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The Fairy Meadow community will soon receive its own ambulance station under the NSW Government’s $232 million Rural Ambulance buy kamagra with free samples Infrastructure Reconfiguration (RAIR) program.Minister for Health Brad Hazzard said Fairy Meadow was identified as the ideal location to base a new station to provide the best ambulance coverage across the Illawarra region, now and in the future.“This is a first for Fairy Meadow, providing paramedics with a modern facility with state-of-the-art equipment to help them carry out their vital job of saving lives in the local Illawarra communities,” Mr Hazzard said.“The next step will be choosing the best site in Fairy Meadow to build the ambulance station. To do this we have expert help from tried and tested international software which maps Triple Zero calls.”NSW Ambulance Assistant Commissioner Clare Lorenzen said the announcement was another welcome NSW Government initiative for regional and rural communities.“Operating from a new base in Fairy Meadow, our local paramedics will be well positioned to continue to provide the best possible high-quality emergency medical care to residents of local communities,” Ms Lorenzen said.“The additional ambulance service in Fairy Meadow will support the Bulli and Wollongong ambulance stations to strengthen the coverage of the Illawarra region.” The RAIR program is the single largest investment in regional NSW Ambulance’s 126-year history, buy kamagra with free samples with 24 new or upgraded ambulance stations already delivered or under construction as part of the $132 million Stage 1 program. The new station for the Illawarra community is part of the NSW Government’s additional $100 million investment in Stage 2 of the RAIR program.In 2020-21, the NSW Government is investing more than $1 buy kamagra with free samples billion in services and capital works for NSW Ambulance.This includes $27 million of funding for 180 new NSW Ambulance staff across NSW, as part of the third tranche of the June 2018 commitment to recruit 750 additional paramedic and control centre staff over four years.Work has started on installing additional security fencing on the Sydney Trains network to prevent trespassing and reduce self-harm incidents in the rail corridor.Minister for Transport and Roads Andrew Constance said the $4.5 million of new fencing is being installed across 2.3 kilometres of the rail corridor by the end of 2021.“This new fencing will not only improve safety and stop people accessing the rail network illegally, it will also help save lives,” Mr Constance said.“Tragically, 16 people lost their lives on the NSW rail network last year.

There were also 155 near misses and 54 people injured from trespassing or entering the Sydney Trains rail corridor.”Minister for Mental Health Bronnie Taylor said any death by suicide is a tragedy that has a profound impact on the whole community.“We know that when we erect physical barriers in identified suicide ‘hot spots’, it significantly reduces the immediate risk to that individual’s life,” Mrs Taylor said.“I encourage anyone who is having suicidal thoughts to seek help, or talk to a trusted friend about their feelings immediately.”Sydney Trains Acting Chief Executive Pete Church said while most of the Sydney Trains network is already fenced, there are a few locations where people have been able to access the rail corridor.“When people trespass in the rail corridor, they not only risk their life, but their actions can have a long lasting impact for their friends and family, as well as our customers and staff,” Mr Church said.TrackSAFE Executive Director Heather Neil said they work closely with Sydney Trains to raise awareness of rail safety issues, and to reduce near misses on the rail network.“Reducing buy kamagra with free samples accessibility to train lines through the installation of fences and other physical barriers is known to be a successful method of reducing trespass and self-harm incidents,” Ms Neil said.There were more than 2,600 trespassing incidents on the network, including nine people caught train surfing, in the 2019-20 financial year. The minimum fine for trespassing is $400 but can be as high as $5,500.Other Sydney Trains initiatives to prevent trespassing and self-harm incidents include:Training for frontline staff to help them recognise the warning signs for suicide.Emergency help points on every platform, which are directly linked to trained security operators 24 hours a day.More than 12,000 CCTV cameras monitoring the network, including high-definition cameras with stronger capabilities to identify trespassers.If you, or someone you know, is thinking about suicide or experiencing a personal crisis or distress, please seek help immediately by calling 000 or one of these services:Lifeline 13 11 14Suicide Call Back Service 1300 659 467NSW Mental buy kamagra with free samples Health Line 1800 011 511.

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What are kamagra uk paypal the key features of hospitals that consistently deliver safe care on labour and http://www.margraf-publishers.de/buy-amoxil-online-cheap/ delivery?. This is the primary question posed by Liberati and colleagues in this kamagra uk paypal issue of BMJ Quality &. Safety.1 The authors propose a framework distilled from observations on a group of high-performing units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and kamagra uk paypal focus groups and involved over 400 hours of total observations at six different maternity care sites. The seven features in their resulting For Us framework correspond well to existing theoretical as well as applied quality improvement strategies.

While we agree that their framework describes features that every labour and kamagra uk paypal delivery unit should strive to include, this approach has some limitations in terms of generalisability. Specifically, Liberati and colleagues studied maternity units that are high performing, but their sample included only large-volume hospitals in what appear to be well-resourced settings. What is potentially kamagra uk paypal missing is observations on underperforming units, and how these findings may or may not apply to smaller, lower resourced settings. Additionally, the structure of the UK’s National Health Service (NHS) also limits generalisability. For example, this is kamagra uk paypal most analogous to employed physician models in the USA, with the potential advantage of a more organisationally oriented provider workforce.

Given that most US hospitals do not have an employed provider model, we can’t assume that these factors will have the same impact in other models of care.In the USA, the Agency for Healthcare Research and Quality (AHRQ) developed a Culture of Safety framework that delineates four key features. (1) organisations recognise that their primary activities are inherently high risk and make it their goal to operate in a reliably kamagra uk paypal safe manner. (2) organisations create kamagra uk paypal a safe and blame-free reporting environment. (3) interdisciplinary and interprofessional collaboration is encouraged to address safety problems. And (4) resources are deliberately allocated and made available to kamagra uk paypal address safety.2 This framework, as does For Us, focuses on a healthcare-oriented conceptualisation of safety and quality, and details medical outcomes as the primary metrics by which to measure success.

Although achievement of these medical quality outcomes is imperative, we propose that there are additional domains needed to provide safe intrapartum care. (A) prioritising kamagra uk paypal patient experience—including emotional safety, birthing with dignity and an expectation of person-centred care. And (B) a unit culture that values low intervention births. Let us consider these domains in more depth.Patient experience and safety kamagra uk paypal are inextricable. While much work has been done to improve physician–patient communication,3 4 few have successfully targeted the perpetuation of dysfunctional behaviours grounded in healthcare professionals’ implicit and explicit biases.5 This may be in part due to the tendency to observe and look for answers from the standpoint of the healthcare system rather than patients.

Women who had recently given birth kamagra uk paypal were included in the study of Liberati and colleagues, but represented only 8 of 65 individual stakeholder interviews, and were not included in focus groups. The framework thus describes a high-functioning system from primarily the kamagra uk paypal healthcare system’s perspective. In general, the patient’s role in achieving safe care includes many aspects, including providing personal information to reach the correct diagnosis, providing their values and lived experience in shared decision-making discussions, choosing their provider such that their needs regarding provider experience and safe practice are met, making sure that they receive the recommended treatments in a timely manner, as well as identifying and reporting errors.6 The detriment to health outcomes among patients who have failed interactions with providers is well documented (eg, leaving against medical advice or experiencing disrespect during their care) while other harms, such as psychological trauma, often go unmeasured.7Emotional and psychological trauma are safety errors, whether or not a patient leaves the hospital physically intact.8 Research has shown that patients experience psychological trauma both as a result of an adverse outcome and as a result of how the incident was managed. In birth, patients conceptualise the meaning of safety very differently from that of the medical system, with physical and emotional safety being inextricably interwoven into a single concept.9 Psychological trauma may manifest in postpartum depression, post-traumatic kamagra uk paypal stress disorder10 and, some studies suggest, reduced childbearing in patients who experience traumatic birth.11 The experience of emotional safety on the part of the patient is only knowable to the patient, and only addressable when health systems—and health services research—ask the appropriate questions. Therefore, patient-reported experience measures and critical examination of the process of patient-centred care should be at the centre of quality improvement.High-performing units prioritise patient voice and patient experience as a part of their culture.

In a recent article, Morton and Simkin12 delineate steps to promote respectful maternity care in institutions, including obtaining unit commitment to respectful care, implementing training programmes to support respectful care as the norm and, finally, instituting respectful treatment of healthcare staff and clinicians kamagra uk paypal by administrators and leaders—in other words, a unit culture of mutual respect and care among the entire team enables respectful care of the patient. Liberati and colleagues address the issue of hierarchies on labour and delivery, making the key observation that high-performing units create hierarchies around expertise rather than formal titles or disciplinary silos. However, this power differential applies to patients as kamagra uk paypal well. The existing hierarchy on most labour units places physicians at the top and patients at the bottom, which often acts to silence patients’ voices.13 Implicit bias and interpersonal racism and sexism contribute to this cycle of silence and mistreatment on labour and delivery units.14 Disrespect and dismissal of patient concerns have been increasingly described, but still lack quantitative measurement in association with maternal and child health outcomes.15 Interventions aimed at harm reduction are emerging,16 but more work is desperately needed in this area.Valuing low intervention is an important dimension of safety. Safety culture, as it is conceptualised by AHRQ and kamagra uk paypal the current study, is ideally created to prevent or respond to harmful safety lapses.

This model is more difficult to apply to an environment where the goal is safe facilitation of a normal biological process. In this setting, interventions (that often beget more interventions) can kamagra uk paypal increase complications. High rates of primary and kamagra uk paypal repeat caesarean deliveries, and other invasive obstetric interventions seen in many birthing units are now widely acknowledged to be overused and overuse constitutes a patient safety risk.17 In our work in California, we have been able to demonstrate that provider attitudes, beliefs and unit culture can drive caesarean delivery overuse in ways that do not contribute to patient safety.18 19 Each intervention needs to be carefully and jointly considered for value and safety. This in no way diminishes the life-saving nature of caesarean delivery when it is medically indicated, but it sets up the expectation that safety measures, processes and procedures must be in place to actively work towards supporting vaginal birth rather than treating each labour as an emergency waiting to happen. The striking variation in obstetric intervention rates among hospitals and kamagra uk paypal providers can provide critical insights.

So, what is the right balance of intervention rates and mother/baby safety outcomes?. In many kamagra uk paypal instances, this may be a false dichotomy. In a study of California hospital labour practices, Lundsberg et al found that hospitals that prioritised low labour interventions and actively supported vaginal birth (eg, delaying admission until active labour onset, use of doulas, intermittent auscultation of fetal heart tones, non-pharmacological pain relief, and so on) had reduced caesarean delivery rates with well-preserved neonatal outcomes.20 It should be noted that in the USA, rates of intervention are starting at a high level so there is less danger of harm from achieving too low a rate. This may not be the case in the kamagra uk paypal UK where there are now formal inquiries examining obstetric care in multiple NHS hospital trusts where poor perinatal outcomes have been linked to a systematic aversion to medical interventions even when indicated.21 Getting this balance right has been referred to as the Goldilocks quandary. Doing too little, too much or just right?.

22In conclusion, physical safety is the bare minimum of what should be expected in childbirth kamagra uk paypal. Patients have a right, and healthcare providers and systems have an obligation to aim higher, to ensure patients emerge from childbirth as healthy or healthier—both physically and psychologically—than before entering the hospital. This can be best achieved by broadening the lens of kamagra uk paypal what we consider essential to safety on maternity units to include prioritising patient experience, birthing with dignity and valuing low intervention rates. All of these domains need to be in balance. Good mother or baby medical outcomes at the kamagra uk paypal cost of high rates of intervention and high maternal psychological trauma are not a success, nor is the opposite.

The true ‘safe’ maternity unit is one that does well on all of these dimensions, which, of course, means that we need to be able to kamagra uk paypal measure each of them. Finally, all of these safety domains, including the ‘For Us’ framework proposed by Liberati and colleagues, focus on unit culture, provider behaviours and processes of care, and thus are within the reach of all maternity units no matter their level of resources.Healthcare-associated s (HCAIs) are those s acquired by an individual who is seeking medical care in any healthcare facility, including acute care hospitals, long-term care facilities (including nursing homes), outpatient surgical centres, dialysis centres or ambulatory care clinics.1 They are further defined as occurring at least 48 hours after hospitalisation or within 30 days of receiving medical care.2 HCAIs have plagued hospitals, physicians and patients for centuries and likely played a role in the reputation that hospitals historically had as dangerous places.3 In the mid-19th century, Ignaz Semmelweis observed that labouring mothers in an obstetrics unit had a high incidence of Puerperal (Childbed) fever, which he thought was related to direct contact with medical students. After working with cadavers, students kamagra uk paypal often moved directly from the anatomy lab to the hospital, leading Semmelweis to postulate that students were contaminated and bringing a pathogen into the unit. He saw dramatic improvements in maternal mortality after introducing a chlorinated lime hand wash for healthcare providers.4 Though not quickly accepted at large, his observations would become part of the foundation of the germ theory that we intuitively accept today.Over a century after Semmelweis introduced the idea of hand hygiene, prevention in healthcare settings has been thrust into the spotlight worldwide. In the 1960s, the US Centers for Disease Control and Prevention (CDC) conducted research within the Comprehensive Hospital s Project and introduced surveillance and kamagra uk paypal control techniques still used today.

