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According to the http://whitemountainmilers.com/moat-mountain-trail/ U.S kamagra uk delivery. Centers for Disease Control and Prevention, itâs safe for us to stop wearing masks in most situations. But itâs not that simple.

Hereâs when, kamagra uk delivery where and why some of us are still wearing masksâand when weâre comfortable going without. Amanda MontaÃ±ez, Associate Graphics Editor Iâm thrilled to be vaccinated and able to take my mask off outside. But when I take my two-year-old to any public indoor setting, Iâm still going to worry about exposing him to unmasked people whose vaccination status I cannot know.

Even though young kids donât kamagra uk delivery tend to get very ill from erectile dysfunction treatment, the risk is still there. (And even if my son ended up with a mild or asymptomatic , I would hate for him to spread it to others at his day care.) I will encourage him to wear a maskâand will happily model that behavior by wearing mineâbut as anyone who has met a two-year-old understands, I canât always count on him to follow instructions. So, I would really prefer everyone stay masked indoors until more of the population is fully vaccinated.

Maya Harty, Senior Secretary This question has certainly been making the rounds just among my small circle of friends kamagra uk delivery and family since the restriction was lifted. Personally, I/we trust the science way more than I trust strangers to abide by the honor system and be truthful and forthcoming about their treatment status. Were everyone vaccinated, weâd still have that very slim chance of contracting the kamagra, but with people who are all-out anti-vaxxers or others who arenât inherently anti-vaxxers but are hesitant to be vaccinated, it just increases that small percentage of risk.

One single-mom vaccinated friend of mine has an elderly kamagra uk delivery mom who is also vaccinated, but worries, if she should get sick, who would look after her 14-year-old son. Another has a toddler and also teaches a fitness class at [the gym chain] Equinox. I walked my dogs the last couple of days up in the suburbs unmasked, but still keep my distance.

But in the city, I wanted to keep my mask on running to the kamagra uk delivery deli. I also think the anticipated stigma attached to those who should be masking may tempt unvaccinated folks not to mask (they may reason, âI should be OK since everyone else is vaccinatedâ). Weâre all basically in the camp of.

How can you really know who is fully kamagra uk delivery vaccinated outside your trusted circle?. Michael Lemonick, Chief Opinion Editor As a fully vaccinated person, Iâve loosened up a bit, especially when Iâm outside but even indoors in a restaurant, for example, thatâs mostly empty and/or enforces social distancing. But I always wear a mask in places where itâs required, either indoors or outdoors (even if the CDC says the latter isnât necessary).

Thatâs out kamagra uk delivery of respect for other people and because I donât like acting as though the rules donât apply to me (again, even if those rules are stricter than what the CDC now allows). Plus, as weâve been reminded by experts and commentators, how does anyone else know I really have been vaccinated?. Since they canât, I donât want to be mistaken for someone who has been ignoring mask guidance all along and now knows they can get away with it more easily.

Gary Stix, kamagra uk delivery Senior Editor, Mind/Brain I donât like wearing a mask. Having one on fogs my glasses even in summer. Iâve tried different masks, liquids, tape and all kinds of linings to prevent fogging.

Nothing works kamagra uk delivery. I still canât see. Another reason I donât like wearing masks is I miss the expressions on peopleâs faces, a key part of social interactions.

Even so, I have worn a mask since it was recommended by public health officials kamagra uk delivery last year, and havenât thought twice about it. The situation is a bit confused at the moment as far as what to do. I will continue to wear one if itâs required by a business or if itâs the protocol for a party or other social event.

I will be very glad when it becomes somewhat clearer kamagra uk delivery as to when itâs okay to take off face coverings for good. But I will put one on again without protest if needed to protect others or myself. Iâm not thrilled about mask-wearing as a symbol of social or political identity because it undercuts the usefulness of these aerosol barriers as public-health measures.

Itâs like being for or against Band-Aids or aspirinâwhich side are kamagra uk delivery you on?. Itâs just not helpful. Laura Helmuth, Editor-in-Chief This kamagra is not over.

erectile dysfunction is highly infectious (and apparently more infectious all the time), kamagra uk delivery and airborne and invisible, and itâs spreading in a population that still has too many people who canât or wonât get vaccinated. Iâm fully vaccinated but will wear a mask for the foreseeable future whenever Iâm in enclosed spaces among strangers (grocery stores, mass transit). I donât know if I can trust them, and they shouldnât have to worry about whether they can trust me.

Itâs a small, kamagra uk delivery simple thing that has become a huge political signal, but fundamentally it signals that we care about other people. Tanya Lewis, Senior Editor, Health and Medicine I feel extremely fortunate to be fully vaccinated. The evidence of the treatmentsâ effectiveness is overwhelmingly strong, and being outside lowers that risk even more.

I feel quite safe not wearing a mask outdoors as long as Iâm not in a crowd, and when Iâm indoors with vaccinated family members kamagra uk delivery or friends. But I plan to keep wearing my mask in most public indoor or crowded settings until the number of erectile dysfunction treatment cases here in New York has dwindled much lower and more people have gotten vaccinated. Iâm not that worried that I myself will become infected and get sick (which is a very kamagra tablet online unlikely but nonzero possibility).

