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NCHS Data buy levitra usa Brief No. 286, September 2017PDF Versionpdf icon (374 KB)Anjel Vahratian, Ph.D.Key findingsData from the National Health Interview Survey, 2015Among those aged 40–59, perimenopausal women (56.0%) were more likely than postmenopausal (40.5%) and premenopausal (32.5%) women to sleep less than 7 hours, on average, in a 24-hour period.Postmenopausal women aged 40–59 were more likely than premenopausal women aged 40–59 to have trouble falling asleep (27.1% compared with 16.8%, respectively), and staying asleep (35.9% compared with 23.7%), four times or more in the past week.Postmenopausal women aged 40–59 (55.1%) were more likely than premenopausal women aged 40–59 (47.0%) to not wake up feeling well rested 4 days or more in the past week.Sleep duration and quality are important contributors to health and wellness. Insufficient sleep is associated with an increased risk for chronic buy levitra usa conditions such as cardiovascular disease (1) and diabetes (2). Women may be particularly vulnerable to sleep problems during times of reproductive hormonal change, such as after the menopausal transition.

Menopause is “the permanent cessation buy levitra usa of menstruation that occurs after the loss of ovarian activity” (3). This data brief describes sleep duration and sleep quality among nonpregnant women aged 40–59 by menopausal status. The age range selected for this analysis reflects the focus on midlife sleep health. In this analysis, 74.2% buy levitra usa of women are premenopausal, 3.7% are perimenopausal, and 22.1% are postmenopausal.

Keywords. Insufficient sleep, menopause, National Health Interview Survey Perimenopausal women were more buy levitra usa likely than premenopausal and postmenopausal women to sleep less than 7 hours, on average, in a 24-hour period.More than one in three nonpregnant women aged 40–59 slept less than 7 hours, on average, in a 24-hour period (35.1%) (Figure 1). Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period (56.0%), compared with 32.5% of premenopausal and 40.5% of postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to sleep less than 7 hours, on average, in a 24-hour period.

Figure 1 buy levitra usa. Percentage of nonpregnant women aged 40–59 who slept less than 7 hours, on average, in a 24-hour period, by menopausal status. United States, 2015image icon1Significant quadratic trend by menopausal status (p buy levitra usa <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual buy levitra usa cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table for buy levitra usa Figure 1pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who had trouble falling asleep four times or more in the past week varied by menopausal status.Nearly one in five nonpregnant women aged 40–59 had trouble falling asleep buy levitra usa four times or more in the past week (19.4%) (Figure 2). The percentage of women in this age group who had trouble falling asleep four times or more in the past week increased from 16.8% among premenopausal women to 24.7% among perimenopausal and 27.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble falling asleep four times or more in the past week.

Figure 2 buy levitra usa. Percentage of nonpregnant women aged 40–59 who had trouble falling asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal status buy levitra usa (p <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle buy levitra usa was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table for Figure 2pdf buy levitra usa icon.SOURCE.

NCHS, National Health Interview Survey, 2015. The percentage of women buy levitra usa aged 40–59 who had trouble staying asleep four times or more in the past week varied by menopausal status.More than one in four nonpregnant women aged 40–59 had trouble staying asleep four times or more in the past week (26.7%) (Figure 3). The percentage of women aged 40–59 who had trouble staying asleep four times or more in the past week increased from 23.7% among premenopausal, to 30.8% among perimenopausal, and to 35.9% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to have trouble staying asleep four times or more in the past week.

Figure 3 buy levitra usa. Percentage of nonpregnant women aged 40–59 who had trouble staying asleep four times or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by buy levitra usa menopausal status (p <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year buy levitra usa ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table buy levitra usa for Figure 3pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. The percentage of women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week varied by menopausal status.Nearly one in two nonpregnant women aged 40–59 did not wake up feeling well rested 4 days or more in the past week (48.9%) (Figure 4). The percentage buy levitra usa of women in this age group who did not wake up feeling well rested 4 days or more in the past week increased from 47.0% among premenopausal women to 49.9% among perimenopausal and 55.1% among postmenopausal women. Postmenopausal women were significantly more likely than premenopausal women to not wake up feeling well rested 4 days or more in the past week.

Figure 4 buy levitra usa. Percentage of nonpregnant women aged 40–59 who did not wake up feeling well rested 4 days or more in the past week, by menopausal status. United States, 2015image icon1Significant linear trend by menopausal status (p <. 0.05).NOTES.

Women were postmenopausal if they had gone without a menstrual cycle for more than 1 year or were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they no longer had a menstrual cycle and their last menstrual cycle was 1 year ago or less. Women were premenopausal if they still had a menstrual cycle. Access data table for Figure 4pdf icon.SOURCE.

NCHS, National Health Interview Survey, 2015. SummaryThis report describes sleep duration and sleep quality among U.S. Nonpregnant women aged 40–59 by menopausal status. Perimenopausal women were most likely to sleep less than 7 hours, on average, in a 24-hour period compared with premenopausal and postmenopausal women.

