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https://www.cityreal.lv/cheap-discount-cialis/ the priority actions in the New Zealand Healthy Ageing Strategy (2016) was to improve models of care for Home and community Support Services (HCSS) in response to the multiple and growing demands on HCSS. The National Framework for HCSS provides guidance for district health boards for future commissioning, developing, delivering and evaluating HCSS to improve national consistency and quality of care. The cialis coupon National Framework for HCSS was developed in collaboration with key stakeholders in the HCSS sector, including older people and their whānau. It includes.

a vision and principles to guide service design core (essential) components of services that could be expected anywhere in the country a draft outcomes framework describing the outcomes sought from HCSS at individual, population and system levels. The National Framework for HCSS covers DHB-funded cialis coupon services for. people aged 65 years and over who have an assessed need in response to an interRAI assessment and meet criteria for funding people considered to be alike in age and interest – for example, Pacific peoples and Māori, aged over 55 years, and others aged over 60 years, with age-related disabilities older people receiving HCSS who require increased support following an acute health episode who have required hospitalisation HCSS that may continue concurrently with short-term Accident Compensation Corporation (ACC) services. Three additional initiatives are linked with developing the National Framework to help achieve consistency in service commissioning, provision and resource allocation.

First, a National Service Specification for cialis coupon HCSS. This service specification will become the nationally mandated specification describing in detail the services and service approaches required of DHBs and providers. This National Service Specification will be implemented by July 2022, in line with DHB service commissioning timetables. This approach cialis coupon aims to achieve the best balance between national consistency and flexibility for DHBs in meeting the needs of their populations.

Second, a nationally consistent case-mix methodology will be developed for all DHBs to use as a way of improving targeting of resources according to need. Some DHBs are already applying case-mix methods to resource allocation or use. However, different cialis coupon versions of the methodology are being used, resulting in some inconsistency in resource allocation and lack of transparency across DHBs. This indicates the need for a single, nationally consistent case-mix method which will also be implemented across all DHBs by July 2022.

Third, a nationally consistent outcomes and measurement framework will be developed for use in HCSS and is expected to be completed by July 2021.The Historical mortality web tool presents mortality data (numbers and age-standardised rates) by sex for certain causes of death from 1948 to 2016. Mortality data by sex, age group and ethnicity (Māori and non-Māori) is presented from 1996 to 2016.The web tool enables you cialis coupon to explore trends over time using interactive graphs and tables. Filtered results and the full data set can be downloaded from within the web tool. The causes of death included are.

All cancer Ischaemic heart disease Cerebrovascular disease Chronic lower respiratory diseases Other forms of heart disease cialis coupon Influenza and Pneumonia Diabetes mellitus Motor vehicle accidents Intentional self-harm Assault All deaths. The full data set presented in the web tool is available for you to download in text file format. A technical document accompanies the web tool. This document contains information about the data source and analytical methods used to produce summary data, and a data dictionary cialis coupon for variables used in the web tool.

About the data used in this edition Data from 1948 to 1995 presented in these tables was sourced from publications in the Ministry of Health Mortality data and stats series. Data from 1996 to 2016 was extracted from the New Zealand Mortality Collection records on 07 June 2019. At the cialis coupon time of extraction, there were 606,450 deaths registered from 1996 to 2016. Included in this data were 641 deaths provisionally coded awaiting coroners’ findings and 41 deaths awaiting coroners’ findings with no known cause.

Ethnic breakdowns of mortality data are only shown from 1996 onwards because there was a significant change in the way ethnicity was defined, and in the way ethnicity data was collected in 1995. For more cialis coupon information please refer to the Ministry of Health report, Mortality and Demographic Data 1996. Disclaimer In this edition, data for causes of death was extracted and recalculated for the years 1996–2016 to reflect ongoing updates to data in the New Zealand Mortality Collection (for example, following the release of coroners’ findings) and the revision of population estimates and projections following each census. For this reason there may be small changes to some numbers and rates from those presented in previous publications and tables.

We have quality checked the cialis coupon collection, extraction, and reporting of the data presented here. However errors can occur. Contact the Ministry of Health if you have any concerns regarding any of the data or analyses presented here, at data-enquires@health.govt.nz.

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11 September 2020 We are pleased to announce enhanced flexibility of training for senior healthcare scientists The Institute of Biomedical Science (IBMS), Royal College of Pathologists (RCPath), National School of Healthcare Science cialis 80mg dosage in Health Education England (NSHCS in HEE), Academy for Healthcare Science (ACHS) cialis drug interactions and Manchester Academy of Healthcare Science Education (MAHSE) have come together to broaden the eligibility criteria for the Higher Specialist Scientific Training (HSST) Programme. The changes will have a direct and positive impact on newly eligible IBMS members who wish to undertake the program.Professor Berne Ferry, Head of the National School of Healthcare Science, who contributed towards the changes commented:Opening up the entry criteria for HSST to allow all eligible scientists to enter the programme is a positive step forward in Healthcare Scientist Education and Training. Allowing eligible Biomedical Scientists to apply is hugely welcomed and the NSHCS in HEE is delighted cialis drug interactions to jointly announce this initiative with the IBMS, RCPath, the ACHS and the MAHSE. Having Biomedical Scientists undertaking HSST alongside Clinical Scientist colleagues can only strengthen, diversify and unify the NHS scientific workforce and help to deliver the necessary scientific leadership which will be crucial for patients in the future.IBMS Council member Dr Jane Needham, the IBMS lead on this project, commented:This is really wonderful news.

It provides a career pathway and an exciting opportunity for our Biomedical Scientists to apply and develop their clinical and scientific knowledge and expertise through the consultant level HSST training programme, with the key benefit of improving and enhancing the clinical care and services we provide to cialis drug interactions our patients.On reviewing the changes, IBMS President Allan Wilson commented:The inclusion of Biomedical Scientists as an eligible professional group for the HSST programme will provide a route to consultant level posts for Biomedical Scientists and recognises the breadth and depth of experience and clinical skills that exist within the profession. This new training route will improve patient pathways by the addition of experienced clinical experts to the currently stretched consultant capacity. This is tremendous news for Biomedical Scientists and healthcare in the UK.If you cialis drug interactions have any questions after reading the statement please contact us via. Website@ibms.orgRead the statement and new eligibility criteria in full (or download) below:Joint Statement on HSST EligibilitySignificant scientific workforce shortages at senior levels have been identified in several Life Science specialties, which have been further highlighted during the COVID-19 pandemic.

The Higher Specialist Scientific Training (HSST) Programme trains Healthcare Scientists to consultant level, however HSST is currently not open to all individual scientists with the potential to develop and take on the role of a cialis drug interactions consultant scientist.The National School of Healthcare Science in Health Education England, Academy for Healthcare Science, Institute of Biomedical Science (IBMS), Royal College of Pathologists (RCPath) and Manchester Academy of Healthcare Scientist Education are pleased to announce a widening of the of the eligibility criteria for HSST. The new criteria will allow appropriately qualified senior Biomedical Scientists, who can demonstrate ability to work at Level 7 via academic and professional qualifications, to apply to join the programme. Both Biomedical Scientists and Clinical Scientists will be subject to the same HSST interview cialis drug interactions process to determine suitability and readiness. The qualifications to confer eligibility will include:1) HCPC Registration as a Biomedical Scientist, IBMS Specialist Diploma and relevant MSc2) HCPC Registration as a Biomedical Scientist, IBMS Specialist Diploma and IBMS Higher Specialist Diploma or IBMS 2-part Fellowship Special Exam3) HCPC Registration as a Biomedical Scientist, IBMS Specialist Diploma and IBMS Diploma of Expert PracticeEligible individuals will also need to meet the requirements of the Universities to commence a doctoral level programme, including a First or 2:1 Bachelor’s degree and a Master’s degree in a relevant subject area or evidence of having written at that standard, and a minimum of four years working in a professional role.

In addition, training departments will need to achieve HSST training accreditation through the NSHCS to be successful in the commissioning cialis drug interactions rounds. This includes demonstration of suitable workplace and research supervision at doctoral level, access to training to meet the specialism curriculum and HSS Standards of Proficiency, and senior level trust support.All Life Science HSSTs must obtain Fellowship of the Royal College of Pathologists during the programme in order to complete HSST, in addition to the academic qualification and evidence of their workplace training. These requirements of the programme are identical for Clinical Scientists and cialis drug interactions Biomedical Scientists on HSST.This revised admission criteria to HSST is endorsed by NHS Education for Scotland - Healthcare Science. We look forward to working with all agencies concerned with the development of the next generation of consultant-level healthcare scientists.All scientists who successfully complete the HSST programme or equivalence are eligible to join the Academy for Healthcare Science HSS Register and become a Fellow.This change to the HSST eligibility criteria will apply from 2021 entry to the HSST programme.7 September 2020 The four day digital event will feature content aimed at all IBMS members and will be free to attend SAVE THE DATE - 16-19th NovemberOur new, virtual CPD event, The Biomedical Scientist Live, will feature a packed line up of knowledge sharing sessions including.

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11 September 2020 We are pleased to announce enhanced flexibility of training for senior healthcare scientists The Institute of Biomedical Science (IBMS), Royal College of Pathologists (RCPath), National School of Healthcare Science in Health Education England (NSHCS in HEE), Academy for Healthcare Science (ACHS) and Manchester Academy of Healthcare Science Education (MAHSE) cialis coupon have come together to broaden the eligibility criteria for https://www.cityreal.lv/non-prescription-cialis/ the Higher Specialist Scientific Training (HSST) Programme. The changes will have a direct and positive impact on newly eligible IBMS members who wish to undertake the program.Professor Berne Ferry, Head of the National School of Healthcare Science, who contributed towards the changes commented:Opening up the entry criteria for HSST to allow all eligible scientists to enter the programme is a positive step forward in Healthcare Scientist Education and Training. Allowing eligible Biomedical Scientists to apply is hugely welcomed cialis coupon and the NSHCS in HEE is delighted to jointly announce this initiative with the IBMS, RCPath, the ACHS and the MAHSE.

Having Biomedical Scientists undertaking HSST alongside Clinical Scientist colleagues can only strengthen, diversify and unify the NHS scientific workforce and help to deliver the necessary scientific leadership which will be crucial for patients in the future.IBMS Council member Dr Jane Needham, the IBMS lead on this project, commented:This is really wonderful news. It provides a career pathway and an exciting opportunity for our Biomedical Scientists to apply and develop their clinical and scientific knowledge and expertise through the consultant level HSST training programme, with the key benefit of improving and enhancing the clinical cialis coupon care and services we provide to our patients.On reviewing the changes, IBMS President Allan Wilson commented:The inclusion of Biomedical Scientists as an eligible professional group for the HSST programme will provide a route to consultant level posts for Biomedical Scientists and recognises the breadth and depth of experience and clinical skills that exist within the profession. This new training route will improve patient pathways by the addition of experienced clinical experts to the currently stretched consultant capacity.

This is tremendous news for Biomedical Scientists and healthcare in the UK.If you have any questions after reading the statement please contact us via cialis coupon. Website@ibms.orgRead the statement and new eligibility criteria in full (or download) below:Joint Statement on HSST EligibilitySignificant scientific workforce shortages at senior levels have been identified in several Life Science specialties, which have been further highlighted during the COVID-19 pandemic. The Higher Specialist Scientific Training (HSST) Programme trains Healthcare Scientists to consultant level, however HSST is currently not open to all individual scientists with the potential to develop and take on the role of a consultant scientist.The National School of Healthcare Science in Health Education England, Academy for Healthcare Science, Institute of Biomedical Science (IBMS), Royal College of Pathologists (RCPath) and Manchester Academy of Healthcare Scientist Education are pleased to announce a widening of the of the eligibility cialis coupon criteria for HSST.

