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Even though it’s crucial to overall health, nearly 70% of Americans buy zithromax usa don’t actually meet the daily intake values for magnesium. Magnesium is necessary for healthy brain function, cardiovascular functions, regulating muscle contractions, regulating blood pressure, and more. The bottom line?. You can’t live without magnesium, buy zithromax usa and you might not be getting enough.Leg Cramps?. So, why do people use magnesium for leg cramps?.

Magnesium plays a role in muscular contraction, and a deficiency in the mineral can actually cause your body to react negatively in the form of more cramps. If you’re buy zithromax usa experiencing frequent and intense leg cramps, you might just be magnesium-deficient.While cramp is a broad term, we all know what it means. Magnesium has also been found to be effective at treating certain kinds of pain but isn’t generally used as a “painkiller” in the general sense. Cramps can occur after a workout, when you’re dehydrated, when you’ve overused or extended a muscle, or even just randomly while you’re sitting at your desk. It’s safe to say that no one enjoys them and taking an OTC medication for them almost seems like overkill.The Best Magnesium Supplements for Leg CrampsReady to learn more buy zithromax usa about the best magnesium supplements for leg cramps on the market?.

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This equates to about a 100-day supply, so you’re getting a great value here for about the size of your large coffee in the morning. The Deciding Factor. The deciding factor for Life Extension is its commitment to quality and incredibly affordable price. Sometimes, supplements can seem too expensive, and fall outside the realm of affordability for most people. With Life Extension, you’re getting a 100-day supply for less than $10.

That’s just $0.80 per day, which is a pretty good deal for what you’re getting. 3. Magnesium Breakthrough By BioOptimizersThe Brand. BioOptimizer’s founder, Wade Lightheart, experienced a significant life event that sent him on a journey toward better health and eventually led to his founding of the company. After his sister passed away from cancer, helping others became a personal mission, and he founded BioOptimizers to do just that.

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The Deciding Factor. Aside from Wade’s inspiring personal story, the deciding factor for BioOptmizers is the fact that its supplement contains seven sources of magnesium for maximum benefits. If you’re looking for a high-quality, potent, and affordable supplement, BioOptimizers offers this and many more!. 4. MgSport High Absorption MagnesiumThe Brand.

Founder David Zelniker founded MgSports nearly 15 years ago after making the decision to take control of his health by taking up cycling. The thought came to create a more easily absorbed and potent magnesium supplement for athletes, so David gathered his team and set to work. Now, 15 years later, he’s proud to offer MgSport High Absorption Magnesium for athletes and everyday folks suffering from muscle cramps and other discomforts.The Price. MgSport’s magnesium costs about $20 per bottle but is currently on sale for $15. You can buy it online at major retailers or directly from MgSports.

The high-absorption formula is up to three times more effective than regular magnesium supplements and contains only natural and intentionally-sourced ingredients.The Deciding Factor. The deciding factor for MgSports’ High Absorption Magnesium is the fact that it’s nearly three times as effective as regular magnesium supplements. This makes it worth the cost of around $20, while still being an affordable option for those with stricter budgets. Overall quality, a proprietary formula, and a good price point.5. Klean Athlete MagnesiumThe Brand.

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With over 40 years in the business, the brand has had plenty of time to perfect its supplements and adapt to changes in the market and the availability of ingredients. For $10 per bottle, you can’t do better!. 7. MagWell With Zinc by LiveWellThe Brand. LiveWell offers a simple approach to supplements, taking only what nature has to offer and leaving out harmful synthetics and other artificial ingredients.

Natural products do work, as we’ve seen time and time again — but it boils down to the quality of those products. You’ll find only the best with LiveWell, as the team is committed to providing a holistic, sustainable, high-quality approach to supplementation. The MagWell tablets with zinc offer just that for a good price.The Price. MagWell by LiveWell contains magnesium and zinc, and costs about $17 per bottle, but if you buy more than one, you can save up to 28%. The highest-tier subscription package sends you 4 bottles every eight months, costing around $15 per bottle.

A one-time purchase will cost you about $20, but even that is still reasonable in comparison to other brands.The Deciding Factor. The deciding factor for MagWell by LiveWell is the holistic, simple approach to the brand’s supplements, as well as the option to sign up for an automatic delivery service. This saves you the time and hassle of trying to shop around every time you run out!. Save time and money with this high-quality brand.8. Essential Elements MagnesiumThe Brand.

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Essential Elements offers a few different options for its magnesium plus zinc supplement. You can purchase just one bottle for about $16, or you can buy multiple bottles for a one-time discount of up to 13% off. If you buy 6 bottles or more, you’ll only spend $13.95 each!. The Deciding Factor. The deciding factor for Essential Elements is most certainly its commitment to quality.

Not many supplement brands are third-party certified, or so dutifully follow the FDA’s good manufacturing practices. This ensures you’re getting a top-notch product, and Essential Elements proves again and again that the customer is their top priority. 9. Ancient Nutrients Magnesium By Ancient Nutrition/Dr. AxeThe Brand.

Dr. Axe is a well-known brand in the realm of personal health and beauty, and is proud to introduce the Ancient Nutrition line of health supplements. Chief among these is the incredible Ancient Nutrient Magnesium supplement, made with only the highest-quality ingredients for maximum value. Co-Founders Josh Axe and Jordan Rubin made a decision to form Dr. Axe in response to their own health challenges, and they’ve never looked back.

Now, Dr. Axe is one of the most well-known and respected brands in natural medicine and supplements.The Price. Each bottle of Ancient Nutrients Magnesium contains 90 capsules, and costs about $30. You can subscribe to a delivery plan for about $5 less, and your capsules are delivered monthly. As far as supplements go, this is about average, especially for such a well-known brand with high-quality ingredients.

The Deciding Factor. The deciding factor for Dr. Axe’s magnesium supplement is both the brand name behind the product and the quality of the ingredients included. Not to mention, the subscription service offers an opportunity to save you some money while providing the added convenience of an automatic renewal. Overall, it’s a great deal, and worth looking into.10.

Doctor’s Best High-Absorption MagnesiumThe Brand. Doctor’s Best is a more common brand, being present on sites like Amazon and The Vitamin Shoppe, and even in drug stores like Walgreens.

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2 June 2022 To celebrate the Queen's Platinum Jubilee, IBMS Council member Jane Needham reflects on how far the biomedical science profession has come over the past 70 years How far we’ve come During difference between zithromax and azithromycin Queen Elizabeth’s 70 years on the throne, the biomedical science profession has evolved from its humble beginnings in acute hospitals to the highly proficient, regulated and expert profession it is today. Scientific Advances and InnovationIn the 1950s, very low numbers of patient samples could be tested each day (around 20 per speciality). There was an emphasis on detection of infectious diseases, particularly TB and cellular disease, through pathology post-mortems. With the emergence of diagnostic haematology and clinical chemistry, difference between zithromax and azithromycin a small repertoire of manual, time-consuming laboratory investigations and procedures were developed. Over the years there were huge and ongoing advances in biomedical science and the technology that supported it – so much so that change management and innovation is now taken as rote.