In contrast, postmenopausal women were most likely to have poor-quality sleep. A greater percentage of postmenopausal women had frequent trouble falling asleep, staying asleep, and not waking well rested compared with premenopausal women. The percentage of perimenopausal women with poor-quality sleep was between the percentages for the other two groups in all three categories. Sleep duration changes with advancing age (4), but sleep duration and quality are also influenced by concurrent changes in women’s reproductive hormone levels (5).

Because sleep is critical for optimal health and well-being (6), the findings in this report highlight areas for further research and targeted health promotion. DefinitionsMenopausal status. A three-level categorical variable was created from a series of questions that asked women. 1) “How old were you when your periods or menstrual cycles started?.

€. 2) “Do you still have periods or menstrual cycles?. €. 3) “When did you have your last period or menstrual cycle?.

€. And 4) “Have you ever had both ovaries removed, either as part of a hysterectomy or as one or more separate surgeries?. € Women were postmenopausal if they a) had gone without a menstrual cycle for more than 1 year or b) were in surgical menopause after the removal of their ovaries. Women were perimenopausal if they a) no longer had a menstrual cycle and b) their last menstrual cycle was 1 year ago or less.

Premenopausal women still had a menstrual cycle.Not waking feeling well rested. Determined by respondents who answered 3 days or less on the questionnaire item asking, “In the past week, on how many days did you wake up feeling well rested?. €Short sleep duration. Determined by respondents who answered 6 hours or less on the questionnaire item asking, “On average, how many hours of sleep do you get in a 24-hour period?.

€Trouble falling asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble falling asleep?. €Trouble staying asleep. Determined by respondents who answered four times or more on the questionnaire item asking, “In the past week, how many times did you have trouble staying asleep?.

€ Data source and methodsData from the 2015 National Health Interview Survey (NHIS) were used for this analysis. NHIS is a multipurpose health survey conducted continuously throughout the year by the National Center for Health Statistics. Interviews are conducted in person in respondents’ homes, but follow-ups to complete interviews may be conducted over the telephone. Data for this analysis came from the Sample Adult core and cancer supplement sections of the 2015 NHIS.

For more information about NHIS, including the questionnaire, visit the NHIS website.All analyses used weights to produce national estimates. Estimates on sleep duration and quality in this report are nationally representative of the civilian, noninstitutionalized nonpregnant female population aged 40–59 living in households across the United States. The sample design is described in more detail elsewhere (7). Point estimates and their estimated variances were calculated using SUDAAN software (8) to account for the complex sample design of NHIS.

Linear and quadratic trend tests of the estimated proportions across menopausal status were tested in SUDAAN via PROC DESCRIPT using the POLY option. Differences between percentages were evaluated using two-sided significance tests at the 0.05 level. About the authorAnjel Vahratian is with the National Center for Health Statistics, Division of Health Interview Statistics. The author gratefully acknowledges the assistance of Lindsey Black in the preparation of this report.

ReferencesFord ES. Habitual sleep duration and predicted 10-year cardiovascular risk using the pooled cohort risk equations among US adults. J Am Heart Assoc 3(6):e001454. 2014.Ford ES, Wheaton AG, Chapman DP, Li C, Perry GS, Croft JB.

Associations between self-reported sleep duration and sleeping disorder with concentrations of fasting and 2-h glucose, insulin, and glycosylated hemoglobin among adults without diagnosed diabetes. J Diabetes 6(4):338–50. 2014.American College of Obstetrics and Gynecology. ACOG Practice Bulletin No.

141. Management of menopausal symptoms. Obstet Gynecol 123(1):202–16. 2014.Black LI, Nugent CN, Adams PF.

Tables of adult health behaviors, sleep. National Health Interview Survey, 2011–2014pdf icon. 2016.Santoro N. Perimenopause.

From research to practice. J Women’s Health (Larchmt) 25(4):332–9. 2016.Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al. Recommended amount of sleep for a healthy adult.

A joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. J Clin Sleep Med 11(6):591–2. 2015.Parsons VL, Moriarity C, Jonas K, et al. Design and estimation for the National Health Interview Survey, 2006–2015.

National Center for Health Statistics. Vital Health Stat 2(165). 2014.RTI International. SUDAAN (Release 11.0.0) [computer software].

2012. Suggested citationVahratian A. Sleep duration and quality among women aged 40–59, by menopausal status. NCHS data brief, no 286.

Hyattsville, MD. National Center for Health Statistics. 2017.Copyright informationAll material appearing in this report is in the public domain and may be reproduced or copied without permission. Citation as to source, however, is appreciated.National Center for Health StatisticsCharles J.

Rothwell, M.S., M.B.A., DirectorJennifer H. Madans, Ph.D., Associate Director for ScienceDivision of Health Interview StatisticsMarcie L. Cynamon, DirectorStephen J. Blumberg, Ph.D., Associate Director for Science.

