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Jay McDowell not only likes cheering on the Chippewas, he has how to buy cheap levitra served as a video coordinator for the CMU football team for 11 years.Jay McDowell has been a video coordinator for the Central Michigan University (CMU) football team for 11 years. He has great passion for his job and the how to buy cheap levitra student athletes he works with. At age 47, he was in the weight room with the team, keeping a respectable pace despite having had major back surgery. In late autumn, however, McDowell contracted erectile dysfunction treatment which stopped him in his tracks how to buy cheap levitra. With multiple complications that required more than two months of hospitalization, it was the constant care and encouragement from the RehabCentre staff at MidMichigan Medical Center – Gratiot that kept him motivated and eventually allowed him to return home to his family.McDowell had been traveling with the CMU football team and, like the athletes, was required to have erectile dysfunction treatment testing multiple times a week.

When he experienced intense back pain from a particularly long bus trip and was feeling “off,” he made how to buy cheap levitra a telephone call to his physician. On that call, it was determined McDowell needed care immediately and that he should get to the emergency room, which he promptly did.“My symptoms hit fast and hard,” said McDowell. €œI had made it through two heart procedures thirteen years prior to this, as well as my fair share of how to buy cheap levitra muscle and bone injuries. Let me tell you, fighting erectile dysfunction treatment was without a doubt my toughest health challenge.”McDowell was admitted at MidMichigan Medical Center in Gratiot. After several weeks in the hospital, he suffered a ruptured colon and underwent surgery to repair it how to buy cheap levitra.

Post-surgery, erectile dysfunction treatment symptoms worsened. McDowell had irregular heart rhythm and how to buy cheap levitra was unable to breathe on his own. He was transferred to MidMichigan Medical Center in Midland where he received a temporary pacemaker and continued treatment for erectile dysfunction treatment. After two how to buy cheap levitra weeks, one of which he spent in a coma, McDowell was transferred to the RehabCentre at Gratiot where staff were determined to help McDowell regain the strength and function he had lost.“Mr. McDowell was a completely independent man before he came to our Medical Center,” said Lynne Burlingame, M.A., C.C.C./S.L.P., program director at MidMichigan’s RehabCentre.

€œUnfortunately, after erectile dysfunction treatment how to buy cheap levitra and the series of subsequent medical issues he endured, he required maximum assistance doing everything when we started. He was very weak and in a lot of pain, but he was also very motivated to improve and pushed hard for progress.”In addition to physical limitations that kept him from standing, walking or sitting up in bed unassisted, McDowell was demonstrating difficulty with cognitive and communication skills. He worked with a speech therapist who helped him how to buy cheap levitra with attention, processing speed, memory and executive functioning. Occupational and physical therapists worked with him three times per day to help him regain his strength and motor skills due to critical illness myopathy.“Critical illness myopathy can develop following severe, extended medical issues such as sepsis, multi-organ failure and acute respiratory distress syndrome,” said Burlingame. €œIt involves rapidly evolving neuromuscular weakness which can cause significant how to buy cheap levitra difficulty weaning from a ventilator and difficulty with functional movement.

Jay required extensive rehab to regain normal function. We were all rooting for him.”“I went from reverse-curling 135 pounds to having trouble lifting my fork,” said how to buy cheap levitra McDowell. €œI really couldn’t do anything on my own, and I had trouble remembering things. It was hard work, but those how to buy cheap levitra therapists were the absolute best. They were right there with me every day, helping me take baby steps toward recovery.

They were always positive how to buy cheap levitra and applied just the right amount of pressure to keep me going. Even if I had wanted to give up, they wouldn’t have let me.”After months in the hospital and many Facetime calls, McDowell’s wife and two children helped him walk out of the building on his own. The Medical how to buy cheap levitra Center staff was just as happy to have him discharged. €œHe walked off the unit after 81 days in the hospital to the CMU fight song and a confetti shower from cheering staff members from all departments who had helped care for him over the course of his stay,” said Burlingame.McDowell is still healing and can’t wait to get back to work with his Chips. €œI am still moving cautiously and my memory is still coming back,” said how to buy cheap levitra McDowell.

€œI was in and out of it so much, much of it is a blur. What I will never forget, however, is how the nurses looked me right in the eyes and actually how to buy cheap levitra saw me - not a number or a patient – but me as a person and as someone’s father, brother, and husband. With all that was going on around them, they truly cared for me. They saved my life.”McDowell confessed that he wasn’t expecting the level of care he how to buy cheap levitra received from his local Medical Center. €œFirst-class doesn’t begin to describe it,” he stated.

When asked what he how to buy cheap levitra wanted to share with others about his experience, his reply was this. €œerectile dysfunction treatment is not a joke. It is as real as real gets, and it affects how to buy cheap levitra everyone differently. Do everything you can to keep yourself and others safe.”Those who would like more information about the RehabCentre at MidMichigan Medical Center – Gratiot may visit www.midmichigan.org/rehabcentre..

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We live canadian generic levitra in unprecedented https://www.bugeyvelo.com/diflucan-150mg-price-in-usa/ times. But what makes them without parallel is not the current levitra crisis nor the continued problems facing minorities in our institutions. Rather, it’s that for the first time, the canadian generic levitra problems of accessibility, rights and freedoms are now invading privileged spaces. There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals. For many, canadian generic levitra the world is not suddenly on fire.

It has long been burning.The present levitra lays bare systemic prejudice against the most vulnerable among us. We at Medical Humanities, with our focus on global health and social justice, welcome discussion about how the crisis has disproportionately affected racial and fiscal minorities, those from the disabled community, those who are LGBTQA+ and other vulnerable groups. What we focus on here, canadian generic levitra now, can lead to greater accessibility and equity in the future.In this expanded issue, we offer some of the incredible work being done across the field of medical humanities prior to the erectile dysfunction treatment crisis, and we are already reviewing articles on the role of health humanities during the levitra. The process of academic publishing tends not to lend itself to immediacy, however, and the challenges of levitra means greater pressure on everyone, from the authors to the reviewers and readers.To remedy this, we at Medical Humanities have been increasing the work on our blog platform, a place where content can be quickly updated, and where conversations can occur among readers and writers. We openly invite submissions concerning the canadian generic levitra levitra, as well as topics relevant to our wider CFP (call for posts/papers) this year on social justice and health, to both blog and journal.

We will do our best to expedite. Finally, we have also been addressing social justice and access in our podcast, where we interviewed disability activist Alice Wong and most recently Dr Oni Blackstock, primary care physician and HIV specialist in New York. We hope to have many canadian generic levitra more on these critical subjects.We wish all of you good health and safety and know that many of you are yet on the front lines. Thank you for being part of the community of Medical Humanities.IntroductionMinecraft is a computer game with no specific goals to accomplish. The gameworld consists of three-dimensional (3D) cubes and objects which the player (Steve) can mine and build into infinitely complex canadian generic levitra (and logically impossible) structures.

Steve sometimes encounters other characters (‘mobs’), such as animals and hostile creatures. He can ‘spawn’ and destroy them. While it canadian generic levitra looks like a harmless game of logical construction, it conveys some worryingly delusive ideas about the real world. The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification in mental health has had various forms throughout history. Mack and colleagues set out a history of canadian generic levitra psychiatric classification beginning in 2600 BC with Egyptian references to melancholia and hysteria.

Through the Ancient Greeks with Hippocrates’ phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease. Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some common trends such as the labels ‘melancholia’ and ‘hysteria’ which have canadian generic levitra survived millennia, the label ‘depression’ is relatively new. The earliest usage noted by Snaith is from 1899. €˜in simple pathological depression…the patient exhibits a growing indifference to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists canadian generic levitra like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge.

This did not happen until the middle of the 20th century. With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate. In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this canadian generic levitra period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical quarrels around categorisation of mental disorders. DSM I and DSM II have been described as products of an American Psychiatric Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories. €˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much canadian generic levitra closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state.

Zimbardo, who described psychiatric care as a controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’. Diagnostic critique has been further developed canadian generic levitra through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science. In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are opposing stances in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility. The nominalism–realism debate is illustrated using as metaphor three different stances a cricket umpire might canadian generic levitra take on calling strikes and balls.

The discussion sets out two of these as extreme views. €˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who canadian generic levitra is characterised as holding particularly extreme views, is named as an archetypal solipsist. There is implied to be a degree of arrogance associated with this view in the illustrative example in which the umpire states ‘there are no balls and there are no strikes until I call them’. Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than to focus on canadian generic levitra its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’.

The natural conclusion the reader is invited to reach is that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’. Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’. The prototypical approach is again canadian generic levitra put forward as a clinically useful middle ground. Illustrations are drawn from natural science. €˜a triangle and a square are never the same’, inciting the reader canadian generic levitra to consider science as value-free.

The prototypical approach emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification. Doing so is more like playing Minecraft canadian generic levitra than cricket. The National Institute for Health and Care Excellence (NICE) guideline for depression is taken as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, specifically subcategories of persistent forms of depression. As well as canadian generic levitra serving a clinical purpose, diagnosis in medicine is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service.

The consequences for recipients of healthcare are therefore significant. Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression. €˜further-line’ treatment of depression (equivalent to canadian generic levitra TRD), CD and ‘depression with co-morbidities’. The latter is subdivided into treatments for ‘complex depression’ and ‘psychotic depression’. These categories and subcategories canadian generic levitra introduce an unfortunate sense of certainty as though these labels represent real things.

An analysis follows of how these definitions play out in terms of grouping of randomised controlled trials in the NICE evidence review. Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years. Dysthymia and double depression (MDD superimposed on dysthymia) were canadian generic levitra included. If 75% of the trial population met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point. If 80% of the trial participants met these criteria, it was reviewed in the TRD canadian generic levitra category.13 Complex depression was defined as ‘depression co-existing with personality disorder’.

To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there is a potential problem with attempting to categorise trial populations into just one of these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information. The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the canadian generic levitra category of further-line treatments (TRD), 64 trials were reviewed. Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’. In drilling down by way of illustration, this analysis considers the 51 trials in the canadian generic levitra augmentation strategy evidence review.

Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs. Fonagy 2015 and Kocsis 200915). About half of the trials (23/51) did not report the mean duration of episode, meaning canadian generic levitra that it is not possible to know what percentage of participants also met the criteria for CD. Of trials that did report episode duration, 17 reported a mean duration longer than 24 months. While the standard deviations varied in size or were unreported, the mean indicates a good likelihood that a significant proportion canadian generic levitra of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE.

For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations. Only 14 of 51 trials report employment data. Of those that do, unemployment ranges canadian generic levitra from 12% to 56% across trial samples. None of the trials report trauma history. About half canadian generic levitra of the trials (26/51) excluded people who were considered a suicide risk.

The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity. Of these, 18 did not exclude any diagnoses, while 12 excluded some (but not all) disorders. The most common diagnoses excluded were psychotic disorders, substance or alcohol abuse, and bipolar disorder (excluded in 26, 25 canadian generic levitra and 23 trials, respectively). Only 7 of 51 trials clearly stated that all axis 1 diagnoses were excluded. This leaves canadian generic levitra only 13 studies providing any data about comorbidity.

Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD. Many stated PD as an exclusion criterion but without defining a threshold for exclusion. For example, PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, canadian generic levitra ‘severe’ or ‘persistent’. Some excluded certain PDs (such as antisocial or borderline) and not others but without reporting the prevalence of those not excluded. In the five trials where prevalence was clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample canadian generic levitra (Town 201715).

Two studies reported the mean number of PDs. 2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The majority of trials (43/51) did not report the prevalence of physical illness. Many stated illness as an exclusion criterion, canadian generic levitra but the definitions and thresholds were vague and could be interpreted in different ways. For example, illness could be excluded if it was ‘unstable’, ‘serious’, ‘significant’, ‘relevant’, or would ‘contraindicate’ or ‘impact’ the medication. Of the eight trials reporting information about physical canadian generic levitra health, there was a wide variation.

Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used scales of physical health. Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a canadian generic levitra dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners. NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials which use more than one of these measures reveals problems in the algorithm. Of the 51 trials, there are 6 instances in which the study canadian generic levitra population falls into NICE’s more severe category according to one measure and into the less severe category according to another.

In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715). The other two trials were designated more severe (Barbee 2011, Dunner 200715). Only 17 of 51 trials reported two or more depression scale measures, leaving canadian generic levitra much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?. A key philosophical error in science is to confuse an absence of knowledge with knowledge of absence. It is likely that some of the study populations deemed lacking in complexity or severity could actually canadian generic levitra have high degrees of complexity and/or severity.

Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm). The information may be non-existent as it was not collected. It may canadian generic levitra be somewhere in the publication pipeline. Or it may be sitting in a database with a research team that has run out of funds for supplementary analyses. Wherever those data are or are not, their absence from canadian generic levitra published articles does not define the phenomenology of depression for the patients who took part.

As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial also meets the guideline criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published cut-off scores). NICE categorised this population as less severe TRD, not CD and not complex.Notes1 canadian generic levitra. Avram H. Mack et canadian generic levitra al.