Itâs more the fact that, in a public setting, there is no way to know if others have been vaccinated, or to signal to them that you have. Under the new guidelines there is nothing to stop unvaccinated people kamagra uk delivery from going maskless as well, and that could jeopardize the health of immunocompromised people, for whom the treatment may be much less effective, and young children who are not yet eligible to be vaccinated. So, Iâm happy to keep wearing a mask in most public spaces to normalize behavior that protects others.

Even once erectile dysfunction treatment is no longer a big threat, Iâll probably wear a mask in places like airports or airplanes, subways and doctorâs offices, to reduce the spread of other respiratory kamagraes like the flu and colds. Andrea Gawrylewski, Senior Editor, Collections Iâm nearly giddy to be going mask-free outside and in public (though Iâm of course still wearing a mask in places that require kamagra uk delivery it, like inside many stores or on public transit). The science is what gives me the freedom to feel safe.

These treatments prevent nearly 100 percent of hospitalizations and death whether you catch the kamagra outdoors or indoorsâbut your chances of even getting erectile dysfunction treatment once vaccinated are extremely low. The latest research shows cases kamagra uk delivery of transmission of the kamagra by vaccinated people are very rare. And research at this moment shows the treatments are protective against most variants of the kamagra.

All this to say. If youâve kamagra uk delivery been vaccinated, you have protected yourself and the person on the street, even if they are not vaccinated. If they are not vaccinated and unmasked, you will likely not infect them.

This is why vaccination is so important. And unfortunately, people who wonât get vaccinated or refuse to wear a mask likely wonât change their minds because you are kamagra uk delivery still wearing a mask outdoors in public. After the collective trauma the country has lived through itâs no wonder there will be an adjustment period and trepidation.

Since I have donât have kids to worry about, the above facts help me feel so much better (though, children are at low risk for serious cases of erectile dysfunction treatment). Science is my kamagra uk delivery biggest comfort. Dean Visser, Chief News Editor erectile dysfunction treatment has been a historic and planetary-scale disaster, a slow-motion asteroid strike that has killed hundreds of thousands of people and derailed millions of other lives.

Wearing a mask for a while longer seems like a pretty small concession. The overall kamagra uk delivery danger is probably waning, but there are still unknowns about transmission by those vaccinated, and by young children. erectile dysfunction treatment also still presents significant extra risks for some groups.

So, Iâll plan to continue wearing a mask in busy outdoor areas and all indoor public ones, until the data become clearer and the local transmission rate gets closer to zero. Itâs really not a serious kamagra uk delivery inconvenience at all. If this helps protect even one personâa vulnerable family member, a friend, a colleague or a total strangerâitâs worth it.

Andrea Thompson, Associate Editor, Sustainability Because I spent most of the kamagra either pregnant or with a small baby, my own habits around masking and distancing have tended to be extremely cautious. While I was pregnant, my husband handled trips to the grocery store and laundromat to reduce the number of indoor kamagra uk delivery spaces I had to enter. When going to the doctorâs officeâpretty much the only place I went insideâI double-masked using N95s or KN95s.

Although my husband and I are both now fully vaccinated, and my son should have antibodies from breast milk, we are still erring on the side of caution because the baby is so young. There is also the difficult mental shift after months of scrupulous mask wearing kamagra uk delivery when going anywhere outside of our apartment, so it will likely take time for us to feel more comfortable going maskless. Right now, we still bring masks with us when we walk the dog or take the baby out in his stroller.

We may not wear them when there are few or no other people around, but we tend to put them on if the sidewalk gets crowded, or if people we pass are themselves wearing masks. Weâll probably start kamagra uk delivery having the odd beer sitting outside at a bar, but we donât plan to eat or drink indoors anytime soon. And weâll continue to wear masks indoors for the time being.

Clara Moskowitz, Senior Editor, Space and Physics Personally, Iâm thrilled to ditch my mask in situations where itâs allowed and now recommended by the CDC. The first time I could go for a morning jog without my mask on kamagra uk delivery felt like a wonderful freedom. My wife and I are fully vaccinated, as are all our adult family members, and I feel pretty confident in the amazing data that shows the treatments are incredibly effective at protecting us from erectile dysfunction treatment and preventing us from spreading it as well.

I have two small children who are not vaccinated, which definitely changes the calculus, but based on the science we have and statistics on little kids getting sick from the kamagra, Iâm not particularly worried about mine getting erectile dysfunction treatment. Iâm more kamagra uk delivery worried about car accidents and drowning and choking and lots of other threats that really do keep me up at night worrying about their safety. I will be thrilled to get them vaccinated as soon as itâs approved for their ages.

Ultimately, though I completely respect people who still feel nervous without masks, or prefer to keep wearing them for any reason, I am personally ready to take mine off in situations where experts are saying itâs okay. For so long I have been kamagra uk delivery part of the chorus saying, âTrust the science!. Â when it meant wearing masks and following all the CDC guidelines.

I feel the same way now that science and the CDC are telling us itâs safe to take our masks off. Plus, I am so sick kamagra uk delivery of my glasses fogging up all the time!. Josh Fischman, Senior Editor, Medicine and Science Policy I still wear a mask in crowds, even outdoors, because other people have no way of knowing that I am fully vaccinatedâI amâand I donât want to scare them.

I want people to know Iâm trying to keep them protected. If a lot more people in the U.S.

According to kamagra online purchase the buy kamagra online no prescription U.S. Centers for Disease Control and Prevention, itâs safe for us to stop wearing masks in most situations. But itâs not that simple.