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Bacteria and clinicians levitra generic online have one thing in dangers of levitra common. Resistance. As widespread antibiotic use has increased, antimicrobial resistance has risen.1 Despite this, many clinicians remain resistant to changing their antibiotic-prescribing habits.1 Antimicrobial stewardship—which focuses on interventions to help optimise antibiotic selection, dose and duration—has gained substantial public health interest while continuing to face frequent frontline clinician opposition.2 3 In this issue of BMJ Quality and Safety, Saini and colleagues’ findings support a seemingly simple antimicrobial stewardship tool. Documentation of antibiotic indications so that explicit reasons for the prescription are recorded.4 In a scoping review of 123 publications, Saini and colleagues found beneficial effects of antibiotic indication documentation on the quality of patient care, including preventing errors, improving antibiotic prescribing and supporting communication at care transitions.4 Yet, critical barriers—often in the form of clinician resistance—diminish the ability of many antibiotic stewards to implement the documentation of antibiotic indication.

Critical questions remain unanswered related to best practices for implementation of antibiotic indications to maximise the benefits and minimise these challenges. Here, we seek to address these questions and offer key insights for implementation.The competing purposes of antibiotic documentationTo understand how best to implement antibiotic indication documentation and engage stakeholders, it is important to understand the myriad and often competing purposes of documentation. Generally, documentation—both related and unrelated to antibiotics—serves many purposes. These vary from the immediately patient relevant (eg, improving interclinician or patient/clinician communication, enabling prospective audit and feedback by pharmacists) to those with delayed clinical relevance (eg, enhancing retrospective research), and those largely for administrative purposes (eg, billing, resource distribution).

In some countries, such as the USA where 35 of the studies included in the scoping review occurred, documentation also serves for legal protection (ie, defensive medicine).5 For antimicrobial stewardship in particular, there is another useful purpose of documentation to consider. Improved mindfulness. Specifically, the act of documentation itself may trigger a mindful moment that forces clinicians to pause and move from system 1 (fast) to system 2 (slow) thinking.6 Slower, deliberative thinking has been shown to serve as an antibiotic self-timeout which reminds clinicians to reconsider antibiotic necessity and appropriateness.7 Similarly, accountable justification, which requires clinicians to explicitly justify an antibiotic treatment plan, has been shown to reduce inappropriate antibiotic prescribing.8Because documentation purposes and thus priorities vary, changes in antibiotic indication documentation can be difficult to implement. For example, Saini and colleagues found that notable barriers to documenting antibiotic indications included competing priorities and time burden.9–11 In our practice, we find that documentation that is not directly and immediately clinically useful is often perceived by clinicians as an irrelevant administrative burden.

Likewise, documentation interventions that hinder billing or quality compliance (eg, public reporting) may encounter leadership resistance. Thus, to engage clinicians and improve rates of antibiotic indication documentation, antimicrobial stewardship programmes must reframe the need for documentation in terms of clinical relevance, while not running counter to administrative needs.9One way to improve clinician buy-in is by focusing on the salient, patient-relevant reasons for improving antibiotic documentation. Take, as one example, care transitions. Nowhere is the need for documentation more acute than during transitions of care, where adverse events are common, often harmful, and where accurate documentation can serve as a critical tool for improving communication.12 Because other forms of communication (eg, notes, verbal) are less common and reliable during care transitions (eg, to retail pharmacies), accurate documentation of antibiotic indications can prevent medication errors.13 When antibiotic prescriptions sent to pharmacies do not include the indication within the patient instructions, the pharmacist is left inferring the indication, reducing their ability to confirm prescription accuracy and prevent errors.13 Antibiotic stewards who wish to improve antibiotic indication documentation at discharge for one purpose (ie, optimising discharge antibiotic prescribing) could therefore have more successful clinical buy-in if they instead framed documentation in terms of improving communication and reducing harmful errors (eg, ‘bug-drug’ mismatch).What do we mean by good documentation?.

As we pause to consider best practices for implementation, it is important to first define what we mean by antibiotic indication documentation. Critically, this includes where documentation should occur. As clinicians ourselves, we recognise that clinicians often document antibiotic indications not once—but many times—including in clinician notes, interclinician handoff tools, inpatient antibiotic orders, outpatient antibiotic prescriptions and patient instructions. This complexity is not accounted for in most studies of antibiotic indications.

In Saini and colleagues’ paper only 19 of the studies refer to documentation of the antibiotic indication as part of the prescription itself. For better or worse, many documentation interventions are operationalised in orders, including adjustments to the electronic health record (EHR) through order sets, drop-down menus and prompted indications.4 This type of EHR-driven documentation can serve as a nudge to improve prescribing, but come with unintended costs.14Notably, all documentation interventions require additional clinician work. While demonstrably important, EHR-focused documentation interventions fail to account for documentation that may—or may not—already be occurring elsewhere. For example, the rise of EHR note templates can both hinder and benefit documentation.