(1994), “A Brief History of Psychiatric Classification. From the Ancients to DSM-IV,” Psychiatric Clinics 17, no. 3. 515–9.2. R.

P. Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no. 3. 387.3. Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &.

Medicine 62, no. 1. 52–7.4. Gerald N. Grob (1991), “Origins of DSM-I.

A Study in Appearance and Reality,” The American Journal of Psychiatry. 421–31.5. Wilson M. Compton and Samuel B. Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no.

4. 198–9.6. Gerald L. Klerman (1984), “A Debate on DSM-III. The Advantages of DSM-III,” The American Journal of Psychiatry.

539–42.7. Thomas E. Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist. 513–5.8. Daniel F.

Hartner and Kari L. Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no. 4. 189–204.9. Sami Timimi (2014), “No More Psychiatric Labels.

Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no. 3. 208–15.10. Allen Frances et al. (1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy.

A Forum for Bioethics and Philosophy of Medicine 19, no. 3. 207–18.11. Andrea Jobst et al. (2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33.

20.12. National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management. Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13. Ibid., 351–62.14.

Ibid., 597.15. Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used. See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16. National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management.

Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17. National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18. Peter Fonagy et al. (2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression. The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no.

3. 312–21.19. American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults. Draft.20. Jacqui Thornton (2018), “Depression in Adults.

Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361. K2681..

We live in unprecedented Diflucan 150mg price in usa times how to buy cheap levitra. But what makes them without parallel is not the current levitra crisis nor the continued problems facing minorities in our institutions. Rather, it’s that for the how to buy cheap levitra first time, the problems of accessibility, rights and freedoms are now invading privileged spaces. There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals.

For many, the world is not suddenly on fire how to buy cheap levitra. It has long been burning.The present levitra lays bare systemic prejudice against the most vulnerable among us. We at Medical Humanities, with our focus on global health and social justice, welcome discussion about how the crisis has disproportionately affected racial and fiscal minorities, those from the disabled community, those who are LGBTQA+ and other vulnerable groups. What we focus on here, now, can lead to greater accessibility and equity in the future.In this how to buy cheap levitra expanded issue, we offer some of the incredible work being done across the field of medical humanities prior to the erectile dysfunction treatment crisis, and we are already reviewing articles on the role of health humanities during the levitra.

The process of academic publishing tends not to lend itself to immediacy, however, and the challenges of levitra means greater pressure on everyone, from the authors to the reviewers and readers.To remedy this, we at Medical Humanities have been increasing the work on our blog platform, a place where content can be quickly updated, and where conversations can occur among readers and writers. We openly invite submissions concerning the levitra, as well as topics relevant how to buy cheap levitra to our wider CFP (call for posts/papers) this year on social justice and health, to both blog and journal. We will do our best to expedite. Finally, we have also been addressing social justice and access in our podcast, where we interviewed disability activist Alice Wong and most recently Dr Oni Blackstock, primary care physician and HIV specialist in New York.

We hope to have many more on these critical how to buy cheap levitra subjects.We wish all of you good health and safety and know that many of you are yet on the front lines. Thank you for being part of the community of Medical Humanities.IntroductionMinecraft is a computer game with no specific goals to accomplish. The gameworld consists of three-dimensional (3D) cubes and objects which the player (Steve) can mine and build how to buy cheap levitra into infinitely complex (and logically impossible) structures. Steve sometimes encounters other characters (‘mobs’), such as animals and hostile creatures.

He can ‘spawn’ and destroy them. While it looks how to buy cheap levitra like a harmless game of logical construction, it conveys some worryingly delusive ideas about the real world. The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification in mental health has had various forms throughout history. Mack and colleagues set out a history of psychiatric classification beginning in 2600 BC with Egyptian references to melancholia how to buy cheap levitra and hysteria.

Through the Ancient Greeks with Hippocrates’ phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease. Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification how to buy cheap levitra identifies some common trends such as the labels ‘melancholia’ and ‘hysteria’ which have survived millennia, the label ‘depression’ is relatively new. The earliest usage noted by Snaith is from 1899.

€˜in simple pathological depression…the patient exhibits a growing indifference to his how to buy cheap levitra former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge. This did not happen until the middle of the 20th century. With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate. In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical how to buy cheap levitra quarrels around categorisation of mental disorders.

DSM I and DSM II have been described as products of an American Psychiatric Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories. €˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between how to buy cheap levitra science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state. Zimbardo, who described psychiatric care as a controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’.

Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other how to buy cheap levitra cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science. In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are opposing stances in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility. The nominalism–realism how to buy cheap levitra debate is illustrated using as metaphor three different stances a cricket umpire might take on calling strikes and balls. The discussion sets out two of these as extreme views.

€˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who is characterised as holding particularly extreme views, is how to buy cheap levitra named as an archetypal solipsist. There is implied to be a degree of arrogance associated with this view in the illustrative example in which the umpire states ‘there are no balls and there are no strikes until I call them’. Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than to focus on its clinical utility and how to buy cheap levitra the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’.

The natural conclusion the reader is invited to reach is that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’. Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’. The prototypical approach is again put forward as a clinically useful middle ground how to buy cheap levitra. Illustrations are drawn from natural science.

€˜a triangle how to buy cheap levitra and a square are never the same’, inciting the reader to consider science as value-free. The prototypical approach emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification. Doing so is more how to buy cheap levitra like playing Minecraft than cricket.

The National Institute for Health and Care Excellence (NICE) guideline for depression is taken as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, specifically subcategories of persistent forms of depression. As well as serving a clinical purpose, how to buy cheap levitra diagnosis in medicine is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service. The consequences for recipients of healthcare are therefore significant. Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression.

€˜further-line’ treatment of depression (equivalent to TRD), CD and ‘depression with co-morbidities’ how to buy cheap levitra. The latter is subdivided into treatments for ‘complex depression’ and ‘psychotic depression’. These categories and subcategories introduce an unfortunate sense how to buy cheap levitra of certainty as though these labels represent real things. An analysis follows of how these definitions play out in terms of grouping of randomised controlled trials in the NICE evidence review.

Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years. Dysthymia and double how to buy cheap levitra depression (MDD superimposed on dysthymia) were included. If 75% of the trial population met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point. If 80% of the trial participants met these how to buy cheap levitra criteria, it was reviewed in the TRD category.13 Complex depression was defined as ‘depression co-existing with personality disorder’.

To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there is a potential problem with attempting to categorise trial populations into just one of these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information. The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the category of further-line treatments (TRD), how to buy cheap levitra 64 trials were reviewed. Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’.

In drilling down by way how to buy cheap levitra of illustration, this analysis considers the 51 trials in the augmentation strategy evidence review. Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs. Fonagy 2015 and Kocsis 200915). About half of the trials (23/51) did not report the mean duration of episode, meaning that it is not possible to know what percentage of participants also met how to buy cheap levitra the criteria for CD.

Of trials that did report episode duration, 17 reported a mean duration longer than 24 months. While the standard deviations varied in size or how to buy cheap levitra were unreported, the mean indicates a good likelihood that a significant proportion of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE. For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations. Only 14 of 51 trials report employment data.

Of those that do, unemployment ranges from 12% to 56% across trial samples how to buy cheap levitra. None of the trials report trauma history. About half of the trials (26/51) excluded people who were how to buy cheap levitra considered a suicide risk. The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity.

Of these, 18 did not exclude any diagnoses, while 12 excluded some (but not all) disorders. The most common diagnoses excluded were psychotic disorders, substance or alcohol abuse, and bipolar disorder (excluded in 26, how to buy cheap levitra 25 and 23 trials, respectively). Only 7 of 51 trials clearly stated that all axis 1 diagnoses were excluded. This leaves how to buy cheap levitra only 13 studies providing any data about comorbidity.

Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD. Many stated PD as an exclusion criterion but without defining a threshold for exclusion. For example, how to buy cheap levitra PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’. Some excluded certain PDs (such as antisocial or borderline) and not others but without reporting the prevalence of those not excluded.

In the five trials where prevalence was how to buy cheap levitra clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample (Town 201715). Two studies reported the mean number of PDs. 2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The majority of trials (43/51) did not report the prevalence of physical illness. Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be interpreted in different ways how to buy cheap levitra.

For example, illness could be excluded if it was ‘unstable’, ‘serious’, ‘significant’, ‘relevant’, or would ‘contraindicate’ or ‘impact’ the medication. Of the eight trials reporting information about physical health, how to buy cheap levitra there was a wide variation. Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used scales of physical health.

Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase how to buy cheap levitra 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners. NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials which use more than one of these measures reveals problems in the algorithm. Of the 51 trials, there are 6 instances in which the study population falls into NICE’s more severe category according to one measure and into the less severe category according to another how to buy cheap levitra. In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715).

The other two trials were designated more severe (Barbee 2011, Dunner 200715). Only 17 of 51 trials reported two or more depression scale measures, leaving much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge how to buy cheap levitra of absence?. A key philosophical error in science is to confuse an absence of knowledge with knowledge of absence. It is likely that some of how to buy cheap levitra the study populations deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity.

Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm). The information may be non-existent as it was not collected. It may how to buy cheap levitra be somewhere in the publication pipeline. Or it may be sitting in a database with a research team that has run out of funds for supplementary analyses.

Wherever those how to buy cheap levitra data are or are not, their absence from published articles does not define the phenomenology of depression for the patients who took part. As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial also meets the guideline criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published cut-off scores). NICE categorised this population as less severe TRD, not CD and not complex.Notes1 how to buy cheap levitra.

Avram H. Mack et how to buy cheap levitra al. (1994), “A Brief History of Psychiatric Classification. From the Ancients to DSM-IV,” Psychiatric Clinics 17, no.

Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no. 3. 387.3. Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &.

Grob (1991), “Origins of DSM-I. A Study in Appearance and Reality,” The American Journal of Psychiatry. 421–31.5. Wilson M.

Compton and Samuel B. Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no. 4. 198–9.6.

Gerald L. Klerman (1984), “A Debate on DSM-III. The Advantages of DSM-III,” The American Journal of Psychiatry. 539–42.7.

Thomas E. Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist. 513–5.8. Daniel F.

Hartner and Kari L. Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no. 4. 189–204.9.

Sami Timimi (2014), “No More Psychiatric Labels. Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no. 3. 208–15.10.

Allen Frances et al. (1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy. A Forum for Bioethics and Philosophy of Medicine 19, no. 3.

207–18.11. Andrea Jobst et al. (2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33. 20.12.

National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management. Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13. Ibid., 351–62.14.

Ibid., 597.15. Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used. See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16. National Institute for Health and Care Excellence (2018), Depression in Adults.

Treatment and Management. Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17. National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18. Peter Fonagy et al.

(2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression. The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no. 3. 312–21.19.

American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults. Draft.20. Jacqui Thornton (2018), “Depression in Adults. Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361.

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How long does levitra stay in the body

ELK CITY canada levitra online pharmacy — One student throws his classmates’ pencil how long does levitra stay in the body box on the floor in anger. Another bites her own arm out of frustration. Others run how long does levitra stay in the body screaming from their classrooms. Some Elk City Elementary School students are celebrating as summer break approaches. Others are dreading the end of the school year, acting out in fear of what the next three months could bring.

School counselor Kim Hamm worries about students who won’t have enough how long does levitra stay in the body to eat this summer. And those without air conditioning or running water. She wonders how many will be left alone while their caretakers are working two or three jobs. And who will spend their days anticipating the next how long does levitra stay in the body attack from an abusive family member. Hamm has spent most of May helping students ages 4 to 9 identify and cope with their feelings, which can be triggered by instability at home.

“They know that, here, they’re safe how long does levitra stay in the body and we’re not going to hurt them,” Hamm said. €œAnd a lot of our kids, unfortunately, don’t go home to that every day.” About 100 miles west of Oklahoma City on Interstate 40, Elk City is home to nearly 12,000 residents whose financial stability ebbs and flows with the volatile oil and gas industry. The nearby North Fork Correctional Facility brought some families to town to be close to a loved one. And students face rates of poverty, special how long does levitra stay in the body needs and suicide higher than the state average. Kim Hamm, an Elk City Elementary School counselor, talks to a pre-kindergarten student who is playing with sensory toys purchased with Project AWARE funds in her office.

Hamm said disadvantaged, abused and neglected students’ behavior deteriorates toward the end of the school year because they’re afraid or stressed about spending months away from school, which provides safety when life at home is turbulent. (Courtesy photo) how long does levitra stay in the body In her six years as a school counselor, Hamm has learned to anticipate these needs, making more time towards the end of the school year to meet with students one-on-one. But she doesn’t always have the bandwidth. School counselors’ duties range from helping develop individualized learning plans for students with special needs to proctoring the third-grade reading test. They enroll students how long does levitra stay in the body in classes and ensure they meet state math and science requirements.