Biomedical scientists and laboratory staff regularly apply new scientific methods and advances to their work, and share best practice through their hospital laboratory networks. The profession now has a massive repertoire of laboratory investigations to apply to patient fluid and tissue samples – and produces all the reports that difference between zithromax and azithromycin identify diseases and monitor the effectiveness of treatments. In the UK, biomedical scientists are now directly involved in over 70% of patient diagnoses and investigate over a billion patient samples every year. Education and TrainingThe last 70 years has seen the profession develop from a narrow field with time consuming processes and an unsupported workforce to a graduate entry-level regulated profession, supported with post-graduate education and training qualifications for life-long learning. Through our professional body, the difference between zithromax and azithromycin Institute of Biomedical Science, and our universities, biomedical scientists can now research, develop and apply the latest science and technology to their practice for their patients – and are now able to progress to the point of working with equivalence to their medical colleagues.

The profession’s education and training materials continue to advance and evolve, periodically bringing our profession’s expertise to whole new levels - using advances in knowledge and practice, and innovations in technology, to provide better services and better patient care. Patient SafetyBy embracing new knowledge and technology, biomedical scientists have dramatically improved patient safety and services. Over the difference between zithromax and azithromycin last 70 years we have seen continuous improvement in the accuracy and precision of diagnostic testing and methodologies. As the profession has moved forward, biomedical scientists have developed and applied more and more stringent internal quality control procedures - extending to the introduction of external quality assurance programmes. There has also been the development of diagnostic laboratory quality standards - with UK laboratories being the first NHS services to have an accreditation programme (this is now delivered through UKAS).

With electronic requesting and transmission of results, risk of errors and turnaround times have been reduced and now digital advances allow for virtual discussions of results and difference between zithromax and azithromycin the sharing of digital samples and expertise across networks – using the profession’s expertise ever more effectively. 70 years of Biomedical ScienceIt was a different world entirely when Queen Elizabeth II was first coronated and our profession is one of the greatest indicators of that. Through embracing scientific advances and innovation, and establishing a well of education and training, our ever-increasing contributions to patient care have become widely recognised. We have moved from being the “back room” of the hospital to the beating heart of healthcare..

2 June 2022 To celebrate the Queen's Platinum Jubilee, IBMS Council member Jane Needham reflects on how far the biomedical science profession has come over the http://okelainc.com/?page_id=7 past 70 years How far we’ve come During Queen Elizabeth’s 70 years on the throne, the biomedical science profession has evolved from its humble beginnings in acute hospitals to the highly proficient, regulated buy zithromax usa and expert profession it is today. Scientific Advances and InnovationIn the 1950s, very low numbers of patient samples could be tested each day (around 20 per speciality). There was an emphasis on detection of infectious diseases, particularly TB and cellular disease, through pathology post-mortems.

With the buy zithromax usa emergence of diagnostic haematology and clinical chemistry, a small repertoire of manual, time-consuming laboratory investigations and procedures were developed. Over the years there were huge and ongoing advances in biomedical science and the technology that supported it – so much so that change management and innovation is now taken as rote. Biomedical scientists and laboratory staff regularly apply new scientific methods and advances to their work, and share best practice through their hospital laboratory networks.

The profession now has a massive repertoire of laboratory investigations to apply to patient fluid and tissue samples – and produces all the reports that identify diseases buy zithromax usa and monitor the effectiveness of treatments. In the UK, biomedical scientists are now directly involved in over 70% of patient diagnoses and investigate over a billion patient samples every year. Education and TrainingThe last 70 years has seen the profession develop from a narrow field with time consuming processes and an unsupported workforce to a graduate entry-level regulated profession, supported with post-graduate education and training qualifications for life-long learning.

Through our professional body, the Institute of Biomedical Science, and our universities, biomedical scientists can now research, develop and apply the latest science and technology to their practice for their patients buy zithromax usa – and are now able to progress to the point of working with equivalence to their where to get zithromax medical colleagues. The profession’s education and training materials continue to advance and evolve, periodically bringing our profession’s expertise to whole new levels - using advances in knowledge and practice, and innovations in technology, to provide better services and better patient care. Patient SafetyBy embracing new knowledge and technology, biomedical scientists have dramatically improved patient safety and services.

Over the last 70 years we have seen continuous improvement in the accuracy buy zithromax usa and precision of diagnostic testing and methodologies. As the profession has moved forward, biomedical scientists have developed and applied more and more stringent internal quality control procedures - extending to the introduction of external quality assurance programmes. There has also been the development of diagnostic laboratory quality standards - with UK laboratories being the first NHS services to have an accreditation programme (this is now delivered through UKAS).

With electronic requesting and transmission of results, risk of errors and turnaround times have been reduced and now digital advances buy zithromax usa allow for virtual discussions of results and the sharing of digital samples and expertise across networks – using the profession’s expertise ever more effectively. 70 years of Biomedical ScienceIt was a different world entirely when Queen Elizabeth II was first coronated and our profession is one of the greatest indicators of that. Through embracing scientific advances and innovation, and establishing a well of education and training, our ever-increasing contributions to patient care have become widely recognised.

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They need to know if you have any of these conditions:;

• kidney disease; liver disease
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• pregnant or trying to get pregnant
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To the Can i buy levitra online Editor buy generic zithromax azithromycin. The BA.4 and BA.5 subvariants of the severe acute respiratory syndrome antibiotics 2 (antibiotics) B.1.1.529 (omicron) variant have shown the capacity of escaping from neutralizing antibodies.1 These subvariants had an appreciable presence in Qatar buy generic zithromax azithromycin by early May 2022 (Fig. S1 in the buy generic zithromax azithromycin Supplementary Appendix, available with the full text of this letter at NEJM.org) and had become the dominant subvariants by June 8 (Fig. S2).

We estimated the effectiveness of previous antibiotics in preventing re with BA.4 and BA.5 subvariants using a test-negative, case–control study design (Section S1).2 We extracted data regarding antibiotics laboratory testing, clinical , vaccination, and demographic details from the national antibiotics databases, which include all results of polymerase-chain-reaction (PCR) and rapid antigen testing conducted at health care facilities in Qatar. Previous was defined as a positive test result at least 90 days before a new positive test finding. Persons with negative results were used as controls.2 To control for differences in antibiotics risk in Qatar, we matched cases and controls according to sex, 10-year age group, nationality, number of coexisting medical conditions, calendar week of testing, method of testing, and reason for testing.2 Previous was further categorized according to its occurrence in Qatar before the December 19, 2021, initiation of the omicron wave (pre-omicron s) or after that date (post-omicron s).3 In the main analysis, we estimated the effectiveness of previous against re with BA.4 or BA.5 using the determination of S-gene target failure (SGTF) on PCR testing between May 7 and July 28, 2022 (Fig. S3).

The SGTF designation indicates the deletion of codons 69 and 70 in the S gene, which is common to omicron subvariants BA.1, BA.4, and BA.5. Because the incidence of BA.1 was negligible during the study, as confirmed by sequencing (Section S2), SGTF was used as a proxy marker for BA.4 or BA.5 . The incidence of other variants that were characterized by SGTF was negligible during the study. We also estimated effectiveness on the assumption that all diagnosed antibiotics s between June 8 and July 28, 2022, were BA.4 or BA.5 s, since these were the dominant subvariants during this period.

Details regarding the study population are shown in Figures S3 and S4. The baseline characteristics of the study population are shown in Table S1. The study population was broadly representative of the population of Qatar (Table S2). Table 1.