While note templates may remind clinicians to include antibiotic indications, they can lead to ‘note bloat’ and additions that are clinically irrelevant. The disjointed approach to documentation can lead to alert fatigue and annoy end-users who fail to see the value in including an indication in the order when it is already documented elsewhere.10 Similarly, too many documentation requirements can lead clinicians to over-ride or bypass mandatory fields.10 11 Finding the ‘sweet spot’ of antibiotic documentation to improve compliance and help stewardship without impeding clinician workflow is critical.Best practices for implementation of antibiotic indicationsWe have summarised some high-level best practices for increasing antibiotic indication documentation in table 1. Critically, improving antibiotic indications requires an easy, user-centred, well-designed process. When not designed and implemented with end-user engagement, clinicians may manipulate or game clinical decision support tools to bypass restrictions and take short cuts.

For example, in a study by Baysari and colleagues, the investigators created a drop-down system for restricted antibiotics that was meant to improve antibiotic-prescribing habits.10 The drop-down included only appropriate indications and clinicians were required to obtain stewardship approval if the planned use was for an indication other than in the drop-down. Rather than waste time by calling for approval, clinicians instead bypassed the approval process and gamed the system by selecting ‘appropriate’ indications, even when that indication was untrue.10 Because of this gaming, the intervention had no effect on antibiotic prescribing or documentation habits.10 When interviewed about these workarounds, clinicians reported they wanted to save time and minimise disruptions to their workflow.10View this table:Table 1 Documentation best practices, barriers and additional questionsIn their scoping review, Saini and colleagues mapped barriers and facilitators using the Capability, Opportunity, Motivation (COM-B) model for behaviour change. They acknowledge opportunity in the form of incentives, rewards and EHR improvements may overcome barriers to documentation such as lack of time and logistical challenges.4 Long term, we need better systems to allow open interactions between all members of the patient’s care team and improve interclinician communication around antibiotic indications. For example, in Taiwan, cloud-based technology allows clinicians, nurses and pharmacists to access patients’ prescription history and has resulted in enhanced medication safety.15 A similar system exists in the USA for opioids and controlled substances.

However, this is a state-dependent rather than a nationwide database. As technology improves, having interoperable systems to allow communication of medication information—including antibiotic indication, dose and duration—may become more feasible.Additionally, Saini and colleagues noted strategies to reduce alert fatigue and increase ease of documentation could help with clinicians’ capability and motivation to provide an indication on the antibiotic prescription.4 For example, automating or prepopulating indications based on documentation elsewhere (eg, in notes) could reduce the burden on clinicians and prevent gaming. Or the reverse—prepopulating notes based on antibiotic orders or prescriptions may better fit into workflow where orders are often written before notes. This latter solution would also provide an opportunity to incorporate ‘nudges’ to prod clinicians towards better prescribing.In summary, we operate in an imperfect system where antibiotic indication documentation serves many purposes and occurs in many forms which can impede implementation.

Myriad strategies to improve documentation have been attempted with mixed results. Until we have a system that can facilitate communication across all pertinent individuals, we must work to optimise what we have. This includes leveraging technology and behaviour change strategies to help documentation serve multiple purposes simultaneously. Doing all that, without increasing burden on clinicians, is the key to any successful antimicrobial stewardship—or documentation—intervention.Ethics statementsPatient consent for publicationNot applicable..

Bacteria and clinicians have one thing in buy levitra usa click here for info common. Resistance. As widespread antibiotic use has increased, antimicrobial resistance has risen.1 Despite this, many clinicians remain resistant to changing their antibiotic-prescribing habits.1 Antimicrobial stewardship—which focuses on interventions to help optimise antibiotic selection, dose and duration—has gained substantial public health interest while continuing to face frequent frontline clinician opposition.2 3 In this issue of BMJ Quality and Safety, Saini and colleagues’ findings support a seemingly simple antimicrobial stewardship tool.

Documentation of antibiotic indications so that explicit reasons for the prescription are recorded.4 In a scoping review of 123 publications, Saini and colleagues found beneficial effects of antibiotic indication documentation on the quality of patient care, including preventing errors, improving antibiotic prescribing and supporting communication at care transitions.4 Yet, critical barriers—often in the form of clinician resistance—diminish the ability of many antibiotic stewards to implement the documentation of antibiotic indication. Critical questions remain unanswered related to best practices for implementation of antibiotic indications to maximise the benefits and minimise these challenges. Here, we seek to address these questions and offer key insights for implementation.The competing purposes of antibiotic documentationTo understand how best to implement antibiotic indication documentation and engage stakeholders, it is important to understand the myriad and often competing purposes of documentation.

Generally, documentation—both related and unrelated to antibiotics—serves many purposes. These vary from the immediately patient relevant (eg, improving interclinician or patient/clinician communication, enabling prospective audit and feedback by pharmacists) to those with delayed clinical relevance (eg, enhancing retrospective research), and those largely for administrative purposes (eg, billing, resource distribution). In some countries, such as the USA where 35 of the studies included in the scoping review occurred, documentation also serves for legal protection (ie, defensive medicine).5 For antimicrobial stewardship in particular, there is another useful purpose of documentation to consider.