They provide college and career advice and help them find and apply for scholarships. They wrangle students during morning how long does levitra stay in the body drop-off and afternoon pick-up, run school-sponsored food and clothes pantries and teach breathing techniques to those with test anxiety. Low pay and increasing obligations have left Oklahoma with a teacher shortage, which means counselors like Hamm are taking on more work leaving less time for struggling students. Counselors refer the most troubled kids to community mental health counselors. But they are also in short how long does levitra stay in the body supply especially in rural areas like Elk City where the ratio of mental healthcare providers to residents is 1 to 150,000.

Without adequate local resources, the responsibility of students’ mental health care is falling to school counselors who are outnumbered and overwhelmed. A federal program is increasing support for students in six rural school districts in what the state mental health and education departments call “mental health deserts.” But schools are finding it difficult to hire qualified caregivers and erectile dysfunction treatment restrictions have halted programs and limited in-person treatment. Students are seen leaving Elk City Elementary School at the end of the school how long does levitra stay in the body day. School counselor Kim Hamm said for some students school is a safe place and leaving is not a happy but fearful time of day for students who don’t have enough to eat or are abused by family members at home. (Whitney Bryen/Oklahoma Watch) A Response Inspired By Sandy Hook Since 2018, the State Department of Education has received two U.S.

Department of Health and how long does levitra stay in the body Human Services grants totaling $18 million. Oklahoma’s Project AWARE, short for Advancing Wellness and Resiliency in Education, is in its third year of the five-year grant at Woodward, Elk City and Weatherford Public Schools and its first year at Ada, Atoka and Checotah Public Schools. Subscribe to Jennifer Palmer's Education Watch how long does levitra stay in the body newsletter Processing… Success!. You're on the list. Whoops!.

There how long does levitra stay in the body was an error and we couldn't process your subscription. Please reload the page and try again. The districts were chosen by the state department for their lack of treatment providers and high-risk student populations. Oklahoma students are some of the most traumatized in the nation, according to several national health rankings including a recent survey conducted by a group based how long does levitra stay in the body at Johns Hopkins University. But kids in these rural districts were more likely to have access to firearms, live in poverty, have an incarcerated parent, use drugs, experience depression and die by suicide, according to the state’s grant application.

These students are more susceptible to mental illness. And without treatment, they can face even more dangerous obstacles as they age, often leading to their own violent encounters, substance how long does levitra stay in the body abuse or incarceration. Subscribe to our First Watch newsletter Processing… Success!. You're on the list how long does levitra stay in the body. Whoops!.

There was an error and we couldn't process your subscription. Please reload the how long does levitra stay in the body page and try again. In one of the country’s deadliest school shootings, a 20-year-old killed six adults and 20 students at Sandy Hook Elementary School in 2012. Since then, the Substance Abuse and Mental Health Services Administration has sent millions to schools nationwide with high-risk students to prevent violence perpetrated by young people. This how long does levitra stay in the body story was reported in partnership with the Solutions Journalism Network.

For more information, go to solutionsjournalism.org. In their first year of the grant, Atoka, Ada and Checotah schools in Eastern Oklahoma spent most of the year assessing student needs and training staff. At Elk City, Weatherford and Woodward schools in Western Oklahoma, Project AWARE forged ahead despite changes to programs that were derailed how long does levitra stay in the body by the levitra. Community events aim to reduce stigma around mental health challenges and treatment and teach parents and students about healthy habits like the importance of sleep and recommendations for social media use. Elk City how long does levitra stay in the body paused events in the spring of 2020 while Weatherford took its online and saw a spike in participation.

Fifth through 12th grade students at all six districts completed mental health assessments, which helps educators identify students who are distracted, unhappy, scared, lonely or are prone to acting out. Community mental health counselors had started to meet with troubled students in some of the Western Oklahoma schools. Parents have to agree to therapy but bringing professionals into the schools reduces barriers for how long does levitra stay in the body families who lack transportation or who feel embarrassed visiting a local treatment facility. Many of these services were paused due to erectile dysfunction treatment. Some Project AWARE schools started group therapy sessions led by licensed mental health professionals for students with chronic stress often triggered by traumatic experiences like an absent or abusive parent.

The grant also trained educators at all six districts in how long does levitra stay in the body a classroom program that teaches conflict resolution and empathy. Liz Henthorn, a kindergarten teacher at Elk City Elementary School, listens as her students rate how they’re feeling at the end of the day. Henthorn checks in with her students twice a how long does levitra stay in the body day through a program known as Circles that she says teaches students coping skills and empathy. (Whitney Bryen/Oklahoma Watch) Just before the bell rang on a Monday afternoon, kindergarteners sat in a circle on a rug at the front of Liz Henthorn’s classroom at Elk City Elementary School. One-by-one the students rated how they’re feeling as they prepared to go home.

They describe their feelings as green, yellow or red if how long does levitra stay in the body they’re having a difficult day and their peers offer comfort and advice. One student said he was feeling sad because his dog ran away that morning. Another student was feeling red because she had a bad dream. Other students spoke up saying they could relate or that they’re sorry how long does levitra stay in the body that happened. “We’re teaching kids to identify their feelings and giving suggestions to cope,” Henthorn said.

€œAnd when we do it as a group the kids are learning about empathy and thinking about ways to help each other and that is just as important.” Liz Henthorn, a kindergarten teacher at Elk City Elementary School, listens as her students rate how they’re feeling at the end of the day. (Whitney Bryen/Oklahoma Watch) Teachers, counselors and administrators were trained how long does levitra stay in the body to provide coping skills to students who face universal challenges like disagreements with classmates or stress about what to do after graduation. But few are qualified to help more critical students, like those with mental illness or who have experienced trauma. Woodward Public Schools reported 82 homeless students during the 2017-18 school year – more than how long does levitra stay in the body twice the state average. Nearly two-thirds of students at Woodward and Elk City Public Schools qualified for free and reduced lunches, compared to the state’s average of 50%.

In Elk City, 140 of the district’s 2,110 students had a parent who was incarcerated. And all three Western Oklahoma how long does levitra stay in the body districts had higher than average suicide rates. Those districts rely on school counselors to support these students, though most lack the training. And the grant does not address the ratio of counselors to students, which is far above national recommendations. Districts also how long does levitra stay in the body planned to increase referrals to community treatment centers facilitated by the grant.

Demand for mental health care spiked during the levitra, further straining the area’s providers and leaving families with few options. Weatherford elementary students are seen eating lunch in the school’s cafeteria. (Whitney Bryen/Oklahoma Watch) The Complicated Search for Counselors School counselors how long does levitra stay in the body can listen to students and offer coping techniques, but their ability to help is limited. Licensed counselors can provide therapy and diagnose students with mental levitra 20mg street price illness. Elk City, Woodward and Weatherford districts hoped to bring more licensed professional counselors into how long does levitra stay in the body schools by hiring new staff and using Project AWARE funds to pay for training for current school counselors.

Each district hired one licensed mental health provider who serves all students. The districts have been unable to hire any new school counselors and no existing counselors have been licensed. The state requires school counselors to have a master’s degree in a related field or two years of experience, and pass the state’s general education, professional teaching and how long does levitra stay in the body school counseling exams. Training for licensed professional counselors requires an additional 60 graduate-level college hours and 3,000 hours of supervised counseling. Counselors must also pass an exam before being licensed.

Education costs are likely to total $21,000 to $33,000 depending on the school, according to the most how long does levitra stay in the body recent state averages. And that doesn’t include fees for supervision or the licensing exam. The grant will pay tuition costs for school counselors to get their license. Only two of 16 school counselors in Elk City, how long does levitra stay in the body Weatherford and Woodward have taken the offer. School counselors said it is still an expensive and lengthy endeavour that results in more work without a boost in pay or a promotion.

“I know that it would give me more in depth counseling training, but I think at this time in my life with small children it’s just probably not going to happen,” said how long does levitra stay in the body Hamm, who has a 10-month-old and a 3-year-old. €œIf I was going to make more as a school counselor with it then maybe I would, but I’m not going to so I’m just not going to spend a whole lot of time to get that.” For school counselors who do get their license, the job doesn’t change much. They often have the same paperwork, testing responsibilities and recess duty. But they’re also counseling the school’s most traumatized kids, a group that is growing following how long does levitra stay in the body the levitra. Oklahoma has 1,841 school counselors and nearly 695,000 students, according to State Department of Education reports.

The department does not track how many school counselors have their professional counseling license. The American School Counselor Association recommends how long does levitra stay in the body a ratio of 1 school counselor to 250 students. Oklahoma mandates 1 school counselor per 450 middle and high school students. The state does not have a threshold for elementary schools. Not how long does levitra stay in the body every school has a dedicated counselor.

Some have teams depending on student population, how schools prioritize funding and disperse tasks. The Association also recommends counselors spend at least 80% how long does levitra stay in the body of their time working directly with or for individual students. Oklahoma Watch interviewed 10 counselors across the state. Most said they spend the majority of their day doing clerical work. Depending on the time of how long does levitra stay in the body year, about 20 to 50% of their time is spent with students.

Elizabeth Moss, a seventh and eighth grade counselor at Woodward Middle School, said she is one of the fortunate ones because she spends about 50% of her time meeting with students one-on-one thanks to the help of her administration. Even with the group sessions she leads, Moss said she still hasn’t been able to meet the national recommendation. €œA lot of what I how long does levitra stay in the body deal with are the results of families who are in crisis, where there’s addiction, other issues that are related to poverty and the kids show up to school and there’s a lot of fallout from that,” Moss said. €œAnd so we have kids who are depressed. We’ve had how long does levitra stay in the body kids who are suicidal.

Anxieties are really high.” Lora Anderson, a school counselor at Ada Junior High School, talks to students about online enrollment and how to choose classes for next school year. (Courtesy photo) Moss is one of two school counselors taking advantage of Project AWARE funding to get her professional counseling license. Her principal took over her how long does levitra stay in the body ACT and pre-ACT testing, scheduling and enrollment duties allowing Moss to spend more time with students in crisis. “I would love to see even more taken off of the shoulders of counselors so that we could take care of our kids’ needs better,” Moss said. €œBut I truly feel blessed here that I am not overwhelmed, like so many counselors.” At Ada Junior High School, counselor Lora Anderson spends about 25% of her time working with troubled students.

Many school counselors go into the job how long does levitra stay in the body to propel students’ academic success, not to provide therapy. Anderson does her best to help students but said she isn’t trained to help kids with acute needs. €œThat’s not what I want to do,” Anderson said after returning to her desk from lunch duty. €œI do so many different things to help how long does levitra stay in the body students. If I wanted to be a mental health counselor, I wouldn’t work in a school.” Michelle Taylor, President-Elect of the Oklahoma School Counselor Association and counselor at Adair High School, said the job has changed a lot since she started and counselors at smaller schools like hers are often overwhelmed juggling paperwork, test proctoring and counseling students.

(Courtesy photo) Michelle Taylor, President-Elect of the Oklahoma School Counselor Association, said the organization doesn’t track how many school counselors have their license how long does levitra stay in the body. But based on training she’s attended and led over the years, Taylor said it’s likely that about 1 in 5 school counselors goes on to become licensed. School counselors are serving dual roles whether they want to or not. Like swim instructors at a pool, most school counselors see how long does levitra stay in the body their role as building stronger swimmers. But as mental health challenges continue to grow, counselors also have to serve as lifeguards, diving into the deep end to rescue drowning kids.

“Counselors in rural schools tend to be treading more water,” Taylor said. €œSome folks are so overwhelmed with the job they have, they don’t have the time or the how long does levitra stay in the body motivation to seek out additional training. It’s just not accessible for folks.” Taylor has been a school counselor for more than 20 years and has her professional counseling license. She currently works with students at Adair High School in northeast Oklahoma. She said the job has how long does levitra stay in the body changed a lot since she started.

Test requirements are constantly evolving. College admissions and scholarship applications how long does levitra stay in the body seem to get longer every year. And students want to talk more. Kids are more willing to open up about their issues, especially since mental health is talked about more openly since the levitra, Taylor said. And school counselors have to be ready to listen how long does levitra stay in the body and help.

“I think we should be the ones doing this work because we already know the students and they already know us so it’s quicker to get to that trust that can take a long time to develop,” Taylor said. €œThat’s when it becomes about priorities and we have to respond to what the students need first and then worry about everything else.” Elk City Middle School students took a mental health screening at the beginning of Lana Graham’s geography class in March. Graham said since the erectile dysfunction levitra began, her students seem more anxious and depressed than ever how long does levitra stay in the body. (Whitney Bryen/Oklahoma Watch) Whitney Bryen is an investigative reporter and visual storyteller at Oklahoma Watch with an emphasis on domestic violence, mental health and nursing homes affected by erectile dysfunction treatment. Contact her at (405) 201-6057 or wbryen@oklahomawatch.org.

Follow her on Twitter @SoonerReporter how long does levitra stay in the body. Support our publicationEvery day we strive to produce journalism that matters — stories that strengthen accountability and transparency, provide value and resonate with readers like you.This work is essential to a better-informed community and a healthy democracy. But it how long does levitra stay in the body isn’t possible without your support. Donate nowFunding Will Expand Use of Telehealth to Integrate Mental and Behavioral Health into Pediatric Primary CareToday, the U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced the availability of $14.2 million from the American Rescue Plan to expand pediatric mental health care access by integrating telehealth services into pediatric primary care.