Hereâs when, where and why some of us are buy kamagra online no prescription still wearing masksâand when weâre comfortable going without. Amanda MontaÃ±ez, Associate Graphics Editor Iâm thrilled to be vaccinated and able to take my mask off outside. But when I take my two-year-old to any public indoor setting, Iâm still going to worry about exposing him to unmasked people whose vaccination status I cannot know.

Even though young kids donât tend to get buy kamagra online no prescription very ill from erectile dysfunction treatment, the risk is still there. (And even if my son ended up with a mild or asymptomatic , I would hate for him to spread it to others at his day care.) I will encourage him to wear a maskâand will happily model that behavior by wearing mineâbut as anyone who has met a two-year-old understands, I canât always count on him to follow instructions. So, I would really prefer everyone stay masked indoors until more of the population is fully vaccinated.

Maya Harty, buy kamagra online no prescription Senior Secretary This question has certainly been making the rounds just among my small circle of friends and family since the restriction was lifted. Personally, I/we trust the science way more than I trust strangers to abide by the honor system and be truthful and forthcoming about their treatment status. Were everyone vaccinated, weâd still have that very slim chance of contracting the kamagra, but with people who are all-out anti-vaxxers or others who arenât inherently anti-vaxxers but are hesitant to be vaccinated, it just increases that small percentage of risk.

One single-mom vaccinated friend of mine has an elderly mom who is also vaccinated, but worries, if she should get sick, who buy kamagra online no prescription would look after her 14-year-old son. Another has a toddler and also teaches a fitness class at [the gym chain] Equinox. I walked my dogs the last couple of days up in the suburbs unmasked, but still keep my distance.

But in the city, I wanted to buy kamagra online no prescription keep my mask on running to the deli. I also think the anticipated stigma attached to those who should be masking may tempt unvaccinated folks not to mask (they may reason, âI should be OK since everyone else is vaccinatedâ). Weâre all basically in the camp of.

How can buy kamagra online no prescription you really know who is fully vaccinated outside your trusted circle?. Michael Lemonick, Chief Opinion Editor As a fully vaccinated person, Iâve loosened up a bit, especially when Iâm outside but even indoors in a restaurant, for example, thatâs mostly empty and/or enforces social distancing. But I always wear a mask in places where itâs required, either indoors or outdoors (even if the CDC says the latter isnât necessary).

Thatâs out of respect for other people and because I donât like acting as though the rules donât apply to me (again, even if those rules are stricter than what the CDC now buy kamagra online no prescription allows). Plus, as weâve been reminded by experts and commentators, how does anyone else know I really have been vaccinated?. Since they canât, I donât want to be mistaken for someone who has been ignoring mask guidance all along and now knows they can get away with it more easily.

Gary Stix, Senior Editor, Mind/Brain I donât like wearing buy kamagra online no prescription a mask. Having one on fogs my glasses even in summer. Iâve tried different masks, liquids, tape and all kinds of linings to prevent fogging.

Nothing works buy kamagra online no prescription. I still canât see. Another reason I donât like wearing masks is I miss the expressions on peopleâs faces, a key part of social interactions.

Even so, I have worn a mask since it was recommended by public health officials last year, and havenât thought twice about buy kamagra online no prescription it. The situation is a bit confused at the moment as far as what to do. I will continue to wear one if itâs required by a business or if itâs the protocol for a party or other social event.

I will be very glad when it becomes somewhat clearer as to when itâs okay to take buy kamagra online no prescription off face coverings for good. But I will put one on again without protest if needed to protect others or myself. Iâm not thrilled about mask-wearing as a symbol of social or political identity because it undercuts the usefulness of these aerosol barriers as public-health measures.

Itâs like being for or against Band-Aids or aspirinâwhich side are you buy kamagra online no prescription on?. Itâs just not helpful. Laura Helmuth, Editor-in-Chief This kamagra is not over.

erectile dysfunction is highly infectious (and apparently more infectious all the time), and airborne and invisible, and itâs spreading in a population that still has too many people who buy kamagra online no prescription canât or wonât get vaccinated. Iâm fully vaccinated but will wear a mask for the foreseeable future whenever Iâm in enclosed spaces among strangers (grocery stores, mass transit). I donât know if I can trust them, and they shouldnât have to worry about whether they can trust me.

Itâs a small, simple thing that has become a huge political signal, but fundamentally it signals that we care about buy kamagra online no prescription other people. Tanya Lewis, Senior Editor, Health and Medicine I feel extremely fortunate to be fully vaccinated. The evidence of the treatmentsâ effectiveness is overwhelmingly strong, and being outside lowers that risk even more.

I feel quite safe not wearing a mask outdoors as long as buy kamagra online no prescription Iâm not in a crowd, and when Iâm indoors with vaccinated family members or friends. But I plan to keep wearing my mask in most public indoor or crowded settings until the number of erectile dysfunction treatment cases here in New York has dwindled much lower and more people have gotten vaccinated. Iâm not that worried that I myself will become infected and get sick this link (which is a very unlikely but nonzero possibility).

Itâs more the fact that, in a public setting, there is no way to know if others have been vaccinated, or to signal to them that you have. Under the new guidelines there is nothing to stop unvaccinated people from going maskless as well, and that could jeopardize the health of immunocompromised people, for whom the buy kamagra online no prescription treatment may be much less effective, and young children who are not yet eligible to be vaccinated. So, Iâm happy to keep wearing a mask in most public spaces to normalize behavior that protects others.

