three to four weeks before surgery, and dropped again, to 3.6%, in those who had surgery five to six weeks after their diagnosis. Patients whose surgery occurred at least seven weeks after their erectile dysfunction treatment diagnosis had a mortality rate of 1.5% 30 days after surgery, the same as for patients who were never diagnosed with the kamagra.

Even after seven weeks, however, patients who still had erectile dysfunction treatment symptoms were more than twice as likely to die after surgery than kamagra green pills people whose symptoms had resolved or who never had symptoms. Some experts said seven weeks is too arbitrary a threshold for scheduling surgery for patients who have had erectile dysfunction treatment. In addition to patients’ recovery status from the kamagra, the calculus will be different for an older patient with chronic conditions who needs major heart surgery, for example, than for a generally healthy person in their 20s who needs a straightforward hernia repair.

€œerectile dysfunction treatment is just one of the things to be taken kamagra green pills into account,” said Dr. Kenneth Sharp, a member of the Board of Regents of the American College of Surgeons and vice chair of the Department of Surgery at Vanderbilt University Medical Center. In December, kamagra green pills the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation issued these guidelines for timing surgery for former erectile dysfunction treatment patients.

€¢ Four weeks if a patient was asymptomatic or had mild, non-respiratory symptoms. €¢ Six weeks for a symptomatic patient who wasn’t hospitalized. €¢ Eight to 10 weeks for a symptomatic patient who has diabetes, is immunocompromised or was kamagra green pills hospitalized.

€¢ Twelve weeks for a patient who spent time in an intensive care unit. Those guidelines are not definitive, according to kamagra green pills the groups. The operation to be performed, patients’ medical conditions and the risk of delaying surgery should all be factored in.

€œLong erectile dysfunction treatment” patients like Colvin who continue to have debilitating symptoms months after 12 weeks have passed require a more thorough evaluation before surgery, said Dr. Beverly Philip, kamagra green pills president of the society. Now that erectile dysfunction treatment has been brought to heel in many areas and treatments are widely available, hospital operating rooms are bustling again.

€œIn talking to surgical colleagues, hospitals are really busy now,” said Dr. Avital O’Glasser, medical director of the outpatient preoperative clinic at kamagra green pills Oregon Health and Sciences University in Portland. €œI’ve seen patients with delayed knee replacements, bariatric surgery, more advanced cancer.” At the beginning of the kamagra, surgical volumes dropped dramatically as many hospitals canceled nonessential procedures and patients avoided facilities packed with erectile dysfunction treatment patients.

From March to kamagra green pills June 2020, the number of inpatient and outpatient surgeries at U.S. Hospitals was 30% lower than in the same period the year before, according to McKinsey &. Company’s quarterly Health System Volumes Survey.

By May 2021, surgical volumes had mostly rebounded, and were just 2% lower than their May 2019 totals, kamagra green pills according to the May survey. Oregon Health and Sciences University clinicians developed a protocol a year ago for clearing any patient who had erectile dysfunction treatment for elective surgery. When obtaining patients’ medical history and conducting physical exams, clinicians look for signs of erectile dysfunction treatment complications that aren’t readily identifiable and determine whether patients have returned to their pre-erectile dysfunction treatment level of health.

The pre-op exam also includes lab and other tests that evaluate cardiopulmonary function, coagulation status, inflammation markers and nutrition, all of which can kamagra green pills be disrupted by erectile dysfunction treatment. If the assessment raises no red flags, patients can be cleared for surgery once they have waited the minimum seven weeks since their erectile dysfunction treatment diagnosis. Originally, the minimum wait for surgery was four weeks, but clinicians kamagra green pills pushed it back to seven after the international study was published, O’Glasser said.

€œWe are still learning about erectile dysfunction treatment, and uncertainty in medicine is one of the biggest challenges we face,” said O’Glasser. €œRight now, our team is erring on the side of caution.” At Memorial Sloan Kettering Cancer Center in New York, doctors don’t follow a specific protocol. €œWe’re taking every kamagra green pills patient one at a time.

There are no hard-and-fast rules at this institution,” said Dr. Jeffrey Drebin, kamagra green pills chair of surgery. Clinicians work to find a balance between the urgency of the cancer surgery and the need to allow enough time to ensure erectile dysfunction treatment recovery, he said.