The funding will expand Pediatric Mental Health Care Access (PMHCA) how long does levitra stay in the body projects into new states and geographic areas nationwide, including tribal areas. These new state and regional networks of pediatric mental health care teams will provide teleconsultations, training, technical assistance and care coordination for pediatric primary care providers to diagnose, treat and refer children and youth with mental health conditions and substance use disorders. Currently, there are 21 PMCHA projects in the country. “Children are struggling with a range of emotional and behavioral challenges arising from the erectile dysfunction treatment levitra, especially those in families with lower incomes or who face other obstacles to how long does levitra stay in the body health care,” said HHS Secretary Xavier Becerra. €œThis program harnesses the power of technology to make mental and behavioral health care more accessible and equitable for our nation’s children, and links pediatric care providers to children and their families who need that specialized care.” Research demonstrates an increased need for pediatric mental and behavioral health care.

In the United States, about 22 percent of children ages 3 to 17 are currently affected by some type of mental, emotional, developmental, or behavioral condition. Only about 20% of children with how long does levitra stay in the body mental, emotional, or behavioral disorders receive care from a specialized provider. €œNow more than ever, families need mental and behavioral health care for their children, but significant disparities in access to this treatment continue to exist,” said Acting HRSA Administrator Diana Espinosa. €œThe expansion of the Pediatric Mental Health Care Access Program how long does levitra stay in the body paves the way for more children to receive necessary mental health services, especially those in underserved communities.” Pediatric mental health care teams will include child and adolescent psychiatrists, licensed mental health professionals, and care coordinators. Pediatric primary care providers can include, but are not limited to, pediatricians, family physicians, nurse practitioners, physician assistants, and care coordinators.

Teams will use telehealth to consult with pediatric primary care providers. To learn about eligibility and how long does levitra stay in the body to apply for the American Rescue Plan Act - Pediatric Mental Health Care Access (PMHCA) – New Area Expansion Notice of Funding Opportunity, visit https://www.grants.gov/web/grants/view-opportunity.html?. OppId=333181. Applications are due July 6, 2021, at 11:59 p.m. ET.

Applicants should contact Madhavi Reddy with any questions. Learn more about HRSA’s Pediatric Mental Health Care Access program..

ELK CITY how to buy cheap levitra https://elvisknight.co.uk/pr-with-content-thought-you-were-all-about-straight-talking/ — One student throws his classmates’ pencil box on the floor in anger. Another bites her own arm out of frustration. Others run screaming from how to buy cheap levitra their classrooms. Some Elk City Elementary School students are celebrating as summer break approaches.

Others are dreading the end of the school year, acting out in fear of what the next three months could bring. School counselor Kim Hamm worries about students how to buy cheap levitra who won’t have enough to eat this summer. And those without air conditioning or running water. She wonders how many will be left alone while their caretakers are working two or three jobs.

And who will spend how to buy cheap levitra their days anticipating the next attack from an abusive family member. Hamm has spent most of May helping students ages 4 to 9 identify and cope with their feelings, which can be triggered by instability at home. “They know that, here, they’re safe and we’re not how to buy cheap levitra going to hurt them,” Hamm said. €œAnd a lot of our kids, unfortunately, don’t go home to that every day.” About 100 miles west of Oklahoma City on Interstate 40, Elk City is home to nearly 12,000 residents whose financial stability ebbs and flows with the volatile oil and gas industry.

The nearby North Fork Correctional Facility brought some families to town to be close to a loved one. And students face rates of poverty, special needs and suicide higher than the state average how to buy cheap levitra. Kim Hamm, an Elk City Elementary School counselor, talks to a pre-kindergarten student who is playing with sensory toys purchased with Project AWARE funds in her office. Hamm said disadvantaged, abused and neglected students’ behavior deteriorates toward the end of the school year because they’re afraid or stressed about spending months away from school, which provides safety when life at home is turbulent.

(Courtesy photo) In her six years as a school counselor, Hamm has learned to anticipate these needs, how to buy cheap levitra making more time towards the end of the school year to meet with students one-on-one. But she doesn’t always have the bandwidth. School counselors’ duties range from helping develop individualized learning plans for students with special needs to proctoring the third-grade reading test. They enroll students in classes and ensure they how to buy cheap levitra meet state math and science requirements.

They provide college and career advice and help them find and apply for scholarships. They wrangle how to buy cheap levitra students during morning drop-off and afternoon pick-up, run school-sponsored food and clothes pantries and teach breathing techniques to those with test anxiety. Low pay and increasing obligations have left Oklahoma with a teacher shortage, which means counselors like Hamm are taking on more work leaving less time for struggling students. Counselors refer the most troubled kids to community mental health counselors.

But they are also in short supply especially in rural areas like Elk City where the ratio of how to buy cheap levitra mental healthcare providers to residents is 1 to 150,000. Without adequate local resources, the responsibility of students’ mental health care is falling to school counselors who are outnumbered and overwhelmed. A federal program is increasing support for students in six rural school districts in what the state mental health and education departments call “mental health deserts.” But schools are finding it difficult to hire qualified caregivers and erectile dysfunction treatment restrictions have halted programs and limited in-person treatment. Students are seen leaving Elk City Elementary School at the end of the how to buy cheap levitra school day.

School counselor Kim Hamm said for some students school is a safe place and leaving is not a happy but fearful time of day for students who don’t have enough to eat or are abused by family members at home. (Whitney Bryen/Oklahoma Watch) A Response Inspired By Sandy Hook Since 2018, the State Department of Education has received two U.S. Department of Health and Human Services grants totaling how to buy cheap levitra $18 million. Oklahoma’s Project AWARE, short for Advancing Wellness and Resiliency in Education, is in its third year of the five-year grant at Woodward, Elk City and Weatherford Public Schools and its first year at Ada, Atoka and Checotah Public Schools.

Subscribe to Jennifer Palmer's Education Watch newsletter Processing… Success! how to buy cheap levitra. You're on the list. Whoops!. There was how to buy cheap levitra an error and we couldn't process your subscription.

Please reload the page and try again. The districts were chosen by the state department for their lack of treatment providers and high-risk student populations. Oklahoma students are some of the most traumatized in the nation, according to several national health rankings including a recent survey conducted by a group based how to buy cheap levitra at Johns Hopkins University. But kids in these rural districts were more likely to have access to firearms, live in poverty, have an incarcerated parent, use drugs, experience depression and die by suicide, according to the state’s grant application.

These students are more susceptible to mental illness. And without treatment, they can face even more dangerous obstacles as they age, often leading to their own violent encounters, substance how to buy cheap levitra abuse or incarceration. Subscribe to our First Watch newsletter Processing… Success!. You're how to buy cheap levitra on the list.

Whoops!. There was an error and we couldn't process your subscription. Please reload how to buy cheap levitra the page and try again. In one of the country’s deadliest school shootings, a 20-year-old killed six adults and 20 students at Sandy Hook Elementary School in 2012.

Since then, the Substance Abuse and Mental Health Services Administration has sent millions to schools nationwide with high-risk students to prevent violence perpetrated by young people. This story was reported in partnership with the how to buy cheap levitra Solutions Journalism Network. For more information, go to solutionsjournalism.org. In their first year of the grant, Atoka, Ada and Checotah schools in Eastern Oklahoma spent most of the year assessing student needs and training staff.

At Elk City, Weatherford and Woodward schools in Western Oklahoma, Project AWARE forged ahead despite changes to programs that how to buy cheap levitra were derailed by the levitra. Community events aim to reduce stigma around mental health challenges and treatment and teach parents and students about healthy habits like the importance of sleep and recommendations for social media use. Elk City paused events in the spring of 2020 while how to buy cheap levitra Weatherford took its online and saw a spike in participation. Fifth through 12th grade students at all six districts completed mental health assessments, which helps educators identify students who are distracted, unhappy, scared, lonely or are prone to acting out.

Community mental health counselors had started to meet with troubled students in some of the Western Oklahoma schools. Parents have how to buy cheap levitra to agree to therapy but bringing professionals into the schools reduces barriers for families who lack transportation or who feel embarrassed visiting a local treatment facility. Many of these services were paused due to erectile dysfunction treatment. Some Project AWARE schools started group therapy sessions led by licensed mental health professionals for students with chronic stress often triggered by traumatic experiences like an absent or abusive parent.

The grant also trained how to buy cheap levitra educators at all six districts in a classroom program that teaches conflict resolution and empathy. Liz Henthorn, a kindergarten teacher at Elk City Elementary School, listens as her students rate how they’re feeling at the end of the day. Henthorn checks in with her students twice a day through a program known as Circles that she says how to buy cheap levitra teaches students coping skills and empathy. (Whitney Bryen/Oklahoma Watch) Just before the bell rang on a Monday afternoon, kindergarteners sat in a circle on a rug at the front of Liz Henthorn’s classroom at Elk City Elementary School.

One-by-one the students rated how they’re feeling as they prepared to go home. They describe their feelings as green, yellow or red if they’re having a difficult day and how to buy cheap levitra their peers offer comfort and advice. One student said he was feeling sad because his dog ran away that morning. Another student was feeling red because she had a bad dream.

Other students spoke up how to buy cheap levitra saying they could relate or that they’re sorry that happened. “We’re teaching kids to identify their feelings and giving suggestions to cope,” Henthorn said. €œAnd when we do it as a group the kids are learning about empathy and thinking about ways to help each other and that is just as important.” Liz Henthorn, a kindergarten teacher at Elk City Elementary School, listens as her students rate how they’re feeling at the end of the day. (Whitney Bryen/Oklahoma Watch) Teachers, counselors and administrators were trained to provide coping how to buy cheap levitra skills to students who face universal challenges like disagreements with classmates or stress about what to do after graduation.

But few are qualified to help more critical students, like those with mental illness or who have experienced trauma. Woodward Public Schools reported 82 homeless students during the 2017-18 school year – how to buy cheap levitra more than twice the state average. Nearly two-thirds of students at Woodward and Elk City Public Schools qualified for free and reduced lunches, compared to the state’s average of 50%. In Elk City, 140 of the district’s 2,110 students had a parent who was incarcerated.

And all three Western Oklahoma districts had higher than average how to buy cheap levitra suicide rates. Those districts rely on school counselors to support these students, though most lack the training. And the grant does not address the ratio of counselors to students, which is far above national recommendations. Districts also planned to increase referrals to how to buy cheap levitra community treatment centers facilitated by the grant.

Demand for mental health care spiked during the levitra, further straining the area’s providers and leaving families with few options. Weatherford elementary students are seen eating lunch in the school’s cafeteria. (Whitney Bryen/Oklahoma Watch) The Complicated Search for Counselors how to buy cheap levitra School counselors can listen to students and offer coping techniques, but their ability to help is limited. Licensed counselors can provide therapy and diagnose students with mental illness.

Elk City, Woodward and Weatherford districts hoped to bring more licensed how to buy cheap levitra professional counselors into schools by hiring new staff and using Project AWARE funds to pay for training for current school counselors. Each district hired one licensed mental health provider who serves all students. The districts have been unable to hire any new school counselors and no existing counselors have been licensed. The state requires school counselors to have a master’s degree in a related field or two years how to buy cheap levitra of experience, and pass the state’s general education, professional teaching and school counseling exams.

Training for licensed professional counselors requires an additional 60 graduate-level college hours and 3,000 hours of supervised counseling. Counselors must also pass an exam before being licensed. Education costs are likely to total $21,000 to $33,000 depending on the school, according to how to buy cheap levitra the most recent state averages. And that doesn’t include fees for supervision or the licensing exam.

The grant will pay tuition costs for school counselors to get their license. Only two how to buy cheap levitra of 16 school counselors in Elk City, Weatherford and Woodward have taken the offer. School counselors said it is still an expensive and lengthy endeavour that results in more work without a boost in pay or a promotion. “I know that it would give me how to buy cheap levitra more in depth counseling training, but I think at this time in my life with small children it’s just probably not going to happen,” said Hamm, who has a 10-month-old and a 3-year-old.

€œIf I was going to make more as a school counselor with it then maybe I would, but I’m not going to so I’m just not going to spend a whole lot of time to get that.” For school counselors who do get their license, the job doesn’t change much. They often have the same paperwork, testing responsibilities and recess duty. But they’re also counseling the school’s most traumatized kids, a how to buy cheap levitra group that is growing following the levitra. Oklahoma has 1,841 school counselors and nearly 695,000 students, according to State Department of Education reports.

The department does not track how many school counselors have their professional counseling license. The American School Counselor Association recommends a ratio of how to buy cheap levitra 1 school counselor to 250 students. Oklahoma mandates 1 school counselor per 450 middle and high school students. The state does not have a threshold for elementary schools.