The new criteria will allow appropriately qualified senior Biomedical Scientists, who can demonstrate ability to work at Level 7 via academic and professional qualifications, to apply to join the programme. Both Biomedical Scientists and Clinical Scientists will be subject cialis coupon to the same HSST interview process to determine suitability and readiness. The qualifications to confer eligibility will include:1) HCPC Registration as a Biomedical Scientist, IBMS Specialist Diploma and relevant MSc2) HCPC Registration as a Biomedical Scientist, IBMS Specialist Diploma and IBMS Higher Specialist Diploma or IBMS 2-part Fellowship Special Exam3) HCPC Registration as a Biomedical Scientist, IBMS Specialist Diploma and IBMS Diploma of Expert PracticeEligible individuals will also need to meet the requirements of the Universities to commence a doctoral level programme, including a First or 2:1 Bachelor’s degree and a Master’s degree in a relevant subject area or evidence of having written at that standard, and a minimum of four years working in a professional role.

In addition, training departments will cialis coupon need to achieve HSST training accreditation through the NSHCS to be successful in the commissioning rounds. This includes demonstration of suitable workplace and research supervision at doctoral level, access to training to meet the specialism curriculum and HSS Standards of Proficiency, and senior level trust support.All Life Science HSSTs must obtain Fellowship of the Royal College of Pathologists during the programme in order to complete HSST, in addition to the academic qualification and evidence of their workplace training. These requirements of the programme are cialis coupon identical for Clinical Scientists and Biomedical Scientists on HSST.This revised admission criteria to HSST is endorsed by NHS Education for Scotland - Healthcare Science.

We look forward to working with all agencies concerned with the development of the next generation of consultant-level healthcare scientists.All scientists who successfully complete the HSST programme or equivalence are eligible to join the Academy for Healthcare Science HSS Register and become a Fellow.This change to the HSST eligibility criteria will apply from 2021 entry to the HSST programme.7 September 2020 The four day digital event will feature content aimed at all IBMS members and will be free to attend SAVE THE DATE - 16-19th NovemberOur new, virtual CPD event, The Biomedical Scientist Live, will feature a packed line up of knowledge sharing sessions including. Workshops, seminars, cialis coupon discussions and demonstrations. The dedicated event website will be live soon and will include more information on how to sign up, free for IBMS members, and the programme of talks.

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Almost 2 million babies are stillborn every year – or 1 every 16 seconds – according to the first ever joint when is the best time to take cialis stillbirth estimates released by UNICEF, WHO, the World Bank Group and the Population Division of dr oz this works better than viagra and cialis the UnitedNations Department of Economic and Social Affairs. The vast majority of stillbirths, 84 per cent, occur in low- and lower-middle-income countries, according to the new report, A Neglected Tragedy. The Global when is the best time to take cialis Burden of Stillbirths. In2019, 3 in 4 stillbirths occurred in sub-Saharan Africa or Southern Asia. A stillbirth is defined in the report as a baby born with no signs of life when is the best time to take cialis at 28 weeks of pregancy or more.

€œLosing a child at birth or during pregnancy is a devastating tragedy for a family, one that is often endured quietly, yet all too frequently, around the world,” said Henrietta Fore, UNICEF Executive Director. €œEvery 16 seconds,a mother somewhere will suffer the unspeakable tragedy of stillbirth when is the best time to take cialis. Beyond the loss of life, the psychological and financial costs for women, families and societies are severe and long lasting. For many of these mothers, it simply didn’thave to be this way. A majority of stillbirths could have been prevented with high quality monitoring, proper antenatal care and when is the best time to take cialis a skilled birth attendant.”The report warns that the COVID-19 pandemic could worsen the global number of stillbirths.

A 50 per cent reduction in health services due to the pandemic could cause nearly 200 000 additional stillbirths over a 12-month period in 117 low- and middle-incomecountries. This corresponds to an increase in the number of stillbirths when is the best time to take cialis by 11.1 per cent. According to modeling done for the report by researchers from the Johns Hopkins Bloomberg School of Public Health, 13 countries could see a 20 per cent increaseor more in the number of stillbirths over a 12-month period. Most stillbirths are due to poor quality of care when is the best time to take cialis during pregnancy and birth. Lack of investments in antenatal and intrapartum services and in strengthening the nursing and midwifery workforce are key challenges, the report says.

Over 40 per cent of stillbirths occur during labour—a loss that could be avoided with access to a trained health worker at childbirth and timely emergency obstetric care. Around half of stillbirths in sub-Saharan Africa and Central and SouthernAsia occur during labour, compared when is the best time to take cialis to 6 per cent in Europe, Northern America, Australia and New Zealand. Even before the pandemic caused critical disruptions in health services, few women in low- and middle-income countries received timely and high-quality care to prevent stillbirths. Half of the 117 countries analyzed in the report have coverage thatranges from a low of less than 2 per cent to a high of only 50 per cent for 8 important maternal when is the best time to take cialis health interventions such as C-section, malaria prevention, management of hypertension in pregnancy and syphilis detection and treatment. Coverage forassisted vaginal delivery - a critical intervention for preventing stillbirths during labour – is estimated to reach less than half of pregnant women who need it.As a result, despite advances in health services to prevent or treat causes of child death, progress in lowering the stillbirth rate has been slow.

From 2000 to when is the best time to take cialis 2019, the annual rate of reduction in the stillbirth rate was just 2.3 per cent, comparedto a 2.9 per cent reduction in neonatal mortality, and 4.3 per cent in mortality among children aged 1–59 months. Progress, however, is possible with sound policy, programmes and investment. "Welcoming a baby into the world should be a time of great joy, but every day thousands of parents experience unbearable sadness because their babies are still born,” said Dr. Tedros Adhanom when is the best time to take cialis Ghebreyesus, WHO Director-General. €œThe tragedyof stillbirth shows how vital it is to reinforce and maintain essential health services, and how critical it is to increase investment in nurses and midwives.” The report also notes that stillbirth is not only a challenge for poor countries.

In 2019, 39 high-income when is the best time to take cialis countries had a higher number of stillbirths than neonatal deaths and 15 countries had a higher number of stillbirths than infant deaths. Amother’s level of education is one of the greatest drivers of inequity in high-income countries. In both low- and high-income settings, stillbirth rates are higher in rural areas than when is the best time to take cialis in urban areas. Socioeconomic status is also linked to greater incidence of stillbirth. For example, in Nepal, women of minority castes had stillbirth rates between40 to 60 per cent higher than women from upper-class castes.Ethnic minorities in high-income countries, in particular, may lack access to enough quality health care.

The report cites that Inuit populations in Canada, for example, have been observed to have stillbirth when is the best time to take cialis rates nearly three times higher than the restof Canada, and African American women in the United States of America have nearly twice the risk of stillbirth compared to white women.“COVID-19 has triggered a devastating secondary health crisis for women, children and adolescents due to disruptions in life-saving health services,” said Muhammad Ali Pate, Global Director for Health, Nutrition and Population at the WorldBank and Director of the Global Financing Facility for Women, Children and Adolescents. €œPregnant women need continued access to quality care, throughout their pregnancy and during childbirth. We are supporting countries in strengthening theirhealth systems to prevent stillbirths and ensure that every pregnant woman can access quality health care services.”The when is the best time to take cialis report link will go live after 00.01 GMT 8 October. Http://uni.cf/stillbirthreport About UN IGME The United Nations Inter-agency Group for Child Mortality Estimation or UN IGME was formed in 2004 to share data on child mortality, improve methods for child mortality estimation, report on progress towards child survival goalsand enhance country capacity to produce timely and properly assessed estimates of child mortality. UN IGME when is the best time to take cialis is led by UNICEF and includes the World Health Organization, the World Bank Group and the United Nations Population Division of the Department ofEconomic and Social Affairs.

For more information visit. Http://www.childmortality.org/For more information or to set up interviews with report authors, mothers and midwives, please contact the listed media contacts..

Almost 2 million babies are stillborn every year – or 1 every 16 seconds – according to the first ever joint stillbirth estimates cialis coupon released by UNICEF, WHO, the World Bank https://www.cityreal.lv/cialis-professional/ Group and the Population Division of the UnitedNations Department of Economic and Social Affairs. The vast majority of stillbirths, 84 per cent, occur in low- and lower-middle-income countries, according to the new report, A Neglected Tragedy. The Global Burden of cialis coupon Stillbirths. In2019, 3 in 4 stillbirths occurred in sub-Saharan Africa or Southern Asia. A stillbirth is defined in cialis coupon the report as a baby born with no signs of life at 28 weeks of pregancy or more.

€œLosing a child at birth or during pregnancy is a devastating tragedy for a family, one that is often endured quietly, yet all too frequently, around the world,” said Henrietta Fore, UNICEF Executive Director. €œEvery 16 seconds,a mother somewhere will suffer the unspeakable cialis coupon tragedy of stillbirth. Beyond the loss of life, the psychological and financial costs for women, families and societies are severe and long lasting. For many of these mothers, it simply didn’thave to be this way. A majority of stillbirths could have been prevented with high quality monitoring, proper antenatal care cialis coupon and a skilled birth attendant.”The report warns that the COVID-19 pandemic could worsen the global number of stillbirths.

A 50 per cent reduction in health services due to the pandemic could cause nearly 200 000 additional stillbirths over a 12-month period in 117 low- and middle-incomecountries. This corresponds to an increase in the cialis coupon number of stillbirths by 11.1 per cent. According to modeling done for the report by researchers from the Johns Hopkins Bloomberg School of Public Health, 13 countries could see a 20 per cent increaseor more in the number of stillbirths over a 12-month period. Most stillbirths are due cialis coupon to poor quality of care during pregnancy and birth. Lack of investments in antenatal and intrapartum services and in strengthening the nursing and midwifery workforce are key challenges, the report says.

Over 40 per cent of stillbirths occur during labour—a loss that could be avoided with access to a trained health worker at childbirth and timely emergency obstetric care. Around half of stillbirths in sub-Saharan Africa and Central cialis coupon and SouthernAsia occur during labour, compared to 6 per cent in Europe, Northern America, Australia and New Zealand. Even before the pandemic caused critical disruptions in health services, few women in low- and middle-income countries received timely and high-quality care to prevent stillbirths. Half of the 117 countries analyzed in the report have coverage thatranges from a low of less than 2 per cent to a high cialis coupon of only 50 per cent for 8 important maternal browse around here health interventions such as C-section, malaria prevention, management of hypertension in pregnancy and syphilis detection and treatment. Coverage forassisted vaginal delivery - a critical intervention for preventing stillbirths during labour – is estimated to reach less than half of pregnant women who need it.As a result, despite advances in health services to prevent or treat causes of child death, progress in lowering the stillbirth rate has been slow.

From 2000 to 2019, the annual rate of reduction in the stillbirth rate was just 2.3 per cent, comparedto a 2.9 per cent reduction in neonatal mortality, and 4.3 cialis coupon per cent in mortality among children aged 1–59 months. Progress, however, is possible with sound policy, programmes and investment. "Welcoming a baby into the world should be a time of great joy, but every day thousands of parents experience unbearable sadness because their babies are still born,” said Dr. Tedros Adhanom cialis coupon Ghebreyesus, WHO Director-General. €œThe tragedyof stillbirth shows how vital it is to reinforce and maintain essential health services, and how critical it is to increase investment in nurses and midwives.” The report also notes that stillbirth is not only a challenge for poor countries.

In 2019, 39 high-income countries had a higher number of stillbirths than neonatal deaths and 15 countries had a higher number of stillbirths than cialis coupon infant deaths. Amother’s level of education is one of the greatest drivers of inequity in high-income countries. In both low- and high-income settings, stillbirth rates are higher in rural cialis coupon areas than in urban areas. Socioeconomic status is also linked to greater incidence of stillbirth. For example, in Nepal, women of minority castes had stillbirth rates between40 to 60 per cent higher than women from upper-class castes.Ethnic minorities in high-income countries, in particular, may lack access to enough quality health care.