For Brian Colvin, whose right rotator cuff is torn, delaying surgery is painful and may worsen the tear. But the rest of kamagra green pills his life is on hold, too. A sales representative for an auto parts company, he hasn’t been able to work since he got sick.

His balance problems make him reluctant to stray far from his home in Crest Hill, Illinois, the Chicago suburb where he lives with his wife and 15-year-old son. Some days he has kamagra green pills more energy and isn’t as short of breath as others. Colvin hopes it’s a sign he’s slowly improving.

But at this kamagra green pills point, it’s hard to be optimistic about the kamagra. €œIt’s always something,” he said. This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues.

Together with Policy kamagra green pills Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation. Related Topics Contact Us Submit a Story Tip.

SACRAMENTO — kamagra oral jelly thailand price Gov kamagra online. Gavin Newsom routinely boasts that California has “one of the highest vaccination rates in the United States of America.” But Newsom, facing a recall election this fall, rarely mentions that the state’s erectile dysfunction treatment uptake has largely stagnated in Black and Latino neighborhoods hardest hit by the erectile dysfunction, and in rural outposts where opposition to treatments runs rampant. In these kamagra oral jelly thailand price communities, deep distrust of government and the U.S. Health care system has collided with the state’s high-stakes effort to finish vaccinating its 34 million treatment-eligible residents. These are places where state health officials believe they can change a significant number of minds.

But the Newsom administration is struggling to do so, public health experts say, hampered by its inconsistent and hastily developed public messaging kamagra oral jelly thailand price and outreach campaign that relies too heavily on private advertising firms and companies such as Google and Blue Shield of California. €œMany people don’t trust information being put out about treatments because it’s coming from private companies that have profit-seeking motives,” said Dr. Tony Iton, a senior vice president at kamagra oral jelly thailand price the California Endowment, which focuses on expanding health care access for Californians. Iton served as Alameda County’s public health officer from 2003 to 2009. What actually works, Iton and other public health experts say, are well-funded, locally designed operations led by organizations that have built trust with residents and are capable of going door to door to dispel treatment mythology, such as local nonprofits, county health departments and community clinics.

EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. But California’s 61 local public health departments have been stunted by kamagra oral jelly thailand price years of declining revenue, budget cuts and staff reductions that have stymied their ability to conduct the expensive and time-consuming public health outreach campaigns necessary to combat treatment skepticism and hesitancy. €œWhen something like erectile dysfunction treatment comes along, local knowledge is absolutely invaluable in reaching every pocket of that community, particularly in building trust in vulnerable populations,” Iton said. €œThe state doesn’t have that, Google doesn’t have that, and certainly Blue Shield doesn’t have that.” Even the Newsom administration’s internal polling shows its efforts are faltering. €œThe resounding barrier to vaccination,” state officials wrote in the latest survey published in June, “has been confusion as a result of inconsistent, contradictory or insufficient messaging from government and public health officials.” kamagra oral jelly thailand price Statewide, nearly 60% of Californians are fully vaccinated, but progress is uneven. Just 39% of eligible Black residents and 40% of Latinos had been vaccinated as of Friday, and local public health officials are intensely worried about regions like the Central Valley, where vaccination rates have stalled, especially given the threat of erectile dysfunction treatment’s dangerous delta variant.

Similar disparities exist by geography, across regions kamagra oral jelly thailand price and even among neighborhoods. The state’s treatment holdouts make up a cohort that cuts across political and geographic ideologies and is dominated by Latinos, African Americans, rural residents and young people. Unlike outright treatment “rejecters,” who lean Republican, undecideds align with Democrats, according to state polling. State officials are trying to change the minds of both “undecideds” and “rejecters,” and are relying primarily on treatment lotteries with giveaways totaling $116.5 million or vacation packages, and glitzy kamagra oral jelly thailand price advertising campaigns featuring paid social media influencers. The state has awarded two $40 million contracts to high-dollar ad agencies for treatment outreach and education.

Companies including Facebook, Google, Comcast and TikTok are providing free advertising on social media, radio and TV, and making charitable contributions to help the state fund its public education campaigns, kamagra oral jelly thailand price state records show. Lackluster vaccination uptake drove the Newsom administration to pursue the more personal approach that public health experts favor, but the still-nascent campaign leaves out large swaths of the state. The administration launched its “Get Out the Vax” campaign in April, enlisting 70 community-based organizations and 2,000 community canvassers, now focused on Los Angeles and Central Valley neighborhoods where vaccinations have plateaued or declined. But county public health officials say the campaign isn’t big enough to combat the treatment misinformation that has infiated regions such as kamagra oral jelly thailand price California’s rural north. €œIt’s terrible,” said Placer County’s health officer, Dr.