Even once erectile dysfunction treatment is no longer a big threat, Iâll probably wear a mask in places like airports or airplanes, subways and doctorâs offices, to reduce the spread of other respiratory kamagraes like the flu and colds. Andrea Gawrylewski, Senior Editor, Collections Iâm nearly giddy to be going mask-free outside and in public (though Iâm of course still wearing a mask in places that require it, like inside many stores or buy kamagra online no prescription on public transit). The science is what gives me the freedom to feel safe.

These treatments prevent nearly 100 percent of hospitalizations and death whether you catch the kamagra outdoors or indoorsâbut your chances of even getting erectile dysfunction treatment once vaccinated are extremely low. The latest research shows cases of transmission of the kamagra by vaccinated people are very rare buy kamagra online no prescription. And research at this moment shows the treatments are protective against most variants of the kamagra.

All this to say. If youâve been vaccinated, buy kamagra online no prescription you have protected yourself and the person on the street, even if they are not vaccinated. If they are not vaccinated and unmasked, you will likely not infect them.

This is why vaccination is so important. And unfortunately, people who wonât get vaccinated or refuse to wear a mask likely wonât change their minds buy kamagra online no prescription because you are still wearing a mask outdoors in public. After the collective trauma the country has lived through itâs no wonder there will be an adjustment period and trepidation.

Since I have donât have kids to worry about, the above facts help me feel so much better (though, children are at low risk for serious cases of erectile dysfunction treatment). Science is my buy kamagra online no prescription biggest comfort. Dean Visser, Chief News Editor erectile dysfunction treatment has been a historic and planetary-scale disaster, a slow-motion asteroid strike that has killed hundreds of thousands of people and derailed millions of other lives.

Wearing a mask for a while longer seems like a pretty small concession. The overall danger is probably waning, but there are still buy kamagra online no prescription unknowns about transmission by those vaccinated, and by young children. erectile dysfunction treatment also still presents significant extra risks for some groups.

So, Iâll plan to continue wearing a mask in busy outdoor areas and all indoor public ones, until the data become clearer and the local transmission rate gets closer to zero. Itâs really not buy kamagra online no prescription a serious inconvenience at all. If this helps protect even one personâa vulnerable family member, a friend, a colleague or a total strangerâitâs worth it.

Andrea Thompson, Associate Editor, Sustainability Because I spent most of the kamagra either pregnant or with a small baby, my own habits around masking and distancing have tended to be extremely cautious. While I was pregnant, my husband handled trips to the grocery store buy kamagra online no prescription and laundromat to reduce the number of indoor spaces I had to enter. When going to the doctorâs officeâpretty much the only place I went insideâI double-masked using N95s or KN95s.

Although my husband and I are both now fully vaccinated, and my son should have antibodies from breast milk, we are still erring on the side of caution because the baby is so young. There is also the difficult mental shift after months buy kamagra online no prescription of scrupulous mask wearing when going anywhere outside of our apartment, so it will likely take time for us to feel more comfortable going maskless. Right now, we still bring masks with us when we walk the dog or take the baby out in his stroller.

We may not wear them when there are few or no other people around, but we tend to put them on if the sidewalk gets crowded, or if people we pass are themselves wearing masks. Weâll probably start having the odd beer sitting outside buy kamagra online no prescription at a bar, but we donât plan to eat or drink indoors anytime soon. And weâll continue to wear masks indoors for the time being.

Clara Moskowitz, Senior Editor, Space and Physics Personally, Iâm thrilled to ditch my mask in situations where itâs allowed and now recommended by the CDC. The first time I could go for a morning jog without my mask on felt like a wonderful buy kamagra online no prescription freedom. My wife and I are fully vaccinated, as are all our adult family members, and I feel pretty confident in the amazing data that shows the treatments are incredibly effective at protecting us from erectile dysfunction treatment and preventing us from spreading it as well.

I have two small children who are not vaccinated, which definitely changes the calculus, but based on the science we have and statistics on little kids getting sick from the kamagra, Iâm not particularly worried about mine getting erectile dysfunction treatment. Iâm more worried about car accidents and drowning and choking and lots of other threats that really do keep me buy kamagra online no prescription up at night worrying about their safety. I will be thrilled to get them vaccinated as soon as itâs approved for their ages.

Ultimately, though I completely respect people who still feel nervous without masks, or prefer to keep wearing them for any reason, I am personally ready to take mine off in situations where experts are saying itâs okay. For so long I have been part buy kamagra online no prescription of the chorus saying, âTrust the science!. Â when it meant wearing masks and following all the CDC guidelines.

I feel the same way now that science and the CDC are telling us itâs safe to take our masks off. Plus, I buy kamagra online no prescription am so sick of my glasses fogging up all the time!. Josh Fischman, Senior Editor, Medicine and Science Policy I still wear a mask in crowds, even outdoors, because other people have no way of knowing that I am fully vaccinatedâI amâand I donât want to scare them.

I want people to know Iâm trying to keep them protected. If a lot more people in the U.S.

What should I tell my health care provider before I take Kamagra?