The creation of the National Healthcare Safety Network (NHSN) propelled control onto a national public health platform in the USA.3 Today, reduction of HCAIs has become a regulatory, financial and quality imperative across the world.Healthcare frequently involves the use of invasive devices and procedures that can increase the risk of HCAIs, including catheter-associated urinary tract s, central-line associated bloodstream s (CLABSIs), surgical site s and ventilator-associated events.5 The development of antimicrobial resistance related to antibiotic misuse or overuse6 has given rise to multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae and diarrheal s with Clostridioides difficile. Today, most states in the USA have passed kamagra uk paypal legislation mandating that healthcare facilities publicly report HCAIs, most often using the CDC NHSN surveillance definition for event reporting.7 Globally, the WHO’s Clean Care is Safer Care Programme is working alongside many nations to introduce surveillance and reporting programmes to strengthen the international response.8The patient environment has become a major focus of control interventions. Although a large proportion of HCAIs are attributed to a patient’s endogenous microflora, up to 40% of nosocomial s are cross-s from the hands of healthcare providers, including transmission from high-touch patient-care surfaces.9 In order for pathogens to be transmitted, they generally must have characteristics that make them more robust in the environment, such as the ability to frequently colonise, survive and remain virulent on environmental surfaces and the ability to transiently colonise and pass from the hands of healthcare providers to patients or environmental surfaces.9 C. Difficile poses additional challenges for environmental control because of its ability to form spores that resist dry heat and many disinfectants.9 Even with active surveillance and the introduction of new environmental dis kamagra uk paypal technologies, such as uaviolet germicidal irradiation,10 studies have demonstrated that patients hospitalised in rooms with previous occupants who were MRSA colonised or infected with C. Difficile were more likely to become contaminated,7 supporting the notion that hospital environments play an important role in HCAI transmission.Both the duration of hospitalisation and frequency of transfer between and within healthcare facilities increase the likelihood of exposure to contaminated environments.

Intrahospital transfers refer to the movement of a patient within a healthcare facility, including transfers from the emergency room to an inpatient unit on admission, between two different units, to a different department for a procedure or diagnostic study or between rooms on the same unit.11 McHaney-Lindstrom and colleagues conducted a retrospective kamagra uk paypal case-control study that found that with every additional intrahospital transfer, the odds of acquiring an with C. Difficile increased by 7%.12 These transfers require a complex cascade of events and are affected by environmental control and communication challenges, professional conflicts related to variation in culture between units, hospital census and provider workload.13 In a systematic review, Bristol and colleagues found that intrahospital transfers are frequently kamagra uk paypal associated with adverse outcomes, such as delirium, increased risk of falls, increased length of stay and prolonged duration of mechanical ventilation and central venous catheterisation.13 This therefore further highlights the significance of intrahospital transfers on patient outcomes.In this issue, Boncea and colleagues report on a retrospective case-control study conducted to estimate the risk of developing a HCAI depending on the number of intrahospital transfers between inpatient units or the same unit.11 The study was conducted in three urban hospitals within one UK hospital organisation. The study focused on patients aged 65 or older, given their higher frequency of access to medical care. Data were collected from the electronic health record (EHR) over a 3-year period and included a total of 24 240 hospitalisations of which 2877 were cases where the patient kamagra uk paypal had a positive clinical culture obtained at least 48 hours after hospitalisation. Cases and controls were matched by potential confounding variables, including Elixhauser comorbidities, age, gender and total number of admissions.

Using multivariable logistic regression modelling, they kamagra uk paypal found that for every additional intrahospital transfer, the odds of acquiring a HCAI increased by 9%, with the most common HCAI being C. Difficile .This study is one of the first to quantify the risk associated with the number of intrahospital transfers and HCAIs. Cases and controls were well matched, kamagra uk paypal and the statistical modelling provides very compelling results. However, it is worth noting some features of the study that can affect the findings. The study does not provide specific details on the kamagra uk paypal active surveillance testing practices of the hospital network.

Without these data, theoretically (and by chance), cases selected for this study could have been colonised by MRSA more frequently than controls, which would introduce a level of bias. C. Difficile was measured from the EHR by positive toxin immunoassay results, but the clinical context of this testing is not clear, raising the possibility that some positive patients may have represented colonisation and not acute . The study also did not adjust for the indication for transfer (eg, transfer to or from the intensive care unit based on patient acuity, transfer for isolation precautions or transfer due to bed capacity or staffing issues) to determine if the patient care needs, isolation status or hospital strain modify the observed risk. As the authors acknowledge, prospective studies are needed to identify the clinical, administrative and systems factors that contribute to more frequent intrahospital transfers.Guidelines for prevention and control of HCAIs include evidence-based interventions that can be broadly categorised as either vertical or horizontal.

Vertical interventions focus on reducing colonisation, and transmission of specific pathogens,7 and include surveillance testing for asymptomatic carriers, contact isolation precautions and targeted decolonisation.7 Horizontal interventions aim to reduce the risk of by a larger group of pathogens, independent of patient-specific conditions, such as optimisation of hand hygiene, antimicrobial stewardship and environmental cleaning practices.7 control programmes are tasked with weighing the risks and benefits of interventions to reduce rates of HCAIs while also being cost effective. Vertical approaches to prevent MRSA transmission and remain controversial due to inconsistent findings.7 In a nationwide US Veteran’s Affairs study that assessed the impact of MRSA surveillance testing and contact isolation in MRSA carriers, researchers demonstrated that these interventions resulted in reduced rates of MRSA and colonisation as well as reductions in the incidence of healthcare-associated C. Difficile and vancomycin-resistant Enterococcus s.14 In contrast, other studies evaluating similar practices in intensive care units found little impact of vertical control measures on MRSA rates15 and describe unintended consequences, such as decreased provider-patient contact, increased patient anxiety and patient dissatisfaction with quality of care.16Under endemic conditions, horizontal interventions may be more cost effective and beneficial given the broader number of microorganisms that can be targeted.7 Hand hygiene remains a core horizontal intervention, but hand hygiene compliance varies widely, with some countries’ hospitals compliance reported as low as 15%.17 Several studies focused on intensive care units have shown significant declines in MRSA colonisation rates when hand hygiene practices improve.7 In addition to hand hygiene, universal decolonisation strategies that typically use chlorhexidine gluconate bathing of high risk patients are more impactful than active surveillance testing for individual pathogens at reducing rates of HCAIs such as CLABSIs.7 A central pillar of control is antimicrobial stewardship. These programmes use coordinated interventions to promote appropriate antimicrobial use, improve patient outcomes, decrease antibiotic resistance and reduce the incidence of s secondary to multidrug-resistant organisms.18 Given variation in environmental dis practices and provider-to-provider communication, reducing the frequency of intrahospital transfers is another potential horizontal intervention to reduce the burden of HCAIs.Boncea and colleagues’ study adds to the growing body of literature that intrahospital transfers may increase the risk of HCAIs. Prior studies have identified that patients experience an average of 2.4 transfers during a hospitalisation and approximately 96% of individuals experience a transfer during hospitalisation.13 Transfers within the hospital also affect patient care and safety in other ways, resulting in delays in diagnosis and treatment due, in part, to poor coordination of care and inadequate handoffs between units.19 Additionally, intrahospital transfers take an average of 1 hour to complete, adding significantly to nursing workload.19The field of control must continue to adapt to changing hospital environments in order to further reduce the risk of HCAIs.

In the most recent progress report from US CDC, one in every 31 US patients will experience a HCAI while hospitalised,20 contributing to preventable deaths and permanent harm and to a tremendous excess cost of care.21 While the impact of these s is readily recognised in the developed world, recent studies indicate that the impact of HCAIs in the developing world is staggering, with one study reporting that the pooled-prevalence of HCAIs in resource-limited settings is 15.5 per 100 patients, compared with 4.5 per 100 patients in the USA and 7.1 per 100 patients in Europe.22 control programmes must continue to survey their respective hospital populations and evolve to the demand of the time, weighing benefits, balancing measures and costs. Reducing the number of intrahospital transfers and improving care coordination across these transitions represent a future opportunity to further reduce the burden of HCAIs..

What are the key features of hospitals that buy kamagra with free samples consistently deliver safe care on labour and delivery?. This is the primary question buy kamagra with free samples posed by Liberati and colleagues in this issue of BMJ Quality &. Safety.1 The authors propose a framework distilled from observations on a group of high-performing units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and focus groups and involved over 400 hours buy kamagra with free samples of total observations at six different maternity care sites.

The seven features in their resulting For Us framework correspond well to existing theoretical as well as applied quality improvement strategies. While we agree that their buy kamagra with free samples framework describes features that every labour and delivery unit should strive to include, this approach has some limitations in terms of generalisability. Specifically, Liberati and colleagues studied maternity units that are high performing, but their sample included only large-volume hospitals in what appear to be well-resourced settings. What is potentially missing is observations buy kamagra with free samples on underperforming units, and how these findings may or may not apply to smaller, lower resourced settings.

Additionally, the structure of the UK’s National Health Service (NHS) also limits generalisability. For example, this is most analogous to employed physician models in buy kamagra with free samples the USA, with the potential advantage of a more organisationally oriented provider workforce. Given that most US hospitals do not have an employed provider model, we can’t assume that these factors will have the same impact in other models of care.In the USA, the Agency for Healthcare Research and Quality (AHRQ) developed a Culture of Safety framework that delineates four key features. (1) organisations recognise that their primary activities are inherently high risk and make it their goal to operate in buy kamagra with free samples a reliably safe manner.

(2) organisations create a safe and buy kamagra with free samples blame-free reporting environment. (3) interdisciplinary and interprofessional collaboration is encouraged to address safety problems. And (4) resources are deliberately allocated and made available to address safety.2 This framework, as buy kamagra with free samples does For Us, focuses on a healthcare-oriented conceptualisation of safety and quality, and details medical outcomes as the primary metrics by which to measure success. Although achievement of these medical quality outcomes is imperative, we propose that there are additional domains needed to provide safe intrapartum care.

(A) prioritising patient experience—including emotional safety, birthing with dignity and an expectation buy kamagra with free samples of person-centred care. And (B) a unit culture that values low intervention births. Let us consider these domains in more depth.Patient experience and safety are inextricable buy kamagra with free samples. While much work has been done to improve physician–patient communication,3 4 few have successfully targeted the perpetuation of dysfunctional behaviours grounded in healthcare professionals’ implicit and explicit biases.5 This may be in part due to the tendency to observe and look for answers from the standpoint of the healthcare system rather than patients.

Women who had recently given birth were included in the study of Liberati and colleagues, but represented only 8 of 65 individual stakeholder interviews, and were buy kamagra with free samples not included in focus groups. The framework thus describes a buy kamagra with free samples high-functioning system from primarily the healthcare system’s perspective. In general, the patient’s role in achieving safe care includes many aspects, including providing personal information to reach the correct diagnosis, providing their values and lived experience in shared decision-making discussions, choosing their provider such that their needs regarding provider experience and safe practice are met, making sure that they receive the recommended treatments in a timely manner, as well as identifying and reporting errors.6 The detriment to health outcomes among patients who have failed interactions with providers is well documented (eg, leaving against medical advice or experiencing disrespect during their care) while other harms, such as psychological trauma, often go unmeasured.7Emotional and psychological trauma are safety errors, whether or not a patient leaves the hospital physically intact.8 Research has shown that patients experience psychological trauma both as a result of an adverse outcome and as a result of how the incident was managed. In birth, patients conceptualise the meaning of safety very differently from that of the medical system, with physical and emotional safety being inextricably interwoven into a single concept.9 Psychological trauma may manifest in postpartum depression, post-traumatic stress disorder10 and, some studies suggest, reduced childbearing in patients who buy kamagra with free samples experience traumatic birth.11 The experience of emotional safety on the part of the patient is only knowable to the patient, and only addressable when health systems—and health services research—ask the appropriate questions.