The report cites that Inuit populations in Canada, for example, have been observed to have stillbirth rates nearly three times higher than the restof Canada, and African American women in the United States of America have nearly twice the risk of stillbirth compared to white women.“COVID-19 has triggered a devastating secondary health crisis for women, children and adolescents due to disruptions in life-saving health services,” said Muhammad Ali Pate, Global Director for Health, Nutrition and Population at the WorldBank and Director of the Global Financing Facility for Women, Children and cialis coupon Adolescents. €œPregnant women need continued access to quality care, throughout their pregnancy and during childbirth. We are supporting countries in strengthening theirhealth systems to prevent stillbirths and ensure that every pregnant woman can access cialis coupon quality health care services.”The report link will go live after 00.01 GMT 8 October. Http://uni.cf/stillbirthreport About UN IGME The United Nations Inter-agency Group for Child Mortality Estimation or UN IGME was formed in 2004 to share data on child mortality, improve methods for child mortality estimation, report on progress towards child survival goalsand enhance country capacity to produce timely and properly assessed estimates of child mortality. UN IGME is led by UNICEF and includes the World Health Organization, the World Bank Group and the cialis coupon United Nations Population Division of the Department ofEconomic and Social Affairs.

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Add public transit https://www.cityreal.lv/non-prescription-cialis/ to the list of things Americans took for granted expired cialis before COVID-19. In the months since congregating indoors became a public health threat, many who built their daily routines around this affordable, climate-friendly public service have felt compelled to stay away from it.Essential workers from the health-care, food and other industries don’t expired cialis all have the ability to opt out, nor do citizens with no other way to get to the groceries or medicine they need. Keeping passengers safe is just one strand in the unprecedented web of challenges now facing transportation directors, and the problems that lie ahead may well be the most daunting of all.Carl Sedoryk, CEO of the Monterey-Salinas Transit District, leads a system that serves a fifth of the California coast, from Paso Robles to San Jose. MST’s service area is almost 300 expired cialis square miles.

In the past, it has carried over 4 million passengers a year. In order to keep on top of service needs during the pandemic, Sedoryk says that he and his staff have found it necessary to monitor and adjust day expired cialis by day, hour by hour, “almost trip by trip.”“It’s a huge amount of work and we’re exhausted, but no one’s complaining,” he says. €œOthers in our community don’t have jobs and there’s satisfaction in knowing we’re here to serve them.”Prepared, But Not for ThisWildfires, earthquakes and floods are all potential risks for Sedoryk’s region and because of this, MST developed a business continuity plan five years ago. MST also is part of the county’s emergency services team and may be called on to transport citizens out of a danger zone or take first responders into it.Over the years, Sedoryk and his team met regularly and expired cialis ran tabletop exercises to consider the best responses to natural disasters, civil disturbances or mass casualty events.

€œIn many ways, we were remarkably prepared but in some areas, we were less prepared,” he says.The continuity plan even included a section on pandemic response, but it did not anticipate an extended public health emergency. €œA disaster like expired cialis a fire has a definable beginning, middle and end — it starts, it rages, it gets put out and then you start recovering,” says Sedoryk. €œThis thing is just never ending.”When the first COVID-19 fatality was recorded in San Jose, a city to which MST travels, Sedoryk gathered his executive team and implemented the first step of the emergency plan, creating an emergency operations center and shifting responsibilities among managers to improve resilience. MST also expired cialis acquired a stock of personal protective equipment.

Ever since a hepatitis outbreak in the region four years ago, the agency had been disinfecting buses and had the supplies and expertise to continue this practice.“We were less prepared for the run on the market for cleaners, masks and supplies,” says Sedoryk. €œWe had to scramble for a couple of months, expired cialis like everyone else, to get our supply chain back in order.”A sanitizer dispenser on a bus. (Photo. MST)Empty Buses and FareboxesThrough the month of April, ridership expired cialis plummeted as much as 80 percent.

Service was cut from 1,100 trips per day to 500. Bus occupancy was restricted to ensure physical distancing could be maintained and passengers were required to wear masks.“We expired cialis didn’t put a hard stop on boarding,” Sedoryk says. €œEspecially in Monterey, people travel in family units and we didn’t want to separate a mother from a child or force members of the same household to sit six feet apart.”So far, California weather has allowed drivers to keep bus windows open. The manufacturers of MST’s buses claim this results in expired cialis complete air exchange every two minutes.The agency provided its drivers with masks, goggles and face shields.

€œWe stopped collecting fares and instituted rear door boarding, to keep passengers from congregating at the front of the bus and potentially exposing the driver,” says Sedoryk.Over time, passengers began to return. Sedoryk estimates that about 60 percent are back, and expired cialis he has restored service to 70 percent of what it was before the pandemic, about 740 buses. Demand is monitored constantly, and new vehicles are added if drivers report that buses are getting crowded.Video cameras on buses allow managers to pay attention to whether drivers are using their PPE expired cialis properly and ensure that passengers follow public health guidelines. €œOver time, fatigue sets in and some stop paying attention,” says Sedoryk.

€œWe continue to encourage them to stay up to speed, but this isn’t the time to be punitive.”MST invested half a million dollars in plastic expired cialis shields at the front of buses to further protect drivers, and has applied to be reimbursed by FEMA. At the beginning of August, it began to collect fares again, for the first time since March 18.Farms in MST's service area are critical to the nation's food supply. The district donated buses to be converted to expired cialis mobile COVID-19 testing labs that could be brought to work sites. (Photo.

Grower-Shipper Association of Central California)Finding New Ways to Serve the CommunityWhile public demand for transportation services waned, Sedoryk and his team began expired cialis to look for other ways to use their resources to support the community. €œAs a public service provider, you don’t restore your service just to restore your service, you try to identify where you can accomplish the most good,” he says.MST reached out to stakeholders in its service zone — the agriculture and hospitality industries, military bases, community colleges, school districts and health-care providers and the groups that represent them to find out what they needed. €œBased on what we were hearing, we started doing a number of things,” says Sedoryk.Unemployment in the county had gone from 3.5 percent to expired cialis 20 percent, causing a tenfold increase in persons with food insecurity. Over the summer, MST's drivers and vehicles that would have otherwise been idle helped Meals on Wheels in Salinas Valley to deliver 8,000 meals to seniors and persons with disabilities.Students living in agricultural communities were having difficulty keeping up with remote learning mandates.

Many had been provided Chromebooks by the state, but they didn’t expired cialis have Internet access. In response, MST parked its Wi-Fi-enabled commuter buses in rural areas to provide hot spots for them.“We’d set them up in parking lots, and people could come in their cars and piggyback on our signal,” says Sedoryk. €œWe were out there every day during the end of the school year, and we’re ramping it up again as the new school year is starting.”MST expired cialis donated a vehicle it no longer needed to a veterans group who used it to take homeless veterans to food, medical services and shelter. The transit agency gave another vehicle to a nonprofit that trains at-risk youth to work in the hospitality industry.

Upon discovering that drivers who expired cialis take disabled veterans to medical appointments had stopped volunteering because they were old, disabled and at high risk of illness, MST found CARES Act funds to take over this service.To support the local agriculture industry, which is critical to the national food supply, MST provided two buses to be converted into mobile COVID-19 testing facilities, to get testing capability out to the workers in the fields. It offered additional support by arranging for 7,500 masks received from the federal government to be distributed to families by organizations serving farmworker communities.Safety messaging and distanced passengers. (Photo. MST)Constant RecalibrationMST also looked at data to understand how transportation needs had changed.

€œWe used the Slido app (an online survey tool) that you see at conferences to survey our passengers and employees and to resurvey community stakeholders,” says Sedoryk.Community colleges have not yet resumed in-person classes. The people going back to work are in tourist-serving industries such as restaurants and hotels, and the shipping and packing facilities of the Salinas Valley. €œWe’re focusing our services there for now,” says Sedoryk.Service to Santa Clara is currently discontinued due to lack of demand. An additional cialis half life factor at play is the complications from inconsistent health guidelines.

The Santa Clara health officer does not want riders to touch the tape on the bus wall to request a stop, but to call out “next stop.”“I’d rather have people press the button and use the hand sanitizer we have on the bus,” says Sedoryk. €œIn places like Japan and Korea, they discourage talking at all because it spreads aerosol whether you’re wearing a mask or not.”Sedoryk recognizes that this is a “granular” problem, but it only adds to the difficulty of doing his job when there is not a coordinated national response to the pandemic. €œWHO information contradicts CDC information, which contradicts state health officer information, which contradicts county health officer operation,” he says.While a typical government agency operates in one location, public transit operations move through multiple locations, across different jurisdictions. MST serves Santa Clara, Monterey, Santa Cruz and San Luis Obispo counties, all of which have different rules.

€œAll you can do is the best you can do, right?. € says Sedoryk.Breaking ground for a new operations and maintenance facility. (Photo. MST)Window Opens for Capital ProjectsDespite challenges, MST is making progress.

Sedoryk says that if it weren’t for the pandemic and the loss of ridership, it would be having a banner year.The agency has broken ground on a new bus operations and maintenance facility, financed through a credit program created under the Transportation Infrastructure Finance and Innovation Act (TIFIA). The district’s 35-year loan could be at a rate as low as 0.75 percent, with no payments for the first five years.In this case, the pandemic made Sedoryk’s life easier. €œNormally, it would require several trips to Washington to get this financing, but we were able to do this via virtual conferencing and have people from all over the country involved," he says.MST also has been selected as the first transportation district in the state to implement a new program from CalTrans, called the California Integrated Travel Project (Cal-ITP). Sedoryk describes this as “an open loop contactless credit card payment system.” The goal is to to have a fee-less VISA card that could be used to pay fares on any transit system in the state.

Because of the pandemic, the state has decided to accelerate development and deployment.As with the TIFIA loan, Sedoryk has been able to collaborate on this work with partners in far-flung locations thanks to Web conferencing. €œWe have people from Sacramento, Toronto, Melbourne and New York on these calls,” he says.There’s a long-range social equity aspect to all this, according to Sedoryk. Many low-income residents don’t have bank accounts, which complicates the process of accessing benefits such as food assistance and creates a paperwork burden on both sides. Eventually, such funds could be sent to the card account and the card could be used for purposes such as purchasing groceries.Wi-Fi-enabled commuter buses were parked in communities where students did not have Internet access, to help them manage remote learning assignments.

(Photo. MST)Cash Flow Is a ProblemAs the pandemic crisis heads into the fall, transit systems are in financial freefall around the country. Big city systems, such as New York City and San Francisco, have seen ridership plummet 90 percent. That has cut into revenue just as states have reduced subsidies in an effort to trim budgets.

The result. Transit agencies across the country are projected to rack up close to $40 billion in budget shortfalls, dwarfing the $2 billion loss inflicted by the 2008 financial crisis, according to The New York Times.MST does not have financial support from local sales taxes, and depends on state sales taxes along with state and federal fuel taxes and farebox revenues to pay for its operations. Partnerships with community colleges, universities, the Monterey Bay Aquarium and military bases also help.But like so many other sources of revenue during the pandemic, partnership funding has disappeared. €œThe aquarium and the universities and the community colleges and the bases are all closed,” he says.

€œWe’re not getting any money from there.”Thanks to CARES Act funding, Sedoryk is confident he can “sail” through the end of this fiscal year. But depending on the situation at the end of the calendar year, he may be forced to look at reductions in force and restructuring of services.So far, he’s been able to avoid layoffs and has been particularly attentive to keeping his drivers on the payroll — he doesn’t want them taking jobs elsewhere, leaving him short-handed if the recovery gains steam. The California transit association has said that CARES Act funding is $3.1 billion short of what the state needs, with major urban areas like Los Angeles and San Francisco most at risk. At this point, it’s uncertain what another federal stimulus package might bring.“If nothing happens there, and nothing happens in Sacramento, there will be a $3.1 billion contraction in our industry and it will affect different localities differently,” he says.

€œIt really depends on their local economies and local funding streams.”For now, he’s watching state sales tax revenue, and there aren’t enough data points yet for him to see a trend. He’ll know more by the end of the year, and if relief from Congress or the state could be in sight.“The fares that passengers pay cover about 20 percent of our costs, and the rest is picked up by a variety of state and federal funding sources,” says Sedoryk. €œBut there’s only so much a person is going to be able to pay.”It’s too early to know what the numbers will be, but at some point, MST, like other transit providers around the country, may have to reconsider the level of service that it is able to provide with the cash flow available to it.The average taxpayer may not think much about the large section of the population that can’t afford a car, or who are too old or disabled to drive, Sedoryk says. €œThere’s a lot of noise to filter through to get that message out, especially these days.”Strength, Stamina and FlexibilityFor now, MST’s attention is on service and safety.