Rob Oldham, who said misinformation is driving treatments down. €œUnfortunately, the lottery kamagra oral jelly thailand price didn’t really help us. We’re working so much harder to get a dozen people vaccinated, whereas before we were doing close to 1,500 shots a day.” State Health and Human Services Secretary Mark Ghaly acknowledged that the state must boost its presence on the ground and said it “needs to do better and more.” At the same time, he and other state officials argue that the treatment lottery is working and that they are seeing progress in hard-hit neighborhoods. This month the state kamagra oral jelly thailand price debuted pop-up treatment clinics at McDonald’s restaurants in 11 counties, and state-funded outreach workers have fanned out in neighborhoods such as South Los Angeles to sign people up for appointments or vaccinate takers from a roving van. treatment canvassers report that the people who don’t want the treatments say they’re concerned about safety or repeat sometimes outrageous rumors, such as the false assertion that treatments turn people into zombies.

€œWe’re seeing lots of disinformation and lack of a sense of urgency,” said Yolanda Richardson, secretary of the California Government Operations Agency and Newsom’s “vaccination czar.” “The work that we have left to do is really finding out what each individual person needs to make that jump.” Carnella Marks of Oroville, in Butte County, offers a telling case of how hard public health officials must work to cut through the thick swamp of misinformation and confusion. Carnella Marks of Oroville, California, pictured with Albert Smith, her late father-in-law, doesn’t believe erectile dysfunction treatments are safe kamagra oral jelly thailand price. She says she wants someone to explain how the treatments work but “nobody’s knocking on my door to talk to me or answer my questions.” (Carnella Marks) Marks, 51, who is Black, has deep misgivings about the safety of the treatments that are rooted in the country’s racist history and her personal experience. When she was pregnant with her second child, her doctor suggested she get a hysterectomy even though she wasn’t ready to stop having kids and had no health complications. She wonders if the kamagra oral jelly thailand price U.S.

Government is experimenting on Black people, as it did on African American men in the Tuskegee syphilis study from the 1930s into the 1970s. €œWhy do they want us to take the treatment kamagra oral jelly thailand price so bad?. € Marks asked. €œWe’ve never been first in line for anything, but now all of a sudden you want to make sure that the African American community gets the treatment?. € She had considered getting vaccinated because she kamagra oral jelly thailand price thought it might be required for work — until government officials paused the single-dose Johnson &.

Johnson shot over concerns it caused blood clots. €œI don’t care what kind of money the governor is shelling out to get me to take the treatment,” said kamagra oral jelly thailand price Marks, who wants to discuss the safety of the treatments with someone who knows. But “nobody’s knocking on my door to talk to me or answer my questions.” Public health experts say it could be possible to change the minds of people like Marks with targeted and relentless outreach by trusted members of the community who acknowledge their fears and mistrust of the medical system. A knock on the door or phone call from an epidemiologist who can explain the science behind vaccinations couldn’t hurt, they added. €œSo many of these people really aren’t treatment hesitant kamagra oral jelly thailand price.

They’re just trying to figure out the facts for themselves and get their questions answered,” said Oldham of Placer County. But the county can’t afford its own campaign, so Oldham said it “Placerizes” state material, adapting messaging for its residents. €œWhat we’ve seen from the state, frankly, is a lack of investment and interest in public health,” kamagra oral jelly thailand price he said. €œI think it builds trust when you have the resources to call people back and tailor a message, but honestly we don’t really have that capacity.” Santa Clara County has created advertising to persuade residents to get vaccinated.(Santa Clara County Public Health) Some counties have committed scarce funds to develop ads targeting populations among whom distrust runs rampant, an effort they say has helped boost vaccination rates. Santa Clara County, for instance, has plowed at least $8.6 million into an outreach campaign and kamagra oral jelly thailand price public service announcements related to erectile dysfunction treatment since March 2020, including Spanish-language ads targeting the county’s large Latino population.