Table 1. Effectiveness of Previous antibiotics in Preventing Re with Omicron BA.4 and BA.5 Subvariants. The effectiveness of pre-omicron against symptomatic BA.4 or BA.5 re was 35.5% (95% confidence interval [CI], 12.1 to 52.7). The effectiveness against any BA.4 or BA.5 re regardless of the presence of symptoms was 27.7% (95% CI, 19.3 to 35.2) (Table 1).

The effectiveness of post-omicron against symptomatic BA.4 or BA.5 re was 76.2% (95% CI, 66.4 to 83.1). The effectiveness against any BA.4 or BA.5 re was 78.0% (95% CI, 75.0 to 80.7). In the analysis of the effectiveness of previous in which we assumed that all diagnosed s were BA.4 or BA.5, we found results that were similar to those of the main analysis. An analysis of effectiveness that was stratified according to the interval since previous showed waning protection over time (Section S3 and Table S3).

Sensitivity analyses that were performed after adjustment for vaccination status and after matching according to the number of treatment doses confirmed the results of the main analysis (Tables S3 and S4). Analyses that were categorized according to vaccination status also confirmed the study results but suggested that effectiveness could be slightly higher among vaccinated persons. Limitations of the study design are discussed in Section S1. Protection from a previous antibiotics against BA.4 or BA.5 re was modest when the previous had been caused by a pre-omicron variant but strong when it had been caused by a post-omicron subvariant (including BA.1 or BA.2).

Protection of a previous against re with a BA.4 or BA.5 subvariant was lower than that against re with a BA.1 or BA.2 subvariant3-5 because of more waning of immune protection over time and a greater capacity for immune-system evasion with the BA.4 and BA.5 subvariants. Heba N. Altarawneh, M.D.Hiam Chemaitelly, Ph.D.Weill Cornell Medicine–Qatar, Doha, QatarHoussein H. Ayoub, Ph.D.Qatar University, Doha, QatarMohammad R.

Hasan, Ph.D.Sidra Medicine, Doha, QatarPeter Coyle, M.D.Hamad Medical Corporation, Doha, QatarHadi M. Yassine, Ph.D.Hebah A. Al-Khatib, Ph.D.Maria K. Smatti, M.Sc.Qatar University, Doha, QatarZaina Al-Kanaani, Ph.D.Einas Al-Kuwari, M.D.Andrew Jeremijenko, M.D.Anvar H.

Kaleeckal, M.Sc.Ali N. Latif, M.D.Riyazuddin M. Shaik, M.Sc.Hamad Medical Corporation, Doha, QatarHanan F. Abdul-Rahim, Ph.D.Gheyath K.

Nasrallah, Ph.D.Qatar University, Doha, QatarMohamed G. Al-Kuwari, M.D.Primary Health Care Corporation, Doha, QatarAdeel A. Butt, M.B., B.S.Hamad Medical Corporation, Doha, QatarHamad E. Al-Romaihi, M.D.Mohamed H.

Al-Thani, M.D.Ministry of Public Health, Doha, QatarAbdullatif Al-Khal, M.D.Hamad Medical Corporation, Doha, QatarRoberto Bertollini, M.D., M.P.H.Ministry of Public Health, Doha, QatarPatrick Tang, M.D., Ph.D.Sidra Medicine, Doha, QatarLaith J. Abu-Raddad, Ph.D.Weill Cornell Medicine–Qatar, Doha, Qatar [email protected] Supported by the Biomedical Research Program and the Biostatistics, Epidemiology, and Biomathematics Research Core at Weill Cornell Medicine–Qatar. The Qatar Ministry of Public Health. Hamad Medical Corporation.

And Sidra Medicine. The Qatar Genome Program and Qatar University Biomedical Research Center supported viral genome sequencing. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on October 5, 2022, at NEJM.org.5 References1.

Hachmann NP, Miller J, Collier A-RY, et al. Neutralization escape by antibiotics omicron subvariants BA.2.12.1, BA.4, and BA.5. N Engl J Med 2022;387:86-88.2. Ayoub HH, Tomy M, Chemaitelly H, et al.

Estimating protection afforded by prior in preventing re. Applying the test-negative study design. January 3, 2022 (https://www.medrxiv.org/content/10.1101/2022.01.02.22268622v1). Preprint.Google Scholar3.

Altarawneh HN, Chemaitelly H, Ayoub HH, et al. Effects of previous and vaccination on symptomatic omicron s. N Engl J Med 2022;387:21-34.4. Altarawneh HN, Chemaitelly H, Hasan MR, et al.

Protection against the omicron variant from previous antibiotics . N Engl J Med 2022;386:1288-1290.5. Chemaitelly H, Ayoub HH, Coyle P, et al. Protection of omicron sub-lineage against re with another omicron sub-lineage.

To the find more Editor buy zithromax usa. The BA.4 and BA.5 subvariants of the severe acute respiratory syndrome antibiotics 2 (antibiotics) B.1.1.529 (omicron) variant have shown the capacity of escaping from neutralizing antibodies.1 These subvariants had an appreciable presence in Qatar by early May 2022 (Fig buy zithromax usa. S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org) and had buy zithromax usa become the dominant subvariants by June 8 (Fig. S2). We estimated the effectiveness of previous antibiotics in preventing re with BA.4 and BA.5 subvariants using a test-negative, case–control study design (Section S1).2 We extracted data regarding antibiotics laboratory testing, clinical , vaccination, and demographic details from the national antibiotics databases, which include all results of polymerase-chain-reaction (PCR) and rapid antigen testing conducted at health care facilities in Qatar.

Previous was defined as a positive test result at least 90 days before a new positive test finding. Persons with negative results were used as controls.2 To control for differences in antibiotics risk in Qatar, we matched cases and controls according to sex, 10-year age group, nationality, number of coexisting medical conditions, calendar week of testing, method of testing, and reason for testing.2 Previous was further categorized according to its occurrence in Qatar before the December 19, 2021, initiation of the omicron wave (pre-omicron s) or after that date (post-omicron s).3 In the main analysis, we estimated the effectiveness of previous against re with BA.4 or BA.5 using the determination of S-gene target failure (SGTF) on PCR testing between May 7 and July 28, 2022 (Fig. S3). The SGTF designation indicates the deletion of codons 69 and 70 in the S gene, which is common to omicron subvariants BA.1, BA.4, and BA.5. Because the incidence of BA.1 was negligible during the study, as confirmed by sequencing (Section S2), SGTF was used as a proxy marker for BA.4 or BA.5 .

The incidence of other variants that were characterized by SGTF was negligible during the study. We also estimated effectiveness on the assumption that all diagnosed antibiotics s between June 8 and July 28, 2022, were BA.4 or BA.5 s, since these were the dominant subvariants during this period. Details regarding the study population are shown in Figures S3 and S4. The baseline characteristics of the study population are shown in Table S1. The study population was broadly representative of the population of Qatar (Table S2).

Table 1. Table 1. Effectiveness of Previous antibiotics in Preventing Re with Omicron BA.4 and BA.5 Subvariants. The effectiveness of pre-omicron against symptomatic BA.4 or BA.5 re was 35.5% (95% confidence interval [CI], 12.1 to 52.7). The effectiveness against any BA.4 or BA.5 re regardless of the presence of symptoms was 27.7% (95% CI, 19.3 to 35.2) (Table 1).