The agency has 250 workers. There was no confirmed COVID-19 case among them until recently and the employee in question had not had contact with passengers or the general public. The county health officer has not identified any instances where a member of the public contracted COVID-19 while an MST passenger.Sedoryk had six district employees go through the contact tracing training developed by Johns Hopkins University. €œOur county is overwhelmed — it’s a small rural county and they weren’t set up to handle this type of emergency,” he says.

€œWe decided to offer our employees help to get them a head start on some of these issues.”The pandemic has led to greatly improved relationships with the local union, in contrast to the complaints and lawsuits brought against leaders of transit districts in other parts of the country by union members who feel they have been put in danger. Sedoryk and the local union president have been meeting daily. €œThis has forced us to not just talk about problems, but to get to know each other as people and develop a relationship — that’s helped out a lot.”MST’s response to the pandemic has changed how the community perceives it, particularly those who work in agriculture. €œThey see us providing buses to turn into mobile COVID-19 labs — not as a stodgy, bureaucratic entitlement program but as a solution that they need.”Better relationships within and without the organization and an enhanced reputation for service help offset the stress caused by conditions and risks that shift day to day, hour by hour.

Sedoryk’s volunteer work as a martial arts instructor, on hold for the time being, has also served him well, he believes.“We focus on strength, stamina and flexibility,” he says. €œThose are good attributes for a martial artist, and they are excellent attributes for an organization — you’ve got to be financially strong, flexible, and you’ve got to be in it for the long haul.” Carl Smith Senior Staff Writercarl.smith@governing.com.

Add public transit to the list of things Americans dr oz this works better than viagra and cialis took for granted before COVID-19 cialis coupon. In the months since congregating cialis coupon indoors became a public health threat, many who built their daily routines around this affordable, climate-friendly public service have felt compelled to stay away from it.Essential workers from the health-care, food and other industries don’t all have the ability to opt out, nor do citizens with no other way to get to the groceries or medicine they need. Keeping passengers safe is just one strand in the unprecedented web of challenges now facing transportation directors, and the problems that lie ahead may well be the most daunting of all.Carl Sedoryk, CEO of the Monterey-Salinas Transit District, leads a system that serves a fifth of the California coast, from Paso Robles to San Jose.

MST’s service area is cialis coupon almost 300 square miles. In the past, it has carried over 4 million passengers a year. In order to keep on top of service cialis coupon needs during the pandemic, Sedoryk says that he and his staff have found it necessary to monitor and adjust day by day, hour by hour, “almost trip by trip.”“It’s a huge amount of work and we’re exhausted, but no one’s complaining,” he says.

€œOthers in our community don’t have jobs and there’s satisfaction in knowing we’re here to serve them.”Prepared, But Not for ThisWildfires, earthquakes and floods are all potential risks for Sedoryk’s region and because of this, MST developed a business continuity plan five years ago. MST also is part of the county’s emergency services team and may be called on to transport citizens out of a danger zone or take first responders into it.Over the years, Sedoryk and his team met regularly and ran tabletop exercises to cialis coupon consider the best responses to natural disasters, civil disturbances or mass casualty events. €œIn many ways, we were remarkably prepared but in some areas, we were less prepared,” he says.The continuity plan even included a section on pandemic response, but it did not anticipate an extended public health emergency.

€œA disaster like a fire has a definable beginning, middle and end — it starts, it rages, it gets put out and then you start recovering,” says cialis coupon Sedoryk. €œThis thing is just never ending.”When the first COVID-19 fatality was recorded in San Jose, a city to which MST travels, Sedoryk gathered his executive team and implemented the first step of the emergency plan, creating an emergency operations center and shifting responsibilities among managers to improve resilience. MST also cialis coupon acquired a stock of personal protective equipment.

Ever since a hepatitis outbreak in the region four years ago, the agency had been disinfecting buses and had the supplies and expertise to continue this practice.“We were less prepared for the run on the market for cleaners, masks and supplies,” says Sedoryk. €œWe had to scramble for a couple of months, like everyone else, to get cialis coupon our supply chain back in order.”A sanitizer dispenser on a bus. (Photo.

MST)Empty Buses and FareboxesThrough the month of April, ridership plummeted as cialis coupon much as 80 percent. Service was cut from 1,100 trips per day to 500. Bus occupancy was restricted to ensure physical distancing could be maintained and cialis coupon passengers were required to wear masks.“We didn’t put a hard stop on boarding,” Sedoryk says.

€œEspecially in Monterey, people travel in family units and we didn’t want to separate a mother from a child or force members of the same household to sit six feet apart.”So far, California weather has allowed drivers to keep bus windows open. The manufacturers of MST’s buses claim this results in complete cialis coupon air exchange every two minutes.The agency provided its drivers with masks, goggles and face shields. €œWe stopped collecting fares and instituted rear door boarding, to keep passengers from congregating at the front of the bus and potentially exposing the driver,” says Sedoryk.Over time, passengers began to return.

Sedoryk estimates that about 60 percent are back, and he has restored cialis coupon service to 70 percent of what it was before the pandemic, about 740 buses. Demand is monitored constantly, and new vehicles are added if drivers report that buses are getting crowded.Video cameras on buses allow managers to pay attention to whether drivers are cialis coupon using their PPE properly and ensure that passengers follow public health guidelines. €œOver time, fatigue sets in and some stop paying attention,” says Sedoryk.

€œWe continue to encourage cialis coupon them to stay up to speed, but this isn’t the time to be punitive.”MST invested half a million dollars in plastic shields at the front of buses to further protect drivers, and has applied to be reimbursed by FEMA. At the beginning of August, it began to collect fares again, for the first time since March 18.Farms in MST's service area are critical to the nation's food supply. The district donated buses to be converted to mobile COVID-19 testing labs cialis coupon that could be brought to work sites.

(Photo. Grower-Shipper Association of Central California)Finding New Ways to Serve the CommunityWhile public demand for transportation services waned, Sedoryk and his team cialis coupon began to look for other ways to use their resources to support the community. €œAs a public service provider, you don’t restore your service just to restore your service, you try to identify where you can accomplish the most good,” he says.MST reached out to stakeholders in its service zone — the agriculture and hospitality industries, military bases, community colleges, school districts and health-care providers and the groups that represent them to find out what they needed.

€œBased on what we were hearing, we started doing a number of things,” says Sedoryk.Unemployment in the county had gone from 3.5 percent to 20 cialis coupon percent, causing a tenfold increase in persons with food insecurity. Over the summer, MST's drivers and vehicles that would have otherwise been idle helped Meals on Wheels in Salinas Valley to deliver 8,000 meals to seniors and persons with disabilities.Students living in agricultural communities were having difficulty keeping up with remote learning mandates. Many had been provided Chromebooks by the state, cialis coupon but they didn’t have Internet access.

In response, MST parked its Wi-Fi-enabled commuter buses in rural areas to provide hot spots for them.“We’d set them up in parking lots, and people could come in their cars and piggyback on our signal,” says Sedoryk. €œWe were out there every day during the end of the school year, and we’re ramping it up again as the new school year cialis coupon is starting.”MST donated a vehicle it no longer needed to a veterans group who used it to take homeless veterans to food, medical services and shelter. The transit agency gave another vehicle to a nonprofit that trains at-risk youth to work in the hospitality industry.

Upon discovering that drivers who take disabled veterans to medical appointments had stopped volunteering because they were old, disabled and at high risk of illness, MST found CARES Act funds to take over this service.To support the local agriculture industry, which is critical to the national food supply, MST cialis coupon provided two buses to be converted into mobile COVID-19 testing facilities, to get testing capability out to the workers in the fields. It offered additional support by arranging for 7,500 masks received from the federal government to be distributed to families by organizations serving farmworker communities.Safety messaging and distanced passengers. (Photo.

MST)Constant RecalibrationMST also looked at data to understand how transportation needs had changed. €œWe used the Slido app (an online survey tool) that you see at conferences to survey our passengers and employees and to resurvey community stakeholders,” says Sedoryk.Community colleges have not yet resumed in-person classes. The people going back to work are in tourist-serving industries such as restaurants and hotels, and the shipping and packing facilities of the Salinas Valley.

€œWe’re focusing our services there for now,” says Sedoryk.Service to Santa Clara is currently discontinued due to lack of demand. An additional factor at play is the complications from inconsistent health guidelines https://www.cityreal.lv/cheap-discount-cialis/. The Santa Clara health officer does not want riders to touch the tape on the bus wall to request a stop, but to call out “next stop.”“I’d rather have people press the button and use the hand sanitizer we have on the bus,” says Sedoryk.

€œIn places like Japan and Korea, they discourage talking at all because it spreads aerosol whether you’re wearing a mask or not.”Sedoryk recognizes that this is a “granular” problem, but it only adds to the difficulty of doing his job when there is not a coordinated national response to the pandemic. €œWHO information contradicts CDC information, which contradicts state health officer information, which contradicts county health officer operation,” he says.While a typical government agency operates in one location, public transit operations move through multiple locations, across different jurisdictions. MST serves Santa Clara, Monterey, Santa Cruz and San Luis Obispo counties, all of which have different rules.

€œAll you can do is the best you can do, right?. € says Sedoryk.Breaking ground for a new operations and maintenance facility. (Photo.

MST)Window Opens for Capital ProjectsDespite challenges, MST is making progress. Sedoryk says that if it weren’t for the pandemic and the loss of ridership, it would be having a banner year.The agency has broken ground on a new bus operations and maintenance facility, financed through a credit program created under the Transportation Infrastructure Finance and Innovation Act (TIFIA). The district’s 35-year loan could be at a rate as low as 0.75 percent, with no payments for the first five years.In this case, the pandemic made Sedoryk’s life easier.

€œNormally, it would require several trips to Washington to get this financing, but we were able to do this via virtual conferencing and have people from all over the country involved," he says.MST also has been selected as the first transportation district in the state to implement a new program from CalTrans, called the California Integrated Travel Project (Cal-ITP). Sedoryk describes this as “an open loop contactless credit card payment system.” The goal is to to have a fee-less VISA card that could be used to pay fares on any transit system in the state. Because of the pandemic, the state has decided to accelerate development and deployment.As with the TIFIA loan, Sedoryk has been able to collaborate on this work with partners in far-flung locations thanks to Web conferencing.

€œWe have people from Sacramento, Toronto, Melbourne and New York on these calls,” he says.There’s a long-range social equity aspect to all this, according to Sedoryk. Many low-income residents don’t have bank accounts, which complicates the process of accessing benefits such as food assistance and creates a paperwork burden on both sides. Eventually, such funds could be sent to the card account and the card could be used for purposes such as purchasing groceries.Wi-Fi-enabled commuter buses were parked in communities where students did not have Internet access, to help them manage remote learning assignments.

(Photo. MST)Cash Flow Is a ProblemAs the pandemic crisis heads into the fall, transit systems are in financial freefall around the country. Big city systems, such as New York City and San Francisco, have seen ridership plummet 90 percent.

That has cut into revenue just as states have reduced subsidies in an effort to trim budgets. The result. Transit agencies across the country are projected to rack up close to $40 billion in budget shortfalls, dwarfing the $2 billion loss inflicted by the 2008 financial crisis, according to The New York Times.MST does not have financial support from local sales taxes, and depends on state sales taxes along with state and federal fuel taxes and farebox revenues to pay for its operations.

Partnerships with community colleges, universities, the Monterey Bay Aquarium and military bases also help.But like so many other sources of revenue during the pandemic, partnership funding has disappeared. €œThe aquarium and the universities and the community colleges and the bases are all closed,” he says. €œWe’re not getting any money from there.”Thanks to CARES Act funding, Sedoryk is confident he can “sail” through the end of this fiscal year.

But depending on the situation at the end of the calendar year, he may be forced to look at reductions in force and restructuring of services.So far, he’s been able to avoid layoffs and has been particularly attentive to keeping his drivers on the payroll — he doesn’t want them taking jobs elsewhere, leaving him short-handed if the recovery gains steam. The California transit association has said that CARES Act funding is $3.1 billion short of what the state needs, with major urban areas like Los Angeles and San Francisco most at risk. At this point, it’s uncertain what another federal stimulus package might bring.“If nothing happens there, and nothing happens in Sacramento, there will be a $3.1 billion contraction in our industry and it will affect different localities differently,” he says.