Health officer Dr. Sara Cody said the county has also enlisted the help of local health clinics, nonprofit groups and county employees of various ethnicities to develop messages that might persuade people to get vaccinated. €œWe are extraordinarily kamagra oral jelly thailand price fortunate,” Cody said. €œThat investment turned out to be one of the most useful. People do have fears, and we want to hear them.” About 73% of the kamagra oral jelly thailand price county’s population is fully vaccinated, while other counties with fewer public health resources, like Placer, have struggled to mount effective campaigns.

There, about 48% of residents are fully vaccinated. treatment canvassers say they are making progress by using personal stories and discussing the science behind the treatments. Ricardo Márquez, a state-funded treatment outreach worker in South Los Angeles, said kamagra oral jelly thailand price he has changed minds. €œSometimes facts and science work, but sometimes people who don’t believe change their minds when I tell them people are dying, like my sweet grandma,” Márquez said. Angela Hart.

ahart@kff.org, @ahartreports Related Topics Contact Us Submit a kamagra oral jelly thailand price Story TipThe week before Brian Colvin was scheduled for shoulder surgery in November, he tested positive for erectile dysfunction treatment. What he thought at first was a head cold had morphed into shortness of breath and chest congestion coupled with profound fatigue and loss see page of balance. Now, seven months kamagra oral jelly thailand price have passed and Colvin, 44, is still waiting to feel well enough for surgery. His surgeon is concerned about risking anesthesia with his ongoing respiratory problems, while Colvin worries he’ll lose his balance and fall on his shoulder before it heals. €œWhen I last spoke with the surgeon, he said to let him know when I’m ready,” Colvin said.

€œBut with all the kamagra oral jelly thailand price symptoms, I’ve never felt ready for surgery.” As the number of people who have had erectile dysfunction treatment grows, medical experts are trying to determine when it’s safe for them to have elective surgery. In addition to concerns about respiratory complications from anesthesia, erectile dysfunction treatment may affect multiple organs and systems, and clinicians are still learning the implications for surgery. A recent study compared the mortality rate in the 30 days following surgery in patients who had a erectile dysfunction treatment and in those who did not. It found that waiting to undergo surgery for at kamagra oral jelly thailand price least seven weeks after a erectile dysfunction treatment reduced the risk of death to that of people who hadn’t been infected in the first place. Patients with lingering erectile dysfunction treatment symptoms should wait even longer, the study suggested.

But, as Colvin’s experience illustrates, such guideposts may be of limited use with a kamagra whose effect on individual patients is so unpredictable kamagra oral jelly thailand price. €œWe know that erectile dysfunction treatment has lingering effects even in people who had relatively mild disease,” said Dr. Don Goldmann, a professor at Harvard Medical School who is a senior fellow and chief scientific officer emeritus at the Institute for Healthcare Improvement. €œWe don’t kamagra oral jelly thailand price know why that is. But it’s reasonable to assume, when we decide how long we should wait before performing elective surgery, that someone’s respiratory or other systems may still be affected.” The study, published in the journal Anaesthesia in March, examined the 30-day postoperative mortality rate of more than 140,000 patients in 116 countries who had elective or emergency surgery in October.

Researchers found that patients who had surgery within two weeks of their erectile dysfunction treatment diagnosis had a 4.1% adjusted mortality rate at 30 days kamagra oral jelly thailand price. The rate decreased to 3.9% in those diagnosed three to four weeks before surgery, and dropped again, to 3.6%, in those who had surgery five to six weeks after their diagnosis. Patients whose surgery occurred at least seven weeks after their erectile dysfunction treatment diagnosis had a mortality rate of 1.5% 30 days after surgery, the same as for patients who were never diagnosed with the kamagra. Even after seven weeks, however, patients who still had erectile dysfunction treatment symptoms were more than twice as likely to die after surgery than people whose symptoms had resolved or who never had symptoms kamagra oral jelly thailand price. Some experts said seven weeks is too arbitrary a threshold for scheduling surgery for patients who have had erectile dysfunction treatment.

In addition to patients’ recovery status from the kamagra, the calculus will be different for an older patient with chronic conditions who needs major heart surgery, for example, than for a generally healthy person in their 20s who needs a straightforward hernia repair. €œerectile dysfunction treatment is just kamagra oral jelly thailand price one of the things to be taken into account,” said Dr. Kenneth Sharp, a member of the Board of Regents of the American College of Surgeons and vice chair of the Department of Surgery at Vanderbilt University Medical Center. In December, the American Society of Anesthesiologists kamagra oral jelly thailand price and the Anesthesia Patient Safety Foundation issued these guidelines for timing surgery for former erectile dysfunction treatment patients. €¢ Four weeks if a patient was asymptomatic or had mild, non-respiratory symptoms.