Improved mindfulness. Specifically, the act of documentation itself may trigger a mindful moment that forces clinicians to pause and move from system 1 (fast) to system 2 (slow) thinking.6 Slower, deliberative thinking has been shown to serve as an antibiotic self-timeout which reminds clinicians to reconsider antibiotic necessity and appropriateness.7 Similarly, accountable justification, which requires clinicians to explicitly justify an antibiotic treatment plan, has been shown to reduce inappropriate antibiotic prescribing.8Because documentation purposes and thus priorities vary, changes in antibiotic indication documentation can be difficult to implement. For example, Saini and colleagues found that notable barriers to documenting antibiotic indications included competing priorities and time burden.9–11 In our practice, we find that documentation that is not directly and immediately clinically useful is often perceived by clinicians as an irrelevant administrative burden.

Likewise, documentation interventions that hinder billing or quality compliance (eg, public reporting) may encounter leadership resistance. Thus, to engage clinicians and improve rates of antibiotic indication documentation, antimicrobial stewardship programmes must reframe the need for documentation in terms of clinical relevance, while not running counter to administrative needs.9One way to improve clinician buy-in is by focusing on the salient, patient-relevant reasons for improving antibiotic documentation. Take, as one example, care transitions.

Nowhere is the need for documentation more acute than during transitions of care, where adverse events are common, often harmful, and where accurate documentation can serve as a critical tool for improving communication.12 Because other forms of communication (eg, notes, verbal) are less common and reliable during care transitions (eg, to retail pharmacies), accurate documentation of antibiotic indications can prevent medication errors.13 When antibiotic prescriptions sent to pharmacies do not include the indication within the patient instructions, the pharmacist is left inferring the indication, reducing their ability to confirm prescription accuracy and prevent errors.13 Antibiotic stewards who wish to improve antibiotic indication documentation at discharge for one purpose (ie, optimising discharge antibiotic prescribing) could therefore have more successful clinical buy-in if they instead framed documentation in terms of improving communication and reducing harmful errors (eg, ‘bug-drug’ mismatch).What do we mean by good documentation?. As we pause to consider best practices for implementation, it is important to first define what we mean by antibiotic indication documentation. Critically, this includes where documentation should occur.

As clinicians ourselves, we recognise that clinicians often document antibiotic indications not once—but many times—including in clinician notes, interclinician handoff tools, inpatient antibiotic orders, outpatient antibiotic prescriptions and patient instructions. This complexity is not accounted for in most studies of antibiotic indications. In Saini and colleagues’ paper only 19 of the studies refer to documentation of the antibiotic indication as part of the prescription itself.

For better or worse, many documentation interventions are operationalised in orders, including adjustments to the electronic health record (EHR) through order sets, drop-down menus and prompted indications.4 This type of EHR-driven documentation can serve as a nudge to improve prescribing, but come with unintended costs.14Notably, all documentation interventions require additional clinician work. While demonstrably important, EHR-focused documentation interventions fail to account for documentation that may—or may not—already be occurring elsewhere. For example, the rise of EHR note templates can both hinder and benefit documentation.

While note templates may remind clinicians to include antibiotic indications, they can lead to ‘note bloat’ and additions that are clinically irrelevant. The disjointed approach to documentation can lead to alert fatigue and annoy end-users who fail to see the value in including an indication in the order when it is already documented elsewhere.10 Similarly, too many documentation requirements can lead clinicians to over-ride or bypass mandatory fields.10 11 Finding the ‘sweet spot’ of antibiotic documentation to improve compliance and help stewardship without impeding clinician workflow is critical.Best practices for implementation of antibiotic indicationsWe have summarised some high-level best practices for increasing antibiotic indication documentation in table 1. Critically, improving antibiotic indications requires an easy, user-centred, well-designed process.

When not designed and implemented with end-user engagement, clinicians may manipulate or game clinical decision support tools to bypass restrictions and take short cuts. For example, in a study by Baysari and colleagues, the investigators created a drop-down system for restricted antibiotics that was meant to improve antibiotic-prescribing habits.10 The drop-down included only appropriate indications and clinicians were required to obtain stewardship approval if the planned use was for an indication other than in the drop-down. Rather than waste time by calling for approval, clinicians instead bypassed the approval process and gamed the system by selecting ‘appropriate’ indications, even when that indication was untrue.10 Because of this gaming, the intervention had no effect on antibiotic prescribing or documentation habits.10 When interviewed about these workarounds, clinicians reported they wanted to save time and minimise disruptions to their workflow.10View this table:Table 1 Documentation best practices, barriers and additional questionsIn their scoping review, Saini and colleagues mapped barriers and facilitators using the Capability, Opportunity, Motivation (COM-B) model for behaviour change.

They acknowledge opportunity in the form of incentives, rewards and EHR improvements may overcome barriers to documentation such as lack of time and logistical challenges.4 Long term, we need better systems to allow open interactions between all members of the patient’s care team and improve interclinician communication around antibiotic indications. For example, in Taiwan, cloud-based technology allows clinicians, nurses and pharmacists to access patients’ prescription history and has resulted in enhanced medication safety.15 A similar system exists in the USA for opioids and controlled substances. However, this is a state-dependent rather than a nationwide database.