€œIt really depends on their local economies and local funding streams.”For now, he’s watching state sales tax revenue, and there aren’t enough data points yet for him to see a trend. He’ll know more by the end of the year, and if relief from Congress or the state could be in sight.“The fares that passengers pay cover about 20 percent of our costs, and the rest is picked up by a variety of state and federal funding sources,” says Sedoryk. €œBut there’s only so much a person is going to be able to pay.”It’s too early to know what the numbers will be, but at some point, MST, like other transit providers around the country, may have to reconsider the level of service that it is able to provide with the cash flow available to it.The average taxpayer may not think much about the large section of the population that can’t afford a car, or who are too old or disabled to drive, Sedoryk says.

€œThere’s a lot of noise to filter through to get that message out, especially these days.”Strength, Stamina and FlexibilityFor now, MST’s attention is on service and safety. The agency has 250 workers. There was no confirmed COVID-19 case among them until recently and the employee in question had not had contact with passengers or the general public.

The county health officer has not identified any instances where a member of the public contracted COVID-19 while an MST passenger.Sedoryk had six district employees go through the contact tracing training developed by Johns Hopkins University. €œOur county is overwhelmed — it’s a small rural county and they weren’t set up to handle this type of emergency,” he says. €œWe decided to offer our employees help to get them a head start on some of these issues.”The pandemic has led to greatly improved relationships with the local union, in contrast to the complaints and lawsuits brought against leaders of transit districts in other parts of the country by union members who feel they have been put in danger.

Sedoryk and the local union president have been meeting daily. €œThis has forced us to not just talk about problems, but to get to know each other as people and develop a relationship — that’s helped out a lot.”MST’s response to the pandemic has changed how the community perceives it, particularly those who work in agriculture. €œThey see us providing buses to turn into mobile COVID-19 labs — not as a stodgy, bureaucratic entitlement program but as a solution that they need.”Better relationships within and without the organization and an enhanced reputation for service help offset the stress caused by conditions and risks that shift day to day, hour by hour.

Sedoryk’s volunteer work as a martial arts instructor, on hold for the time being, has also served him well, he believes.“We focus on strength, stamina and flexibility,” he says. €œThose are good attributes for a martial artist, and they are excellent attributes for an organization — you’ve got to be financially strong, flexible, and you’ve got to be in it for the long haul.” Carl Smith Senior Staff Writercarl.smith@governing.com.

Cialis viagra uk

Protecting the safety and health of essential workers who support America’s food security—including the meat, cialis viagra uk poultry, and pork processing industries—is a top priority for the Occupational Safety and Health Administration (OSHA).OSHA and the Centers for Disease Control and Prevention issued additional guidance to reduce the risk of exposure to the coronavirus and keep workers safe and healthy in the does insurance cover cialis meatpacking and meat processing industries —including those involved in beef, pork, and poultry operations. This new guidance provides specific recommendations for employers to meet their obligations to protect workers in these facilities, where people normally work closely together and share workspaces and equipment. Here are cialis viagra uk eight ways to help minimize meat processing workers’ exposure to the coronavirus.

Screen workers before they enter the workplace. If a worker becomes sick, send them home and disinfect their workstation and any tools they used. Move workstations farther cialis viagra uk apart.

Install partitions between workstations using strip curtains, plexiglass, or similar materials. To limit spread between groups, assign the same workers to the same shifts with the same coworkers. Prevent workers from using avodart and cialis other cialis viagra uk workers’ equipment.

Allow workers to wear face coverings when entering, inside, and exiting the facility. Encourage workers to report any safety and health concerns to their supervisors.OSHA is committed to ensuring that workers and employers in essential industries have clear guidance to keep workers safe and healthy from the coronavirus—including guidance for essential workers in construction, manufacturing, package delivery, and retail. Workers and employers who have questions or concerns about cialis viagra uk workplace safety can contact OSHA online or by phone at 1-800-321-6742 (OSHA).

You can find additional resources and learn more about OSHA’s response to the coronavirus at www.osha.gov/coronavirus. Loren Sweatt is the Principal Deputy Assistant Secretary for the U.S. Department of Labor’s Occupation Safety and Health Administration Editor’s Note cialis viagra uk.

It is important to note that information and guidance about COVID-19 continually evolve as conditions change. Workers and employers are encouraged to regularly refer to the resources below for updates:.

Protecting the safety and health of essential workers who support America’s food security—including the meat, poultry, and pork processing industries—is a top priority cialis coupon for the Occupational Safety and Health Administration (OSHA).OSHA weblink and the Centers for Disease Control and Prevention issued additional guidance to reduce the risk of exposure to the coronavirus and keep workers safe and healthy in the meatpacking and meat processing industries —including those involved in beef, pork, and poultry operations. This new guidance provides specific recommendations for employers to meet their obligations to protect workers in these facilities, where people normally work closely together and share workspaces and equipment. Here are eight ways to help minimize meat processing workers’ exposure to cialis coupon the coronavirus.

Screen workers before they enter the workplace. If a worker becomes sick, send them home and disinfect their workstation and any tools they used. Move workstations cialis coupon farther apart.

Install partitions between workstations using strip curtains, plexiglass, or similar materials. To limit spread between groups, assign the same workers to the same shifts with the same coworkers. Prevent workers from using dr oz this works better than viagra and cialis other workers’ equipment cialis coupon.

Allow workers to wear face coverings when entering, inside, and exiting the facility. Encourage workers to report any safety and health concerns to their supervisors.OSHA is committed to ensuring that workers and employers in essential industries have clear guidance to keep workers safe and healthy from the coronavirus—including guidance for essential workers in construction, manufacturing, package delivery, and retail. Workers and employers who have questions or concerns about workplace safety can contact OSHA online or cialis coupon by phone at 1-800-321-6742 (OSHA).

You can find additional resources and learn more about OSHA’s response to the coronavirus at www.osha.gov/coronavirus. Loren Sweatt is the Principal Deputy Assistant Secretary for the U.S. Department of Labor’s cialis coupon Occupation Safety and Health Administration Editor’s Note.

It is important to note that information and guidance about COVID-19 continually evolve as conditions change. Workers and employers are encouraged to regularly refer to the resources below for updates:.

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How to https://www.cityreal.lv/cheap-discount-cialis/ cite cialis classification this article:Singh OP. The need for routine psychiatric assessment of COVID-19 survivors. Indian J Psychiatry 2020;62:457-8COVID-19 pandemic is expected to bring a Tsunami of mental cialis classification health issues.

Public health emergencies may affect the well-being, safety, and security of both individuals and communities, which lead to a range of emotional reactions, unhealthy behavior, and noncompliance, with public health directives (such as home confinement and vaccination) in people who contact the disease as well as in the general population.[1] Thus far, there has been an increased emphasis on psychosocial factors such as loneliness, effect of quarantine, uncertainty, vulnerability to COVID-19 infection, economic factors, and career difficulties, which may lead to increased psychiatric morbidity.Time has now come to pay attention to the direct effect of the virus on brain and psychiatric adverse symptoms, resulting from the treatment provided. Viral infections cialis classification are known to be associated with psychiatric disorders such as depression, bipolar disorder, obsessive–compulsive disorder (OCD), or schizophrenia. There was an increased incidence of psychiatric disorders following the Influenza Pandemic.

Karl Menninger described 100 cases of influenza presenting with psychiatric sequelae, which could mainly be cialis classification categorized as dementia praecox, delirium, other psychoses, and unclassified subtypes. Dementia praecox constituted the largest number among all these cases.[2] Neuroinflammation is now known as the key factor in genesis and exacerbation of psychiatric disorders, particularly depression and bipolar disorders.Emerging evidence points toward the neurotropic properties of the SARS-CoV-2 virus. Loss of smell and taste as an initial symptom cialis classification points toward early involvement of olfactory bulb.

The rapid spread to brain has been demonstrated through retrograde axonal transport.[3] The virus can enter the brain through endothelial cells lining the blood–brain barrier and also through other nerves such as the vagus nerve.[4] Cytokine storm, a serious immune reaction to the virus, can activate brain glial cells, leading to delirium, depression, bipolar disorder, and OCD.Studies examining psychiatric disorders in acute patients suffering from COVID-19 found almost 40% of such patients suffering from anxiety, depression, and posttraumatic stress disorder.[5] The data on long-term psychiatric sequelae in patients who have recovered from acute illness are limited. There are anecdotal reports of psychosis and mania occurring in patients of COVID-19 following discharge from hospital. This may be either due to the direct effect of cialis classification the virus on the brain or due to the neuropsychiatric effects of drugs used to treat the infection or its complications.

For example, behavioral toxicity of high-dose corticosteroids which are frequently used during the treatment of severe cases to prevent and manage cytokine storm.The patients with COVID-19 can present with many neuropsychiatric disorders, which may be caused by direct inflammation, central nervous system effects of cytokine storm, aberrant epigenetic modifications of stress-related genes, glial activation, or treatment emergent effects.[6] To assess and manage various neuropsychiatric complications of COVID-19, the psychiatric community at large should equip itself with appropriate assessment tools and management guidelines to effectively tackle this unprecedented wave of psychiatric ailments. References cialis classification 1.Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic.

N Engl J cialis classification Med 2020;383:510-2. 2.Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown etiology in Wuhan, cialis classification China.

The mystery and the miracle. J Med Virol 2020;92:401-2. 3.Fodoulian L, Tuberosa J, Rossier D, Landis cialis classification BN, Carleton A, Rodriguez I.

SARS-CoV-2 receptor and entry genes are expressed by sustentacular cells in the human olfactory neuroepithelium. BioRxiv 2020.03.31.013268 cialis classification. Doi.

Https://doi.org/10.1101/2020.03.31.013268. 4.Lochhead JJ, Thorne RG. Intranasal delivery of biologics to the central nervous system.

Adv Drug Deliv Rev 2012;64:614-28. 5.Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections.

A systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020;7:611-27. 6.Steardo L Jr., Steardo L, Verkhratsky A.

Psychiatric face of COVID-19. Transl Psychiatry 2020;10:261. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1169_2Abstract The COVID-19 pandemic has emerged as a major stressor of a global scale, affecting all aspects of our lives, and is likely to contribute to a surge of mental ill health.

Ancient Hindu scriptures, notably the Bhagavad Gita, have a wealth of insights that can help approaches to build psychological resilience for individuals at risk, those affected, as well as for caregivers. The path of knowledge (Jnana yoga) promotes accurate awareness of nature of the self, and can help reframe our thinking from an “I” to a “we mode,” much needed for collectively mitigating the spread of the coronavirus. The path of action (Karma yoga) teaches the art of selfless action, providing caregivers and frontline health-care providers a framework to continue efforts in the face of uncertain consequences.

Finally, the path of meditation (Raja yoga) offers a multipronged approach to healthy lifestyle and mindful meditation, which may improve resilience to the illness and its severe consequences. While more work is needed to empirically examine the potential value of each of these approaches in modern psychotherapy, the principles herein may already help individuals facing and providing care for the COVID-19 pandemic.Keywords. Bhagavad Gita, Covid-19, YogaHow to cite this article:Keshavan MS.

Building resilience in the COVID-19 era. Three paths in the Bhagavad Gita. Indian J Psychiatry 2020;62:459-61The COVID-19 crisis has changed our world in just a matter of months, thrusting us into danger, uncertainty, fear, and of course social isolation.

At the time of this writing, over 11 million individuals have been affected worldwide (India is fourth among all countries, 674,515) and over half a million people have died. The COVID-19 pandemic has been an unprecedented global stressor, not only because of the disease burden and mortality but also because of economic upheaval. The very fabric of the society is disrupted, affecting housing, personal relationships, travel, and all aspects of lifestyle.

The overwhelmed health-care system is among the most major stressors, leading to a heightened sense of vulnerability. No definitive treatments or vaccine is on the horizon yet. Psychiatry has to brace up to an expected mental health crisis resulting from this global stressor, not only with regard to treating neuropsychiatric consequences but also with regard to developing preventive approaches and building resilience.Thankfully, there is a wealth of wisdom to help us in our ancient scriptures such as the Bhagavad Gita[1] for building psychological resilience.