Therefore, patient-reported experience measures and critical examination of the process of patient-centred care should be at the centre of quality improvement.High-performing units prioritise patient voice and patient experience as a part of their culture. In a recent buy kamagra with free samples article, Morton and Simkin12 delineate steps to promote respectful maternity care in institutions, including obtaining unit commitment to respectful care, implementing training programmes to support respectful care as the norm and, finally, instituting respectful treatment of healthcare staff and clinicians by administrators and leaders—in other words, a unit culture of mutual respect and care among the entire team enables respectful care of the patient. Liberati and colleagues address the issue of hierarchies on labour and delivery, making the key observation that high-performing units create hierarchies around expertise rather than formal titles or disciplinary silos. However, this power differential applies to buy kamagra with free samples patients as well.

The existing hierarchy on most labour units places physicians at the top and patients at the bottom, which often acts to silence patients’ voices.13 Implicit bias and interpersonal racism and sexism contribute to this cycle of silence and mistreatment on labour and delivery units.14 Disrespect and dismissal of patient concerns have been increasingly described, but still lack quantitative measurement in association with maternal and child health outcomes.15 Interventions aimed at harm reduction are emerging,16 but more work is desperately needed in this area.Valuing low intervention is an important dimension of safety. Safety culture, as it is conceptualised by AHRQ and the current study, is ideally created to prevent or respond to buy kamagra with free samples harmful safety lapses. This model is more difficult to apply to an environment where the goal is safe facilitation of a normal biological process. In this buy kamagra with free samples setting, interventions (that often beget more interventions) can increase complications.

High rates of primary and repeat caesarean deliveries, and other invasive obstetric interventions seen in many birthing units are now widely acknowledged to be overused and overuse constitutes a patient safety risk.17 In our work in California, we buy kamagra with free samples have been able to demonstrate that provider attitudes, beliefs and unit culture can drive caesarean delivery overuse in ways that do not contribute to patient safety.18 19 Each intervention needs to be carefully and jointly considered for value and safety. This in no way diminishes the life-saving nature of caesarean delivery when it is medically indicated, but it sets up the expectation that safety measures, processes and procedures must be in place to actively work towards supporting vaginal birth rather than treating each labour as an emergency waiting to happen. The striking variation in obstetric intervention rates among hospitals and buy kamagra with free samples providers can provide critical insights. So, what is the right balance of intervention rates and mother/baby safety outcomes?.

In many buy kamagra with free samples instances, this may be a false dichotomy. In a study of California hospital labour practices, Lundsberg et al found that hospitals that prioritised low labour interventions and actively supported vaginal birth (eg, delaying admission until active labour onset, use of doulas, intermittent auscultation of fetal heart tones, non-pharmacological pain relief, and so on) had reduced caesarean delivery rates with well-preserved neonatal outcomes.20 It should be noted that in the USA, rates of intervention are starting at a high level so there is less danger of harm from achieving too low a rate. This may not be the case in the UK where there are now buy kamagra with free samples formal inquiries examining obstetric care in multiple NHS hospital trusts where poor perinatal outcomes have been linked to a systematic aversion to medical interventions even when indicated.21 Getting this balance right has been referred to as the Goldilocks quandary. Doing too little, too much or just right?.

22In conclusion, physical safety is the bare minimum of what should buy kamagra with free samples be expected in childbirth. Patients have a right, and healthcare providers and systems have an obligation to aim higher, to ensure patients emerge from childbirth as healthy or healthier—both physically and psychologically—than before entering the hospital. This can be best achieved by broadening buy kamagra with free samples the lens of what we consider essential to safety on maternity units to include prioritising patient experience, birthing with dignity and valuing low intervention rates. All of these domains need to be in balance.

Good mother or baby medical outcomes at the cost of high rates of intervention and high maternal buy kamagra with free samples psychological trauma are not a success, nor is the opposite. The true ‘safe’ maternity unit is buy kamagra with free samples one that does well on all of these dimensions, which, of course, means that we need to be able to measure each of them. Finally, all of these safety domains, including the ‘For Us’ framework proposed by Liberati and colleagues, focus on unit culture, provider behaviours and processes of care, and thus are within the reach of all maternity units no matter their level of resources.Healthcare-associated s (HCAIs) are those s acquired by an individual who is seeking medical care in any healthcare facility, including acute care hospitals, long-term care facilities (including nursing homes), outpatient surgical centres, dialysis centres or ambulatory care clinics.1 They are further defined as occurring at least 48 hours after hospitalisation or within 30 days of receiving medical care.2 HCAIs have plagued hospitals, physicians and patients for centuries and likely played a role in the reputation that hospitals historically had as dangerous places.3 In the mid-19th century, Ignaz Semmelweis observed that labouring mothers in an obstetrics unit had a high incidence of Puerperal (Childbed) fever, which he thought was related to direct contact with medical students. After working with cadavers, students often moved directly from the anatomy lab to the hospital, leading Semmelweis to postulate that buy kamagra with free samples students were contaminated and bringing a pathogen into the unit.

He saw dramatic improvements in maternal mortality after introducing a chlorinated lime hand wash for healthcare providers.4 Though not quickly accepted at large, his observations would become part of the foundation of the germ theory that we intuitively accept today.Over a century after Semmelweis introduced the idea of hand hygiene, prevention in healthcare settings has been thrust into the spotlight worldwide. In the 1960s, the US Centers for Disease Control and Prevention buy kamagra with free samples (CDC) conducted research within the Comprehensive Hospital s Project and introduced surveillance and control techniques still used today. The creation of the National Healthcare Safety Network (NHSN) propelled control onto a national public health platform in the USA.3 Today, reduction of HCAIs has become a regulatory, financial and quality imperative across the world.Healthcare frequently involves the use of invasive devices and procedures that can increase the risk of HCAIs, including catheter-associated urinary tract s, central-line associated bloodstream s (CLABSIs), surgical site s and ventilator-associated events.5 The development of antimicrobial resistance related to antibiotic misuse or overuse6 has given rise to multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae and diarrheal s with Clostridioides difficile. Today, most states in the USA have passed legislation buy kamagra with free samples mandating that healthcare facilities publicly report HCAIs, most often using the CDC NHSN surveillance definition for event reporting.7 Globally, the WHO’s Clean Care is Safer Care Programme is working alongside many nations to introduce surveillance and reporting programmes to strengthen the international response.8The patient environment has become a major focus of control interventions.

Although a large proportion of HCAIs are attributed to a patient’s endogenous microflora, up to 40% of nosocomial s are cross-s from the hands of healthcare providers, including transmission from high-touch patient-care surfaces.9 In order for pathogens to be transmitted, they generally must have characteristics that make them more robust in the environment, such as the ability to frequently colonise, survive and remain virulent on environmental surfaces and the ability to transiently colonise and pass from the hands of healthcare providers to patients or environmental surfaces.9 C. Difficile poses additional challenges for environmental control because of its ability buy kamagra with free samples to form spores that resist dry heat and many disinfectants.9 Even with active surveillance and the introduction of new environmental dis technologies, such as uaviolet germicidal irradiation,10 studies have demonstrated that patients hospitalised in rooms with previous occupants who were MRSA colonised or infected with C. Difficile were more likely to become contaminated,7 supporting the notion that hospital environments play an important role in HCAI transmission.Both the duration of hospitalisation and frequency of transfer between and within healthcare facilities increase the likelihood of exposure to contaminated environments. Intrahospital transfers refer to the movement of a patient within a healthcare facility, including transfers from the emergency room to an inpatient unit buy kamagra with free samples on admission, between two different units, to a different department for a procedure or diagnostic study or between rooms on the same unit.11 McHaney-Lindstrom and colleagues conducted a retrospective case-control study that found that with every additional intrahospital transfer, the odds of acquiring an with C.

Difficile increased by 7%.12 These transfers require a complex cascade of events and are affected by environmental control and communication challenges, professional conflicts related to variation in culture between units, hospital census and provider workload.13 In a systematic review, Bristol and colleagues found that intrahospital transfers are frequently associated with adverse outcomes, such as delirium, increased risk of falls, increased length of stay and prolonged duration of mechanical ventilation and central venous catheterisation.13 This therefore further highlights the significance of intrahospital transfers on patient outcomes.In this issue, Boncea and colleagues report on a retrospective case-control study conducted to estimate the risk of developing a HCAI depending on the number of intrahospital transfers between inpatient units or the same unit.11 The study was conducted in three urban hospitals buy kamagra with free samples within one UK hospital organisation. The study focused on patients aged 65 or older, given their higher frequency of access to medical care. Data were collected from the electronic health record (EHR) over a 3-year period and included a total of 24 240 hospitalisations of which 2877 were cases buy kamagra with free samples where the patient had a positive clinical culture obtained at least 48 hours after hospitalisation. Cases and controls were matched by potential confounding variables, including Elixhauser comorbidities, age, gender and total number of admissions.

Using multivariable logistic regression modelling, they found that for every additional intrahospital transfer, the odds of buy kamagra with free samples acquiring a HCAI increased by 9%, with the most common HCAI being C. Difficile .This study is one of the first to quantify the risk associated with the number of intrahospital transfers and HCAIs. Cases and controls were well buy kamagra with free samples matched, and the statistical modelling provides very compelling results. However, it is worth noting some features of the study that can affect the findings.

The study does not buy kamagra with free samples provide specific details on the active surveillance testing practices of the hospital network. Without these data, theoretically (and by chance), cases selected for this study could have been colonised by MRSA more frequently than controls, which would introduce a level of bias. C. Difficile was measured from the EHR by positive toxin immunoassay results, but the clinical context of this testing is not clear, raising the possibility that some positive patients may have represented colonisation and not acute .

The study also did not adjust for the indication for transfer (eg, transfer to or from the intensive care unit based on patient acuity, transfer for isolation precautions or transfer due to bed capacity or staffing issues) to determine if the patient care needs, isolation status or hospital strain modify the observed risk. As the authors acknowledge, prospective studies are needed to identify the clinical, administrative and systems factors that contribute to more frequent intrahospital transfers.Guidelines for prevention and control of HCAIs include evidence-based interventions that can be broadly categorised as either vertical or horizontal. Vertical interventions focus on reducing colonisation, and transmission of specific pathogens,7 and include surveillance testing for asymptomatic carriers, contact isolation precautions and targeted decolonisation.7 Horizontal interventions aim to reduce the risk of by a larger group of pathogens, independent of patient-specific conditions, such as optimisation of hand hygiene, antimicrobial stewardship and environmental cleaning practices.7 control programmes are tasked with weighing the risks and benefits of interventions to reduce rates of HCAIs while also being cost effective. Vertical approaches to prevent MRSA transmission and remain controversial due to inconsistent findings.7 In a nationwide US Veteran’s Affairs study that assessed the impact of MRSA surveillance testing and contact isolation in MRSA carriers, researchers demonstrated that these interventions resulted in reduced rates of MRSA and colonisation as well as reductions in the incidence of healthcare-associated C.

Difficile and vancomycin-resistant Enterococcus s.14 In contrast, other studies evaluating similar practices in intensive care units found little impact of vertical control measures on MRSA rates15 and describe unintended consequences, such as decreased provider-patient contact, increased patient anxiety and patient dissatisfaction with quality of care.16Under endemic conditions, horizontal interventions may be more cost effective and beneficial given the broader number of microorganisms that can be targeted.7 Hand hygiene remains a core horizontal intervention, but hand hygiene compliance varies widely, with some countries’ hospitals compliance reported as low as 15%.17 Several studies focused on intensive care units have shown significant declines in MRSA colonisation rates when hand hygiene practices improve.7 In addition to hand hygiene, universal decolonisation strategies that typically use chlorhexidine gluconate bathing of high risk patients are more impactful than active surveillance testing for individual pathogens at reducing rates of HCAIs such as CLABSIs.7 A central pillar of control is antimicrobial stewardship. These programmes use coordinated interventions to promote appropriate antimicrobial use, improve patient outcomes, decrease antibiotic resistance and reduce the incidence of s secondary to multidrug-resistant organisms.18 Given variation in environmental dis practices and provider-to-provider communication, reducing the frequency of intrahospital transfers is another potential horizontal intervention to reduce the burden of HCAIs.Boncea and colleagues’ study adds to the growing body of literature that intrahospital transfers may increase the risk of HCAIs. Prior studies have identified that patients experience an average of 2.4 transfers during a hospitalisation and approximately 96% of individuals experience a transfer during hospitalisation.13 Transfers within the hospital also affect patient care and safety in other ways, resulting in delays in diagnosis and treatment due, in part, to poor coordination of care and inadequate handoffs between units.19 Additionally, intrahospital transfers take an average of 1 hour to complete, adding significantly to nursing workload.19The field of control must continue to adapt to changing hospital environments in order to further reduce the risk of HCAIs. In the most recent progress report from US CDC, one in every 31 US patients will experience a HCAI while hospitalised,20 contributing to preventable deaths and permanent harm and to a tremendous excess cost of care.21 While the impact of these s is readily recognised in the developed world, recent studies indicate that the impact of HCAIs in the developing world is staggering, with one study reporting that the pooled-prevalence of HCAIs in resource-limited settings is 15.5 per 100 patients, compared with 4.5 per 100 patients in the USA and 7.1 per 100 patients in Europe.22 control programmes must continue to survey their respective hospital populations and evolve to the demand of the time, weighing benefits, balancing measures and costs.