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

eye or vision problems, including a rare inherited eye disease called retinitis pigmentosa
heart disease, angina, high or low blood pressure, a history of heart attack, or other heart problems
kidney disease
liver disease
stroke
an unusual or allergic reaction to sildenafil, other medicines, foods, dyes, or preservatives

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By Dennis Thompson HealthDay ReporterFRIDAY, June 4, 2021 buy kamagra over the counter (HealthDay News) -- A twice-daily pill can dramatically reduce the risk of breast cancer recurrence in women who are genetically prone to the disease, researchers report.The pill â olaparib (Lynparza) â works by blocking a natural enzyme called PARP that normally fixes DNA damage in healthy cells, but in these women actually promotes the growth of cancerous cells.Early high-risk breast cancer patients taking olaparib for a year had a 42% reduced risk of cancer recurrence or death compared to those given a placebo, said lead researcher Dr. Andrew Tutt, director of the Breast Cancer Now Toby Robins Research Center at the Institute of Cancer Research in London."Patients who received olaparib after surgery and chemotherapy were more likely to be alive without cancer and avoid metastasis than the patients who received placebo," he said.These results were presented Thursday at an online meeting of the American Society of Clinical Oncology. Findings presented at meetings should be considered preliminary until published in a peer-reviewed journal.Continued buy kamagra over the counter Olaparib already is approved to treat patients with metastatic breast cancer who have mutations in the BRCA1 or BRCA2 genes.

These genes typically suppress cancer, but mutations actually increase cancer risk for some people.About 5% of breast cancers are associated with BRCA1 or BRCA2 mutations, Tutt noted.Breast cancers that occur due to BRCA1 or BRCA2 mutations rely on the PARP enzyme to remain alive, grow and divide. Drugs called PARP inhibitors take advantage of this fact to block the enzyme and prevent the cancer from coming back.In this clinical trial, more than 1,800 patients with stage 2 to 3 breast cancers treated with surgery and chemotherapy were randomly assigned to take either 300 milligrams of olaparib or buy kamagra over the counter a placebo twice a day for a year.Patients on olaparib had a three-year invasive disease-free survival rate â no recurring breast cancer or other new cancers â of about 86%, compared with 77% for those taking a placebo, the findings showed.Dr. Amy Tiersten is a professor of hematology and medical oncology with the Icahn School of Medicine at Mount Sinai in New York City.

She said, "We have already known for some buy kamagra over the counter time that PARP inhibitors have activity in patients with metastatic breast cancer, but this is the first time we have seen efficacy in the early-stage setting. This study showed a substantial reduction in the risk of recurrence in this population and, therefore, the potential to cure more patients with BRCA-associated early breast cancer."Continued Side effects were consistent with previous studies of olaparib, Tutt said. The most serious common buy kamagra over the counter side effects included anemia, lower white blood cell counts and fatigue.Tutt said the study shows the importance of performing genetic testing on cancer patients, to look for traits and mutations that could be exploited to improve treatment and survival."There certainly is a case for a mindset change in the community around where we use germline genetic testing," Tutt said.

"We've classically thought about it as something to do to determine someone's risk of the disease and inform perhaps other members of their family if they've already had it."Instead of just assessing risk, this genetic information can be used to save lives, Tutt noted.Dr. Lori Pierce, president of the American Society of Clinical Oncology, agreed."This further highlights the importance of genetic testing in appropriate patients so that we know which patients buy kamagra over the counter will benefit from this therapy," Pierce said. "I think it may even open the door to additional trials of adjuvant PARP inhibitors for other BRCA1- and 2-associated cancers."Continued Olaparib can be a pricey drug.

The cost for a supply of sixty 100-milligram tablets is a little more than $7,500, according to Drugs.com buy kamagra over the counter. More information Dana-Farber Cancer Institute has more about PARP inhibitors.SOURCES. Andrew Tutt, buy kamagra over the counter MBChB, PhD, director, Breast Cancer Now Toby Robins Research Center, Institute of Cancer Research, London.

Lori Pierce, MD, president, American Society of Clinical Oncology, Alexandria, Va.. Amy Tiersten, MD, professor, hematology and medical oncology, Icahn School of buy kamagra over the counter Medicine at Mount Sinai, New York City. Presentation, American Society of Clinical Oncology, June 3, 2021, onlineAt Boston University, a team of researchers is working to better understand how language and speech is processed in the brain, and how to best rehabilitate people who have lost their ability to communicate due to brain damage caused by a stroke, trauma, or another type of brain injury.

This type of language loss is called aphasia, a long-term neurological buy kamagra over the counter disorder caused by damage to the part of the brain responsible for language production and processing that impacts over a million people in the US."It's a huge problem," says Swathi Kiran, director of BU's Aphasia Research Lab, and College of Health &. Rehabilitation Sciences. Sargent College associate dean for research and James buy kamagra over the counter and Cecilia Tse Ying Professor in Neurorehabilitation.

"It's something our lab is working to tackle at multiple levels."For the last decade, Kiran and her team have studied the brain to see how it changes as people's language skills improve with speech therapy. More recently, buy kamagra over the counter they've developed new methods to predict a person's ability to improve even before they start therapy. In a new paper published in Scientific Reports, Kiran and collaborators at BU and the University of Texas at Austin report they can predict language recovery in Hispanic patients who speak both English and Spanish fluently -- a group of aphasia patients particularly at risk of long-term language loss -- using sophisticated computer models of the brain.