The Bhagavad Gita is a dialog between the Pandava prince Arjuna and his charioteer Krishna in the epic Mahabharata, the great tale of the Bharata Dynasty, authored by Sage Vyasa (c. 4–5 B.C.E.). The dialog occurs in the 6th chapter of the epic and has over 700 verses.

In this epic story, Arjuna, the righteous Pandava hero was faced with the dilemma of waging a war against his cousins, the Kauravas, for territory. Arjuna is confused and has no will to initiate the war. In this context, Krishna, his charioteer and spiritual mentor, counsels him.

The key principles of this spiritual discourse in the Gita are embodied in the broad concept of yoga, which literally means “Yog” or “to unite.” Applying three tenets of yoga can greatly help developing resilience at individual, group, and societal levels. A fourth path, Bhakti yoga, is a spiritual approach in the Gita which emphasizes loving devotion toward a higher power or principle, which may or may not involve a personal god. In this editorial, I focus on three paths that have considerable relevance to modern approaches to reliance-focused psychotherapy that may be especially relevant in the COVID-19 era.

Path of Knowledge The first concept in the Gita is the path of knowledge (Jnana Yoga, chapter 2). The fundamental goal of Jnana yoga is to liberate oneself from the limited view of the individual ego, and to develop the awareness of one's self as part of a larger, universal self. Hindu philosophers were among the earliest to ask the question of “who am I” and concluded that the self is not what it seems.

The self as we all know is a collection of our physical, mental, and social attributes that we create for ourselves with input from our perceptions, and input by our families and society. Such a world view leads to a tendency to crave for the “I” and for what is mine, and not consider the “We.” As Krishna in the Bhagavad Gita points out, the person who sees oneself in others, and others in oneself, really “sees.” Such awareness, which guides action in service of self as well as others, is critically important in our goals of collectively preventing the spread of the coronavirus. A glaring example is the use of face masks, known to effectively slow the viral infection.

Using the mask is as important to protecting oneself from the virus as well as protecting others from oneself. Nations such as the USA (and their leaders), who have given mixed messages to the public about the need to wear masks, have been showing a strikingly high number of cases as well as mortality. Unfortunately, such reluctance to wear masks (and thus model protective hygiene for the population), as in the case of the US leader, has stemmed from ego or vanity-related issues (i.e., how he would appear to other leaders!.

). This factor may at least partly underlie the worse COVID-19 outcome in the USA. The simple lesson here is that it is important to first flatten the ego if one wants to flatten the pandemic curve!.

Path of Action The second key concept is the path of action (Karma yoga, chapter 3). Karma yoga is all about taking action without thinking, “what's in it for me.” As such, it seeks to mainly let go of one's ego. In the Bhagavad Gita, Arjuna is ambivalent about fighting because of the conflict regarding the outcome brought on by waging the war, i.e., having to kill some of his own kith and kin.

Krishna reminds him that he should not hesitate, because it is his nature and duty (or Dharma), as a warrior, to protect the larger good, though it will have some downside consequences. The frontline health-care worker caring for severely ill patients with COVID-19 is likely to have a similar emotional reaction as Arjuna, facing a lack of adequate treatments, high likelihood of mortality and of unpredictable negative outcomes, and risk to him/herself. Compounding this, especially when resources such as ventilators are limited, the doctor may have to make tough decisions of whose life to save and whose not.

Adding to this are personal emotions when facing with the death of patients, having to deliver bad news, and dealing with grieving relatives.[2] All these are likely to result in emotional anguish and guilt, leading to burnout and a war “neurosis.”So, what should the frontline health-care provider should do?. Krishna's counsel would be that the doctor should continue to perform his/her own dharma, but do so without desire or attachment, thereby performing action in the spirit of https://www.cityreal.lv/cheap-discount-cialis/ Karma yoga. Such action would be with detachment, without a desire for personal gain and being unperturbed by success or failure.

Such “Nishkaama Karma” (or selfless action) may help doctors working today in the COVID outbreak to carry forward their work with compassion, and accept the results of their actions with equanimity and without guilt. Krishna points out that training one's mind to engage in selfless action is not easy but requires practice (Abhyasa). Krishna is also emphatic about the need to protect oneself, in order to be able to effectively carry out one's duties.

Path of Meditation The third core concept in the Gita is the path of meditation and self-reflection (Raja yoga, or Dhyana yoga, chapter 6). It is considered the royal path (Raja means royal) for attaining self-realization, and often considered the 8-fold path of yoga (Ashtanga yoga) designed to discipline lifestyle, the body and mind toward realizing mindfulness and self-reflection. These techniques, which originated in India over two millennia ago, have evolved over recent decades and anticipate several approaches to contemplative psychotherapy, including dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based stress reduction.[3] These approaches are of particular relevance for stress reduction and resilience building in individuals faced by COVID-19-related emotional difficulties as well as health-care providers.[4]The majority of people affected by the COVID-19 virus recover, but about 20% have severe disease, and the mortality is around 5%.

Older individuals, those with obesity and comorbid medical illnesses such as diabetes and lung disease, are particularly prone to developing severe disease. It is possible that a state of chronic low-grade inflammation which underlies each of these conditions may increase the risk of disproportionate host immune reactions (with excessive release of cytokines), characterizing severe disease in those with COVID-19.[4] With this in mind, it is important to note that exercise, some forms of meditation, anti-inflammatory and antioxidant diet (such as turmeric and melatonin), and yoga have known benefits in reducing inflammation.[5],[6],[7],[8],[9] Sleep loss also elevates inflammatory cytokines. Healthy sleep may reduce inflammation.[10] Clearly, a healthy lifestyle, including healthy sleep, exercise, and diet, may be protective against developing COVID-19-related severe complications.

These principles of healthy living are beautifully summarized in the Bhagavad Gita.Yuktahara-viharasya yukta-cestasya karmasuYukta-svapnavabodhasya yogo bhavati duhkha-haHe who is temperate in his habits of eating, sleeping, working and recreation can mitigate all sorrows by practicing the yoga system.–Bhagavad Gita, Chapter 6, verse 17.The relevance of the Bhagavad Gita for modern psychotherapy has been widely reviewed.[11],[12] However, relatively little empirical literature exists on the effectiveness of versus spiritually integrated psychotherapy incorporating Hindu psychotherapeutic insights. Clearly, more work is needed, and COVID-19 may provide an opportunity for conducting further empirical research.[13] In the meantime, using the principles outlined here may already be of benefit in helping those in need, and may be rapidly enabled in the emerging era of telehealth and digital health.[14]Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Pandurangi AK, Shenoy S, Keshavan MS.

Psychotherapy in the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8. 2.Arango C.

Lessons learned from the coronavirus health crisis in Madrid, Spain. How COVID-19 has changed our lives in the last 2 weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry 2020;26:S0006-3223 (20) 31493-1.

3.Keshavan MS, Gangadhar GN, Hinduism PA. In. Spirituality and Mental Health Across Cultures, Evidence-Based Implications for Clinical Practice.

Oxford, England. Oxford University Press. In Press.

4.Habersaat KB, Betsch C, Danchin M, Sunstein CR, Böhm R, Falk A, et al. Ten considerations for effectively managing the COVID-19 transition. Nat Hum Behav 2020;4:677-87.

Doi. 10.1038/s41562-020-0906-x. Epub 2020 Jun 24.

5.Kumar K. Building resilience to Covid-19 disease severity. J Med Res Pract 2020;9:1-7.

6.Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and Yoga practices as potential adjunctive treatment of SARS-CoV-2 infection and COVID-19. A brief overview of key subjects [published online ahead of print, 2020 Jun 22].

J Altern Complement Med 2020;26:10.1089/acm. 2020.0177. [doi.

10.1089/acm. 2020.0177]. 7.Gupta H, Gupta M, Bhargava S.

Potential use of turmeric in COVID-19 [published online ahead of print, 2020 Jul 1]. Clin Exp Dermatol. 2020;10.1111/ced.14357.

Doi:10.1111/ced.14357. 8.Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological implications of physical inactivity among older adults during the COVID-19 pandemic [published online ahead of print, 2020 Jun 25].

Gerontology 2020:26;1-8. [doi. 10.1159/000509216].

9.El-Missiry MA, El-Missiry ZM, Othman AI. Melatonin is a potential adjuvant to improve clinical outcomes in individuals with obesity and diabetes with coexistence of Covid-19 [published online ahead of print, 2020 Jun 29]. Eur J Pharmacol 2020;882:173329.

10.Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010;24:775-84.

11.Balodhi JP, Keshavan MS. Bhagavad Gita and psychotherapy. Asian J Psychiatr 2011;4:300-2.

12.Bhatia SC, Madabushi J, Kolli V, Bhatia SK, Madaan V. The Bhagavad Gita and contemporary psychotherapies. Indian J Psychiatry 2013;55:S315-21.

13.Keshavan MS. Pandemics and psychiatry. Repositioning research in context of COVID-19 [published online ahead of print, 2020 May 7].

Asian J Psychiatr 2020;51:102159. [doi. 10.1016/j.ajp.

2020.102159]. 14.Torous J, Keshavan M. COVID-19, mobile health and serious mental illness.

Schizophr Res 2020;218:36-7. Correspondence Address:Matcheri S KeshavanRoom 542, Massachusetts Mental Health Center, 75 Fenwood Road, Boston, MA 02115 USASource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_829_20.

How to cialis coupon cialis efectos adversos cite this article:Singh OP. The need for routine psychiatric assessment of COVID-19 survivors. Indian J Psychiatry 2020;62:457-8COVID-19 pandemic is cialis coupon expected to bring a Tsunami of mental health issues. Public health emergencies may affect the well-being, safety, and security of both individuals and communities, which lead to a range of emotional reactions, unhealthy behavior, and noncompliance, with public health directives (such as home confinement and vaccination) in people who contact the disease as well as in the general population.[1] Thus far, there has been an increased emphasis on psychosocial factors such as loneliness, effect of quarantine, uncertainty, vulnerability to COVID-19 infection, economic factors, and career difficulties, which may lead to increased psychiatric morbidity.Time has now come to pay attention to the direct effect of the virus on brain and psychiatric adverse symptoms, resulting from the treatment provided.

Viral infections are known to be associated with psychiatric disorders such as depression, cialis coupon bipolar disorder, obsessive–compulsive disorder (OCD), or schizophrenia. There was an increased incidence of psychiatric disorders following the Influenza Pandemic. Karl Menninger described 100 cases of influenza presenting with psychiatric sequelae, which could mainly be categorized cialis coupon as dementia praecox, delirium, other psychoses, and unclassified subtypes. Dementia praecox constituted the largest number among all these cases.[2] Neuroinflammation is now known as the key factor in genesis and exacerbation of psychiatric disorders, particularly depression and bipolar disorders.Emerging evidence points toward the neurotropic properties of the SARS-CoV-2 virus.

Loss of smell and taste cialis coupon as an initial symptom points toward early involvement of olfactory bulb. The rapid spread to brain has been demonstrated through retrograde axonal transport.[3] The virus can enter the brain through endothelial cells lining the blood–brain barrier and also through other nerves such as the vagus nerve.[4] Cytokine storm, a serious immune reaction to the virus, can activate brain glial cells, leading to delirium, depression, bipolar disorder, and OCD.Studies examining psychiatric disorders in acute patients suffering from COVID-19 found almost 40% of such patients suffering from anxiety, depression, and posttraumatic stress disorder.[5] The data on long-term psychiatric sequelae in patients who have recovered from acute illness are limited. There are anecdotal reports of psychosis and mania occurring in patients of COVID-19 following discharge from hospital. This may be either due to the direct effect of the virus cialis coupon on the brain or due to the neuropsychiatric effects of drugs used to treat the infection or its complications.