As technology improves, having interoperable systems to allow communication of medication information—including antibiotic indication, dose and duration—may become more feasible.Additionally, Saini and colleagues noted strategies to reduce alert fatigue and increase ease of documentation could help with clinicians’ capability and motivation to provide an indication on the antibiotic prescription.4 For example, automating or prepopulating indications based on documentation elsewhere (eg, in notes) could reduce the burden on clinicians and prevent gaming. Or the reverse—prepopulating notes based on antibiotic orders or prescriptions may better fit into workflow where orders are often written before notes. This latter solution would also provide an opportunity to incorporate ‘nudges’ to prod clinicians towards better prescribing.In summary, we operate in an imperfect system where antibiotic indication documentation serves many purposes and occurs in many forms which can impede implementation.

Myriad strategies to improve documentation have been attempted with mixed results. Until we have a system that can facilitate communication across all pertinent individuals, we must work to optimise what we have. This includes leveraging technology and behaviour change strategies to help documentation serve multiple purposes simultaneously.

Doing all that, without increasing burden on clinicians, is the key to any successful antimicrobial stewardship—or documentation—intervention.Ethics statementsPatient consent for publicationNot applicable..

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"We need can levitra be bought over the counter to be able to move as soon as possible."Jones Soda's cannabis offshoot, Mary JonesSource. Jones SodaMeet Mary Jones, the new brand from Jones Soda that will feature cannabis-infused sodas, gummies and syrups.It's a bold step for the publicly traded company, which is best can levitra be bought over the counter known for its craft soda, but its relatively small size means it may feel it can take risks that larger rivals Coca-Cola and PepsiCo are shy to try.Cannabis is still federally illegal, and the drink giants are wary of crossing that line. The closest that Pepsi has come is its recent launch of a line of hemp-infused Rockstar energy drinks, although hemp seed has no dramatic effects when consumed.Alcohol companies have embraced cannabinoids to a greater degree. Corona brewer Constellation Brands owns a stake in cannabis company Canopy Growth, while Molson Coors sells CBD-infused drinks made through a joint can levitra be bought over the counter venture.For 2021, Jones Soda reported revenue of $14.8 million, less than .04% of Coke's revenue for the full year. The company has a market value of $37.3 million and is trading at 55 cents a share."We're a small player in soda, but we're going to be the biggest national player when it comes to a recognizable [consumer-packaged goods] name in cannabis," Jones Soda marketing chief Bohb Blair said in an interview.The launch also follows a broader trend within the beverage industry blurring the lines between different categories.

Pepsi is moving its Mountain Dew soda into alcohol with Hard Mtn Dew, while Anheuser-Busch InBev's Bud Light Seltzer launched a hard soda variety in December.On April 1, can levitra be bought over the counter Mary Jones will launch in California, which has a legal cannabis market of roughly $4 billion. According to Blair, nearly a can levitra be bought over the counter third of adult Californians shop in dispensaries, creating a huge market for its products.While Californians are often stereotyped as health-conscious consumers who prefer green juice over soda, Blair said the existing cannabis drinks — made with low dosage and light flavor — has left the door open to consumers who want a cannabis beverage packed with flavor."Health claims aren't our equity, full flavor is," Blair said. "We had some conversations early on. Should we be putting CBD in can levitra be bought over the counter this?. And no, it's not who we are.""If we crack it in California, we're going to do gangbusters as we go through the Midwest and East," he added.The initial launch will include four different product lines.

12-ounce bottles of soda infused with can levitra be bought over the counter 10 milligrams of cannabis. 16-ounce cans of soda infused with 100 milligrams of cannabis. Syrup designed to mix with can levitra be bought over the counter other drinks or on food with 1000 milligrams of cannabis per bottle. And gummies infused with five milligrams of cannabis, shaped like mini Jones Soda bottles.If we crack it in California, we're going to do gangbusters as we go through the Midwest and East.Bohb BlairJones Soda marketing chiefThe company has even bigger plans can levitra be bought over the counter. It's looking to expand in all states where it's legal for adults to use cannabis and — eventually — nationwide."We have been putting all of these pieces in place since we announced our intention to establish a cannabis division last July, and we fully expect the brand to deliver solid strategic growth for the company," CEO Mark Murray said in a statement.The decision to move into cannabis came about as Jones worked to expand its portfolio beyond soda.

Blair said the company is confident that it will pay off, given Jones Soda's playful and recognizable branding, popular flavors that can levitra be bought over the counter will work with cannabis and the potential appeal to new consumers."A lot of the cannabis category is leaf, but that's the legacy part of the category, the mature part," Blair said. "If you look at the new consumer to cannabis, the people who want to bring it to a party or have it in a meal, a lot of them are turning to beverages and edibles. And it turns out those are not as easy to make."But selling cannabis, even where it's legal, comes can levitra be bought over the counter with its own set of challenges. Jones Soda is betting that its expertise as an independent soda company can levitra be bought over the counter will translate into the distribution of cannabis-infused products as well. The company is already familiar with operating on a state-by-state basis.In California, the products will be sold in dispensaries, where the company contends that it's unlikely they'll be confused with non-cannabis versions of Jones' drinks.The company also tried to design Mary Jones' packaging to straddle the line between benefiting from Jones Soda's brand recognition and making it different enough as a signal to consumers.