Not every school has a dedicated counselor how to buy cheap levitra. Some have teams depending on student population, how schools prioritize funding and disperse tasks. The Association also recommends counselors spend how to buy cheap levitra at least 80% of their time working directly with or for individual students. Oklahoma Watch interviewed 10 counselors across the state.

Most said they spend the majority of their day doing clerical work. Depending on the time how to buy cheap levitra of year, about 20 to 50% of their time is spent with students. Elizabeth Moss, a seventh and eighth grade counselor at Woodward Middle School, said she is one of the fortunate ones because she spends about 50% of her time meeting with students one-on-one thanks to the help of her administration. Even with the group sessions she leads, Moss said she still hasn’t been able to meet the national recommendation.

€œA lot of what I deal with are the results of families who are in crisis, where there’s addiction, other issues how to buy cheap levitra that are related to poverty and the kids show up to school and there’s a lot of fallout from that,” Moss said. €œAnd so we have kids who are depressed. We’ve had kids who how to buy cheap levitra are suicidal. Anxieties are really high.” Lora Anderson, a school counselor at Ada Junior High School, talks to students about online enrollment and how to choose classes for next school year.

(Courtesy photo) Moss is one of two school counselors taking advantage of Project AWARE funding to get her professional counseling license. Her principal took over how to buy cheap levitra her ACT and pre-ACT testing, scheduling and enrollment duties allowing Moss to spend more time with students in crisis. “I would love to see even more taken off of the shoulders of counselors so that we could take care of our kids’ needs better,” Moss said. €œBut I truly feel blessed here that I am not overwhelmed, like so many counselors.” At Ada Junior High School, counselor Lora Anderson spends about 25% of her time working with troubled students.

Many school counselors go into the job to propel students’ academic how to buy cheap levitra success, not to provide therapy. Anderson does her best to help students but said she isn’t trained to help kids with acute needs. €œThat’s not what I want to do,” Anderson said after returning to her desk from lunch duty. €œI do so many how to buy cheap levitra different things to help students.

If I wanted to be a mental health counselor, I wouldn’t work in a school.” Michelle Taylor, President-Elect of the Oklahoma School Counselor Association and counselor at Adair High School, said the job has changed a lot since she started and counselors at smaller schools like hers are often overwhelmed juggling paperwork, test proctoring and counseling students. (Courtesy photo) how to buy cheap levitra Michelle Taylor, President-Elect of the Oklahoma School Counselor Association, said the organization doesn’t track how many school counselors have their license. But based on training she’s attended and led over the years, Taylor said it’s likely that about 1 in 5 school counselors goes on to become licensed. School counselors are serving dual roles whether they want to or not.

Like swim instructors at a pool, most school counselors see their role as building stronger how to buy cheap levitra swimmers. But as mental health challenges continue to grow, counselors also have to serve as lifeguards, diving into the deep end to rescue drowning kids. “Counselors in rural schools tend to be treading more water,” Taylor said. €œSome folks are so overwhelmed with the job they have, how to buy cheap levitra they don’t have the time or the motivation to seek out additional training.

It’s just not accessible for folks.” Taylor has been a school counselor for more than 20 years and has her professional counseling license. She currently works with students at Adair High School in northeast Oklahoma. She said the job has changed a lot since how to buy cheap levitra she started. Test requirements are constantly evolving.

College admissions and scholarship applications seem to get how to buy cheap levitra longer every year. And students want to talk more. Kids are more willing to open up about their issues, especially since mental health is talked about more openly since the levitra, Taylor said. And school counselors have to be ready to listen and how to buy cheap levitra help.

“I think we should be the ones doing this work because we already know the students and they already know us so it’s quicker to get to that trust that can take a long time to develop,” Taylor said. €œThat’s when it becomes about priorities and we have to respond to what the students need first and then worry about everything else.” Elk City Middle School students took a mental health screening at the beginning of Lana Graham’s geography class in March. Graham said since the erectile dysfunction levitra began, her students seem more anxious and depressed how to buy cheap levitra than ever. (Whitney Bryen/Oklahoma Watch) Whitney Bryen is an investigative reporter and visual storyteller at Oklahoma Watch with an emphasis on domestic violence, mental health and nursing homes affected by erectile dysfunction treatment.

Contact her at (405) 201-6057 or wbryen@oklahomawatch.org. Follow her on Twitter @SoonerReporter how to buy cheap levitra. Support our publicationEvery day we strive to produce journalism that matters — stories that strengthen accountability and transparency, provide value and resonate with readers like you.This work is essential to a better-informed community and a healthy democracy. But it isn’t possible without how to buy cheap levitra your support.

Donate nowFunding Will Expand Use of Telehealth to Integrate Mental and Behavioral Health into Pediatric Primary CareToday, the U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced the availability of $14.2 million from the American Rescue Plan to expand pediatric mental health care access by integrating telehealth services into pediatric primary care. The funding will expand Pediatric Mental Health Care Access (PMHCA) projects into how to buy cheap levitra new states and geographic areas nationwide, including tribal areas. These new state and regional networks of pediatric mental health care teams will provide teleconsultations, training, technical assistance and care coordination for pediatric primary care providers to diagnose, treat and refer children and youth with mental health conditions and substance use disorders.

Currently, there are 21 PMCHA projects in the country. “Children are struggling with how to buy cheap levitra a range of emotional and behavioral challenges arising from the erectile dysfunction treatment levitra, especially those in families with lower incomes or who face other obstacles to health care,” said HHS Secretary Xavier Becerra. €œThis program harnesses the power of technology to make mental and behavioral health care more accessible and equitable for our nation’s children, and links pediatric care providers to children and their families who need that specialized care.” Research demonstrates an increased need for pediatric mental and behavioral health care. In the United States, about 22 percent of children ages 3 to 17 are currently affected by some type of mental, emotional, developmental, or behavioral condition.

Only about how to buy cheap levitra 20% of children with mental, emotional, or behavioral disorders receive care from a specialized provider. €œNow more than ever, families need mental and behavioral health care for their children, but significant disparities in access to this treatment continue to exist,” said Acting HRSA Administrator Diana Espinosa. €œThe expansion of the Pediatric Mental Health Care how to buy cheap levitra Access Program paves the way for more children to receive necessary mental health services, especially those in underserved communities.” Pediatric mental health care teams will include child and adolescent psychiatrists, licensed mental health professionals, and care coordinators. Pediatric primary care providers can include, but are not limited to, pediatricians, family physicians, nurse practitioners, physician assistants, and care coordinators.

Teams will use telehealth to consult with pediatric primary care providers. To learn about eligibility and to apply for the American Rescue Plan Act - Pediatric Mental Health Care Access (PMHCA) – New Area Expansion Notice of Funding how to buy cheap levitra Opportunity, visit https://www.grants.gov/web/grants/view-opportunity.html?. OppId=333181. Applications are due July 6, 2021, at 11:59 p.m.

ET. Applicants should contact Madhavi Reddy with any questions. Learn more about HRSA’s Pediatric Mental Health Care Access program..

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SALT LAKE viagra vs cialis vs levitra reddit CITY, Nov. 10, 2020 (GLOBE NEWSWIRE) -- Health Catalyst, Inc. (Nasdaq.

HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today reported financial results for the quarter ended September 30, 2020.“In the third quarter of 2020, I am pleased to share that we achieved strong performance across our business, including exceeding the mid-point of our quarterly guidance for both revenue and Adjusted EBITDA,” said Dan Burton, CEO of Health Catalyst. €œIn addition to this financial and operational execution, we are excited to announce the promotion of Patrick Nelli, our current Chief Financial Officer, to the role President of Health Catalyst, effective January 1, 2021. Patrick's responsibilities as President will include all the major growth functions of the company, including with existing customers, new customers, international expansion, sales operations, marketing and communications.

Additionally, I am pleased to announce the promotion of Bryan Hunt, our current Senior Vice President of Financial Planning &. Analysis to the role of Chief Financial Officer, effective January 1, 2021. Patrick and Bryan, in their newly appointed roles, have my full support and confidence and the unanimous support and confidence of our board of directors.

Lastly, I would also like to share two additional promotions related to these changes. Jason Alger, our Senior Vice President of Finance, has been promoted to Chief Accounting Officer, and Adam Brown, our Senior Vice President of Investor Relations, has been promoted to Senior Vice President of Investor Relations and Finance Planning &. Analysis.”Financial Highlights for the Three Months Ended September 30, 2020 Key Financial Metrics Three Months EndedSeptember 30, Year over Year Change 2020 2019 GAAP Financial Data.

(in thousands, except percentages) Technology revenue $ 27,964 $ 21,160 32% Professional services revenue $ 19,227 $ 18,263 5% Total revenue $ 47,191 $ 39,423 20% Loss from operations $ (23,458 ) $ (20,736 ) (13)% Net loss $ (27,326 ) $ (21,416 ) (28)% Other Non-GAAP Financial Data:(1) Adjusted Technology Gross Profit $ 19,115 $ 14,484 32% Adjusted Technology Gross Margin 68 % 68 % Adjusted Professional Services Gross Profit $ 4,823 $ 6,677 (28)% Adjusted Professional Services Gross Margin 25 % 37 % Total Adjusted Gross Profit $ 23,938 $ 21,161 13% Total Adjusted Gross Margin 51 % 54 % Adjusted EBITDA $ (6,434 ) $ (8,446 ) 24% ________________________(1) These measures are not calculated in accordance with generally accepted accounting principles in the United States (GAAP). See the accompanying "Non-GAAP Financial Measures" section below for more information about these financial measures, including the limitations of such measures, and for a reconciliation of each measure to the most directly comparable measure calculated in accordance with GAAP.Financial OutlookHealth Catalyst provides forward-looking guidance on total revenue, a GAAP measure, and Adjusted EBITDA, a non-GAAP measure.For the fourth quarter of 2020, we expect:Total revenue between $50.5 million and $53.5 million, and Adjusted EBITDA between $(7.3) million and $(5.3) millionFor the full year of 2020, we expect:Total revenue between $186.1 million and $189.1 million, and Adjusted EBITDA between $(23.9) million and $(21.9) millionWe have not reconciled guidance for Adjusted EBITDA to net loss, the most directly comparable GAAP measure, and have not provided forward-looking guidance for net loss, because there are items that may impact net loss, including stock-based compensation, that are not within our control or cannot be reasonably predicted.Quarterly Conference Call DetailsThe company will host a conference call to review the results today, Tuesday, November 10, 2020 at 5:00 p.m. E.T.

The conference call can be accessed by dialing 1-877-295-1104 for U.S. Participants, or 1-470-495-9486 for international participants, and referencing participant code 7195951. A live audio webcast will be available online at https://ir.healthcatalyst.com/.

A replay of the call will be available via webcast for on-demand listening shortly after the completion of the call, at the same web link, and will remain available for approximately 90 days.About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial, and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.Available InformationHealth Catalyst intends to use its Investor Relations website as a means of disclosing material non-public information and for complying with its disclosure obligations under Regulation FD.Forward-Looking StatementsThis release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended, and the Private Securities Litigation Reform Act of 1995, as amended.

These forward-looking statements include statements regarding our future growth and our financial outlook for Q4 and fiscal year 2020. Forward-looking statements are subject to risks and uncertainties and are based on potentially inaccurate assumptions that could cause actual results to differ materially from those expected or implied by the forward-looking statements. Actual results may differ materially from the results predicted, and reported results should not be considered as an indication of future performance.Important risks and uncertainties that could cause our actual results and financial condition to differ materially from those indicated in the forward-looking statements include, among others, the following.

(i) changes in laws and regulations applicable to our business model. (ii) changes in market or industry conditions, regulatory environment and receptivity to our technology and services. (iii) results of litigation or a security incident.

(iv) the loss of one or more key customers or partners. (v) the impact of erectile dysfunction treatment on our business and results of operation. And (vi) changes to our abilities to recruit and retain qualified team members.

For a detailed discussion of the risk factors that could affect our actual results, please refer to the risk factors identified in our SEC reports, including, but not limited to the Annual Report on Form 10-K for the year ended December 31, 2019 filed with the SEC on February 28, 2020 and the Quarterly Report on Form 10-Q for the fiscal quarter ended September 30, 2020 expected to be filed with the SEC on or about November 10, 2020. All information provided in this release and in the attachments is as of the date hereof, and we undertake no duty to update or revise this information unless required by law. Condensed Consolidated Balance Sheets (in thousands, except share and per share data, unaudited) As ofSeptember 30, As ofDecember 31, 2020 2019 Assets Current assets.