For example, behavioral toxicity of high-dose corticosteroids which are frequently used during the treatment of severe cases to prevent and manage cytokine storm.The patients with COVID-19 can present with many neuropsychiatric disorders, which may be caused by direct inflammation, central nervous system effects of cytokine storm, aberrant epigenetic modifications of stress-related genes, glial activation, or treatment emergent effects.[6] To assess and manage various neuropsychiatric complications of COVID-19, the psychiatric community at large should equip itself with appropriate assessment tools and management guidelines to effectively tackle this unprecedented wave of psychiatric ailments. References 1.Pfefferbaum B, North cialis coupon CS. Mental health and the COVID-19 pandemic. N Engl J cialis coupon Med 2020;383:510-2.

2.Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown cialis coupon etiology in Wuhan, China. The mystery and the miracle. J Med Virol 2020;92:401-2.

3.Fodoulian L, Tuberosa J, Rossier D, Landis BN, Carleton A, Rodriguez cialis coupon I. SARS-CoV-2 receptor and entry genes are expressed by sustentacular cells in the human olfactory neuroepithelium. BioRxiv 2020.03.31.013268 cialis coupon. Doi.

Https://doi.org/10.1101/2020.03.31.013268. 4.Lochhead JJ, Thorne RG. Intranasal delivery of biologics to the central nervous system. Adv Drug Deliv Rev 2012;64:614-28.

5.Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections. A systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020;7:611-27.

6.Steardo L Jr., Steardo L, Verkhratsky A. Psychiatric face of COVID-19. Transl Psychiatry 2020;10:261. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1169_2Abstract The COVID-19 pandemic has emerged as a major stressor of a global scale, affecting all aspects of our lives, and is likely to contribute to a surge of mental ill health. Ancient Hindu scriptures, notably the Bhagavad Gita, have a wealth of insights that can help approaches to build psychological resilience for individuals at risk, those affected, as well as for caregivers.

The path of knowledge (Jnana yoga) promotes accurate awareness of nature of the self, and can help reframe our thinking from an “I” to a “we mode,” much needed for collectively mitigating the spread of the coronavirus. The path of action (Karma yoga) teaches the art of selfless action, providing caregivers and frontline health-care providers a framework to continue efforts in the face of uncertain consequences. Finally, the path of meditation (Raja yoga) offers a multipronged approach to healthy lifestyle and mindful meditation, which may improve resilience to the illness and its severe consequences. While more work is needed to empirically examine the potential value of each of these approaches in modern psychotherapy, the principles herein may already help individuals facing and providing care for the COVID-19 pandemic.Keywords.

Bhagavad Gita, Covid-19, YogaHow to cite this article:Keshavan MS. Building resilience in the COVID-19 era. Three paths in the Bhagavad Gita. Indian J Psychiatry 2020;62:459-61The COVID-19 crisis has changed our world in just a matter of months, thrusting us into danger, uncertainty, fear, and of course social isolation.

At the time of this writing, over 11 million individuals have been affected worldwide (India is fourth among all countries, 674,515) and over half a million people have died. The COVID-19 pandemic has been an unprecedented global stressor, not only because of the disease burden and mortality but also because of economic upheaval. The very fabric of the society is disrupted, affecting housing, personal relationships, travel, and all aspects of lifestyle. The overwhelmed health-care system is among the most major stressors, leading to a heightened sense of vulnerability.

No definitive treatments or vaccine is on the horizon yet. Psychiatry has to brace up to an expected mental health crisis resulting from this global stressor, not only with regard to treating neuropsychiatric consequences but also with regard to developing preventive approaches and building resilience.Thankfully, there is a wealth of wisdom to help us in our ancient scriptures such as the Bhagavad Gita[1] for building psychological resilience. The Bhagavad Gita is a dialog between the Pandava prince Arjuna and his charioteer Krishna in the epic Mahabharata, the great tale of the Bharata Dynasty, authored by Sage Vyasa (c. 4–5 B.C.E.).

The dialog occurs in the 6th chapter of the epic and has over 700 verses. In this epic story, Arjuna, the righteous Pandava hero was faced with the dilemma of waging a war against his cousins, the Kauravas, for territory. Arjuna is confused and has no will to initiate the war. In this context, Krishna, his charioteer and spiritual mentor, counsels him.

The key principles of this spiritual discourse in the Gita are embodied in the broad concept of yoga, which literally means “Yog” or “to unite.” Applying three tenets of yoga can greatly help developing resilience at individual, group, and societal levels. A fourth path, Bhakti yoga, is a spiritual approach in the Gita which emphasizes loving devotion toward a higher power or principle, which may or may not involve a personal god. In this editorial, I focus on three paths that have considerable relevance to modern approaches to reliance-focused psychotherapy that may be especially relevant in the COVID-19 era. Path of Knowledge The first concept in the Gita is the path of knowledge (Jnana Yoga, chapter 2).

The fundamental goal of Jnana yoga is to liberate oneself from the limited view of the individual ego, and to develop the awareness of one's self as part of a larger, universal self. Hindu philosophers were among the earliest to ask the question of “who am I” and concluded that the self is not what it seems. The self as we all know is a collection of our physical, mental, and social attributes that we create for ourselves with input from our perceptions, and input by our families and society. Such a world view leads to a tendency to crave for the “I” and for what is mine, and not consider the “We.” As Krishna in the Bhagavad Gita points out, the person who sees oneself in others, and others in oneself, really “sees.” Such awareness, which guides action in service of self as well as others, is critically important in our goals of collectively preventing the spread of the coronavirus.

A glaring example is the use of face masks, known to effectively slow the viral infection. Using the mask is as important to protecting oneself from the virus as well as protecting others from oneself. Nations such as the USA (and their leaders), who have given mixed messages to the public about the need to wear masks, have been showing a strikingly high number of cases as well as mortality. Unfortunately, such reluctance to wear masks (and thus model protective hygiene for the population), as in the case of the US leader, has stemmed from ego or vanity-related issues (i.e., how he would appear to other leaders!.

). This factor may at least partly underlie the worse COVID-19 outcome in the USA. The simple lesson here is that it is important to first flatten the ego if one wants to flatten the pandemic curve!. Path of Action The second key concept is the path of action (Karma yoga, chapter 3).

Karma yoga is all about taking action without thinking, “what's in it for me.” As such, it seeks to mainly let go of one's ego. In the Bhagavad Gita, Arjuna is ambivalent about fighting because of the conflict regarding the outcome brought on by waging the war, i.e., having to kill some of his own kith and kin. Krishna reminds him that he should not hesitate, because it is his nature and duty (or Dharma), as a warrior, to protect the larger good, though it will have some downside consequences. The frontline health-care worker caring for severely ill patients with COVID-19 is likely to have a similar emotional reaction as Arjuna, facing a lack of adequate treatments, high likelihood of mortality and of unpredictable negative outcomes, and risk to him/herself.

Compounding this, especially when resources such as ventilators are limited, the doctor may have to make tough decisions of whose life to save and whose not. Adding to this are personal emotions when facing with the death of patients, having to deliver bad news, and dealing with grieving relatives.[2] All these are likely to result in emotional anguish and guilt, leading to burnout and a war “neurosis.”So, what should the frontline health-care provider should do?. Krishna's counsel would be that the doctor should continue to perform his/her own dharma, but do so without desire or attachment, thereby performing action in the spirit of Karma yoga. Such action would be with detachment, without a desire for personal gain and being unperturbed by success or failure.

Such “Nishkaama Karma” (or selfless action) may help doctors working today in the COVID outbreak to carry forward their work with compassion, and accept the results of their actions with equanimity and without guilt. Krishna points out that training one's mind to engage in selfless action is not easy but requires practice (Abhyasa). Krishna is also emphatic about the need to protect oneself, in order to be able to effectively carry out one's duties. Path of Meditation The third core concept in the Gita is the path of meditation and self-reflection (Raja yoga, or Dhyana yoga, chapter 6).

It is considered the royal path (Raja means royal) for attaining self-realization, and often considered the 8-fold path of yoga (Ashtanga yoga) designed to discipline lifestyle, the body and mind toward realizing mindfulness and self-reflection. These techniques, which originated in India over two millennia ago, have evolved over recent decades and anticipate several approaches to contemplative psychotherapy, including dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based stress reduction.[3] These approaches are of particular relevance for stress reduction and resilience building in individuals faced by COVID-19-related emotional difficulties as well as health-care providers.[4]The majority of people affected by the COVID-19 virus recover, but about 20% have severe disease, and the mortality is around 5%. Older individuals, those with obesity and comorbid medical illnesses such as diabetes and lung disease, are particularly prone to developing severe disease. It is possible that a state of chronic low-grade inflammation which underlies each of these conditions may increase the risk of disproportionate host immune reactions (with excessive release of cytokines), characterizing severe disease in those with COVID-19.[4] With this in mind, it is important to note that exercise, some forms of meditation, anti-inflammatory and antioxidant diet (such as turmeric and melatonin), and yoga have known benefits in reducing inflammation.[5],[6],[7],[8],[9] Sleep loss also elevates inflammatory cytokines.

Healthy sleep may reduce inflammation.[10] Clearly, a healthy lifestyle, including healthy sleep, exercise, and diet, may be protective against developing COVID-19-related severe complications. These principles of healthy living are beautifully summarized in the Bhagavad Gita.Yuktahara-viharasya yukta-cestasya karmasuYukta-svapnavabodhasya yogo bhavati duhkha-haHe who is temperate in his habits of eating, sleeping, working and recreation can mitigate all sorrows by practicing the yoga system.–Bhagavad Gita, Chapter 6, verse 17.The relevance of the Bhagavad Gita for modern psychotherapy has been widely reviewed.[11],[12] However, relatively little empirical literature exists on the effectiveness of versus spiritually integrated psychotherapy incorporating Hindu psychotherapeutic insights. Clearly, more work is needed, and COVID-19 may provide an opportunity for conducting further empirical research.[13] In the meantime, using the principles outlined here may already be of benefit in helping those in need, and may be rapidly enabled in the emerging era of telehealth and digital health.[14]Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Pandurangi AK, Shenoy S, Keshavan MS.

Psychotherapy in the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8. 2.Arango C. Lessons learned from the coronavirus health crisis in Madrid, Spain.

How COVID-19 has changed our lives in the last 2 weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry 2020;26:S0006-3223 (20) 31493-1. [doi. 10.1016/j.biopsych.

2020.04.003]. 3.Keshavan MS, Gangadhar GN, Hinduism PA. In. Spirituality and Mental Health Across Cultures, Evidence-Based Implications for Clinical Practice.

Oxford, England. Oxford University Press. In Press. 4.Habersaat KB, Betsch C, Danchin M, Sunstein CR, Böhm R, Falk A, et al.

Ten considerations for effectively managing the COVID-19 transition. Nat Hum Behav 2020;4:677-87. Doi. 10.1038/s41562-020-0906-x.

Epub 2020 Jun 24. 5.Kumar K. Building resilience to Covid-19 disease severity. J Med Res Pract 2020;9:1-7.

6.Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and Yoga practices as potential adjunctive treatment of SARS-CoV-2 infection and COVID-19. A brief overview of key subjects [published online ahead of print, 2020 Jun 22]. J Altern Complement Med 2020;26:10.1089/acm.

7.Gupta H, Gupta M, Bhargava S. Potential use of turmeric in COVID-19 [published online ahead of print, 2020 Jul 1]. Clin Exp Dermatol. 2020;10.1111/ced.14357.

Doi:10.1111/ced.14357. 8.Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological implications of physical inactivity among older adults during the COVID-19 pandemic [published online ahead of print, 2020 Jun 25]. Gerontology 2020:26;1-8.

[doi. 10.1159/000509216]. 9.El-Missiry MA, El-Missiry ZM, Othman AI. Melatonin is a potential adjuvant to improve clinical outcomes in individuals with obesity and diabetes with coexistence of Covid-19 [published online ahead of print, 2020 Jun 29].

Eur J Pharmacol 2020;882:173329. 10.Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010;24:775-84.

11.Balodhi JP, Keshavan MS. Bhagavad Gita and psychotherapy. Asian J Psychiatr 2011;4:300-2. 12.Bhatia SC, Madabushi J, Kolli V, Bhatia SK, Madaan V.

The Bhagavad Gita and contemporary psychotherapies. Indian J Psychiatry 2013;55:S315-21. 13.Keshavan MS. Pandemics and psychiatry.