€¢ Six weeks for a symptomatic patient who wasn’t hospitalized. €¢ Eight kamagra oral jelly thailand price to 10 weeks for a symptomatic patient who has diabetes, is immunocompromised or was hospitalized. €¢ Twelve weeks for a patient who spent time in an intensive care unit. Those guidelines are not definitive, according to the kamagra oral jelly thailand price groups. The operation to be performed, patients’ medical conditions and the risk of delaying surgery should all be factored in.

€œLong erectile dysfunction treatment” patients like Colvin who continue to have debilitating symptoms months after 12 weeks have passed require a more thorough evaluation before surgery, said Dr. Beverly Philip, kamagra oral jelly thailand price president of the society. Now that erectile dysfunction treatment has been brought to heel in many areas and treatments are widely available, hospital operating rooms are bustling again. €œIn talking to surgical colleagues, hospitals are really busy now,” said Dr. Avital O’Glasser, medical director of the outpatient preoperative clinic at Oregon Health kamagra oral jelly thailand price and Sciences University in Portland.

€œI’ve seen patients with delayed knee replacements, bariatric surgery, more advanced cancer.” At the beginning of the kamagra, surgical volumes dropped dramatically as many hospitals canceled nonessential procedures and patients avoided facilities packed with erectile dysfunction treatment patients. From March to June 2020, the number of inpatient and kamagra oral jelly thailand price outpatient surgeries at U.S. Hospitals was 30% lower than in the same period the year before, according to McKinsey &. Company’s quarterly Health System Volumes Survey. By May 2021, surgical volumes had mostly rebounded, and kamagra oral jelly thailand price were just 2% lower than their May 2019 totals, according to the May survey.

Oregon Health and Sciences University clinicians developed a protocol a year ago for clearing any patient who had erectile dysfunction treatment for elective surgery. When obtaining patients’ medical history and conducting physical exams, clinicians look for signs of erectile dysfunction treatment complications that aren’t readily identifiable and determine whether patients have returned to their pre-erectile dysfunction treatment level of health. The pre-op exam also includes lab and other tests that evaluate kamagra oral jelly thailand price cardiopulmonary function, coagulation status, inflammation markers and nutrition, all of which can be disrupted by erectile dysfunction treatment. If the assessment raises no red flags, patients can be cleared for surgery once they have waited the minimum seven weeks since their erectile dysfunction treatment diagnosis. Originally, the minimum wait for surgery was four weeks, but clinicians pushed it back to seven after the international study was published, O’Glasser said kamagra oral jelly thailand price.

€œWe are still learning about erectile dysfunction treatment, and uncertainty in medicine is one of the biggest challenges we face,” said O’Glasser. €œRight now, our team is erring on the side of caution.” At Memorial Sloan Kettering Cancer Center in New York, doctors don’t follow a specific protocol. €œWe’re taking every patient one at a time kamagra oral jelly thailand price. There are no hard-and-fast rules at this institution,” said Dr. Jeffrey Drebin, chair of kamagra oral jelly thailand price surgery.

Clinicians work to find a balance between the urgency of the cancer surgery and the need to allow enough time to ensure erectile dysfunction treatment recovery, he said. For Brian Colvin, whose right rotator cuff is torn, delaying surgery is painful and may worsen the tear. But the rest of his life kamagra oral jelly thailand price is on hold, too. A sales representative for an auto parts company, he hasn’t been able to work since he got sick. His balance problems make him reluctant to stray far from his home in Crest Hill, Illinois, the Chicago suburb where he lives with his wife and 15-year-old son.

Some days he has more energy and isn’t as short of breath as kamagra oral jelly thailand price others. Colvin hopes it’s a sign he’s slowly improving. But at this point, it’s hard to be optimistic kamagra oral jelly thailand price about the kamagra. €œIt’s always something,” he said. This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues.

Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation) kamagra oral jelly thailand price. KFF is an endowed nonprofit organization providing information on health issues to the nation. Related Topics Contact Us Submit a Story Tip.

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