The effectiveness of post-omicron against symptomatic BA.4 or BA.5 re was 76.2% (95% CI, 66.4 to 83.1). The effectiveness against any BA.4 or BA.5 re was 78.0% (95% CI, 75.0 to 80.7). In the analysis of the effectiveness of previous in which we assumed that all diagnosed s were BA.4 or BA.5, we found results that were similar to those of the main analysis. An analysis of effectiveness that was stratified according to the interval since previous showed waning protection over time (Section S3 and Table S3). Sensitivity analyses that were performed after adjustment for vaccination status and after matching according to the number of treatment doses confirmed the results of the main analysis (Tables S3 and S4).

Analyses that were categorized according to vaccination status also confirmed the study results but suggested that effectiveness could be slightly higher among vaccinated persons. Limitations of the study design are discussed in Section S1. Protection from a previous antibiotics against BA.4 or BA.5 re was modest when the previous had been caused by a pre-omicron variant but strong when it had been caused by a post-omicron subvariant (including BA.1 or BA.2). Protection of a previous against re with a BA.4 or BA.5 subvariant was lower than that against re with a BA.1 or BA.2 subvariant3-5 because of more waning of immune protection over time and a greater capacity for immune-system evasion with the BA.4 and BA.5 subvariants. Heba N.

Altarawneh, M.D.Hiam Chemaitelly, Ph.D.Weill Cornell Medicine–Qatar, Doha, QatarHoussein H. Ayoub, Ph.D.Qatar University, Doha, QatarMohammad R. Hasan, Ph.D.Sidra Medicine, Doha, QatarPeter Coyle, M.D.Hamad Medical Corporation, Doha, QatarHadi M. Yassine, Ph.D.Hebah A. Al-Khatib, Ph.D.Maria K.

Smatti, M.Sc.Qatar University, Doha, QatarZaina Al-Kanaani, Ph.D.Einas Al-Kuwari, M.D.Andrew Jeremijenko, M.D.Anvar H. Kaleeckal, M.Sc.Ali N. Latif, M.D.Riyazuddin M. Shaik, M.Sc.Hamad Medical Corporation, Doha, QatarHanan F. Abdul-Rahim, Ph.D.Gheyath K.

Nasrallah, Ph.D.Qatar University, Doha, QatarMohamed G. Al-Kuwari, M.D.Primary Health Care Corporation, Doha, QatarAdeel A. Butt, M.B., B.S.Hamad Medical Corporation, Doha, QatarHamad E. Al-Romaihi, M.D.Mohamed H. Al-Thani, M.D.Ministry of Public Health, Doha, QatarAbdullatif Al-Khal, M.D.Hamad Medical Corporation, Doha, QatarRoberto Bertollini, M.D., M.P.H.Ministry of Public Health, Doha, QatarPatrick Tang, M.D., Ph.D.Sidra Medicine, Doha, QatarLaith J.

Abu-Raddad, Ph.D.Weill Cornell Medicine–Qatar, Doha, Qatar [email protected] Supported by the Biomedical Research Program and the Biostatistics, Epidemiology, and Biomathematics Research Core at Weill Cornell Medicine–Qatar. The Qatar Ministry of Public Health. Hamad Medical Corporation. And Sidra Medicine. The Qatar Genome Program and Qatar University Biomedical Research Center supported viral genome sequencing.

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on October 5, 2022, at NEJM.org.5 References1. Hachmann NP, Miller J, Collier A-RY, et al. Neutralization escape by antibiotics omicron subvariants BA.2.12.1, BA.4, and BA.5. N Engl J Med 2022;387:86-88.2.

Ayoub HH, Tomy M, Chemaitelly H, et al. Estimating protection afforded by prior in preventing re. Applying the test-negative study design. January 3, 2022 (https://www.medrxiv.org/content/10.1101/2022.01.02.22268622v1). Preprint.Google Scholar3.

Altarawneh HN, Chemaitelly H, Ayoub HH, et al. Effects of previous and vaccination on symptomatic omicron s. N Engl J Med 2022;387:21-34.4. Altarawneh HN, Chemaitelly H, Hasan MR, et al. Protection against the omicron variant from previous antibiotics .

N Engl J Med 2022;386:1288-1290.5. Chemaitelly H, Ayoub HH, Coyle P, et al. Protection of omicron sub-lineage against re with another omicron sub-lineage. Nat Commun 2022;13:4675-4675..

Zithromax action

Concern about the link between opioid prescribing and preventable adverse drug events has led to a series of initiatives to reduce opioid use, with opioids identified as one of three high-priority check this site out drug classes targeted to reduce patient harms in the United States (US)’s National Action Plan for Adverse Drug Event Prevention.1 Variation zithromax action in opioid prescribing practices by physicians has been observed, yet the reasons why these differences exist remain largely unknown. A better understanding of these differences may help to improve prescribing practice zithromax action for opioids. Sex and gender considerations in opioid prescribing practices have not been well studied and zithromax action may help address this important knowledge gap.There is some evidence to suggest that sex and gender of physicians can affect prescribing practices for older adults.2 Patient gender has also been related to the experience of health conditions, health-seeking behaviours and medication use.3–5 Sex (biologic), a term describing the physical characteristics and biological attributes of males, females and intersex individuals, influences biological manifestations of medical conditions and responses to drug therapy.5 In contrast, gender (sociocultural) refers to the socially constructed norms, behaviours and roles associated with being a man, woman or gender diverse person.6 While these concepts are related, they are often incorrectly interchanged. Considering sex and gender, and how they intersect with key identity factors such as age, culture, race and ethnicity, is an analytical approach7 that can be applied to systematically explore the influence of sex and gender on prescribing practices, revealing potentially important differences or trends that would otherwise remain obscured. Such an zithromax action approach provides the opportunity to inform prescribing practices in general, and pain management strategies in particular.

This will allow healthcare provision to be tailored to the zithromax action unique needs of women, men and gender diverse people, including those in different age groups, acknowledging the evolution of health and medication needs across the life span.The study by Tamblyn and colleagues,8 published in this edition of the journal, underscores the utility and value of considering patient and provider sex along with other key identity factors such as age, race and culture in all clinical research. This study also presents the opportunity to consider the wider role of patient and physician gender on prescribing, and why the inclusion of both sex and gender may be essential to uncovering important variations in clinical practice, and to capturing the diversity of health needs and experiences in patient populations.In their study, Tamblyn8 zithromax action set out to explore the impact of physician characteristics, including clinical competence, specialty and country of origin, on opioid prescribing for chronic non-cancer pain. The authors examined the opioid prescribing patterns of a cohort of international medical graduates in the US who completed their Clinical Skills Assessment requirement for the Educational Commission for Foreign Medical Graduates between 1998 and 2004. They were managing older zithromax action patients covered by the Medicare part D drug insurance programme who were receiving care in an ambulatory setting for chronic non-cancer pain in 2014 and 2015. Logistic and linear regression were used to explore the association of the prescribing physician’s characteristics with opioid prescribing and the doses prescribed.Outcomes measured in the study included opioid prescribing within 90 days of the clinical evaluation, whether the patient received a non-opioid intervention (eg, physiotherapy treatment or a non-steroidal anti-inflammatory drug) prior to the opioid prescription, and the opioid dose that was prescribed.8 The former outcome is particularly important, as opioids are not first-line therapy for chronic pain.9Notably, even though it zithromax action was not identified as one of the primary variables of interest, the Tamblyn study8 revealed the importance of routinely stratifying data by sex.