Reducing the number of intrahospital transfers and improving care coordination across these transitions represent a future opportunity to further reduce the burden of HCAIs..

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Maeda Y, Nakamura kamagra gold 100 M, Ninomiya H, et he said al. Trends in intensive neonatal care during the erectile dysfunction treatment outbreak in Japan. Arch Dis Child Fetal kamagra gold 100 Neonatal Ed 2021;106:327–29. Doi. 10.1136/archdischild-2020-320521The authors have noticed an error in table 1 of their short report recently published.

They mistakenly kamagra gold 100 showed values for weeks 10–17 of 2019 instead of those for weeks 2–9 of 2020. The values for ‘Births before 33 6/7 weeks’ and ‘Births between 34 0/7 and 36 6/7 weeks’ of Table 1 should be amended as follows:Births before 33 6/7 weeksWeeks 2-9, 2020. 83, instead of 99Difference (% change). 17 (20.5), instead of 33 (33.3)Births between 34 0/7 and 36 kamagra gold 100 6/7 weeksWeeks 2-9, 2020. 207, instead of 211Difference (% change).

17 (8.2), instead of 21 (10.0)Accordingly, the second sentence of the subsection ‘Preterm births’ should also be corrected to “The number of preterm births showed a statistically significant reduction in weeks 2–9 vs weeks 10–17 of 2020. Births before 33 6/7 gestational weeks from 83 to kamagra gold 100 66 (aIRR, 0.71. 95% CI, 0.50 to 1.00. P=0.05) and births between 34 0/7 and 36 6/7 gestational weeks from 207 to 190 (aIRR, 0.85. 95% CI, 0.74 to 0.98 kamagra gold 100.

P=0.02) (figure 1 and table 1).Reviewing recordings of neonatal resuscitation with parentsFew of us relish the thought of our performance in a challenging situation being recorded and reviewed by others, but many have accepted it for research purposes in the context of newborn resuscitation. At Leiden University Medical Centre Neonatal Unit kamagra gold 100 they have been recording videos of all newborn resuscitations since 2014 in order to study and improve care during transition. The recordings are kept as a part of the medical record and, in contrast with other published practice to date, parents are offered an opportunity to review the recording with a professional and to have still images from it or a copy of the video. In this qualitative study Maria C den Boer and colleagues interviewed parents of preterm babies who had viewed their baby’s recording to provide insight into their experience. The study included 25 parents kamagra gold 100 of 31 preterm babies with median gestational age 27+5 weeks.

Four of the babies had gone on to die in the neonatal unit. Most parents offered the opportunity to see the recording wished to do so and around two thirds asked for images or a copy. The parental experiences of kamagra gold 100 viewing the videos were very positive. The experience improved their understanding of what had happened, enhanced their family relationships, and increased their appreciation of the care team.Colm O’Donnell discusses his own experience with researching video recordings of resuscitation, beginning with a visit to Neil Finer and Wade Rich at University of California, San Diego in 2003. Colm also has positive experiences of sharing the recordings with families.

The team in kamagra gold 100 Leiden recommend this practice. Both articles are an interesting read that will challenge your assumptions and stimulate reflection. See page F346 and F344Physiological responses to facemask application in newborns immediately after birthVincent Gaertner and colleagues reviewed video recordings of initial stabilisation at birth of term and late-preterm infants who were enrolled in a randomised trial of different face-masks. 128 face-mask applications were kamagra gold 100 evaluated. In eleven percent of face-mask applications the infant stopped breathing.

When apnoea occurred after mask application there was a median fall in heart rate of 38 beats per minute. These episodes are kamagra gold 100 considered to represent the trigeminocardiac reflex and recovered within 30 s. Apnoea was also observed after face-mask reapplications, although less frequently. There were a median of kamagra gold 100 4 face-mask applications per infant, suggesting a lot of additional potential for avoidable interruption of support. This observation of apneoa after face-mask application is less frequent than in previous reports in more preterm infants but is still quite common.

See page F381Outcomes of a uniformly active approach to infants born at 22–24 weeks of gestationThis single centre report by Fanny Söderström and colleagues from Uppsala in Sweden describes the outcomes of infants born at 22 to 24 weeks gestation between 2006 and 2015. In this institution, all mother-infant dyads at risk for extremely preterm delivery are provided proactive treatment kamagra gold 100. This includes intrauterine referral when approaching 22 weeks of gestation, provision of tocolytics, antenatal steroids and family counselling. There were 222 liveborn infants born at the hospital or admitted soon after birth. There had been four fetal deaths during in utero transport to the centre and there kamagra gold 100 were 14 stillbirths of fetuses that were alive at admission.

Two infants died in the delivery room after birth. Survival of the liveborn babies was 52% at 22 weeks, 64% at 23 weeks and 70% at 25 weeks. Follow-up information kamagra gold 100 was available for 93% of infants. There were 10 infants with cerebral palsy and no infants who were blind or deaf. Around a third had diagnosis of developmental delay.

The study provides a measure of what can be achieved when decisions to initiate treatment are not selective according to the views kamagra gold 100 of the parents and physicians. See page F413Bronchopulmonary dysplasia and growthTheodore Dassios and colleagues analysed data from the UK National Neonatal Research Database for the years 2014 to 2018. They looked at postnatal growth kamagra gold 100 in all liveborn infants born before 28 weeks gestation and admitted to neonatal units. There were 11 806 infants. Bronchopulmonary dysplsia was defined as any requirement for respiratory support at 36 weeks and affected 57%.

As measured by change in weight and head circumference z-scores from birth to discharge, the infants who developed kamagra gold 100 BPD grew slightly better than those who did not. See page F386Disorders of vision in neonatal hypoxic-ischaemic encephalopathyEva Nagy and colleagues undertook a systematic review of reports of outcome after hypoxic ischaemic encephalopathy to evaluate the evidence relating to visual impairment. Although this is a recognised complication of hypoxic ischaemic encephalopathy, it has not been well described. They identified six studies kamagra gold 100 that enrolled 283 term born infants that met their inclusion criteria. Some form of visual impairment was reported in 35% but there was huge variation in the techniques used for assessment.

It remains difficult to advise families about the risks and nature of visual impairments that might be encountered. There are lots of barriers to kamagra gold 100 obtaining good information in this area because of the need for prolonged follow-up and difficulty in testing individuals with other difficulties. See page F357Management of systemic hypotension in term infants with persistent pulmonary hypertension of the newbornHeather Siefkes and Satyan Lakshminrusimha present a beautifully illustrated review of the multiple factors contributing to haemodynamic disturbance in infants with PPHN, and the mechanisms of action of the various candidate therapeutic agents. This supports a reasoned approach to treatment. The challenge remains to supplement this with high quality kamagra gold 100 evidence.

The HIP trial report illustrates the enormous challenge of studying treatments for haemodynamic disturbance in the immediate newborn period and the hurdles that need to be overcome to enable progress. See page F446 and F398Ethics statementsPatient consent for publicationNot required..

Maeda Y, Buy lasix Nakamura M, Ninomiya H, buy kamagra with free samples et al. Trends in intensive neonatal care during the erectile dysfunction treatment outbreak in Japan. Arch Dis Child Fetal Neonatal Ed 2021;106:327–29 buy kamagra with free samples. Doi.

10.1136/archdischild-2020-320521The authors have noticed an error in table 1 of their short report recently published. They mistakenly showed values for weeks 10–17 of 2019 buy kamagra with free samples instead of those for weeks 2–9 of 2020. The values for ‘Births before 33 6/7 weeks’ and ‘Births between 34 0/7 and 36 6/7 weeks’ of Table 1 should be amended as follows:Births before 33 6/7 weeksWeeks 2-9, 2020. 83, instead of 99Difference (% change).

17 (20.5), instead of 33 (33.3)Births between 34 0/7 buy kamagra with free samples and 36 6/7 weeksWeeks 2-9, 2020. 207, instead of 211Difference (% change). 17 (8.2), instead of 21 (10.0)Accordingly, the second sentence of the subsection ‘Preterm births’ should also be corrected to “The number of preterm births showed a statistically significant reduction in weeks 2–9 vs weeks 10–17 of 2020. Births before 33 6/7 gestational weeks from 83 to 66 (aIRR, 0.71 buy kamagra with free samples.

95% CI, 0.50 to 1.00. P=0.05) and births between 34 0/7 and 36 6/7 gestational weeks from 207 to 190 (aIRR, 0.85. 95% CI, 0.74 to buy kamagra with free samples 0.98. P=0.02) (figure 1 and table 1).Reviewing recordings of neonatal resuscitation with parentsFew of us relish the thought of our performance in a challenging situation being recorded and reviewed by others, but many have accepted it for research purposes in the context of newborn resuscitation.

At Leiden University Medical Centre Neonatal Unit they have been recording videos of all newborn resuscitations since 2014 in order to study and buy kamagra with free samples improve care during transition. The recordings are kept as a part of the medical record and, in contrast with other published practice to date, parents are offered an opportunity to review the recording with a professional and to have still images from it or a copy of the video. In this qualitative study Maria C den Boer and colleagues interviewed parents of preterm babies who had viewed their baby’s recording to provide insight into their experience. The study included 25 parents of 31 preterm babies with buy kamagra with free samples median gestational age 27+5 weeks.

Four of the babies had gone on to die in the neonatal unit. Most parents offered the opportunity to see the recording wished to do so and around two thirds asked for images or a copy. The parental experiences of viewing the videos were buy kamagra with free samples very positive. The experience improved their understanding of what had happened, enhanced their family relationships, and increased their appreciation of the care team.Colm O’Donnell discusses his own experience with researching video recordings of resuscitation, beginning with a visit to Neil Finer and Wade Rich at University of California, San Diego in 2003.

Colm also has positive experiences of sharing the recordings with families. The team buy kamagra with free samples in Leiden recommend this practice. Both articles are an interesting read that will challenge your assumptions and stimulate reflection. See page F346 and F344Physiological responses to facemask application in newborns immediately after birthVincent Gaertner and colleagues reviewed video recordings of initial stabilisation at birth of term and late-preterm infants who were enrolled in a randomised trial of different face-masks.

128 face-mask applications were evaluated buy kamagra with free samples. In eleven percent of face-mask applications the infant stopped breathing. When apnoea occurred after mask application there was a median fall in heart rate of 38 beats per minute. These episodes are considered to represent the trigeminocardiac reflex and recovered within buy kamagra with free samples 30 s.

Apnoea was also observed after face-mask reapplications, although less frequently. There were a median of buy kamagra with free samples 4 face-mask applications per infant, suggesting a lot of additional potential for avoidable interruption of support. This observation of apneoa after face-mask application is less frequent than in previous reports in more preterm infants but is still quite common. See page F381Outcomes of a uniformly active approach to infants born at 22–24 weeks of gestationThis single centre report by Fanny Söderström and colleagues from Uppsala in Sweden describes the outcomes of infants born at 22 to 24 weeks gestation between 2006 and 2015.

In this institution, all mother-infant buy kamagra with free samples dyads at risk for extremely preterm delivery are provided proactive treatment. This includes intrauterine referral when approaching 22 weeks of gestation, provision of tocolytics, antenatal steroids and family counselling. There were 222 liveborn infants born at the hospital or admitted soon after birth. There had buy kamagra with free samples been four fetal deaths during in utero transport to the centre and there were 14 stillbirths of fetuses that were alive at admission.

Two infants died in the delivery room after birth. Survival of the liveborn babies was 52% at 22 weeks, 64% at 23 weeks and 70% at 25 weeks. Follow-up information was available for 93% buy kamagra with free samples of infants. There were 10 infants with cerebral palsy and no infants who were blind or deaf.

Around a third had diagnosis of developmental delay. The study provides a measure of what can be achieved when decisions to initiate treatment are not selective according to the views of the parents and buy kamagra with free samples physicians. See page F413Bronchopulmonary dysplasia and growthTheodore Dassios and colleagues analysed data from the UK National Neonatal Research Database for the years 2014 to 2018. They looked at postnatal growth in all liveborn infants born before 28 weeks gestation and admitted to buy kamagra with free samples neonatal units.

There were 11 806 infants. Bronchopulmonary dysplsia was defined as any requirement for respiratory support at 36 weeks and affected 57%. As measured by change in weight and head circumference z-scores from birth to discharge, the buy kamagra with free samples infants who developed BPD grew slightly better than those who did not. See page F386Disorders of vision in neonatal hypoxic-ischaemic encephalopathyEva Nagy and colleagues undertook a systematic review of reports of outcome after hypoxic ischaemic encephalopathy to evaluate the evidence relating to visual impairment.