Cash and cash equivalents $ 111,239 $ 18,032 Short-term investments 163,898 210,245 Accounts receivable, net 36,339 27,570 Prepaid expenses and other assets 11,290 8,392 Total current assets 322,766 264,239 Property and equipment, net 5,319 4,295 Intangible assets, net 105,926 25,535 Operating lease right-of-use assets 25,833 3,787 Goodwill 107,822 3,694 Other assets 2,997 810 Total assets $ 570,663 $ 302,360 Liabilities and stockholders’ equity Current liabilities. Accounts payable $ 5,189 $ 3,622 Accrued liabilities 14,061 8,944 Acquisition-related consideration payable 3,214 2,192 Deferred revenue 35,090 30,653 Operating lease liabilities 2,425 2,806 Contingent consideration liabilities 5,893 — Total current liabilities 65,872 48,217 Long-term debt, net of current portion 166,200 48,200 Acquisition-related consideration payable, net of current portion — 1,860 Deferred revenue, net of current portion 1,635 1,459 Operating lease liabilities, net of current portion 24,245 1,654 Contingent consideration liabilities, net of current portion 10,279 — Other liabilities 2,817 326 Total liabilities 271,048 101,716 Commitments and contingencies Stockholders’ equity. Common stock, $0.001 par value.

42,239,922 and 36,678,854 shares issued and outstanding as of September 30, 2020 and December 31, 2019, respectively 42 37 Additional paid-in capital 982,139 811,049 Accumulated deficit (682,632 ) (610,514 ) Accumulated other comprehensive income 66 72 Total stockholders' equity 299,615 200,644 Total liabilities and stockholders’ equity $ 570,663 $ 302,360 Condensed Consolidated Statements of Operations (in thousands, except per share data, unaudited) Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Revenue. Technology $ 27,964 $ 21,160 $ 78,150 $ 61,393 Professional services 19,227 18,263 57,416 50,047 Total revenue 47,191 39,423 135,566 111,440 Cost of revenue, excluding depreciation and amortization. Technology(1) 9,045 6,740 25,148 20,536 Professional services(1)(3) 15,307 11,892 46,401 33,132 Total cost of revenue, excluding depreciation and amortization 24,352 18,632 71,549 53,668 Operating expenses.

Sales and marketing(1)(3) 14,629 14,721 40,618 35,579 Research and development(1)(3) 13,390 13,477 38,539 33,209 General and administrative(1)(2)(4)(5) 13,297 11,013 31,111 23,333 Depreciation and amortization 4,981 2,316 10,952 6,844 Total operating expenses 46,297 41,527 121,220 98,965 Loss from operations (23,458 ) (20,736 ) (57,203 ) (41,193 ) Loss on extinguishment of debt — — (8,514 ) (1,670 ) Interest and other expense, net (3,854 ) (659 ) (7,500 ) (2,924 ) Loss before income taxes (27,312 ) (21,395 ) (73,217 ) (45,787 ) Income tax provision (benefit) 14 21 (1,218 ) 43 Net loss $ (27,326 ) $ (21,416 ) $ (71,999 ) $ (45,830 ) Less. Accretion of redeemable convertible preferred stock — 18,170 — 180,826 Net loss attributable to common stockholders $ (27,326 ) $ (39,586 ) $ (71,999 ) $ (226,656 ) Net loss per share attributable to common stockholders, basic and diluted $ (0.68 ) $ (1.40 ) $ (1.87 ) $ (17.78 ) Weighted-average shares outstanding used in calculating net loss per share attributable to common stockholders, basic and diluted 40,292 28,223 38,517 12,750 Adjusted net loss(6) $ (8,287 ) $ (9,817 ) $ (20,110 ) $ (26,014 ) Pro forma adjusted net loss per share, basic and diluted(6) $ (0.21 ) $ (0.27 ) $ (0.52 ) $ (0.72 ) Pro forma as adjusted weighted-average number of shares outstanding used in calculating Adjusted Net Loss per share, basic and diluted(6) 40,292 36,373 38,517 36,183 _______________(1) Includes stock-based compensation expense as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Stock-Based Compensation Expense.

(in thousands) (in thousands) Cost of revenue, excluding depreciation and amortization. Technology $ 196 $ 64 $ 575 $ 129 Professional services 903 306 2,609 593 Sales and marketing 3,233 1,358 9,724 2,639 Research and development 2,025 3,067 5,987 3,502 General and administrative 3,139 5,179 8,388 6,165 Total $ 9,496 $ 9,974 $ 27,283 $ 13,028 (2) Includes acquisition transaction costs as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Acquisition transaction costs.

(in thousands) (in thousands) General and administrative $ 1,399 $ — $ 2,670 $ — Total $ 1,399 $ — $ 2,670 $ — (3) Includes post-acquisition restructuring costs as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Post-Acquisition Restructuring Costs. (in thousands) (in thousands) Cost of revenue, excluding depreciation and amortization.

Professional services $ — $ — $ — $ 108 Sales and marketing — — — 306 Research and development — — — 32 Total $ — $ — $ — $ 446 (4) Includes the change in fair value of contingent consideration liabilities, as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Change in fair value of contingent consideration liabilities. (in thousands) (in thousands) General and administrative $ 564 $ — $ (1,004 ) $ — Total $ 564 $ — $ (1,004 ) $ — (5) Includes duplicate headquarters rent expense, as follows.

Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Duplicate Headquarters Rent Expense. (in thousands) (in thousands) General and administrative $ 584 $ — $ 709 $ — Total $ 584 $ — $ 709 $ — (6) Includes pro forma adjustments to net loss attributable to common stockholders and the weighted average number of common shares outstanding directly attributable to the closing of our initial public offering on July 29, 2019 as well as certain other non-GAAP adjustments. Refer to the "Non-GAAP Financial Measures—Pro Forma Adjusted Net Loss Per Share" section below for further details.

Condensed Consolidated Statements of Cash Flows (in thousands, unaudited) Nine Months EndedSeptember 30, Cash flows from operating activities 2020 2019 Net loss $ (71,999 ) $ (45,830 ) Adjustments to reconcile net loss to net cash used in operating activities. Depreciation and amortization 10,952 6,844 Loss on extinguishment of debt 8,514 1,670 Amortization of debt discount and issuance costs 5,260 797 Non-cash operating lease expense 2,865 2,696 Investment discount and premium amortization 854 (443 ) Provision for expected credit losses 822 — Stock-based compensation expense 27,283 13,028 Deferred tax (benefit) provision (1,280 ) — Change in fair value of contingent consideration liabilities (1,004 ) — Other 85 (36 ) Change in operating assets and liabilities. Accounts receivable, net (4,450 ) (3,323 ) Prepaid expenses and other assets (2,937 ) (1,362 ) Accounts payable, accrued liabilities, and other liabilities 6,567 1,661 Deferred revenue (838 ) 7,601 Operating lease liabilities (2,701 ) (2,426 ) Net cash used in operating activities (22,007 ) (19,123 ) Cash flows from investing activities Purchase of short-term investments (163,346 ) (221,444 ) Proceeds from the sale and maturity of short-term investments 208,467 37,277 Acquisition of businesses, net of cash acquired (102,471 ) — Purchase of property and equipment (2,071 ) (1,658 ) Purchase of intangible assets (1,249 ) (1,747 ) Proceeds from sale of property and equipment 10 40 Net cash used in investing activities (60,660 ) (187,532 ) Cash flows from financing activities Proceeds from convertible note securities, net of issuance costs 222,482 — Purchase of capped calls concurrent with issuance of convertible senior notes (21,743 ) — Proceeds from credit facilities, net of debt issuance costs — 47,169 Repayment of credit facilities (57,043 ) (21,821 ) Proceeds from exercise of stock options 29,393 2,177 Proceeds from employee stock purchase plan 3,528 1,216 Payments of acquisition-related consideration (748 ) (773 ) Proceeds from initial public offering, net of underwriters’ discounts and commissions — 194,649 Proceeds from the issuance of redeemable convertible preferred stock, net of issuance costs — 12,073 Payments of deferred offering costs — (4,407 ) Net cash provided by financing activities 175,869 230,283 Effect of exchange rate on cash and cash equivalents 5 — Net increase in cash and cash equivalents 93,207 23,628 Cash and cash equivalents at beginning of period 18,032 28,431 Cash and cash equivalents at end of period $ 111,239 $ 52,059 Non-GAAP Financial MeasuresTo supplement our financial information presented in accordance with GAAP, we believe certain non-GAAP measures, including Adjusted Gross Profit, Adjusted Gross Margin, Adjusted EBITDA, Adjusted Net Loss, and Adjusted Net Loss per share, basic and diluted, are useful in evaluating our operating performance.

We use this non-GAAP financial information to evaluate our ongoing operations, as a component in determining employee bonus compensation, and for internal planning and forecasting purposes. We believe that non-GAAP financial information, when taken collectively, may be helpful to investors because it provides consistency and comparability with past financial performance. However, non-GAAP financial information is presented for supplemental informational purposes only, has limitations as an analytical tool and should not be considered in isolation or as a substitute for financial information presented in accordance with GAAP.

In addition, other companies, including companies in our industry, may calculate similarly-titled non-GAAP measures differently or may use other measures to evaluate their performance. A reconciliation is provided below for each non-GAAP financial measure to the most directly comparable financial measure stated in accordance with GAAP. Investors are encouraged to review the related GAAP financial measures and the reconciliation of these non-GAAP financial measures to their most directly comparable GAAP financial measures, and not to rely on any single financial measure to evaluate our business.Adjusted Gross Profit and Adjusted Gross MarginAdjusted Gross Profit is a non-GAAP financial measure that we define as revenue less cost of revenue, excluding depreciation and amortization and excluding (i) stock-based compensation and (ii) post-acquisition restructuring costs (none during periods presented).

We define Adjusted Gross Margin as our Adjusted Gross Profit divided by our revenue. We believe Adjusted Gross Profit and Adjusted Gross Margin are useful to investors as they eliminate the impact of certain non-cash expenses and allow a direct comparison of these measures between periods without the impact of non-cash expenses and certain other non-recurring operating expenses. The following is a reconciliation of revenue, the most directly comparable GAAP financial measure, to Adjusted Gross Profit, for the three months ended September 30, 2020 and 2019.

Three Months Ended September 30, 2020 (in thousands, except percentages) Technology Professional Services Total Revenue $ 27,964 $ 19,227 $ 47,191 Cost of revenue, excluding depreciation and amortization (9,045 ) (15,307 ) (24,352 ) Gross profit, excluding depreciation and amortization 18,919 3,920 22,839 Add. Stock-based compensation 196 903 1,099 Adjusted Gross Profit $ 19,115 $ 4,823 $ 23,938 Gross margin, excluding depreciation and amortization 68 % 20 % 48 % Adjusted Gross Margin 68 % 25 % 51 % Three Months Ended September 30, 2019 (in thousands, except percentages) Technology Professional Services Total Revenue $ 21,160 $ 18,263 $ 39,423 Cost of revenue, excluding depreciation and amortization (6,740 ) (11,892 ) (18,632 ) Gross profit, excluding depreciation and amortization 14,420 6,371 20,791 Add. Stock-based compensation 64 306 370 Adjusted Gross Profit $ 14,484 $ 6,677 $ 21,161 Gross margin, excluding depreciation and amortization 68 % 35 % 53 % Adjusted Gross Margin 68 % 37 % 54 % Adjusted EBITDAAdjusted EBITDA is a non-GAAP financial measure that we define as net loss adjusted for (i) interest and other expense, net, (ii) loss on extinguishment of debt (none in periods presented), (iii) income tax (benefit) provision, (iv) depreciation and amortization, (v) stock-based compensation, (vi) acquisition transaction costs, (vii) change in fair value of contingent consideration liability, (viii) duplicate headquarters rent expense, and (ix) post-acquisition restructuring costs when they are incurred.

We believe Adjusted EBITDA provides investors with useful information on period-to-period performance as evaluated by management and comparison with our past financial performance and is useful in evaluating our operating performance compared to that of other companies in our industry, as this metric generally eliminates the effects of certain items that may vary from company to company for reasons unrelated to overall operating performance. The following is a reconciliation of our net loss, the most directly comparable GAAP financial measure, to Adjusted EBITDA, for the three months ended September 30, 2020 and 2019. Three Months EndedSeptember 30, 2020 2019 (in thousands) Net loss $ (27,326 ) $ (21,416 ) Add.

Interest and other expense, net 3,854 659 Income tax (benefit) provision 14 21 Depreciation and amortization 4,981 2,316 Stock-based compensation 9,496 9,974 Acquisition transaction costs 1,399 — Change in fair value of contingent consideration liability 564 — Duplicate headquarters rent expense 584 — Adjusted EBITDA $ (6,434 ) $ (8,446 ) Pro Forma Adjusted Net Loss Per ShareAdjusted Net Loss is a non-GAAP financial measure that we define as net loss attributable to common stockholders adjusted for (i) accretion of redeemable convertible preferred stock, (ii) stock-based compensation, (iii) amortization of acquired intangibles, (iv) loss on debt extinguishment, (v) acquisition transaction costs, (vi) change in fair value of contingent consideration liability, (vii) non-cash interest expense related to our convertible senior notes, (viii) duplicate headquarters rent expense (see explanation above), and (ix) post-acquisition restructuring costs. Non-cash interest expense related to our convertible senior notes relates to the convertible senior notes that were issued in a private placement in April 2020. Under GAAP, we are required to separately account for liability (debt) and equity (conversion option) components of the convertible senior notes.