They say the breakthrough could be a game changer for the field of speech therapy and for stroke survivors impacted by aphasia."This [paper] uses computational modeling buy kamagra over the counter to predict rehabilitation outcomes in a population of neurological disorders that are really underserved," Kiran says. In the US, Hispanic stroke survivors are nearly two times less likely to be insured than all other racial or ethnic groups, Kiran says, and therefore they experience greater difficulties in accessing language rehabilitation. On top of that, oftentimes speech therapy is only available in one language, buy kamagra over the counter even though patients may speak multiple languages at home, making it difficult for clinicians to prioritize which language a patient should receive therapy in."This work started with the question, 'If someone had a stroke in this country and [the patient] speaks two languages, which language should they receive therapy in?.

'" says Kiran. "Are they more likely to improve buy kamagra over the counter if they receive therapy in English?. Or in Spanish?.

"This first-of-its-kind technology addresses that need by using sophisticated neural network models that simulate the brain of a bilingual person that is language impaired, and their brain's response to therapy in English and buy kamagra over the counter Spanish. The model can then identify the optimal language to target during treatment, and predict the outcome after therapy to forecast how well a person will recover their language skills. They found that the models predicted treatment effects accurately in the treated language, meaning these computational tools could guide healthcare providers to prescribe the best possible rehabilitation plan."There is more recognition with the kamagra that people from different populations -- whether [those be differences of] race, ethnicity, different disability, socioeconomic status -- don't receive the same level of [healthcare]," says Kiran.

"The problem we're trying to solve here is, for our patients, buy kamagra over the counter health disparities at their worst. They are from a population that, the data shows, does not have great access to care, and they have communication problems [due to aphasia]."As part of this work, the team is examining how recovery in one language impacts recovery of the other -- will learning the word "dog" in English lead to a patient recalling the word "perro," the word for dog in Spanish?. "If you're bilingual you may go back and forth between languages, and what we're trying to do [in our lab] is use that as a therapy piece," says Kiran.Clinical trials using this technology are already underway, which will soon buy kamagra over the counter provide an even clearer picture of how the models can potentially be implemented in hospital and clinical settings."We are trying to develop effective therapy programs, but we also try to deal with the patient as a whole," Kiran says.

"This is why we care deeply about these health disparities and the patient's overall well-being." Story Source. Materials provided by buy kamagra over the counter Boston University. Original written by Jessica Colarossi.

Note. Content may be edited for style and length.New research from MSU shows that an infant's gut microbiome could contain clues to help monitor and support healthy neurological developmentWhy do some babies react to perceived danger more than others?. According to new research from Michigan State University and the University of North Carolina, Chapel Hill, part of the answer may be found in a surprising place.

An infant's digestive system.The human digestive system is home to a vast community of microorganisms known as the gut microbiome. The MSU-UNC research team discovered that the gut microbiome was different in infants with strong fear responses and infants with milder reactions.These fear responses -- how someone reacts to a scary situation -- in early life can be indicators of future mental health. And there is growing evidence tying neurological well-being to the microbiome in the gut.The new findings suggest that the gut microbiome could one day provide researchers and physicians with a new tool to monitor and support healthy neurological development."This early developmental period is a time of tremendous opportunity for promoting healthy brain development," said MSU's Rebecca Knickmeyer, leader of the new study published June 2 in the journal Nature Communications.

Children should be aware of threats in their environment and be ready to respond to them" said Knickmeyer, who also works in MSU's Institute for Quantitative Health Science and Engineering, or IQ. "But if they can't dampen that response when they're safe, they may be at heightened risk to develop anxiety and depression later on in life."On the other end of the response spectrum, children with exceptionally muted fear responses may go on to develop callous, unemotional traits associated with antisocial behavior, Knickmeyer said.To determine whether the gut microbiome was connected to fear response in humans, Knickmeyer and her co-workers designed a pilot study with about 30 infants. The researchers selected the cohort carefully to keep as many factors impacting the gut microbiome as consistent as possible.

For example, all of the children were breastfed and none was on antibiotics.The researchers then characterized the children's microbiome by analyzing stool samples and assessed a child's fear response using a simple test. Observing how a child reacted to someone entering the room while wearing a Halloween mask."We really wanted the experience to be enjoyable for both the kids and their parents. The parents were there the whole time and they could jump in whenever they wanted," Knickmeyer said.

"These are really the kinds of experiences infants would have in their everyday lives."Compiling all the data, the researchers saw significant associations between specific features of the gut microbiome and the strength of infant fear responses. advertisement For example, children with uneven microbiomes at 1 month of age were more fearful at 1 year of age. Uneven microbiomes are dominated by a small set of bacteria, whereas even microbiomes are more balanced.The researchers also discovered that the content of the microbial community at 1 year of age related to fear responses.

Compared with less fearful children, infants with heightened responses had more of some types of bacteria and less of others.The team, however, did not observe a connection between the children's gut microbiome and how the children reacted to strangers who weren't wearing masks. Knickmeyer said this is likely due to the different parts of the brain involved with processing potentially frightening situations."With strangers, there is a social element. So children may have a social wariness, but they don't see strangers as immediate threats," Knickmeyer said.

That's one of many interesting possibilities uncovered by this new study, which the team is currently working to replicate. Knickmeyer is also preparing to start up new lines of inquiry with new collaborations at IQ, asking new questions that she's excited to answer."We have a great opportunity to support neurological health early on," she said. "Our long-term goal is that we'll learn what we can do to foster healthy growth and development.".