Although this is a recognised complication of hypoxic ischaemic encephalopathy, it has not been well described. They identified six studies that buy kamagra with free samples enrolled 283 term born infants that met their inclusion criteria. Some form of visual impairment was reported in 35% but there was huge variation in the techniques used for assessment. It remains difficult to advise families about the risks and nature of visual impairments that might be encountered.

There are lots of barriers to obtaining good information in this area because of the need for prolonged follow-up and difficulty in testing individuals with other difficulties buy kamagra with free samples. See page F357Management of systemic hypotension in term infants with persistent pulmonary hypertension of the newbornHeather Siefkes and Satyan Lakshminrusimha present a beautifully illustrated review of the multiple factors contributing to haemodynamic disturbance in infants with PPHN, and the mechanisms of action of the various candidate therapeutic agents. This supports a reasoned approach to treatment. The challenge remains buy kamagra with free samples to supplement this with high quality evidence.

The HIP trial report illustrates the enormous challenge of studying treatments for haemodynamic disturbance in the immediate newborn period and the hurdles that need to be overcome to enable progress. See page F446 and F398Ethics statementsPatient consent for publicationNot required..

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Some people have opted for off-exchange coverage because their preferred health insurer wasn’t participating in the exchange in their area. This might have been a deciding factor for an applicant who was only eligible for a very small subsidy — or no subsidy at all — and was willing to pay full price for an off-exchange plan from the insurer of their choice. But 2022 is the fourth year in a row with increasing insurer participation in the exchanges, and some big-name insurers are joining or rejoining the exchanges in quite a can i get kamagra over the counter few states. So if you haven’t checked your on-exchange options in a while, this fall is definitely the time to do so. You might be surprised to see how many options you have, and again, how affordable they are.

4 can i get kamagra over the counter. Consumers enrolled in on-exchange plans, but no income details on file and no recent coverage reconsiderations If you’re already enrolled in an on-exchange plan and you had given the exchange a projection of your income for 2021, you probably saw your subsidy amount increase at some point this year. But if the exchange didn’t have an income on file for you, they wouldn’t have been able to activate a subsidy on your behalf (on the HealthCare.gov platform, subsidy amounts were automatically updated in September for people who hadn’t updated their accounts by that point, but only if you had provided a projected income to the exchange when you enrolled in coverage for 2021). And even if your subsidy amount did get updated, you might have remained on the plan you had picked last fall, despite the option to pick a different one after the ARP was can i get kamagra over the counter enacted. The good news is that you’ll be able to claim your full premium tax credit, for the entirety of 2021, when you file your 2021 tax return (assuming you had on-exchange health coverage throughout the year).

And during the open enrollment period for 2022 coverage, you can provide income information to the exchange so that a subsidy is paid on your behalf each month next year. Reconsidering your can i get kamagra over the counter plan choice during open enrollment might end up being beneficial as well. If you didn’t qualify for a subsidy in the past, or if you only qualified for a modest subsidy, you might have picked a Bronze plan or even a catastrophic plan, in an effort to keep your monthly premiums affordable. But with the ARP in place, you might find that you can afford a more robust health plan. And if your income doesn’t exceed 250% of the poverty level (and especially if it doesn’t exceed 200% of the poverty level), pay close attention to the can i get kamagra over the counter available Silver plans.

The larger subsidies may make it possible for you to afford a Silver plan with built-in cost-sharing reductions that significantly reduce out-of-pocket costs. One other point to keep in mind. If you are receiving a premium subsidy this year, be aware that it might change next can i get kamagra over the counter year due to a new insurer entering the market in your area and offering lower-priced plans. Here’s more about how this works, and what to consider as you’re shopping for coverage this fall. The takeaway point here?.

Even if you’ve been happy with can i get kamagra over the counter your plan, you should check your options during open enrollment. This is not the year to let your plan auto-renew. Be sure you’ve provided the exchange with an updated income projection for 2022, and actively compare the plans that are available to you. It’s possible that a plan with better coverage or a broader provider network might be affordable to you for 2022, even if it was financially out of reach when you checked last fall. Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

Thanks to the American Rescue Plan, consumers who in previous years might have found themselves outside the eligible level for subsidies – or who may have found that subsidy amounts were so low as to not be enticing – are now among those buy kamagra with free samples eligible for premium tax credits. So if you haven’t shopped for health insurance lately, you might be surprised to see how affordable your health coverage options are this fall (starting November 1), and how many plan options are available in your area. Millions have already tapped into the subsidies Most people who currently have coverage through the health insurance exchanges have seen improved affordability this year thanks to the American Rescue Plan (ARP).

That includes millions of people who were buy kamagra with free samples already enrolled in plans when the ARP was enacted last March, as well as millions of others who signed up during the special enrollment period that continued through mid-August in most states (and is still ongoing in some states). Use our updated subsidy calculator to estimate how much you can save on your 2021 health insurance premiums. But there are still millions of others who are either uninsured or have obtained coverage elsewhere.

And there are also people who already had coverage in the exchange buy kamagra with free samples in 2021 but didn’t take the option to switch to a more robust plan after the ARP was implemented. If you’re in either of these categories, you don’t want to miss the open enrollment period in the fall of 2021. The Build Back Better Act, which is still under consideration in Congress, would extend the ARP’s subsidies and ensure that health insurance stays affordable in 2023 and beyond.

But even without any new legislative buy kamagra with free samples action, most of the ARP’s subsidy enhancements will remain in place for 2022. That means there will continue to be no upper income limit for premium tax credit (subsidy) eligibility, and the percentage of income that people have to pay for the benchmark plan will continue to be lower than it was in prior years. The overall result is that subsidies are larger than they were in the past, and available to more people.

Who should make a point to review buy kamagra with free samples their subsidy eligibility?. So who needs to pay close attention this fall, during open enrollment?. In reality, anyone who doesn’t have access to Medicare, Medicaid, or an employer-sponsored health plan – because even if you’re already enrolled and happy with the plan you have, auto-renewal is not in your best interest.

But there are several groups of people who really need to shop for coverage buy kamagra with free samples this fall. Let’s take a look at what each of these groups can expect, and why you shouldn’t let open enrollment pass you by if you’re in one of these categories. 1.

The uninsured – eligible for low-cost or NO-cost coverage The majority of uninsured Americans buy kamagra with free samples cite the cost of coverage as the reason they don’t have health insurance. Yet millions of those individuals are eligible for free or very low-cost health coverage but haven’t yet enrolled. This has been the case in prior years as well, but premium-free or very low-cost health plans are even more widely available as a result of the ARP.

If you’re uninsured because you don’t think health insurance is affordable, know that more than a buy kamagra with free samples third of the people who enrolled via HealthCare.gov during the erectile dysfunction treatment/ARP special enrollment period this year purchased plans for less than $10/month. Even if you’ve checked in previous years and couldn’t afford the plans that were available, you’ll want to check again this fall, since the subsidy rules have changed since last year. 2.

Consumers enrolled in non-ACA-compliant plans There are millions of Americans who have purchased health coverage that isn’t compliant with buy kamagra with free samples the ACA. Most of these plans are either less robust than ACA-compliant plans, or use medical underwriting, or both. They include.

Health care sharing ministry plans Farm Bureau non-insurance plans Short-term health insurance plans Fixed indemnity plans Grandmothered plans (no longer for sale, but some plans remain in effect) Grandfathered plans (no longer for sale, but some plans remain in effect) Direct primary care (DPC) memberships Discount plans People purchase or keep these plans buy kamagra with free samples for a variety of reasons. But chief among them has long been the fact that ACA-compliant coverage was unaffordable – or was assumed to be unaffordable. There are also people who prefer some of the benefits that some of these plans offer (the fellowship of being part of a health care sharing ministry, for instance, or the abundantly available primary care with a DPC membership).

But by and large, the reason people buy kamagra with free samples choose coverage that isn’t ACA-compliant, or that isn’t even insurance at all, is because ACA-compliant coverage doesn’t fit in their budgets. This has long included a few main groups of people. Those who earned too much to qualify for subsidies, those affected by the “family glitch,” and those who qualified for only minimal subsidy assistance and still felt that the coverage available in the exchange wasn’t affordable.

(Another group of people unable to afford coverage are those who earn less than the poverty level in 11 states that have refused to expand Medicaid and thus have a coverage buy kamagra with free samples gap. Some people in the coverage gap purchase non-ACA-compliant coverage, but this population is also likely to not have any coverage at all. If you or a loved one are in the coverage gap, we encourage you to read this article.) The ARP has not fixed the family glitch or the coverage gap, although there are legislative and administrative solutions under consideration for each of these.

But the ARP has addressed the other two issues, and those buy kamagra with free samples provisions remain in place for 2022. The income cap for subsidy eligibility has been eliminated, which means that some applicants can qualify for subsidies with income far above 400% of the poverty level. And for those who were already eligible for subsidies, the subsidy amounts are larger than they used to be, making coverage more affordable.

So if you are enrolled in any sort of self-purchased health plan that isn’t compliant with the ACA, you owe it to yourself to check your on-exchange options this fall, during the open enrollment period. Keep in mind that you can do that through the exchange, through buy kamagra with free samples an enhanced direct enrollment entity, or with the assistance of a health insurance broker. 3.

Buyers enrolled in off-exchange health plans There are also people who have “off-exchange” ACA-compliant plans that they’ve purchased directly from an insurance company, without using the exchange. (Note that this is not the same thing as enrolling in an on-exchange buy kamagra with free samples plans through an enhanced direct enrollment entity, many of which are insurance companies). There are a variety of reasons people have chosen to enroll in off-exchange health plans over the last several years.

And for some of those enrollees, 2022 might be the year to switch to an on-exchange plan. Since 2018, some people have opted for off-exchange plans if they weren’t eligible for premium subsidies and wanted to enroll in a buy kamagra with free samples Silver-level plan. This was a very rational choice, encouraged by state insurance commissioners and marketplaces alike.

But if you’ve been buying off-exchange coverage in order to get a Silver plan with a lower price tag, the primary point to keep in mind for 2022 is that you might find that you’re now eligible for premium subsidies. Just like the people described above, who have enrolled in various non-ACA-compliant plans in an effort to obtain affordable coverage, the elimination of the income limit for subsidy eligibility is a game changer for people who were buying off-exchange coverage to buy kamagra with free samples get a lower price on a Silver plan. Some people have opted for off-exchange coverage because their preferred health insurer wasn’t participating in the exchange in their area.

This might have been a deciding factor for an applicant who was only eligible for a very small subsidy — or no subsidy at all — and was willing to pay full price for an off-exchange plan from the insurer of their choice. But 2022 is the fourth year in a row with increasing insurer buy kamagra with free samples participation in the exchanges, and some big-name insurers are joining or rejoining the exchanges in quite a few states. So if you haven’t checked your on-exchange options in a while, this fall is definitely the time to do so.

You might be surprised to see how many options you have, and again, how affordable they are. 4 buy kamagra with free samples. Consumers enrolled in on-exchange plans, but no income details on file and no recent coverage reconsiderations If you’re already enrolled in an on-exchange plan and you had given the exchange a projection of your income for 2021, you probably saw your subsidy amount increase at some point this year.

But if the exchange didn’t have an income on file for you, they wouldn’t have been able to activate a subsidy on your behalf (on the HealthCare.gov platform, subsidy amounts were automatically updated in September for people who hadn’t updated their accounts by that point, but only if you had provided a projected income to the exchange when you enrolled in coverage for 2021). And even if your subsidy amount did get updated, you might have remained on the plan you had picked last fall, despite the option to pick a different one after the ARP was enacted. The good news is that you’ll be able to claim your full premium tax credit, for the entirety of 2021, when you file your 2021 tax return (assuming you had on-exchange health coverage throughout the year).

And during the open enrollment period for 2022 coverage, you can provide income information to the exchange so that a subsidy is paid on your behalf each month next year. Reconsidering your plan choice during open enrollment might end up being beneficial as well. If you didn’t qualify for a subsidy in the past, or if you only qualified for a modest subsidy, you might have picked a Bronze plan or even a catastrophic plan, in an effort to keep your monthly premiums affordable.

But with the ARP in place, you might find that you can afford a more robust health plan. And if your income doesn’t exceed 250% of the poverty level (and especially if it doesn’t exceed 200% of the poverty level), pay close attention to the available Silver plans. The larger subsidies may make it possible for you to afford a Silver plan with built-in cost-sharing reductions that significantly reduce out-of-pocket costs.

One other point to keep in mind. If you are receiving a premium subsidy this year, be aware that it might change next year due to a new insurer entering the market in your area and offering lower-priced plans. Here’s more about how this works, and what to consider as you’re shopping for coverage this fall.