Repositioning research in context of COVID-19 [published online ahead of print, 2020 May 7]. Asian J Psychiatr 2020;51:102159. [doi. 10.1016/j.ajp.

2020.102159]. 14.Torous J, Keshavan M. COVID-19, mobile health and serious mental illness. Schizophr Res 2020;218:36-7.

Correspondence Address:Matcheri S KeshavanRoom 542, Massachusetts Mental Health Center, 75 Fenwood Road, Boston, MA 02115 USASource of Support. None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_829_20.

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Allscripts Healthcare Solutions is selling its care coordination subsidiary CarePort Health to WellSky, the companies said Tuesday.WellSky, a company that develops software tools for post-acute care providers, has entered into a definitive agreement to acquire CarePort for $1.35 billion, representing more than 13 times https://www.cityreal.lv/cheap-discount-cialis/ CarePort's revenue over the last cheap viagra and cialis 12 months and roughly 21 times the company's adjusted earnings before interest, taxes and amortization.CarePort represents roughly 6% of Allscripts' revenue. Allscripts and WellSky, which is owned by private-equity firms TPG Capital and Leonard cheap viagra and cialis Green &. Partners, expect the sale to close before year-end.WellSky officials said buying CarePort, which connects acute and post-acute care providers and payers, will better position the company to manage the acute-care discharge process, as well as tracking for patients across post-acute care settings.Under the agreement, CarePort's customers and employees will transition to WellSky."Together with CarePort, WellSky will establish new, meaningful connections between historically disparate settings of care," Bill Miller, CEO of WellSky, said in a statement.Rick Poulton, Allscripts' president and chief financial officer, said the sale for Allscripts "unlocks significant value for our shareholders" and "enables us to increase our focus on our core business."Allscripts will use proceeds from the sale to "invest in its solutions, further deleverage the company's balance sheet and support significant share repurchases," according to a news release.Allscripts in July announced plans to sell EPSi, a business unit focused on financial decision support, to Strata Decision Technology for $365 million.At the time, Poulton acknowledged that Allscripts could continue to divest businesses in its data analytics and care coordination segment—the segment that houses CarePort—since they tend to do more business outside the Allscripts EHR customer base. "We're not predicting or foreshadowing anything, but they certainly are possibilities," he told investment analysts in July.Allscripts posted $406.2 million in revenue for this year's second quarter, down 8.6% from the year-ago quarter, which executives attributed cheap viagra and cialis to lower patient volumes linked with the COVID-19 pandemic.

The company reported an operating loss of $4.7 million, down from a reported $4.7 million in operating income in the year-ago quarter.The company in May withdrew its full-year 2020 financial outlook due to uncertainty from the pandemic.Mayo Clinic and Safe Health Group on Monday announced their collaboration on a new venture known Safe Health Systems, which they say can enable commodity diagnostics at a mass scale and help reduce the cost of low-complexity care processes.Launched as part of the Mayo Clinic Platform, the proprietary data platform, SAFE, can boost access to affordable treatment for common medical conditions, including COVID-19.This venture, launched as part of the Mayo Clinic Platform, "will provide the suite of apps and services that universities, employers and organizations need to restart in-person activities and support new care models," said platform president Dr. John Halamka cheap viagra and cialis. HIMSS20 cheap viagra and cialis Digital Learn on-demand, earn credit, find products and solutions. Get Started >>.

The SAFE platform can help speed the deployment of custom digital health applications, enabling artificial intelligence-powered care automation and cheap viagra and cialis remote point of care diagnostics. As deployed for COVID-19 testing, the technology links patients, clinicians and test providers through a smartphone app called HealthCheck. Once vaccines become available, the app can support vaccine workflow and verification.Beyond COVID-19, its initial focus is cheap viagra and cialis to support testing for sexually transmitted diseases, strep throat, urinary tract infections, flu, ear infection and other common conditions. Platform developers note that an absence of remote testing is a limiting factor for telehealth treatment of those and other low-complexity ailments.In an appearance at HLTH VRTL 2020 Monday, Halamka explained how the SAFE platform can help navigation of what cheap viagra and cialis he calls the five stages of the pandemic.

Isolation, testing and contact tracing, pre-vaccine return to work or return to school, vaccine distribution, and the new post-pandemic normal."What are the software systems and functionality you need in each of those transitions?. You can see that it will evolve over time," said Halamka."Imagine I woke cheap viagra and cialis up this morning and I have lost my sense of taste or smell. That's concerning. If I feel that cheap viagra and cialis I need a certain kind of test, it may very well be that I would reach out to a clinician.

And the SHS app enables the easy connection of a patient with signs and symptoms to a cheap viagra and cialis physician who can review them and ensure the right test is ordered."That test may be an in-laboratory test. It could be an at-home gathered test or an at-home point-of-care test – all these different kinds of modalities are supported," he explained."And then, once a test result comes back, we have to take action based on signs and symptoms, based on the prevalence of infections in my community, based on my results and the accuracy of those results. Maybe I cheap viagra and cialis quarantine, maybe I don't. Maybe I get additional testing.

So that workflow has to be cheap viagra and cialis supported. Mayo Clinic creates the algorithms around interpreting test results and then creating next actions."If a patient recovers and tests negative, and a workplace or school needs a "trustable validation of cheap viagra and cialis that test," said Halamka, the application "creates a QR code and a whole workflow that will enable a trusted back to work or back or back to school passport to appear on the phone as a result of the test."Beyond those applications, the app also incorporates software development tools for contact tracing workflow."And then we start to move into vaccines," he said. "So let's imagine over the next year, six different vaccines will be available. They'll have different target populations, different availability, different dosing cheap viagra and cialis.

You'll need to understand which vaccine is right for you and how to get it. And the app will incorporate cheap viagra and cialis that logic."Once you have a vaccine, [it] should generate a passport," he added. "Given the vaccine and the timing of the vaccine, are you safe cheap viagra and cialis to travel?. Are you safe to return to work?.

Are you likely to have cheap viagra and cialis immunity?. And so the workflow of recording vaccines, displaying vaccines in a trustable manner, is also included in the app."Halamka called the new collaboration a good example a "joint activity between an agile software developer, Safe Health Systems, and a trusted medical institution with clinical experience and data, Mayo Clinic, working together to create an end-to-end COVID-19 solution that covers all five stages as we go through the pandemic and its resolution." Twitter. @MikeMiliardHITNEmail the writer. Mike.miliard@himssmedia.comHealthcare IT News is a HIMSS publication..

Allscripts Healthcare Solutions is selling its care coordination subsidiary CarePort Health to cialis coupon WellSky, the companies said https://www.cityreal.lv/cheap-discount-cialis/ Tuesday.WellSky, a company that develops software tools for post-acute care providers, has entered into a definitive agreement to acquire CarePort for $1.35 billion, representing more than 13 times CarePort's revenue over the last 12 months and roughly 21 times the company's adjusted earnings before interest, taxes and amortization.CarePort represents roughly 6% of Allscripts' revenue. Allscripts and WellSky, which is owned cialis coupon by private-equity firms TPG Capital and Leonard Green &. Partners, expect the sale to close before year-end.WellSky officials said buying CarePort, which connects acute and post-acute care providers and payers, will better position the company to manage the acute-care discharge process, as well as tracking for patients across post-acute care settings.Under the agreement, CarePort's customers and employees will transition to WellSky."Together with CarePort, WellSky will establish new, meaningful connections between historically disparate settings of care," Bill Miller, CEO of WellSky, said in a statement.Rick Poulton, Allscripts' president and chief financial officer, said the sale for Allscripts "unlocks significant value for our shareholders" and "enables us to increase our focus on our core business."Allscripts will use proceeds from the sale to "invest in its solutions, further deleverage the company's balance sheet and support significant share repurchases," according to a news release.Allscripts in July announced plans to sell EPSi, a business unit focused on financial decision support, to Strata Decision Technology for $365 million.At the time, Poulton acknowledged that Allscripts could continue to divest businesses in its data analytics and care coordination segment—the segment that houses CarePort—since they tend to do more business outside the Allscripts EHR customer base. "We're not predicting or foreshadowing anything, but they certainly are possibilities," he told investment analysts in July.Allscripts posted $406.2 million in revenue for this year's second cialis coupon quarter, down 8.6% from the year-ago quarter, which executives attributed to lower patient volumes linked with the COVID-19 pandemic. The company reported an operating loss of $4.7 million, down from a reported $4.7 million in operating income in the year-ago quarter.The company in May withdrew its full-year 2020 financial outlook due to uncertainty from the pandemic.Mayo Clinic and Safe Health Group on Monday announced their collaboration on a new venture known Safe Health Systems, which they say can enable commodity diagnostics at a mass scale and help reduce the cost of low-complexity care processes.Launched as part of the Mayo Clinic Platform, the proprietary data platform, SAFE, can boost access to affordable treatment for common medical conditions, including COVID-19.This venture, launched as part of the Mayo Clinic Platform, "will provide the suite of apps and services that universities, employers and organizations need to restart in-person activities and support new care models," said platform president Dr.

John Halamka cialis coupon. HIMSS20 Digital Learn on-demand, earn credit, find cialis coupon products and solutions. Get Started >>. The SAFE platform can help speed the deployment of custom cialis coupon digital health applications, enabling artificial intelligence-powered care automation and remote point of care diagnostics. As deployed for COVID-19 testing, the technology links patients, clinicians and test providers through a smartphone app called HealthCheck.

Once vaccines become available, the app can support vaccine workflow and verification.Beyond COVID-19, its initial focus is to support testing for sexually transmitted diseases, strep throat, urinary cialis coupon tract infections, flu, ear infection and other common conditions. Platform developers note that an absence of remote testing is a limiting factor for telehealth treatment of those and other low-complexity ailments.In an appearance at HLTH VRTL 2020 Monday, Halamka explained how cialis coupon the SAFE platform can help navigation of what he calls the five stages of the pandemic. Isolation, testing and contact tracing, pre-vaccine return to work or return to school, vaccine distribution, and the new post-pandemic normal."What are the software systems and functionality you need in each of those transitions?. You can see that it will evolve over time," said Halamka."Imagine I woke up cialis coupon this morning and I have lost my sense of taste or smell. That's concerning.

If I feel that I need a certain kind of test, it may cialis coupon very well be that I would reach out to a clinician. And the SHS app enables the easy connection of a patient cialis coupon with signs and symptoms to a physician who can review them and ensure the right test is ordered."That test may be an in-laboratory test. It could be an at-home gathered test or an at-home point-of-care test – all these different kinds of modalities are supported," he explained."And then, once a test result comes back, we have to take action based on signs and symptoms, based on the prevalence of infections in my community, based on my results and the accuracy of those results. Maybe I quarantine, maybe I don't cialis coupon. Maybe I get additional testing.

So that workflow cialis coupon has to be supported. Mayo Clinic creates the algorithms around interpreting test results and then cialis coupon creating next actions."If a patient recovers and tests negative, and a workplace or school needs a "trustable validation of that test," said Halamka, the application "creates a QR code and a whole workflow that will enable a trusted back to work or back or back to school passport to appear on the phone as a result of the test."Beyond those applications, the app also incorporates software development tools for contact tracing workflow."And then we start to move into vaccines," he said. "So let's imagine over the next year, six different vaccines will be available. They'll have different target cialis coupon populations, different availability, different dosing. You'll need to understand which vaccine is right for you and how to get it.

And the app will incorporate that logic."Once you have a cialis coupon vaccine, [it] should generate a passport," he added. "Given the vaccine and the timing of the cialis coupon vaccine, are you safe to travel?. Are you safe to return to work?. Are you likely cialis coupon to have immunity?. And so the workflow of recording vaccines, displaying vaccines in a trustable manner, is also included in the app."Halamka called the new collaboration a good example a "joint activity between an agile software developer, Safe Health Systems, and a trusted medical institution with clinical experience and data, Mayo Clinic, working together to create an end-to-end COVID-19 solution that covers all five stages as we go through the pandemic and its resolution." Twitter.

@MikeMiliardHITNEmail the writer. Mike.miliard@himssmedia.comHealthcare IT News is a HIMSS publication..


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