Further, the study underlines the importance of the collection and use of sex and age disaggregated data to better understand health status.10 More specifically, this study illustrates why it is important to consider provider sex in opioid prescribing, as well as gender-related sociocultural factors. First, there are important physician and patient factors that relate to their sex and others that are gender related zithromax action. Most (61%) of the prescribing physicians in this study zithromax action were men. This is in part because medicine itself is gendered.11 While the proportion of female physicians has grown substantially over the past few decades, they remain under-represented in most specialties, especially those that are higher paying, including some of those explored within the present study.11 12Women are more likely than men to experience the chronic conditions that cause pain.13 The most common chronic non-cancer conditions being managed in this study were back and neck pain, zithromax action migraine/headaches, rheumatoid or osteoarthritis, and neuropathic pain. Each of these conditions occur more commonly in older women than in older men.

For example, compared with men of the same age, women aged 65 years and older in Canada are 1.9 times more likely to zithromax action have been diagnosed with rheumatoid arthritis and are 1.4 times more likely to have been diagnosed with osteoarthritis.14 Migraine headaches are experienced by almost twice as many women as men (7.4% of women compared with 3.4% of men)10 and neuropathic pain is similarly more prevalent among women.13 The predominance of older women experiencing these chronic non-cancer pain conditions may be one reason why more than 66% of the older patients being managed for chronic pain in the Tamblyn study were women. Unless these differences are examined using sex and age disaggregated data, important patterns in the characteristics of the prescribers and the differences in pain experienced by older women and men will remain hidden in the data.A second salient finding of this study was that the odds of prescribing an opioid for non-cancer chronic conditions was 11% higher zithromax action for male physicians (OR 1.11, 95% CI 1.03 to 1.19).8 Further, for every 10% increase in the clinical encounter score (used to measure clinical competence), the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94), but not for male physicians (OR 0.99, 95% CI 0.92 to 1.07).8 These findings align with the existing literature that reports on correlations between physician gender-related sociocultural factors and prescribing behaviour, patient care and clinical outcomes. Female physicians have been shown to prescribe medications at lower doses than male physicians.15 The initiation of medications at low doses, using the ‘start low, go slow approach’, is a practice from geriatric medicine that minimises the risk of harm in older adults, as adverse events are often dose zithromax action related.16 This was illustrated in a study of the initiation of drug therapy for the management of dementia. Female prescribers were more likely than their male counterparts to initiate cholinesterase inhibitor therapy at a lower-than-recommended dose and for a shorter duration.15 Previous literature on the prescribing of opioids similarly finds that female physicians prescribe opioids more sparingly than their male counterparts.17 When it comes to patient–clinician interactions, female physicians have been characterised as providing more patient-centred and empathetic care.18 19 Compared with their male counterparts, they have been shown to spend more time with patients, engage in more communicative and active partnerships, and provide more psychosocial support and counselling.19 Female physicians have also been shown to adhere more closely to clinical guidelines20 and practise more evidence-based medicine.21 These differences in care delivery and treatment provision may be linked to the more conservative prescribing practices of female physicians demonstrated in the present study and elsewhere.15 17The differences in opioid prescribing practices between male and female physicians observed in the Tamblyn study are not isolated to pain management or opioid prescribing. Rather, this zithromax action study contributes to recent evidence from different clinical settings and specialties, suggesting that patients cared for by female physicians may have better clinical outcomes compared with their male colleagues.

For instance, when matched for patient, surgeon and hospital characteristics in a large zithromax action population-based cohort study, patients of female surgeons identified as having 1 of 25 index procedures were found to experience lower risk of short-term postoperative death than those cared for by male surgeons.22 Similarly, female internists treating older adults hospitalised with a medical condition were found to provide significantly better outcomes than their male colleagues in terms of 30-day mortality and readmission rates.23Data on physician and patient sex or gender-related sociocultural factors are often not reported on or described in research studies, making further synthesis of findings through meta-analysis difficult.24 Consistent reporting of this information can allow for aggregation of data and establishment of stronger correlations between prescriber sex and gender, and clinical outcomes.Finally, considering a sex-based and gender-based analytical approach that includes an intersection with cultural factors for both patients and prescribers may be key to a better understanding of opioid prescribing and pain management. Gender-based psychosocial patient factors have been related to behavioural responses and expressions of perceived pain, which often reflect societal norms.25 As a social construct, gender is understood to be context specific and thus varying cultural expectations for pain management, potentially linked to country of origin, may influence how a patient experiences pain and a physician’s likelihood of opioid prescribing for common pain problems. In the present study, Tamblyn found that while the prescriber’s country of origin did not influence the odds of opioid prescribing, US and Canadian physicians, both men and women, prescribed opioids at higher doses.8 Therefore, the potential influence of cultural norms and gender in relation to clinical treatment and diagnosis of pain may also reveal disproportionate cross-national impacts that would otherwise remain hidden.This study has highlighted the importance of considering patient and prescriber sex, gender and other key identity factors including age and culture, in all research studies in order to better zithromax action inform clinical care. Given the risks associated with potentially inappropriate opioid use in older adults, it is worth exploring further how the more cautious practices of female physicians could offer a learning opportunity to optimise health outcomes for all.Ethics statementsPatient consent for publicationNot required.Ensuring patient safety in low-and-middle-income countries (LMICs) requires tailored zithromax action approaches that are appropriate to the unique challenges faced by health systems in LMICs. To date, the evidence zithromax action on how to effectively improve patient safety in LMICs is limited and although we can infer lessons from high-income countries (HICs), there are meaningful differences between HICs and LMICs that require careful study.

The study by Hall et al1 in this issue of BMJ Quality &. Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, zithromax action is therefore a welcome addition to this evidence base.1 Based on the findings from Hall et al,1 and the growing focus in the field of implementation science to analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them.2 LMICs have unique contextual factors that require interventions to be adapted, rather than directly transported from HICs.Mixed-methods implementation science studies like those employed in Hall et al’s paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice. Hall et al1 used the Consolidated Framework for Implementation Research (CFIR)3 to identify facilitators and barriers for implementation zithromax action and inform the optimisation of patient safety implementation strategies in Guatemala. They evaluated implementation determinants acting across multiple zithromax action levels, including the individual, inner organisational context, and external environment which led to several insights related to the overall health system and context. The authors found that clinical staff were intrinsically motivated to provide high-quality and safe care for their patients, but often faced systems barriers of insufficient time, resources and staff to implement known evidence-based protocols.

Some of these are similar as experienced in HICs, but others zithromax action unique for the context of LMICs. In addition, due to the hierarchical structure of the system, staff mentioned the need for increased governance and system/organizational-level structures to support and encourage patient safety.While the CFIR framework proved to be a helpful tool in the Hall et al1 study for identifying individual determinants, many existing implementation science theories, models and frameworks fail to consider the characteristics of the overall health system within which a discrete implementation strategy is embedded zithromax action. For example, the current Expert Recommendations for Implementing Change compilation of implementation strategies has generated a list of 73 discrete implementation strategies that can be adopted for patient safety.4 Yet, we question whether any discrete implementation strategy can—or should be—divorced from the overall system in which strategies operate. Our group recently proposed a modified version of the zithromax action CFIR framework for use in LMICs, which includes a new domain focused on ‘Characteristics of Systems’ to address this gap. Systems design features such as the degree of centralisation, availability of supplies, public/private mix and renumeration mechanisms can strongly influence the degree to which policies and practice are taken up zithromax action and need to be considered when studying implementation success.