The takeaway point here?. Even if you’ve been happy with your plan, you should check your options during open enrollment. This is not the year to let your plan auto-renew.

Be sure you’ve provided the exchange with an updated income projection for 2022, and actively compare the plans that are available to you. It’s possible that a plan with better coverage or a broader provider network might be affordable to you for 2022, even if it was financially out of reach when you checked last fall. Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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Meaningful social interactions are critical buy kamagra jelly online to an individual's well-being, and such interactions rely on people's behaviors towards one another. In research published in Science, investigators at Massachusetts General Hospital (MGH) have mapped the neurons in the buy kamagra jelly online brain that allow a monkey to process and remember the interactions and behaviors of another monkey to influence the animal's own actions. The findings might be used to develop treatment strategies for people with neuropsychiatric conditions.The study had three Rhesus monkeys sit around a rotary table and take turns to offer an apple slice to one of the other two monkeys. At the same time, the researchers recorded the activity of individual neurons in a brain area known to play a role in social cognition, called the dorsomedial prefrontal cortex (dmPFC).During these interactions, the monkeys reciprocated past buy kamagra jelly online offers of an apple slice and retaliated when they did not receive a slice from another. The researchers' recordings identified distinct neurons in the dmPFC that responded to the actions of other monkeys in the group.

Certain neurons were activated with a particular action and outcome of specific individuals within the group (such buy kamagra jelly online as a neighbor monkey offering an apple slice leads to the outcome of receiving the reward). Many of the neurons encoded information not only about the actions and outcomes of specific individuals but also about their past behavior. This information about past interactions with group members influenced an animal's upcoming decisions to reciprocate or retaliate, and investigators could use the neuronal information to predict which monkey would receive an apple slice from a particular monkey even before it was offered."This finding suggested buy kamagra jelly online that the dmPFC plays a role in strategic decisions. To test this idea, we disrupted the normal activity in this area and found that the animals were less likely to reciprocate," says lead author Raymundo Báez-Mendoza, PhD, an investigator in the Department of Neurosurgery at MGH.The results suggest that the dmPFC plays an important role in mapping out our actions and outcomes as well as the actions of others. "In neuropsychiatric conditions in which this ability is compromised, treatments aimed at improving the functioning of this brain area, either directly or indirectly, might improve buy kamagra jelly online peoples' lives," says senior author Ziv Williams, MD.Co-authors include Emma P.

Mastrobattista, and Amy J. Wang, MD.Funding for the study was provided buy kamagra jelly online by the National Institutes of Health, the Brain &. Behavior Research Foundation, the MGH Fund for Medical Discovery, and the Howard Hughes Medical Institute. Story Source buy kamagra jelly online. Materials provided by Massachusetts General Hospital.

Note. Content may be edited for style and length.Whether chatting with friends at a dinner party or managing a high-stakes meeting at work, communicating with others in a group requires a complex set of mental tasks. Our brains must track who is speaking and what is being said, as well as what our relationship to that person may be -- because, after all, we probably give the opinion of our best friend more weight than that of a complete stranger.A study published today in the journal Science provides the first glimpse into how the brains of social mammals process these types of complex group interactions.In the study, neuroscientists at the University of California, Berkeley, used wireless neural recording devices to track the brain activity of Egyptian fruit bats as they freely interacted in groups and occasionally vocalized to each other through high-pitched screeches and grunts."Most studies of communication, particularly vocalization, are typically performed with single animals or with pairs of animals, but basically none have been conducted in actual group settings," said study co-first author Maimon Rose, a graduate student in the NeuroBat Lab at UC Berkeley. "However, many social mammals, including humans, typically interact in groups. Egyptian fruit bats, specifically, like to interact within large colonies."By tracking which of the bats vocalized, while simultaneously measuring the real-time neural activity in both the vocalizing and the listening bats, the researchers were able to decode how neurons in the bats' frontal cortices distinguished among vocalizations made by themselves and by others, as well how the bats distinguished among different individuals in the group.When they compared the neural recordings among the different bats, they also found that brain activity became highly correlated when a bat made a vocalization.

Surprisingly, they found that communication produced by bats that were "friendlier" -- those that spent more time in close proximity to others -- induced a higher degree of correlations across the brains of the group members. advertisement "Other neuroscience studies have tried to examine small pieces of these interactions individually. For example, one study might examine how neurons respond when somebody else speaks, and then a separate study might look at how neurons respond when that individual speaks," said study senior author Michael Yartsev,an assistant professor of neurobiology and bioengineering at UC Berkeley. "This study is the first to really put all of these pieces together to get a full picture of communication within a social group."Thousands of squabbling roommatesLike humans, Egyptian fruit bats are highly social creatures. After long nights spent flying 10 miles or more in search of ripe fruit, these nocturnal animals pass the daylight hours packed into tight caves and crevices alongside hundreds or thousands of other bats.

Not surprisingly, studies suggest that these bats typically vocalize to squabble over food, sleeping space and mating attempts."These bats are very long-lived -- they live about 25 years -- and basically their entire lives are spent in this group social living," Yartsev said. "So, the ability to live together in a group and communicate with each other is an inherent feature of their lives."Even in laboratory settings, bats seem to prefer the comfort of a crowd, typically spending most of their time physically pressed against each other in a tight cluster. Notably, aside from making clicking noises for echolocation, Egyptian fruit bats do not engage in any long-distance form of communication and appear to vocalize to other bats only when clustered together. advertisement "If you visit these bat caves, you can just look up and see tens of thousands of animals," Yartsev said. "So, it really wouldn't make sense for a bat to shout across to the cave to another bat."Bats' habit of only vocalizing within tight social clumps makes them ideal subjects for studying group communication because, if a bat does call out while in a cluster, that call is most likely an indicator that social communication is taking place.

However, this behavior also posed one of many technical challenges for the research team, said study co-first author Boaz Styr, a postdoctoral researcher in the NeuroBat Lab."One big problem was trying to identify which bat made a vocalization, because they spend their time in tight clusters and sometimes obscure each other," Styr said. "Even though we had high resolution cameras recording at different angles, and lots of microphones around, it could be hard to pinpoint which bat was making a call at exactly which point."During the experiments, four to eight bats were allowed to freely interact in a darkened enclosure in the lab, and allowed to spontaneously vocalize. To accurately identify which bat made each vocalization, the team developed wireless vibration sensors that the bats could wear around their necks, almost like necklaces, and which could detect the vibrations created when a bat made a call."These vibration sensors, paired with our ability to wirelessly record neural data from multiple bats at the same time, allowed us to create this experiment in which the bats could freely behave and spontaneously communicate," Styr said. "Getting all of these technical things to work together was extremely challenging, but it allowed us to ask these very important questions."Neurons for self and othersIn one set of experiments, the researchers allowed groups of four or five bats to freely interact within a darkened enclosure in the lab, while carefully monitoring each bat's vocalizations and brain activity.They found that, within each bat's frontal cortex -- an area known to be involved in mediating social behaviors in animals and humans -- separate sets of neurons were activated, depending on which bat in the group vocalized. In other words, a vocalization from one bat would stimulate activity in one set of neurons, while a vocalization from a different bat would stimulate a different set of neurons.

These correlations were so strong that, after identifying which sets of neurons corresponded to which bat, the researchers could identify which bat had vocalized purely by looking at the neural activity of the other bats."What these individual neurons cared about was, 'Am I making the call?. Or is somebody else making the call?. ' no matter what type of vocalization it was," Styr said. "Other neurons were only sensitive to when one specific bat within the group was talking."Earlier work from the NeuroBat Lab has demonstrated that the brains of bat pairs tend to sync up when they socialize. In this study, the authors discovered that during vocal communication, the whole group syncs up together.

This effect was not observed when the bats simply heard playback of the same sounds, suggesting that this phenomenon was specific to active communication taking place among the group members.Intriguingly, the degree of correlation among the group members' brains appeared to depend on which bat was talking, with some bats having stronger synchronization with specific individuals. Remarkably, these inter-brain patterns lasted for weeks, presumably representing stable social relationships among the individuals.To better understand how social dynamics impact brain activity, the researchers conducted a separate set of experiments in which eight bats were allowed to freely interact in a larger enclosure. In addition to monitoring the vocalizations and neural activity of each bat, they also tracked each bat's spatial position relative to the other bats in the group."Bats can recognize and have stable social relationships with other individual bats, even over long periods of time and in different circumstances," Rose said. "And because we had this group of bats, we decided to track their positions in a larger area to see if that would tell us anything about their social relationships -- who likes whom, and who are more sociable bats and the less sociable bats."They found that, while most "in-cluster" bats spent nearly all their time clumped together with other bats, a couple of "out-of-cluster" bats spent more time off to the side, separate from the group. Surprisingly, the team also found that the in-cluster or out-of-cluster status of a bat impacted the neural activity of the other bats during vocalizations."We found that when the in-cluster bats vocalized, they elicited a much more accurate neural representation of their identity in the other bats and also elicited a much higher level of brain synchrony within the group," Rose said.

"So, while its not entirely clear what exactly is going on, it seems that the behavior of the out-of-cluster bats really shifts their neural representation in the brains of the other bats."Understanding the neural underpinnings of why some individuals can navigate almost any social situation with ease, while others are consistently ostracized or misunderstood, could have major implications for improving human mental health, Yartsev said. He hopes the study inspires neuroscientists to take a more comprehensive look at group communication within other social mammals."Often, in neuroscience, we like to take a simplified approach and focus on one component of a complex process at a time," Yartsev said. "But in reality, the social world is complex. When we spend time with our friends, there's a lot of relationship history and baggage that comes with each interaction. What happened yesterday, who that person is friends with, how each person feels in the moment.

And so, breaking things down and looking at them individually can give an illusion of control but, in fact, make it very difficult to get the complete picture.""Our brains, and those of animals, have evolved for and constantly struggle with the complexity of real life," Yartsev added. "I personally believe that to truly understand the brain, we need to embrace this complexity, rather than fear it, and, indeed, every time we did so, we found out something new and exciting. I hope that this, as well as our other studies, demonstrate that we need to study the brain in all its complexity."Co-authors of the paper include Tobias A. Schmid and Julie E. Elie of UC Berkeley.

This research was supported by the National Institutes of Health (Award DP2-DC016163), the National Institute of Mental Health (Award 1-R01MH25387-01), the New York Stem Cell Foundation (Award NYSCF-R-NI40), the Alfred P. Sloan Foundation (Award FG-2017-9646), the Brain Research Foundation (Award BRFSG-2017-09), the Packard Fellowship (Award 2017-66825), the Klingenstein Simons Fellowship, the Human Frontiers Science Program, the Pew Charitable Trust (Award 00029645), the McKnight Foundation, the Dana Foundation and the Human Frontiers Science Program postdoctoral fellowship.In a new paper, scientists suggest that efforts to understand human cognition should expand beyond the study of individual brains. They call on neuroscientists to incorporate evidence from social science disciplines to better understand how people think."Accumulating evidence indicates that memory, reasoning, decision-making and other higher-level functions take place across people," the researchers wrote in a review in the journal Frontiers in Systems Neuroscience. "Cognition extends into the physical world and the brains of others."The co-authors -- neuroscientist Aron Barbey, a professor of psychology at the University of Illinois Urbana-Champaign. Richard Patterson, a professor emeritus of philosophy at Emory University.

And Steven Sloman, a professor of cognitive, linguistic and psychological sciences at Brown University -- wanted to address the limitations of studying brains in isolation, out of the context in which they operate and stripped of the resources they rely on for optimal function."In cognitive neuroscience, the standard approach is essentially to assume that knowledge is represented in the individual brain and transferred between individuals," Barbey said. "But there are, we think, important cases where those assumptions begin to break down."Take, for instance, the fact that people often "outsource" the task of understanding or coming to conclusions about complex subject matter, using other people's expertise to guide their own decision-making."Most people will agree that smoking contributes to the incidence of lung cancer -- without necessarily understanding precisely how that occurs," Barbey said. "And when doctors diagnose and treat disease, they don't transfer all of their knowledge to their patients. Instead, patients rely on doctors to help them decide the best course of action. advertisement "Without relying on experts in our community, our beliefs would become untethered from the social conventions and scientific evidence that are necessary to support them," he said.