Accordingly, for GAAP purposes we are required to recognize the effective interest expense on our convertible senior notes and amortize the issuance costs over the term of the notes. The difference between the effective interest expense and the contractual interest expense, and the amortization expense of issuance costs are excluded from management’s assessment of our operating performance because management believes that these non-cash expenses are not indicative of ongoing operating performance.We believe Adjusted Net Loss provides investors with useful information on period-to-period performance as evaluated by management and comparison with our past financial performance and is useful in evaluating our operating performance compared to that of other companies in our industry, as this metric generally eliminates the effects of certain items that may vary from company to company for reasons unrelated to overall operating performance.On July 29, 2019, we closed our initial public offering (our IPO) in which we issued and sold 8,050,000 shares (inclusive of the underwriters’ option to purchase an additional 1,050,000 shares) of common stock at $26.00 per share. We received net proceeds of $194.6 million after deducting underwriting discounts and commissions and before deducting offering costs of $4.6 million.

Upon the closing of our IPO, all shares of our outstanding redeemable convertible preferred stock converted into 23,151,481 shares of common stock on a one-for-one basis. We have prepared the below adjusted condensed consolidated statement of operations data to present pro forma adjusted net loss per share amounts that will be comparable between the current and prior periods presented as if the conversion of all outstanding shares of redeemable convertible preferred stock and the issuance of the IPO shares had occurred as of the beginning of the prior year comparative periods. Three Months Ended September 30, Nine Months Ended September 30, 2020 2019 2020 2019 Numerator.

(in thousands, except share and per share amounts) Net loss attributable to common stockholders $ (27,326 ) $ (39,586 ) $ (71,999 ) $ (226,656 ) Add Accretion of redeemable convertible preferred stock — 18,170 — 180,826 Stock-based compensation 9,496 9,974 27,283 13,028 Amortization of acquired intangibles 4,276 1,625 8,786 4,672 Loss on extinguishment of debt — — 8,514 1,670 Acquisition transaction costs 1,399 — 2,670 — Change in fair value of contingent consideration liability 564 — (1,004 ) — Non-cash interest expense related to convertible senior notes 2,720 — 4,931 — Duplicate headquarters rent expense 584 — 709 — Post-acquisition restructuring costs — — — 446 Adjusted Net Loss $ (8,287 ) $ (9,817 ) $ (20,110 ) $ (26,014 ) Denominator. Weighted-average number of shares used in calculating net loss per share attributable to common stockholders, basic and diluted 40,292,380 28,222,555 38,517,272 12,749,903 Pro forma adjustments Pro forma adjustment to reflect issuance and conversion of redeemable convertible preferred stock to common stock, assuming the conversion took place as of the beginning of the 2019 period — 6,039,517 — 17,384,812 Pro forma adjustment to reflect issuance of shares of common stock as part of IPO, assuming the issuance took place as of the beginning of the 2019 period — 2,111,413 — 6,048,718 Pro forma as adjusted weighted-average number of shares used in calculating Adjusted Net Loss per share, basic and diluted 40,292,380 36,373,485 38,517,272 36,183,433 Pro forma adjusted net loss per share, basic and diluted $ (0.21 ) $ (0.27 ) $ (0.52 ) $ (0.72 ) Health Catalyst Investor Relations Contact:Adam BrownSenior Vice President, Investor Relations+1 (855)-309-6800ir@healthcatalyst.comHealth Catalyst Media Contact:Amanda Hundtamanda.hundt@healthcatalyst.com+1 (575) 491-0974 Source. Health Catalyst, Inc..

SALT LAKE CITY, how to buy cheap levitra https://www.maralegal.com/walmart-pharmacy-levitra-cost Nov. 10, 2020 (GLOBE NEWSWIRE) -- Health Catalyst, Inc. (Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today reported financial results for the quarter ended September 30, 2020.“In the third quarter of 2020, I am pleased to share that we achieved strong performance across our business, including exceeding the mid-point of our quarterly guidance for both revenue and Adjusted EBITDA,” said Dan Burton, CEO of Health Catalyst. €œIn addition to this financial and operational execution, we are excited to announce the promotion of Patrick Nelli, our current Chief Financial Officer, to the role President of Health Catalyst, effective January 1, 2021.

Patrick's responsibilities as President will include all the major growth functions of the company, including with existing customers, new customers, international expansion, sales operations, marketing and communications. Additionally, I am pleased to announce the promotion of Bryan Hunt, our current Senior Vice President of Financial Planning &. Analysis to the role of Chief Financial Officer, effective January 1, 2021. Patrick and Bryan, in their newly appointed roles, have my full support and confidence and the unanimous support and confidence of our board of directors. Lastly, I would also like to share two additional promotions related to these changes.

Jason Alger, our Senior Vice President of Finance, has been promoted to Chief Accounting Officer, and Adam Brown, our Senior Vice President of Investor Relations, has been promoted to Senior Vice President of Investor Relations and Finance Planning &. Analysis.”Financial Highlights for the Three Months Ended September 30, 2020 Key Financial Metrics Three Months EndedSeptember 30, Year over Year Change 2020 2019 GAAP Financial Data. (in thousands, except percentages) Technology revenue $ 27,964 $ 21,160 32% Professional services revenue $ 19,227 $ 18,263 5% Total revenue $ 47,191 $ 39,423 20% Loss from operations $ (23,458 ) $ (20,736 ) (13)% Net loss $ (27,326 ) $ (21,416 ) (28)% Other Non-GAAP Financial Data:(1) Adjusted Technology Gross Profit $ 19,115 $ 14,484 32% Adjusted Technology Gross Margin 68 % 68 % Adjusted Professional Services Gross Profit $ 4,823 $ 6,677 (28)% Adjusted Professional Services Gross Margin 25 % 37 % Total Adjusted Gross Profit $ 23,938 $ 21,161 13% Total Adjusted Gross Margin 51 % 54 % Adjusted EBITDA $ (6,434 ) $ (8,446 ) 24% ________________________(1) These measures are not calculated in accordance with generally accepted accounting principles in the United States (GAAP). See the accompanying "Non-GAAP Financial Measures" section below for more information about these financial measures, including the limitations of such measures, and for a reconciliation of each measure to the most directly comparable measure calculated in accordance with GAAP.Financial OutlookHealth Catalyst provides forward-looking guidance on total revenue, a GAAP measure, and Adjusted EBITDA, a non-GAAP measure.For the fourth quarter of 2020, we expect:Total revenue between $50.5 million and $53.5 million, and Adjusted EBITDA between $(7.3) million and $(5.3) millionFor the full year of 2020, we expect:Total revenue between $186.1 million and $189.1 million, and Adjusted EBITDA between $(23.9) million and $(21.9) millionWe have not reconciled guidance for Adjusted EBITDA to net loss, the most directly comparable GAAP measure, and have not provided forward-looking guidance for net loss, because there are items that may impact net loss, including stock-based compensation, that are not within our control or cannot be reasonably predicted.Quarterly Conference Call DetailsThe company will host a conference call to review the results today, Tuesday, November 10, 2020 at 5:00 p.m. E.T.

The conference call can be accessed by dialing 1-877-295-1104 for U.S. Participants, or 1-470-495-9486 for international participants, and referencing participant code 7195951. A live audio webcast will be available online at https://ir.healthcatalyst.com/. A replay of the call will be available via webcast for on-demand listening shortly after the completion of the call, at the same web link, and will remain available for approximately 90 days.About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial, and operational improvements.

Health Catalyst envisions a future in which all healthcare decisions are data informed.Available InformationHealth Catalyst intends to use its Investor Relations website as a means of disclosing material non-public information and for complying with its disclosure obligations under Regulation FD.Forward-Looking StatementsThis release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended, and the Private Securities Litigation Reform Act of 1995, as amended. These forward-looking statements include statements regarding our future growth and our financial outlook for Q4 and fiscal year 2020. Forward-looking statements are subject to risks and uncertainties and are based on potentially inaccurate assumptions that could cause actual results to differ materially from those expected or implied by the forward-looking statements. Actual results may differ materially from the results predicted, and reported results should not be considered as an indication of future performance.Important risks and uncertainties that could cause our actual results and financial condition to differ materially from those indicated in the forward-looking statements include, among others, the following. (i) changes in laws and regulations applicable to our business model.

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

For a detailed discussion of the risk factors that could affect our actual results, please refer to the risk factors identified in our SEC reports, including, but not limited to the Annual Report on Form 10-K for the year ended December 31, 2019 filed with the SEC on February 28, 2020 and the Quarterly Report on Form 10-Q for the fiscal quarter ended September 30, 2020 expected to be filed with the SEC on or about November 10, 2020. All information provided in this release and in the attachments is as of the date hereof, and we undertake no duty to update or revise this information unless required by law. Condensed Consolidated Balance Sheets (in thousands, except share and per share data, unaudited) As ofSeptember 30, As ofDecember 31, 2020 2019 Assets Current assets. Cash and cash equivalents $ 111,239 $ 18,032 Short-term investments 163,898 210,245 Accounts receivable, net 36,339 27,570 Prepaid expenses and other assets 11,290 8,392 Total current assets 322,766 264,239 Property and equipment, net 5,319 4,295 Intangible assets, net 105,926 25,535 Operating lease right-of-use assets 25,833 3,787 Goodwill 107,822 3,694 Other assets 2,997 810 Total assets $ 570,663 $ 302,360 Liabilities and stockholders’ equity Current liabilities. Accounts payable $ 5,189 $ 3,622 Accrued liabilities 14,061 8,944 Acquisition-related consideration payable 3,214 2,192 Deferred revenue 35,090 30,653 Operating lease liabilities 2,425 2,806 Contingent consideration liabilities 5,893 — Total current liabilities 65,872 48,217 Long-term debt, net of current portion 166,200 48,200 Acquisition-related consideration payable, net of current portion — 1,860 Deferred revenue, net of current portion 1,635 1,459 Operating lease liabilities, net of current portion 24,245 1,654 Contingent consideration liabilities, net of current portion 10,279 — Other liabilities 2,817 326 Total liabilities 271,048 101,716 Commitments and contingencies Stockholders’ equity.

Common stock, $0.001 par value. 42,239,922 and 36,678,854 shares issued and outstanding as of September 30, 2020 and December 31, 2019, respectively 42 37 Additional paid-in capital 982,139 811,049 Accumulated deficit (682,632 ) (610,514 ) Accumulated other comprehensive income 66 72 Total stockholders' equity 299,615 200,644 Total liabilities and stockholders’ equity $ 570,663 $ 302,360 Condensed Consolidated Statements of Operations (in thousands, except per share data, unaudited) Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Revenue. Technology $ 27,964 $ 21,160 $ 78,150 $ 61,393 Professional services 19,227 18,263 57,416 50,047 Total revenue 47,191 39,423 135,566 111,440 Cost of revenue, excluding depreciation and amortization. Technology(1) 9,045 6,740 25,148 20,536 Professional services(1)(3) 15,307 11,892 46,401 33,132 Total cost of revenue, excluding depreciation and amortization 24,352 18,632 71,549 53,668 Operating expenses. Sales and marketing(1)(3) 14,629 14,721 40,618 35,579 Research and development(1)(3) 13,390 13,477 38,539 33,209 General and administrative(1)(2)(4)(5) 13,297 11,013 31,111 23,333 Depreciation and amortization 4,981 2,316 10,952 6,844 Total operating expenses 46,297 41,527 121,220 98,965 Loss from operations (23,458 ) (20,736 ) (57,203 ) (41,193 ) Loss on extinguishment of debt — — (8,514 ) (1,670 ) Interest and other expense, net (3,854 ) (659 ) (7,500 ) (2,924 ) Loss before income taxes (27,312 ) (21,395 ) (73,217 ) (45,787 ) Income tax provision (benefit) 14 21 (1,218 ) 43 Net loss $ (27,326 ) $ (21,416 ) $ (71,999 ) $ (45,830 ) Less.

Accretion of redeemable convertible preferred stock — 18,170 — 180,826 Net loss attributable to common stockholders $ (27,326 ) $ (39,586 ) $ (71,999 ) $ (226,656 ) Net loss per share attributable to common stockholders, basic and diluted $ (0.68 ) $ (1.40 ) $ (1.87 ) $ (17.78 ) Weighted-average shares outstanding used in calculating net loss per share attributable to common stockholders, basic and diluted 40,292 28,223 38,517 12,750 Adjusted net loss(6) $ (8,287 ) $ (9,817 ) $ (20,110 ) $ (26,014 ) Pro forma adjusted net loss per share, basic and diluted(6) $ (0.21 ) $ (0.27 ) $ (0.52 ) $ (0.72 ) Pro forma as adjusted weighted-average number of shares outstanding used in calculating Adjusted Net Loss per share, basic and diluted(6) 40,292 36,373 38,517 36,183 _______________(1) Includes stock-based compensation expense as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Stock-Based Compensation Expense. (in thousands) (in thousands) Cost of revenue, excluding depreciation and amortization. Technology $ 196 $ 64 $ 575 $ 129 Professional services 903 306 2,609 593 Sales and marketing 3,233 1,358 9,724 2,639 Research and development 2,025 3,067 5,987 3,502 General and administrative 3,139 5,179 8,388 6,165 Total $ 9,496 $ 9,974 $ 27,283 $ 13,028 (2) Includes acquisition transaction costs as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Acquisition transaction costs.