Although we strongly advocate for the inclusion of a systems domain in both high-income and low-income settings, LMICs face unique systems-level contextual determinants, which warrant specific exploration in implementation science studies and local strategy adaptation to maximise implementation effectiveness.In contrast to many of the challenges facing high-income health systems, many health systems in LMICs are still focused on guaranteeing a minimum zithromax action level of facilities, people and supplies, without which delivering high-quality care may be nearly impossible. Facility readiness surveys across 10 LMICs have shown that only 1% of health centres have all the diagnostics tests and medicines required to perform basic patient services.5 A similar assessment in Mozambique found that essential medicines for primary care were stocked out 20% of the time and upwards of 50% for mental health medications.6 With very limited trained human resources for primary healthcare, nurses in Mozambique are often forced to deliver sub-standard care as they race to evaluate 60 or more patients in a day and patients wait hours in the heat to be seen.7 Similarly, throughout the buy antibiotics zithromax, providers in India,8 Nigeria,9 Brazil and around the world10 have had the impossible job of trying to deliver safe and effective care when their health systems have failed to guarantee basic supplies like oxygen, resulting in numerous preventable deaths. Providers cannot be expected to focus on preventing unnecessary when they do not have latex zithromax action gloves or N95 masks to prevent themselves from contracting buy antibiotics, Ebola or other infectious diseases. Similarly, we cannot expect to achieve high-quality mental healthcare with only one psychiatrist per 2 million people and when the antipsychotic medication a patient was prescribed last month zithromax action is now out of stock in an entire province.11 When health systems struggle to guarantee the basics needed to provide essential primary healthcare, providers cannot be expected to provide optimal care. Patient safety efforts must address underlying systems weaknesses and not only add burden—or worse—blame providers who are trying the best they can to provide quality care under circumstances designed by the systems in which they operate.The financing of patient safety programmes is also important to consider, as it reflects priorities, potential for scale, as well as possible interruptions or delays in implementation.

The Hall et al1 study zithromax action identified the lack of financial support and organisational incentives as a barrier to implementation effectiveness. LMICs continue to rely on significant contributions from donor assistance and are at greater risk of a mismatch in the priorities of funding agents compared with HICs.12 Donor-assisted funds also tend to be earmarked and time-bound, restricting health systems’ ability to flexibly use the funds and hampering a smooth transition from pilot stage to zithromax action scaled implementation. The modified CFIR that our group proposed includes these constructs, as well as the perceived ability for a programme to scale, particularly in LMICs where fragmented implementation efforts and pilots are rampant.It is also critical to consider the administrative design of health systems in LMICs zithromax action as a construct in the modified CFIR, as rolling out a patient safety programme in a highly centralised system versus one that is highly decentralised or even federated will influence implementation effectiveness. The Hall et al1 study found that providers were highly motivated on their own to focus on patient safety, but felt limited by their own decision-making autonomy, and lack of national or facility level policies and organisational support. If patient zithromax action safety efforts focus on isolated implementation strategies that are divorced from an understanding of the system within which it will be integrated, the results will be poor.Patient safety efforts also require that adverse events are reliably monitored, reported and properly incentivised.

According to WHO, ‘each year 134 million adverse events occur in hospitals in LMICs due zithromax action to unsafe care, resulting in 2.6 million deaths,’13 yet those figures only capture reported events. Providers who participated in the Hall et al1 study felt that patient safety would not progress in their Guatemalan setting zithromax action without accurate patient outcome data, accountability, incentives aligned to outcomes and clear governing policies. The strength of the health information system in LMICs, the culture around reporting and the way leaders use those data are therefore critical determinants that we argued should be included in a modified CFIR. Taking a zithromax action systems lens would also highlight that data reporting is linked with financing. The variables collected to monitor effectiveness of health programmes in LMICs are often dictated by donor priorities leading to proprietary, siloed systems and inefficiencies for health workers,14 15 an issue which many donors are now trying to combat.16The field of implementation science can help us critically evaluate policies and norms that are considered essential for ‘safe’ care in HICs, but which lack real-world zithromax action evidence in LMICs.

We need to recognise that HICs and LMICs may differ in their definition of ‘safe’ and the way to minimise errors and adverse events may differ across settings. For example, in Western countries, only zithromax action physicians were initially allowed to monitor HIV/AIDS treatment—it was considered ‘unsafe’ for anyone else to do so. Yet, studies in LMICs have demonstrated that care can be effectively and safely administered by non-physician clinicians, such as nurses,17 an approach that may or zithromax action may not be accepted in HICs. We have seen the same pattern demonstrated with task-sharing in family planning,18 mental health,19 20 surgical equipment21 and other non-communicable diseases.22 Implementation science can continue to build our understanding of what patient safety means in LMICs.How we achieve healthcare delivery with no adverse events in LMICs will zithromax action differ across cultures and health systems contexts. Implementers, researchers, managers and policy-makers should consider building patient safety programmes that use implementation strategies targeting the numerous barriers that exist at the provider level and also at the level of the health system as a whole.

Future implementation research efforts to improve patient safety in zithromax action LMICs should use frameworks, such as the expanded CFIR adapted for LMICs, to evaluate determinants of patient safety at all levels with a specific focus on the systems domain. Without this holistic focus, narrowly defined patient safety programmes will likely have limited effects to improve care for patients and their outcomes zithromax action. Worse, these programmes could demoralise the limited number of trained health providers who are already overburdened as they work on the front lines to ensure ‘health for all’ across LMICs.Ethics statementsPatient consent for publicationNot required..

Concern about the link between opioid prescribing and preventable adverse drug events has led to a series buy zithromax usa of initiatives to reduce opioid use, with opioids identified as one of three high-priority drug classes targeted to reduce patient harms in the United States (US)’s National Action Plan for Adverse How to get a lasix prescription from your doctor Drug Event Prevention.1 Variation in opioid prescribing practices by physicians has been observed, yet the reasons why these differences exist remain largely unknown. A better understanding of these differences may help to improve prescribing buy zithromax usa practice for opioids. Sex and gender considerations in opioid prescribing practices have not been well studied and may help address this important knowledge gap.There is some evidence to suggest that sex and gender of physicians can affect prescribing practices for older adults.2 Patient gender has also been related to the experience of health conditions, health-seeking behaviours and medication use.3–5 Sex (biologic), a term describing the physical characteristics and biological attributes of males, buy zithromax usa females and intersex individuals, influences biological manifestations of medical conditions and responses to drug therapy.5 In contrast, gender (sociocultural) refers to the socially constructed norms, behaviours and roles associated with being a man, woman or gender diverse person.6 While these concepts are related, they are often incorrectly interchanged. Considering sex and gender, and how they intersect with key identity factors such as age, culture, race and ethnicity, is an analytical approach7 that can be applied to systematically explore the influence of sex and gender on prescribing practices, revealing potentially important differences or trends that would otherwise remain obscured.