By Dennis Thompson HealthDay ReporterFRIDAY, June 4, 2021 (HealthDay News) -- A twice-daily pill can dramatically reduce the risk of breast cancer recurrence in women who are genetically prone to the disease, researchers report.The pill â olaparib (Lynparza) â works by blocking a natural enzyme called PARP that normally fixes DNA damage in healthy cells, but in these women actually promotes the growth of cancerous cells.Early high-risk breast cancer patients taking olaparib for a year had a 42% reduced risk of buy kamagra online no prescription can i buy kamagra cancer recurrence or death compared to those given a placebo, said lead researcher Dr. Andrew Tutt, director of the Breast Cancer Now Toby Robins Research Center at the Institute of Cancer Research in London."Patients who received olaparib after surgery and chemotherapy were more likely to be alive without cancer and avoid metastasis than the patients who received placebo," he said.These results were presented Thursday at an online meeting of the American Society of Clinical Oncology. Findings presented at meetings should be considered preliminary until published buy kamagra online no prescription in a peer-reviewed journal.Continued Olaparib already is approved to treat patients with metastatic breast cancer who have mutations in the BRCA1 or BRCA2 genes. These genes typically suppress cancer, but mutations actually increase cancer risk for some people.About 5% of breast cancers are associated with BRCA1 or BRCA2 mutations, Tutt noted.Breast cancers that occur due to BRCA1 or BRCA2 mutations rely on the PARP enzyme to remain alive, grow and divide. Drugs called PARP inhibitors take advantage of this fact to block the enzyme and prevent the cancer from coming back.In this clinical trial, more than 1,800 patients with stage 2 to 3 breast cancers treated with surgery and chemotherapy were randomly assigned to take either 300 milligrams of olaparib or a placebo twice a day for a year.Patients on olaparib had a three-year invasive disease-free survival rate â no recurring breast cancer or other new cancers â of about 86%, compared with 77% for those taking buy kamagra online no prescription a placebo, the findings showed.Dr.

Amy Tiersten is a professor of hematology and medical oncology with the Icahn School of Medicine at Mount Sinai in New York City. She said, "We have already known for some time that PARP inhibitors have activity in patients with metastatic breast cancer, but this buy kamagra online no prescription is the first time we have seen efficacy in the early-stage setting. This study showed a substantial reduction in the risk of recurrence in this population and, therefore, the potential to cure more patients with BRCA-associated early breast cancer."Continued Side effects were consistent with previous studies of olaparib, Tutt said. The most serious common side effects included anemia, lower white blood cell counts and fatigue.Tutt said the study shows the importance of performing genetic testing on cancer patients, to look for traits and mutations that could be exploited to improve treatment and survival."There certainly is a case buy kamagra online no prescription for a mindset change in the community around where we use germline genetic testing," Tutt said. "We've classically thought about it as something to do to determine someone's risk of the disease and inform perhaps other members of their family if they've already had it."Instead of just assessing risk, this genetic information can be used to save lives, Tutt noted.Dr.

Lori Pierce, president of the American Society of Clinical Oncology, agreed."This further highlights the importance of genetic testing in appropriate patients buy kamagra online no prescription so that we know which patients will benefit from this therapy," Pierce said. "I think it may even open the door to additional trials of adjuvant PARP inhibitors for other BRCA1- and 2-associated cancers."Continued Olaparib can be a pricey drug. The cost for a supply of sixty 100-milligram tablets is a little buy kamagra online no prescription more than $7,500, according to Drugs.com. More information Dana-Farber Cancer Institute has more about PARP inhibitors.SOURCES. Andrew Tutt, MBChB, PhD, director, Breast Cancer Now Toby Robins Research Center, Institute of Cancer buy kamagra online no prescription Research, London.

Lori Pierce, MD, president, American Society of Clinical Oncology, Alexandria, Va.. Amy Tiersten, MD, professor, hematology and medical oncology, Icahn School of Medicine at Mount Sinai, New York buy kamagra online no prescription City. Presentation, American Society of Clinical Oncology, June 3, 2021, onlineAt Boston University, a team of researchers is working to better understand how language and speech is processed in the brain, and how to best rehabilitate people who have lost their ability to communicate due to brain damage caused by a stroke, trauma, or another type of brain injury. This type of language loss is called aphasia, a long-term neurological disorder caused by damage to the part of the brain responsible for language production and processing that impacts over a million people in the US."It's a buy kamagra online no prescription huge problem," says Swathi Kiran, director of BU's Aphasia Research Lab, and College of Health &. Rehabilitation Sciences.

Sargent College associate dean for research and James and Cecilia buy kamagra online no prescription Tse Ying Professor in Neurorehabilitation. "It's something our lab is working to tackle at multiple levels."For the last decade, Kiran and her team have studied the brain to see how it changes as people's language skills improve with speech therapy. More recently, they've buy kamagra online no prescription developed new methods to predict a person's ability to improve even before they start therapy. In a new paper published in Scientific Reports, Kiran and collaborators at BU and the University of Texas at Austin report they can predict language recovery in Hispanic patients who speak both English and Spanish fluently -- a group of aphasia patients particularly at risk of long-term language loss -- using sophisticated computer models of the brain. They say the breakthrough could be a game buy kamagra online no prescription changer for the field of speech therapy and for stroke survivors impacted by aphasia."This [paper] uses computational modeling to predict rehabilitation outcomes in a population of neurological disorders that are really underserved," Kiran says.