(in thousands) (in thousands) General and administrative $ 1,399 $ — $ 2,670 $ — Total $ 1,399 $ — $ 2,670 $ — (3) Includes post-acquisition restructuring costs as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Post-Acquisition Restructuring Costs. (in thousands) (in thousands) Cost of revenue, excluding depreciation and amortization. Professional services $ — $ — $ — $ 108 Sales and marketing — — — 306 Research and development — — — 32 Total $ — $ — $ — $ 446 (4) Includes the change in fair value of contingent consideration liabilities, as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Change in fair value of contingent consideration liabilities.

(in thousands) (in thousands) General and administrative $ 564 $ — $ (1,004 ) $ — Total $ 564 $ — $ (1,004 ) $ — (5) Includes duplicate headquarters rent expense, as follows. Three Months EndedSeptember 30, Nine Months EndedSeptember 30, 2020 2019 2020 2019 Duplicate Headquarters Rent Expense. (in thousands) (in thousands) General and administrative $ 584 $ — $ 709 $ — Total $ 584 $ — $ 709 $ — (6) Includes pro forma adjustments to net loss attributable to common stockholders and the weighted average number of common shares outstanding directly attributable to the closing of our initial public offering on July 29, 2019 as well as certain other non-GAAP adjustments. Refer to the "Non-GAAP Financial Measures—Pro Forma Adjusted Net Loss Per Share" section below for further details. Condensed Consolidated Statements of Cash Flows (in thousands, unaudited) Nine Months EndedSeptember 30, Cash flows from operating activities 2020 2019 Net loss $ (71,999 ) $ (45,830 ) Adjustments to reconcile net loss to net cash used in operating activities.

Depreciation and amortization 10,952 6,844 Loss on extinguishment of debt 8,514 1,670 Amortization of debt discount and issuance costs 5,260 797 Non-cash operating lease expense 2,865 2,696 Investment discount and premium amortization 854 (443 ) Provision for expected credit losses 822 — Stock-based compensation expense 27,283 13,028 Deferred tax (benefit) provision (1,280 ) — Change in fair value of contingent consideration liabilities (1,004 ) — Other 85 (36 ) Change in operating assets and liabilities. Accounts receivable, net (4,450 ) (3,323 ) Prepaid expenses and other assets (2,937 ) (1,362 ) Accounts payable, accrued liabilities, and other liabilities 6,567 1,661 Deferred revenue (838 ) 7,601 Operating lease liabilities (2,701 ) (2,426 ) Net cash used in operating activities (22,007 ) (19,123 ) Cash flows from investing activities Purchase of short-term investments (163,346 ) (221,444 ) Proceeds from the sale and maturity of short-term investments 208,467 37,277 Acquisition of businesses, net of cash acquired (102,471 ) — Purchase of property and equipment (2,071 ) (1,658 ) Purchase of intangible assets (1,249 ) (1,747 ) Proceeds from sale of property and equipment 10 40 Net cash used in investing activities (60,660 ) (187,532 ) Cash flows from financing activities Proceeds from convertible note securities, net of issuance costs 222,482 — Purchase of capped calls concurrent with issuance of convertible senior notes (21,743 ) — Proceeds from credit facilities, net of debt issuance costs — 47,169 Repayment of credit facilities (57,043 ) (21,821 ) Proceeds from exercise of stock options 29,393 2,177 Proceeds from employee stock purchase plan 3,528 1,216 Payments of acquisition-related consideration (748 ) (773 ) Proceeds from initial public offering, net of underwriters’ discounts and commissions — 194,649 Proceeds from the issuance of redeemable convertible preferred stock, net of issuance costs — 12,073 Payments of deferred offering costs — (4,407 ) Net cash provided by financing activities 175,869 230,283 Effect of exchange rate on cash and cash equivalents 5 — Net increase in cash and cash equivalents 93,207 23,628 Cash and cash equivalents at beginning of period 18,032 28,431 Cash and cash equivalents at end of period $ 111,239 $ 52,059 Non-GAAP Financial MeasuresTo supplement our financial information presented in accordance with GAAP, we believe certain non-GAAP measures, including Adjusted Gross Profit, Adjusted Gross Margin, Adjusted EBITDA, Adjusted Net Loss, and Adjusted Net Loss per share, basic and diluted, are useful in evaluating our operating performance. We use this non-GAAP financial information to evaluate our ongoing operations, as a component in determining employee bonus compensation, and for internal planning and forecasting purposes. We believe that non-GAAP financial information, when taken collectively, may be helpful to investors because it provides consistency and comparability with past financial performance. However, non-GAAP financial information is presented for supplemental informational purposes only, has limitations as an analytical tool and should not be considered in isolation or as a substitute for financial information presented in accordance with GAAP.

In addition, other companies, including companies in our industry, may calculate similarly-titled non-GAAP measures differently or may use other measures to evaluate their performance. A reconciliation is provided below for each non-GAAP financial measure to the most directly comparable financial measure stated in accordance with GAAP. Investors are encouraged to review the related GAAP financial measures and the reconciliation of these non-GAAP financial measures to their most directly comparable GAAP financial measures, and not to rely on any single financial measure to evaluate our business.Adjusted Gross Profit and Adjusted Gross MarginAdjusted Gross Profit is a non-GAAP financial measure that we define as revenue less cost of revenue, excluding depreciation and amortization and excluding (i) stock-based compensation and (ii) post-acquisition restructuring costs (none during periods presented). We define Adjusted Gross Margin as our Adjusted Gross Profit divided by our revenue. We believe Adjusted Gross Profit and Adjusted Gross Margin are useful to investors as they eliminate the impact of certain non-cash expenses and allow a direct comparison of these measures between periods without the impact of non-cash expenses and certain other non-recurring operating expenses.

The following is a reconciliation of revenue, the most directly comparable GAAP financial measure, to Adjusted Gross Profit, for the three months ended September 30, 2020 and 2019. Three Months Ended September 30, 2020 (in thousands, except percentages) Technology Professional Services Total Revenue $ 27,964 $ 19,227 $ 47,191 Cost of revenue, excluding depreciation and amortization (9,045 ) (15,307 ) (24,352 ) Gross profit, excluding depreciation and amortization 18,919 3,920 22,839 Add. Stock-based compensation 196 903 1,099 Adjusted Gross Profit $ 19,115 $ 4,823 $ 23,938 Gross margin, excluding depreciation and amortization 68 % 20 % 48 % Adjusted Gross Margin 68 % 25 % 51 % Three Months Ended September 30, 2019 (in thousands, except percentages) Technology Professional Services Total Revenue $ 21,160 $ 18,263 $ 39,423 Cost of revenue, excluding depreciation and amortization (6,740 ) (11,892 ) (18,632 ) Gross profit, excluding depreciation and amortization 14,420 6,371 20,791 Add. Stock-based compensation 64 306 370 Adjusted Gross Profit $ 14,484 $ 6,677 $ 21,161 Gross margin, excluding depreciation and amortization 68 % 35 % 53 % Adjusted Gross Margin 68 % 37 % 54 % Adjusted EBITDAAdjusted EBITDA is a non-GAAP financial measure that we define as net loss adjusted for (i) interest and other expense, net, (ii) loss on extinguishment of debt (none in periods presented), (iii) income tax (benefit) provision, (iv) depreciation and amortization, (v) stock-based compensation, (vi) acquisition transaction costs, (vii) change in fair value of contingent consideration liability, (viii) duplicate headquarters rent expense, and (ix) post-acquisition restructuring costs when they are incurred. We believe Adjusted EBITDA provides investors with useful information on period-to-period performance as evaluated by management and comparison with our past financial performance and is useful in evaluating our operating performance compared to that of other companies in our industry, as this metric generally eliminates the effects of certain items that may vary from company to company for reasons unrelated to overall operating performance.

The following is a reconciliation of our net loss, the most directly comparable GAAP financial measure, to Adjusted EBITDA, for the three months ended September 30, 2020 and 2019. Three Months EndedSeptember 30, 2020 2019 (in thousands) Net loss $ (27,326 ) $ (21,416 ) Add. Interest and other expense, net 3,854 659 Income tax (benefit) provision 14 21 Depreciation and amortization 4,981 2,316 Stock-based compensation 9,496 9,974 Acquisition transaction costs 1,399 — Change in fair value of contingent consideration liability 564 — Duplicate headquarters rent expense 584 — Adjusted EBITDA $ (6,434 ) $ (8,446 ) Pro Forma Adjusted Net Loss Per ShareAdjusted Net Loss is a non-GAAP financial measure that we define as net loss attributable to common stockholders adjusted for (i) accretion of redeemable convertible preferred stock, (ii) stock-based compensation, (iii) amortization of acquired intangibles, (iv) loss on debt extinguishment, (v) acquisition transaction costs, (vi) change in fair value of contingent consideration liability, (vii) non-cash interest expense related to our convertible senior notes, (viii) duplicate headquarters rent expense (see explanation above), and (ix) post-acquisition restructuring costs. Non-cash interest expense related to our convertible senior notes relates to the convertible senior notes that were issued in a private placement in April 2020. Under GAAP, we are required to separately account for liability (debt) and equity (conversion option) components of the convertible senior notes.

Accordingly, for GAAP purposes we are required to recognize the effective interest expense on our convertible senior notes and amortize the issuance costs over the term of the notes. The difference between the effective interest expense and the contractual interest expense, and the amortization expense of issuance costs are excluded from management’s assessment of our operating performance because management believes that these non-cash expenses are not indicative of ongoing operating performance.We believe Adjusted Net Loss provides investors with useful information on period-to-period performance as evaluated by management and comparison with our past financial performance and is useful in evaluating our operating performance compared to that of other companies in our industry, as this metric generally eliminates the effects of certain items that may vary from company to company for reasons unrelated to overall operating performance.On July 29, 2019, we closed our initial public offering (our IPO) in which we issued and sold 8,050,000 shares (inclusive of the underwriters’ option to purchase an additional 1,050,000 shares) of common stock at $26.00 per share. We received net proceeds of $194.6 million after deducting underwriting discounts and commissions and before deducting offering costs of $4.6 million. Upon the closing of our IPO, all shares of our outstanding redeemable convertible preferred stock converted into 23,151,481 shares of common stock on a one-for-one basis. We have prepared the below adjusted condensed consolidated statement of operations data to present pro forma adjusted net loss per share amounts that will be comparable between the current and prior periods presented as if the conversion of all outstanding shares of redeemable convertible preferred stock and the issuance of the IPO shares had occurred as of the beginning of the prior year comparative periods.

Three Months Ended September 30, Nine Months Ended September 30, 2020 2019 2020 2019 Numerator. (in thousands, except share and per share amounts) Net loss attributable to common stockholders $ (27,326 ) $ (39,586 ) $ (71,999 ) $ (226,656 ) Add Accretion of redeemable convertible preferred stock — 18,170 — 180,826 Stock-based compensation 9,496 9,974 27,283 13,028 Amortization of acquired intangibles 4,276 1,625 8,786 4,672 Loss on extinguishment of debt — — 8,514 1,670 Acquisition transaction costs 1,399 — 2,670 — Change in fair value of contingent consideration liability 564 — (1,004 ) — Non-cash interest expense related to convertible senior notes 2,720 — 4,931 — Duplicate headquarters rent expense 584 — 709 — Post-acquisition restructuring costs — — — 446 Adjusted Net Loss $ (8,287 ) $ (9,817 ) $ (20,110 ) $ (26,014 ) Denominator. Weighted-average number of shares used in calculating net loss per share attributable to common stockholders, basic and diluted 40,292,380 28,222,555 38,517,272 12,749,903 Pro forma adjustments Pro forma adjustment to reflect issuance and conversion of redeemable convertible preferred stock to common stock, assuming the conversion took place as of the beginning of the 2019 period — 6,039,517 — 17,384,812 Pro forma adjustment to reflect issuance of shares of common stock as part of IPO, assuming the issuance took place as of the beginning of the 2019 period — 2,111,413 — 6,048,718 Pro forma as adjusted weighted-average number of shares used in calculating Adjusted Net Loss per share, basic and diluted 40,292,380 36,373,485 38,517,272 36,183,433 Pro forma adjusted net loss per share, basic and diluted $ (0.21 ) $ (0.27 ) $ (0.52 ) $ (0.72 ) Health Catalyst Investor Relations Contact:Adam BrownSenior Vice President, Investor Relations+1 (855)-309-6800ir@healthcatalyst.comHealth Catalyst Media Contact:Amanda Hundtamanda.hundt@healthcatalyst.com+1 (575) 491-0974 Source. Health Catalyst, Inc..

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