Such an approach provides the opportunity to inform prescribing practices in general, buy zithromax usa and pain management strategies in particular. This will allow healthcare provision to be tailored to the unique needs of women, men and gender diverse people, including those in different age groups, acknowledging the evolution of health and medication needs across the life span.The study by Tamblyn and colleagues,8 published in this edition of the journal, buy zithromax usa underscores the utility and value of considering patient and provider sex along with other key identity factors such as age, race and culture in all clinical research. This study also presents the opportunity to consider the wider role buy zithromax usa of patient and physician gender on prescribing, and why the inclusion of both sex and gender may be essential to uncovering important variations in clinical practice, and to capturing the diversity of health needs and experiences in patient populations.In their study, Tamblyn8 set out to explore the impact of physician characteristics, including clinical competence, specialty and country of origin, on opioid prescribing for chronic non-cancer pain. The authors examined the opioid prescribing patterns of a cohort of international medical graduates in the US who completed their Clinical Skills Assessment requirement for the Educational Commission for Foreign Medical Graduates between 1998 and 2004.

They were managing older patients covered by the Medicare part D drug insurance programme who were receiving care in an buy zithromax usa ambulatory setting for chronic non-cancer pain in 2014 and 2015. Logistic and linear regression were used to explore the association of the prescribing physician’s characteristics with opioid prescribing and the doses prescribed.Outcomes measured in the study included opioid prescribing within 90 days of the clinical evaluation, whether the patient received a non-opioid intervention (eg, physiotherapy treatment or a non-steroidal anti-inflammatory drug) prior to the opioid prescription, and the opioid dose that was prescribed.8 The former outcome is particularly important, as opioids are not first-line therapy for chronic pain.9Notably, even though it was not identified as one of the primary variables of interest, the Tamblyn study8 revealed the importance of routinely stratifying buy zithromax usa data by sex. Further, the study underlines the importance of the collection and use of sex and age disaggregated data to better understand health status.10 More specifically, this study illustrates why it is important to consider provider sex in opioid prescribing, as well as gender-related sociocultural factors. First, there are important physician and patient factors that relate to their sex and others that are gender buy zithromax usa related.

Most (61%) of buy zithromax usa the prescribing physicians in this study were men. This is in part because medicine itself is gendered.11 While the proportion of female physicians has grown substantially over the past few decades, they remain under-represented in most specialties, especially those that are higher paying, including some of those explored within the present study.11 12Women are more likely than men to experience the chronic conditions that cause pain.13 The most common chronic non-cancer conditions being managed in this study were back and neck pain, buy zithromax usa migraine/headaches, rheumatoid or osteoarthritis, and neuropathic pain. Each of these conditions occur more commonly in older women than in older men. For example, compared with men of the same age, women aged 65 years and older in Canada are 1.9 times more likely to have been diagnosed with rheumatoid arthritis and are 1.4 times more likely to have been diagnosed with osteoarthritis.14 Migraine headaches are experienced by buy zithromax usa almost twice as many women as men (7.4% of women compared with 3.4% of men)10 and neuropathic pain is similarly more prevalent among women.13 The predominance of older women experiencing these chronic non-cancer pain conditions may be one reason why more than 66% of the older patients being managed for chronic pain in the Tamblyn study were women.

Unless these differences are examined using sex and age disaggregated data, important patterns in the characteristics of the prescribers and the differences in pain experienced by older women and men will remain hidden in the data.A second salient finding of this study was that the odds of prescribing an opioid for non-cancer chronic conditions was 11% higher for male physicians (OR 1.11, 95% CI 1.03 to 1.19).8 Further, for every 10% increase in the clinical encounter score (used to measure clinical competence), the odds of prescribing an opioid decreased by 16% for female physicians (OR 0.84, 95% CI 0.75 to 0.94), but not for male physicians (OR 0.99, 95% CI 0.92 to 1.07).8 These findings align with the existing literature that buy zithromax usa reports on correlations between physician gender-related sociocultural factors and prescribing behaviour, patient care and clinical outcomes. Female physicians have been shown to prescribe buy zithromax usa medications at lower doses than male physicians.15 The initiation of medications at low doses, using the ‘start low, go slow approach’, is a practice from geriatric medicine that minimises the risk of harm in older adults, as adverse events are often dose related.16 This was illustrated in a study of the initiation of drug therapy for the management of dementia. Female prescribers were more likely than their male counterparts to initiate cholinesterase inhibitor therapy at a lower-than-recommended dose and for a shorter duration.15 Previous literature on the prescribing of opioids similarly finds that female physicians prescribe opioids more sparingly than their male counterparts.17 When it comes to patient–clinician interactions, female physicians have been characterised as providing more patient-centred and empathetic care.18 19 Compared with their male counterparts, they have been shown to spend more time with patients, engage in more communicative and active partnerships, and provide more psychosocial support and counselling.19 Female physicians have also been shown to adhere more closely to clinical guidelines20 and practise more evidence-based medicine.21 These differences in care delivery and treatment provision may be linked to the more conservative prescribing practices of female physicians demonstrated in the present study and elsewhere.15 17The differences in opioid prescribing practices between male and female physicians observed in the Tamblyn study are not isolated to pain management or opioid prescribing. Rather, this study contributes to recent evidence from different clinical settings and specialties, suggesting that patients cared for by female physicians may have better buy zithromax usa clinical outcomes compared with their male colleagues.

For instance, when matched for patient, surgeon and hospital characteristics in a large population-based cohort study, patients of female surgeons identified as having 1 of 25 index procedures were found to experience lower risk of short-term postoperative death than those cared for by male surgeons.22 Similarly, female internists treating older adults hospitalised with a medical condition buy zithromax usa were found to provide significantly better outcomes than their male colleagues in terms of 30-day mortality and readmission rates.23Data on physician and patient sex or gender-related sociocultural factors are often not reported on or described in research studies, making further synthesis of findings through meta-analysis difficult.24 Consistent reporting of this information can allow for aggregation of data and establishment of stronger correlations between prescriber sex and gender, and clinical outcomes.Finally, considering a sex-based and gender-based analytical approach that includes an intersection with cultural factors for both patients and prescribers may be key to a better understanding of opioid prescribing and pain management. Gender-based psychosocial patient factors have been related to behavioural responses and expressions of perceived pain, which often reflect societal norms.25 As a social construct, gender is understood to be context specific and thus varying cultural expectations for pain management, potentially linked to country of origin, may influence how a patient experiences pain and a physician’s likelihood of opioid prescribing for common pain problems. In the present study, Tamblyn found buy zithromax usa that while the prescriber’s country of origin did not influence the odds of opioid prescribing, US and Canadian physicians, both men and women, prescribed opioids at higher doses.8 Therefore, the potential influence of cultural norms and gender in relation to clinical treatment and diagnosis of pain may also reveal disproportionate cross-national impacts that would otherwise remain hidden.This study has highlighted the importance of considering patient and prescriber sex, gender and other key identity factors including age and culture, in all research studies in order to better inform clinical care. Given the risks associated with potentially inappropriate opioid use in older adults, it is worth exploring further how the more cautious practices of female physicians could buy zithromax usa offer a learning opportunity to optimise health outcomes for all.Ethics statementsPatient consent for publicationNot required.Ensuring patient safety in low-and-middle-income countries (LMICs) requires tailored approaches that are appropriate to the unique challenges faced by health systems in LMICs.

To date, the evidence on how to effectively improve patient safety in LMICs is limited and although we can infer lessons from high-income countries (HICs), there are meaningful differences between HICs and LMICs that require careful study buy zithromax usa. The study by Hall et al1 in this issue of BMJ Quality &. Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, is therefore a welcome addition to buy zithromax usa this evidence base.1 Based on the findings from Hall et al,1 and the growing focus in the field of implementation science to analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them.2 LMICs have unique contextual factors that require interventions to be adapted, rather than directly transported from HICs.Mixed-methods implementation science studies like those employed in Hall et al’s paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice. Hall et al1 used the buy zithromax usa Consolidated Framework for Implementation Research (CFIR)3 to identify facilitators and barriers for implementation and inform the optimisation of patient safety implementation strategies in Guatemala.