The logo uses the same font can levitra be bought over the counter for "Jones," but with the "N" backwards. Following local regulations, the products have the dosage in larger font than any other claims.The name itself is a play on "Mary Jane," a common nickname for marijuana."Coke has Diet Coke, and people get that 100%," Blair said. "So we qualified Jones with Mary Jones."The World Health Organization (WHO) and the Medicines Patent Pool (MPP) jointly welcome the announcement that the United States National Institutes of can levitra be bought over the counter Health (NIH) will offer several technologies to the erectile dysfunction treatment Technology Access Pool (C-TAP) for potential licensing through MPP. The announcement was made today at the can levitra be bought over the counter U.S. erectile dysfunction treatment Dialogue with Ministers of Health meeting in the presence of WHO Director-General, Dr Tedros Adhanom Ghebreyesus, and NIAID Director and Chief Medical Advisor to the President of United States, Anthony Fauci.“I thank NIH for its offer of innovative therapeutics, treatments and diagnostic methods for erectile dysfunction treatment,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

€œVoluntary sharing of technologies through non-exclusive agreements will not only help us put the levitra behind us can levitra be bought over the counter. It will also empower low- and middle-income countries to produce their own medical products and achieve equitable access.”“NIH were the first to share their patents with MPP for an HIV product back in 2010 when we were created,” said Charles Gore, MPP Executive Director. €œWe will be honoured to sign public health-driven transparent non-exclusive licence can levitra be bought over the counter agreements with NIH under the auspices of C-TAP when the negotiations have concluded, with the goal to provide access of these innovative technologies to people in need around the world and help put an end to the levitra.”Launched in 2020 by the WHO Director-General and the President of Costa Rica, and supported by 43 Member States, C-TAP aims to facilitate timely, equitable and affordable access to erectile dysfunction treatment health products by boosting their production and supply through open, non-exclusive licensing agreements. MPP provides the licensing expertise to this initiative and holds the licences..

Pfizer plans to submit data to the Food and Drug Administration for a fourth erectile dysfunction treatment shot soon, and it's working on a treatment that protects against all erectile dysfunction variants, CEO Albert Bourla told CNBC on Friday."I think we're going to submit to FDA a significant progress of data about the need for a fourth dose, and they need to make their own conclusions, of course, and then CDC also buy levitra usa. €¦ It's clear that there is a need in an environment of omicron to boost the immune response," Bourla said in an interview on "Squawk Box." "We are making a treatment that covers omicron buy levitra usa and all the other variants. There are so much trials that are going right now, and a lot of them we'll start reading by the end of the month," he continued later, adding that he's optimistic from the preliminary data he's seen so for.Bourla's comments come exactly two years after erectile dysfunction treatment was declared a levitra by the World Health Organization on March 11, 2020 and the global economy ground to a halt.levitra-fighting measures put into place shortly after, including mask mandates and travel restrictions, and then a major breakthrough came when erectile dysfunction treatments were developed and cleared for use.Since then, around 81.4% of the American population five years old or older have received at least one dose of treatment out of the three cleared in the U.S. From Pfizer, buy levitra usa Moderna and Johnson &. Johnson, according to the Centers for Disease Control and Prevention.

Currently, daily erectile dysfunction treatment cases and deaths have dropped sharply since peaking in January this year due buy levitra usa to the omicron wave. Several states have buy levitra usa lifted mask mandates in schools and other public places.Companies including Google and Apple have called workers back into the office. Businesses, including restaurants, entertainment venues and more have also roared back to life.Despite some semblance of normal returning, Bourla maintained that he's remaining vigilant in creating effective treatments. "I think the biggest question of all of us is how to stay ahead of the levitra."He said Pfizer buy levitra usa is working on developing a treatment that prevents in addition to preventing hospitalizations and severe cases of the levitra, adding that making long-lasting treatments is also a priority. "We can't have treatments every five, six months," Bourla said.

"We need to buy levitra usa be able to move as soon as possible."Jones Soda's cannabis offshoot, Mary JonesSource. Jones SodaMeet Mary Jones, the new brand from Jones Soda that will feature cannabis-infused sodas, gummies and syrups.It's a bold step for the publicly traded company, which is best known for its craft soda, but its relatively small size means it may feel it can take risks that larger buy levitra usa rivals Coca-Cola and PepsiCo are shy to try.Cannabis is still federally illegal, and the drink giants are wary of crossing that line. The closest that Pepsi has come is its recent launch of a line of hemp-infused Rockstar energy drinks, although hemp seed has no dramatic effects when consumed.Alcohol companies have embraced cannabinoids to a greater degree. Corona brewer Constellation Brands owns a stake in cannabis company Canopy Growth, while Molson Coors sells CBD-infused drinks buy levitra usa made through a joint venture.For 2021, Jones Soda reported revenue of $14.8 million, less than .04% of Coke's revenue for the full year. The company has a market value of $37.3 million and is trading at 55 cents a share."We're a small player in soda, but we're going to be the biggest national player when it comes to a recognizable [consumer-packaged goods] name in cannabis," Jones Soda marketing chief Bohb Blair said in an interview.The launch also follows a broader trend within the beverage industry blurring the lines between different categories.