"It would become unclear, for example, whether 'smoking causes lung cancer,' bringing into question the truth of our beliefs, the motivation for our actions."To understand the role that knowledge serves in human intelligence, the researchers wrote that it is necessary to look beyond the individual and to study the community."Cognition is, to a large extent, a group activity, not an individual one," Sloman said. "People depend on others for their reasoning, judgment and decision-making. Cognitive neuroscience is not able to shed light on this aspect of cognitive processing."The limitations of individual knowledge and human dependence on others for understanding are the themes of "The Knowledge Illusion. Why We Never Think Alone," a book Sloman wrote with Phil Fernbach, a cognitive scientist and professor of marketing at the University of Colorado."The challenge for cognitive neuroscience becomes how to capture knowledge that does not reside in the individual brain but is outsourced to the community," Barbey said. advertisement Neuroscientific methods such as functional MRI were designed to track activity in one brain at a time and have limited capacity for capturing the dynamics that occur when individuals interact in large communities, he said.Some neuroscientists are trying to overcome this limitation.

In a recent study, researchers placed two people face-to-face in a scanner and tracked their brain activity and eye movements while they interacted. Other teams use a technique called "hyperscanning," which allows the simultaneous recording of brain activity in people who are physically distant from each another but interacting online.Such efforts have found evidence suggesting that the same brain regions are activated in people who are effectively communicating with one another or cooperating on a task, Barbey said. These studies are also showing how brains operate differently from one another, depending on the type of interaction and the context.Several fields of research are ahead of neuroscience in understanding and embracing the collective, collaborative nature of knowledge, Patterson said. For example, "social epistemology" recognizes that knowledge is a social phenomenon that depends on community norms, a shared language and a reliable method for testing the trustworthiness of potential sources."Philosophers studying natural language also illustrate how knowledge relies on the community," Patterson said. "For example, according to 'externalism,' the meaning of words depends on how they are used and represented within a social context.

Thus, the meaning of the word and its correct use depends on collective knowledge that extends beyond the individual."To address these shortfalls, neuroscientists can look to other social science fields, Barbey said."We need to incorporate not only neuroscience evidence, but also evidence from social psychology, social anthropology and other disciplines that are better positioned to study the community of knowledge," he said.Want to ensure your child hits their expected developmental milestones?. New UBC research suggests living in areas with high exposure to greenspace can help set them up for success.For the study, researchers at the UBC faculty of forestry and faculty of medicine analyzed the developmental scores of 27,372 children in Metro Vancouver who attended kindergarten between 2005 and 2011. They estimated the amount of greenspace around each child's residence from birth to age five. They also assessed levels of traffic-related air pollution and community noise.The results highlight the fundamental importance of natural green spaces like street trees, parks and community gardens, authors say."Most of the children were doing well in their development, in terms of language skills, cognitive capacity, socialization and other outcomes," says study author Ingrid Jarvis (she/her), a PhD candidate in the department of forest and conservation sciences at UBC. "But what's interesting is that those children living in a residential location with more vegetation and richer natural environments showed better overall development than their peers with less greenspace."According to the researchers, the reason for this is partly greenspaces' ability to reduce the harmful effects of air pollution and noise -- environmental challenges that have been shown to adversely affect children's health and development through increased stress, sleep disturbances and central nervous system damage."Few studies have investigated this pathway linking greenspace and developmental outcomes among children, and we believe this is the first Canadian study to do so," adds Jarvis.The researchers assessed early childhood development using the Early Development Instrument (EDI), a survey completed by kindergarten teachers for each child.

The tool measures a child's ability to meet age-appropriate developmental expectations."More research is needed, but our findings suggest that urban planning efforts to increase greenspace in residential neighbourhoods and around schools are beneficial for early childhood development, with potential health benefits throughout life," says the study's senior author and UBC research associate, Matilda van den Bosch (she/her)."Time in nature can benefit everyone, but if we want our children to have a good head start, it's important to provide an enriching environment through nature contact. Access to greenspace from a very young age can help ensure good social, emotional and mental development among children." Story Source. Materials provided by University of British Columbia. Note. Content may be edited for style and length.Brain tumors are difficult to contain and often resistant to conventional treatment methods.

Predicting tumor cell behavior requires a better understanding of their invasion mechanism. Now, researchers from University of Fukui, Japan, have used high-density nanofibers that mimic the microenvironment of the brain to capture these tumor cells, opening doors to novel therapeutic solutions for aggressive brain cancer.Our body heals its injuries by essentially replacing damaged cells with new cells. The new cells often migrate to the site of injury, a process known as "cell migration." However, abnormal cell migration can also facilitate the transport and spread of cancer cells within the body. Glioblastoma multiforme (GBM) is one such example of a highly invasive brain tumor that spreads via migration of the tumor cells. The frequency at which such tumor cells spread and grow make conventional tumor removal methods ineffective.

Furthermore, options such as radiotherapy and chemotherapy are harmful to healthy cells and cause adverse effects. In order to develop improved therapeutic strategies, a precise understanding of the invasion mechanism of GBM cells is necessary.An alternative treatment strategy in consideration involves capturing the migrating tumor cells. It turns out that cell migration is dictated by the structure and the orientation of the "extracellular matrix" (ECM) -- fibrous structures surrounding the cells. By engineering similar structures of desired geometries, it is, therefore, possible to exert control over the migration process.Now in a study published in ACS Applied Bio Materials, researchers from University of Fukui, Japan, have designed a platform based on nanofibers that resemble the ECM to examine their effect on GBM cells. "We fabricated a nanofibrous sheet in which the fiber density changes from end to end gradually using a technique called 'electrospinning' and carried out a culture experiment of brain tumor cells," says Dr.

Satoshi Fujita, who headed the study.The researchers observed clear distinctions in cell movement in nanofibers of different densities. They found that the denser fibers promoted the formation of "focal adhesions" clusters in the cells that resulted in a slower cell migration.Taking advantage of this negative correlation between cell movement and fiber density, the researchers were able to control and direct the migration of cells by designing a nanofibrous sheet with stepwise varying densities. By arranging the fibers in a high-to-low density configuration, they were able to restrict the movement of cells as most of them were captured in the high-density zones. On the other hand, a low-to-high density configuration had the opposite effect and encouraged migration.In addition, they noticed that the gaps between the zones hindered cell migration, leading to cells being trapped in the high-density zones. This one-way migration was observed for the first time and the researchers named it "cell trapping" after fish and insect traps that cause their prey to travel along a single direction before trapping it."The study demonstrates the feasibility of capturing migrating cells using electrospun nanofibers that mimic the microenvironment of the brain," comments Dr.

Fujita.With such remarkable findings, the team is excited about the future prospects of their nanofiber-based platform. "It is available for the design of scaffolding materials, which are the basis of regenerative medicine, in combination with various fiber processing technologies and material surface treatment technologies. This could lead to the development of practical applications of regenerative medicines," speculates Dr. Fujita, "In addition, it can be used as a processing technology for culture carriers for efficient production of biological drugs including proteins, antibodies, and treatments." Story Source. Materials provided by University of Fukui.

Note. Content may be edited for style and length..

Meaningful social interactions are buy kamagra with free samples critical to an individual's well-being, and such interactions rely on people's behaviors towards one another. In research published in Science, investigators at Massachusetts General Hospital (MGH) have mapped buy kamagra with free samples the neurons in the brain that allow a monkey to process and remember the interactions and behaviors of another monkey to influence the animal's own actions. The findings might be used to develop treatment strategies for people with neuropsychiatric conditions.The study had three Rhesus monkeys sit around a rotary table and take turns to offer an apple slice to one of the other two monkeys. At the same time, the researchers recorded the activity of individual neurons in a brain area known to play a buy kamagra with free samples role in social cognition, called the dorsomedial prefrontal cortex (dmPFC).During these interactions, the monkeys reciprocated past offers of an apple slice and retaliated when they did not receive a slice from another.

The researchers' recordings identified distinct neurons in the dmPFC that responded to the actions of other monkeys in the group. Certain neurons were activated with a particular action and outcome of specific individuals within the group (such as a neighbor monkey offering an apple slice leads to the outcome buy kamagra with free samples of receiving the reward). Many of the neurons encoded information not only about the actions and outcomes of specific individuals but also about their past behavior. This information about past interactions with group members influenced an animal's upcoming decisions to reciprocate or retaliate, and investigators could use the neuronal information to predict which monkey would receive an apple slice from a particular monkey even before it was offered."This finding suggested that the dmPFC plays a buy kamagra with free samples role in strategic decisions.

To test this idea, we disrupted the normal activity in this area and found that the animals were less likely to reciprocate," says lead author Raymundo Báez-Mendoza, PhD, an investigator in the Department of Neurosurgery at MGH.The results suggest that the dmPFC plays an important role in mapping out our actions and outcomes as well as the actions of others. "In neuropsychiatric conditions in which this ability is compromised, treatments aimed at improving the functioning of this brain area, either directly or indirectly, might improve peoples' lives," says buy kamagra with free samples senior author Ziv Williams, MD.Co-authors include Emma P. Mastrobattista, and Amy J. Wang, MD.Funding for the study was provided by buy kamagra with free samples the National Institutes of Health, the Brain &.

Behavior Research Foundation, the MGH Fund for Medical Discovery, and the Howard Hughes Medical Institute. Story Source buy kamagra with free samples. Materials provided by Massachusetts General Hospital. Note.

Content may be edited for style and length.Whether chatting with friends at a dinner party or managing a high-stakes meeting at work, communicating with others in a group requires a complex set of mental tasks. Our brains must track who is speaking and what is being said, as well as what our relationship to that person may be -- because, after all, we probably give the opinion of our best friend more weight than that of a complete stranger.A study published today in the journal Science provides the first glimpse into how the brains of social mammals process these types of complex group interactions.In the study, neuroscientists at the University of California, Berkeley, used wireless neural recording devices to track the brain activity of Egyptian fruit bats as they freely interacted in groups and occasionally vocalized to each other through high-pitched screeches and grunts."Most studies of communication, particularly vocalization, are typically performed with single animals or with pairs of animals, but basically none have been conducted in actual group settings," said study co-first author Maimon Rose, a graduate student in the NeuroBat Lab at UC Berkeley. "However, many social mammals, including humans, typically interact in groups. Egyptian fruit bats, specifically, like to interact within large colonies."By tracking which of the bats vocalized, while simultaneously measuring the real-time neural activity in both the vocalizing and the listening bats, the researchers were able to decode how neurons in the bats' frontal cortices distinguished among vocalizations made by themselves and by others, as well how the bats distinguished among different individuals in the group.When they compared the neural recordings among the different bats, they also found that brain activity became highly correlated when a bat made a vocalization.

Surprisingly, they found that communication produced by bats that were "friendlier" -- those that spent more time in close proximity to others -- induced a higher degree of correlations across the brains of the group members. advertisement "Other neuroscience studies have tried to examine small pieces of these interactions individually. For example, one study might examine how neurons respond when somebody else speaks, and then a separate study might look at how neurons respond when that individual speaks," said study senior author Michael Yartsev,an assistant professor of neurobiology and bioengineering at UC Berkeley. "This study is the first to really put all of these pieces together to get a full picture of communication within a social group."Thousands of squabbling roommatesLike humans, Egyptian fruit bats are highly social creatures.

After long nights spent flying 10 miles or more in search of ripe fruit, these nocturnal animals pass the daylight hours packed into tight caves and crevices alongside hundreds or thousands of other bats. Not surprisingly, studies suggest that these bats typically vocalize to squabble over food, sleeping space and mating attempts."These bats are very long-lived -- they live about 25 years -- and basically their entire lives are spent in this group social living," Yartsev said. "So, the ability to live together in a group and communicate with each other is an inherent feature of their lives."Even in laboratory settings, bats seem to prefer the comfort of a crowd, typically spending most of their time physically pressed against each other in a tight cluster. Notably, aside from making clicking noises for echolocation, Egyptian fruit bats do not engage in any long-distance form of communication and appear to vocalize to other bats only when clustered together.

advertisement "If you visit these bat caves, you can just look up and see tens of thousands of animals," Yartsev said. "So, it really wouldn't make sense for a bat to shout across to the cave to another bat."Bats' habit of only vocalizing within tight social clumps makes them ideal subjects for studying group communication because, if a bat does call out while in a cluster, that call is most likely an indicator that social communication is taking place. However, this behavior also posed one of many technical challenges for the research team, said study co-first author Boaz Styr, a postdoctoral researcher in the NeuroBat Lab."One big problem was trying to identify which bat made a vocalization, because they spend their time in tight clusters and sometimes obscure each other," Styr said. "Even though we had high resolution cameras recording at different angles, and lots of microphones around, it could be hard to pinpoint which bat was making a call at exactly which point."During the experiments, four to eight bats were allowed to freely interact in a darkened enclosure in the lab, and allowed to spontaneously vocalize.