They evaluated implementation determinants acting across multiple levels, including the individual, inner organisational context, and external environment which led to buy zithromax usa several insights related to the overall health system and context. The authors found that clinical staff were intrinsically motivated to provide high-quality and safe care for their patients, but often faced systems barriers of insufficient time, resources and staff to implement known evidence-based protocols. Some of these are similar as buy zithromax usa experienced in HICs, but others unique for the context of LMICs. In addition, due to the hierarchical structure of the system, staff mentioned the need for increased governance and system/organizational-level structures to support and encourage patient safety.While the CFIR framework proved to be a helpful tool in the Hall et al1 study for identifying individual buy zithromax usa determinants, many existing implementation science theories, models and frameworks fail to consider the characteristics of the overall health system within which a discrete implementation strategy is embedded.

For example, the current Expert Recommendations for Implementing Change compilation of implementation strategies has generated a list of 73 discrete implementation strategies that can be adopted for patient safety.4 Yet, we question whether any discrete implementation strategy can—or should be—divorced from the overall system in which strategies operate. Our group recently proposed a modified version of the CFIR framework buy zithromax usa for use in LMICs, which includes a new domain focused on ‘Characteristics of Systems’ to address this gap. Systems design buy zithromax usa features such as the degree of centralisation, availability of supplies, public/private mix and renumeration mechanisms can strongly influence the degree to which policies and practice are taken up and need to be considered when studying implementation success. Although we strongly advocate for the inclusion of a systems domain in both high-income and low-income settings, LMICs face unique systems-level contextual determinants, which warrant specific exploration in implementation science studies and local strategy adaptation to maximise implementation effectiveness.In contrast to many of the challenges buy zithromax usa facing high-income health systems, many health systems in LMICs are still focused on guaranteeing a minimum level of facilities, people and supplies, without which delivering high-quality care may be nearly impossible.

Facility readiness surveys across 10 LMICs have shown that only 1% of health centres have all the diagnostics tests and medicines required to perform basic patient services.5 A similar assessment in Mozambique found that essential medicines for primary care were stocked out 20% of the time and upwards of 50% for mental health medications.6 With very limited trained human resources for primary healthcare, nurses in Mozambique are often forced to deliver sub-standard care as they race to evaluate 60 or more patients in a day and patients wait hours in the heat to be seen.7 Similarly, throughout the buy antibiotics zithromax, providers in India,8 Nigeria,9 Brazil and around the world10 have had the impossible job of trying to deliver safe and effective care when their health systems have failed to guarantee basic supplies like oxygen, resulting in numerous preventable deaths. Providers cannot be expected to focus on preventing unnecessary when they do not have latex gloves or N95 masks to prevent themselves from buy zithromax usa contracting buy antibiotics, Ebola or other infectious diseases. Similarly, we cannot expect to achieve high-quality mental healthcare with only one psychiatrist per 2 million buy zithromax usa people and when the antipsychotic medication a patient was prescribed last month is now out of stock in an entire province.11 When health systems struggle to guarantee the basics needed to provide essential primary healthcare, providers cannot be expected to provide optimal care. Patient safety efforts must address underlying systems weaknesses and not only add burden—or worse—blame providers who are trying the best they can to provide quality care under circumstances designed by the systems in which they operate.The financing of patient safety programmes is also important to consider, as it reflects priorities, potential for scale, as well as possible interruptions or delays in implementation.

The Hall et al1 study identified the lack of financial buy zithromax usa support and organisational incentives as a barrier to implementation effectiveness. LMICs continue to rely on significant contributions from donor assistance and are at greater risk of a mismatch in the priorities of funding agents compared with HICs.12 Donor-assisted funds also tend to be earmarked and time-bound, restricting health systems’ ability to flexibly use the funds and hampering a smooth transition from pilot stage to buy zithromax usa scaled implementation. The modified CFIR that our group proposed includes these constructs, as well as the perceived ability for a programme to scale, particularly in LMICs where fragmented implementation efforts and pilots are rampant.It is also critical to consider the administrative design of health systems in LMICs as a construct in the modified CFIR, as rolling out a patient safety programme in a highly centralised system versus one that is highly decentralised buy zithromax usa or even federated will influence implementation effectiveness. The Hall et al1 study found that providers were highly motivated on their own to focus on patient safety, but felt limited by their own decision-making autonomy, and lack of national or facility level policies and organisational support.

If patient safety efforts focus on isolated implementation strategies that are divorced from an understanding of the system within which it will be integrated, the results will be poor.Patient safety efforts buy zithromax usa also require that adverse events are reliably monitored, reported and properly incentivised. According to WHO, ‘each year 134 million adverse events occur in hospitals in LMICs due to unsafe care, resulting in 2.6 million deaths,’13 yet those figures only buy zithromax usa capture reported events. Providers who participated in the Hall et al1 study felt that patient safety would not progress in their Guatemalan setting without accurate patient outcome data, accountability, incentives aligned to buy zithromax usa outcomes and clear governing policies. The strength of the health information system in LMICs, the culture around reporting and the way leaders use those data are therefore critical determinants that we argued should be included in a modified CFIR.

Taking a systems lens would also highlight that data buy zithromax usa reporting is linked with financing. The variables collected to monitor effectiveness of health programmes in LMICs are often dictated by donor priorities leading to proprietary, siloed buy zithromax usa systems and inefficiencies for health workers,14 15 an issue which many donors are now trying to combat.16The field of implementation science can help us critically evaluate policies and norms that are considered essential for ‘safe’ care in HICs, but which lack real-world evidence in LMICs. We need to recognise that HICs and LMICs may differ in their definition of ‘safe’ and the way to minimise errors and adverse events may differ across settings. For example, in Western countries, only physicians were initially allowed buy zithromax usa to monitor HIV/AIDS treatment—it was considered ‘unsafe’ for anyone else to do so.

Yet, studies in LMICs have demonstrated that care can be effectively and safely administered by buy zithromax usa non-physician clinicians, such as nurses,17 an approach that may or may not be accepted in HICs. We have seen the same pattern demonstrated with task-sharing in buy zithromax usa family planning,18 mental health,19 20 surgical equipment21 and other non-communicable diseases.22 Implementation science can continue to build our understanding of what patient safety means in LMICs.How we achieve healthcare delivery with no adverse events in LMICs will differ across cultures and health systems contexts. Implementers, researchers, managers and policy-makers should consider building patient safety programmes that use implementation strategies targeting the numerous barriers that exist at the provider level and also at the level of the health system as a whole. Future implementation research efforts to improve patient safety in LMICs should use frameworks, such as the expanded CFIR adapted for LMICs, to evaluate determinants of patient safety at all levels with a buy zithromax usa specific focus on the systems domain.

Without this holistic focus, narrowly defined patient safety programmes will likely have limited effects to improve care for buy zithromax usa patients and their outcomes. Worse, these programmes could demoralise the limited number of trained health providers who are already overburdened as they work on the front lines to ensure ‘health for all’ across LMICs.Ethics statementsPatient consent for publicationNot required..