Pepsi is moving its Mountain Dew buy levitra usa soda into alcohol with Hard Mtn Dew, while Anheuser-Busch InBev's Bud Light Seltzer launched a hard soda variety in December.On April 1, Mary Jones will launch in California, which has a legal cannabis market of roughly $4 billion. According to Blair, nearly a third of adult Californians shop in dispensaries, creating a huge market for its products.While Californians are often stereotyped as health-conscious consumers who prefer green juice over soda, Blair said the existing cannabis drinks — made with low dosage and light flavor — has left the door open to consumers who want a cannabis beverage packed with flavor."Health claims aren't our buy levitra usa equity, full flavor is," Blair said. "We had some conversations early on. Should we be putting CBD in this? buy levitra usa. And no, it's not who we are.""If we crack it in California, we're going to do gangbusters as we go through the Midwest and East," he added.The initial launch will include four different product lines.

12-ounce bottles of soda infused with 10 buy levitra usa milligrams of cannabis. 16-ounce cans of soda infused with 100 milligrams of cannabis. Syrup designed to mix buy levitra usa with other drinks or on food with 1000 milligrams of cannabis per bottle. And gummies infused with five milligrams of cannabis, shaped like mini Jones Soda bottles.If we crack it in California, we're going to do gangbusters as we go through the Midwest and buy levitra usa East.Bohb BlairJones Soda marketing chiefThe company has even bigger plans. It's looking to expand in all states where it's legal for adults to use cannabis and — eventually — nationwide."We have been putting all of these pieces in place since we announced our intention to establish a cannabis division last July, and we fully expect the brand to deliver solid strategic growth for the company," CEO Mark Murray said in a statement.The decision to move into cannabis came about as Jones worked to expand its portfolio beyond soda.

Blair said the company is confident that it will pay off, given Jones Soda's playful and recognizable branding, popular flavors that buy levitra usa will work with cannabis and the potential appeal to new consumers."A lot of the cannabis category is leaf, but that's the legacy part of the category, the mature part," Blair said. "If you look at the new consumer to cannabis, the people who want to bring it to a party or have it in a meal, a lot of them are turning to beverages and edibles. And it turns out those are not as easy to make."But selling cannabis, even buy levitra usa where it's legal, comes with its own set of challenges. Jones Soda is betting that its expertise as an independent soda company will translate into the buy levitra usa distribution of cannabis-infused products as well. The company is already familiar with operating on a state-by-state basis.In California, the products will be sold in dispensaries, where the company contends that it's unlikely they'll be confused with non-cannabis versions of Jones' drinks.The company also tried to design Mary Jones' packaging to straddle the line between benefiting from Jones Soda's brand recognition and making it different enough as a signal to consumers.

The logo uses the same font for "Jones," but with the buy levitra usa "N" backwards. Following local regulations, the products have the dosage in larger font than any other claims.The name itself is a play on "Mary Jane," a common nickname for marijuana."Coke has Diet Coke, and people get that 100%," Blair said. "So we qualified Jones with Mary Jones."The World Health Organization (WHO) and the Medicines Patent Pool (MPP) jointly welcome the announcement that the United States National buy levitra usa Institutes of Health (NIH) will offer several technologies to the erectile dysfunction treatment Technology Access Pool (C-TAP) for potential licensing through MPP. The announcement was made today at the buy levitra usa U.S. erectile dysfunction treatment Dialogue with Ministers of Health meeting in the presence of WHO Director-General, Dr Tedros Adhanom Ghebreyesus, and NIAID Director and Chief Medical Advisor to the President of United States, Anthony Fauci.“I thank NIH for its offer of innovative therapeutics, treatments and diagnostic methods for erectile dysfunction treatment,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

€œVoluntary sharing of technologies through non-exclusive agreements will buy levitra usa not only help us put the levitra behind us. It will also empower low- and middle-income countries to produce their own medical products and achieve equitable access.”“NIH were the first to share their patents with MPP for an HIV product back in 2010 when we were created,” said Charles Gore, MPP Executive Director. €œWe will be honoured to sign public health-driven transparent non-exclusive licence agreements with NIH under the auspices of C-TAP when the negotiations have concluded, with the goal to provide access of these innovative technologies to people in need around buy levitra usa the world and help put an end to the levitra.”Launched in 2020 by the WHO Director-General and the President of Costa Rica, and supported by 43 Member States, C-TAP aims to facilitate timely, equitable and affordable access to erectile dysfunction treatment health products by boosting their production and supply through open, non-exclusive licensing agreements. MPP provides the licensing expertise to this initiative and holds the licences..