To accurately identify which bat made each vocalization, the team developed wireless vibration sensors that the bats could wear around their necks, almost like necklaces, and which could detect the vibrations created when a bat made a call."These vibration sensors, paired with our ability to wirelessly record neural data from multiple bats at the same time, allowed us to create this experiment in which the bats could freely behave and spontaneously communicate," Styr said. "Getting all of these technical things to work together was extremely challenging, but it allowed us to ask these very important questions."Neurons for self and othersIn one set of experiments, the researchers allowed groups of four or five bats to freely interact within a darkened enclosure in the lab, while carefully monitoring each bat's vocalizations and brain activity.They found that, within each bat's frontal cortex -- an area known to be involved in mediating social behaviors in animals and humans -- separate sets of neurons were activated, depending on which bat in the group vocalized. In other words, a vocalization from one bat would stimulate activity in one set of neurons, while a vocalization from a different bat would stimulate a different set of neurons. These correlations were so strong that, after identifying which sets of neurons corresponded to which bat, the researchers could identify which bat had vocalized purely by looking at the neural activity of the other bats."What these individual neurons cared about was, 'Am I making the call?.

Or is somebody else making the call?. ' no matter what type of vocalization it was," Styr said. "Other neurons were only sensitive to when one specific bat within the group was talking."Earlier work from the NeuroBat Lab has demonstrated that the brains of bat pairs tend to sync up when they socialize. In this study, the authors discovered that during vocal communication, the whole group syncs up together.

This effect was not observed when the bats simply heard playback of the same sounds, suggesting that this phenomenon was specific to active communication taking place among the group members.Intriguingly, the degree of correlation among the group members' brains appeared to depend on which bat was talking, with some bats having stronger synchronization with specific individuals. Remarkably, these inter-brain patterns lasted for weeks, presumably representing stable social relationships among the individuals.To better understand how social dynamics impact brain activity, the researchers conducted a separate set of experiments in which eight bats were allowed to freely interact in a larger enclosure. In addition to monitoring the vocalizations and neural activity of each bat, they also tracked each bat's spatial position relative to the other bats in the group."Bats can recognize and have stable social relationships with other individual bats, even over long periods of time and in different circumstances," Rose said. "And because we had this group of bats, we decided to track their positions in a larger area to see if that would tell us anything about their social relationships -- who likes whom, and who are more sociable bats and the less sociable bats."They found that, while most "in-cluster" bats spent nearly all their time clumped together with other bats, a couple of "out-of-cluster" bats spent more time off to the side, separate from the group.

Surprisingly, the team also found that the in-cluster or out-of-cluster status of a bat impacted the neural activity of the other bats during vocalizations."We found that when the in-cluster bats vocalized, they elicited a much more accurate neural representation of their identity in the other bats and also elicited a much higher level of brain synchrony within the group," Rose said. "So, while its not entirely clear what exactly is going on, it seems that the behavior of the out-of-cluster bats really shifts their neural representation in the brains of the other bats."Understanding the neural underpinnings of why some individuals can navigate almost any social situation with ease, while others are consistently ostracized or misunderstood, could have major implications for improving human mental health, Yartsev said. He hopes the study inspires neuroscientists to take a more comprehensive look at group communication within other social mammals."Often, in neuroscience, we like to take a simplified approach and focus on one component of a complex process at a time," Yartsev said. "But in reality, the social world is complex.

When we spend time with our friends, there's a lot of relationship history and baggage that comes with each interaction. What happened yesterday, who that person is friends with, how each person feels in the moment. And so, breaking things down and looking at them individually can give an illusion of control but, in fact, make it very difficult to get the complete picture.""Our brains, and those of animals, have evolved for and constantly struggle with the complexity of real life," Yartsev added. "I personally believe that to truly understand the brain, we need to embrace this complexity, rather than fear it, and, indeed, every time we did so, we found out something new and exciting.

I hope that this, as well as our other studies, demonstrate that we need to study the brain in all its complexity."Co-authors of the paper include Tobias A. Schmid and Julie E. Elie of UC Berkeley. This research was supported by the National Institutes of Health (Award DP2-DC016163), the National Institute of Mental Health (Award 1-R01MH25387-01), the New York Stem Cell Foundation (Award NYSCF-R-NI40), the Alfred P.

Sloan Foundation (Award FG-2017-9646), the Brain Research Foundation (Award BRFSG-2017-09), the Packard Fellowship (Award 2017-66825), the Klingenstein Simons Fellowship, the Human Frontiers Science Program, the Pew Charitable Trust (Award 00029645), the McKnight Foundation, the Dana Foundation and the Human Frontiers Science Program postdoctoral fellowship.In a new paper, scientists suggest that efforts to understand human cognition should expand beyond the study of individual brains. They call on neuroscientists to incorporate evidence from social science disciplines to better understand how people think."Accumulating evidence indicates that memory, reasoning, decision-making and other higher-level functions take place across people," the researchers wrote in a review in the journal Frontiers in Systems Neuroscience. "Cognition extends into the physical world and the brains of others."The co-authors -- neuroscientist Aron Barbey, a professor of psychology at the University of Illinois Urbana-Champaign. Richard Patterson, a professor emeritus of philosophy at Emory University.

And Steven Sloman, a professor of cognitive, linguistic and psychological sciences at Brown University -- wanted to address the limitations of studying brains in isolation, out of the context in which they operate and stripped of the resources they rely on for optimal function."In cognitive neuroscience, the standard approach is essentially to assume that knowledge is represented in the individual brain and transferred between individuals," Barbey said. "But there are, we think, important cases where those assumptions begin to break down."Take, for instance, the fact that people often "outsource" the task of understanding or coming to conclusions about complex subject matter, using other people's expertise to guide their own decision-making."Most people will agree that smoking contributes to the incidence of lung cancer -- without necessarily understanding precisely how that occurs," Barbey said. "And when doctors diagnose and treat disease, they don't transfer all of their knowledge to their patients. Instead, patients rely on doctors to help them decide the best course of action.

advertisement "Without relying on experts in our community, our beliefs would become untethered from the social conventions and scientific evidence that are necessary to support them," he said. "It would become unclear, for example, whether 'smoking causes lung cancer,' bringing into question the truth of our beliefs, the motivation for our actions."To understand the role that knowledge serves in human intelligence, the researchers wrote that it is necessary to look beyond the individual and to study the community."Cognition is, to a large extent, a group activity, not an individual one," Sloman said. "People depend on others for their reasoning, judgment and decision-making. Cognitive neuroscience is not able to shed light on this aspect of cognitive processing."The limitations of individual knowledge and human dependence on others for understanding are the themes of "The Knowledge Illusion.

Why We Never Think Alone," a book Sloman wrote with Phil Fernbach, a cognitive scientist and professor of marketing at the University of Colorado."The challenge for cognitive neuroscience becomes how to capture knowledge that does not reside in the individual brain but is outsourced to the community," Barbey said. advertisement Neuroscientific methods such as functional MRI were designed to track activity in one brain at a time and have limited capacity for capturing the dynamics that occur when individuals interact in large communities, he said.Some neuroscientists are trying to overcome this limitation. In a recent study, researchers placed two people face-to-face in a scanner and tracked their brain activity and eye movements while they interacted. Other teams use a technique called "hyperscanning," which allows the simultaneous recording of brain activity in people who are physically distant from each another but interacting online.Such efforts have found evidence suggesting that the same brain regions are activated in people who are effectively communicating with one another or cooperating on a task, Barbey said.

These studies are also showing how brains operate differently from one another, depending on the type of interaction and the context.Several fields of research are ahead of neuroscience in understanding and embracing the collective, collaborative nature of knowledge, Patterson said. For example, "social epistemology" recognizes that knowledge is a social phenomenon that depends on community norms, a shared language and a reliable method for testing the trustworthiness of potential sources."Philosophers studying natural language also illustrate how knowledge relies on the community," Patterson said. "For example, according to 'externalism,' the meaning of words depends on how they are used and represented within a social context. Thus, the meaning of the word and its correct use depends on collective knowledge that extends beyond the individual."To address these shortfalls, neuroscientists can look to other social science fields, Barbey said."We need to incorporate not only neuroscience evidence, but also evidence from social psychology, social anthropology and other disciplines that are better positioned to study the community of knowledge," he said.Want to ensure your child hits their expected developmental milestones?.

New UBC research suggests living in areas with high exposure to greenspace can help set them up for success.For the study, researchers at the UBC faculty of forestry and faculty of medicine analyzed the developmental scores of 27,372 children in Metro Vancouver who attended kindergarten between 2005 and 2011. They estimated the amount of greenspace around each child's residence from birth to age five. They also assessed levels of traffic-related air pollution and community noise.The results highlight the fundamental importance of natural green spaces like street trees, parks and community gardens, authors say."Most of the children were doing well in their development, in terms of language skills, cognitive capacity, socialization and other outcomes," says study author Ingrid Jarvis (she/her), a PhD candidate in the department of forest and conservation sciences at UBC. "But what's interesting is that those children living in a residential location with more vegetation and richer natural environments showed better overall development than their peers with less greenspace."According to the researchers, the reason for this is partly greenspaces' ability to reduce the harmful effects of air pollution and noise -- environmental challenges that have been shown to adversely affect children's health and development through increased stress, sleep disturbances and central nervous system damage."Few studies have investigated this pathway linking greenspace and developmental outcomes among children, and we believe this is the first Canadian study to do so," adds Jarvis.The researchers assessed early childhood development using the Early Development Instrument (EDI), a survey completed by kindergarten teachers for each child.

The tool measures a child's ability to meet age-appropriate developmental expectations."More research is needed, but our findings suggest that urban planning efforts to increase greenspace in residential neighbourhoods and around schools are beneficial for early childhood development, with potential health benefits throughout life," says the study's senior author and UBC research associate, Matilda van den Bosch (she/her)."Time in nature can benefit everyone, but if we want our children to have a good head start, it's important to provide an enriching environment through nature contact. Access to greenspace from a very young age can help ensure good social, emotional and mental development among children." Story Source. Materials provided by University of British Columbia. Note.

Content may be edited for style and length.Brain tumors are difficult to contain and often resistant to conventional treatment methods. Predicting tumor cell behavior requires a better understanding of their invasion mechanism. Now, researchers from University of Fukui, Japan, have used high-density nanofibers that mimic the microenvironment of the brain to capture these tumor cells, opening doors to novel therapeutic solutions for aggressive brain cancer.Our body heals its injuries by essentially replacing damaged cells with new cells. The new cells often migrate to the site of injury, a process known as "cell migration." However, abnormal cell migration can also facilitate the transport and spread of cancer cells within the body.

Glioblastoma multiforme (GBM) is one such example of a highly invasive brain tumor that spreads via migration of the tumor cells. The frequency at which such tumor cells spread and grow make conventional tumor removal methods ineffective. Furthermore, options such as radiotherapy and chemotherapy are harmful to healthy cells and cause adverse effects. In order to develop improved therapeutic strategies, a precise understanding of the invasion mechanism of GBM cells is necessary.An alternative treatment strategy in consideration involves capturing the migrating tumor cells.

It turns out that cell migration is dictated by the structure and the orientation of the "extracellular matrix" (ECM) -- fibrous structures surrounding the cells. By engineering similar structures of desired geometries, it is, therefore, possible to exert control over the migration process.Now in a study published in ACS Applied Bio Materials, researchers from University of Fukui, Japan, have designed a platform based on nanofibers that resemble the ECM to examine their effect on GBM cells. "We fabricated a nanofibrous sheet in which the fiber density changes from end to end gradually using a technique called 'electrospinning' and carried out a culture experiment of brain tumor cells," says Dr. Satoshi Fujita, who headed the study.The researchers observed clear distinctions in cell movement in nanofibers of different densities.

They found that the denser fibers promoted the formation of "focal adhesions" clusters in the cells that resulted in a slower cell migration.Taking advantage of this negative correlation between cell movement and fiber density, the researchers were able to control and direct the migration of cells by designing a nanofibrous sheet with stepwise varying densities. By arranging the fibers in a high-to-low density configuration, they were able to restrict the movement of cells as most of them were captured in the high-density zones. On the other hand, a low-to-high density configuration had the opposite effect and encouraged migration.In addition, they noticed that the gaps between the zones hindered cell migration, leading to cells being trapped in the high-density zones. This one-way migration was observed for the first time and the researchers named it "cell trapping" after fish and insect traps that cause their prey to travel along a single direction before trapping it."The study demonstrates the feasibility of capturing migrating cells using electrospun nanofibers that mimic the microenvironment of the brain," comments Dr.

Fujita.With such remarkable findings, the team is excited about the future prospects of their nanofiber-based platform. "It is available for the design of scaffolding materials, which are the basis of regenerative medicine, in combination with various fiber processing technologies and material surface treatment technologies. This could lead to the development of practical applications of regenerative medicines," speculates Dr. Fujita, "In addition, it can be used as a processing technology for culture carriers for efficient production of biological drugs including proteins, antibodies, and treatments." Story Source.

Materials provided by University of Fukui. Note. Content may be edited for style and length..