In the US, Hispanic stroke survivors are nearly two times less likely to be insured than all other racial or ethnic groups, Kiran says, and therefore they experience greater difficulties in accessing language rehabilitation. On top of that, oftentimes speech therapy is only available in one language, even though patients may buy kamagra online no prescription speak multiple languages at home, making it difficult for clinicians to prioritize which language a patient should receive therapy in."This work started with the question, 'If someone had a stroke in this country and [the patient] speaks two languages, which language should they receive therapy in?. '" says Kiran. "Are they more likely to improve buy kamagra online no prescription if they receive therapy in English?. Or in Spanish?.

"This first-of-its-kind buy kamagra online no prescription technology addresses that need by using sophisticated neural network models that simulate the brain of a bilingual person that is language impaired, and their brain's response to therapy in English and Spanish. The model can then identify the optimal language to target during treatment, and predict the outcome after therapy to forecast how well a person will recover their language skills. They found that the models predicted treatment effects accurately in the treated language, meaning these computational tools could guide healthcare providers to prescribe the best possible rehabilitation plan."There is more recognition with the kamagra that people from different populations -- whether [those be differences of] race, ethnicity, different disability, socioeconomic status -- don't receive the same level of [healthcare]," says Kiran. "The problem we're trying to solve here buy kamagra without prescription is, for our buy kamagra online no prescription patients, health disparities at their worst. They are from a population that, the data shows, does not have great access to care, and they have communication problems [due to aphasia]."As part of this work, the team is examining how recovery in one language impacts recovery of the other -- will learning the word "dog" in English lead to a patient recalling the word "perro," the word for dog in Spanish?.

"If you're bilingual you may go back and forth between languages, and what we're trying to do [in our lab] is use that as a therapy piece," says Kiran.Clinical trials using this technology are already underway, which will buy kamagra online no prescription soon provide an even clearer picture of how the models can potentially be implemented in hospital and clinical settings."We are trying to develop effective therapy programs, but we also try to deal with the patient as a whole," Kiran says. "This is why we care deeply about these health disparities and the patient's overall well-being." Story Source. Materials provided buy kamagra online no prescription by Boston University. Original written by Jessica Colarossi. Note.

Content may be edited for style and length.New research from MSU shows that an infant's gut microbiome could contain clues to help monitor and support healthy neurological developmentWhy do some babies react to perceived danger more than others?. According to new research from Michigan State University and the University of North Carolina, Chapel Hill, part of the answer may be found in a surprising place. An infant's digestive system.The human digestive system is home to a vast community of microorganisms known as the gut microbiome. The MSU-UNC research team discovered that the gut microbiome was different in infants with strong fear responses and infants with milder reactions.These fear responses -- how someone reacts to a scary situation -- in early life can be indicators of future mental health. And there is growing evidence tying neurological well-being to the microbiome in the gut.The new findings suggest that the gut microbiome could one day provide researchers and physicians with a new tool to monitor and support healthy neurological development."This early developmental period is a time of tremendous opportunity for promoting healthy brain development," said MSU's Rebecca Knickmeyer, leader of the new study published June 2 in the journal Nature Communications.

"The microbiome is an exciting new target that can be potentially used for that."Studies of this connection and its role in fear response in animals led Knickmeyer, an associate professor in the College of Human Medicine's Department of Pediatrics and Human Development, and her team to look for something similar in humans. And studying how humans, especially young children, handle fear is important because it can help forecast mental health in some cases. advertisement "Fear reactions are a normal part of child development. Children should be aware of threats in their environment and be ready to respond to them" said Knickmeyer, who also works in MSU's Institute for Quantitative Health Science and Engineering, or IQ. "But if they can't dampen that response when they're safe, they may be at heightened risk to develop anxiety and depression later on in life."On the other end of the response spectrum, children with exceptionally muted fear responses may go on to develop callous, unemotional traits associated with antisocial behavior, Knickmeyer said.To determine whether the gut microbiome was connected to fear response in humans, Knickmeyer and her co-workers designed a pilot study with about 30 infants.

The researchers selected the cohort carefully to keep as many factors impacting the gut microbiome as consistent as possible. For example, all of the children were breastfed and none was on antibiotics.The researchers then characterized the children's microbiome by analyzing stool samples and assessed a child's fear response using a simple test. Observing how a child reacted to someone entering the room while wearing a Halloween mask."We really wanted the experience to be enjoyable for both the kids and their parents. The parents were there the whole time and they could jump in whenever they wanted," Knickmeyer said. "These are really the kinds of experiences infants would have in their everyday lives."Compiling all the data, the researchers saw significant associations between specific features of the gut microbiome and the strength of infant fear responses.

advertisement For example, children with uneven microbiomes at 1 month of age were more fearful at 1 year of age. Uneven microbiomes are dominated by a small set of bacteria, whereas even microbiomes are more balanced.The researchers also discovered that the content of the microbial community at 1 year of age related to fear responses. Compared with less fearful children, infants with heightened responses had more of some types of bacteria and less of others.The team, however, did not observe a connection between the children's gut microbiome and how the children reacted to strangers who weren't wearing masks. Knickmeyer said this is likely due to the different parts of the brain involved with processing potentially frightening situations."With strangers, there is a social element. So children may have a social wariness, but they don't see strangers as immediate threats," Knickmeyer said.

"When children see a mask, they don't see it as social. It goes into that quick-and-dirty assessment part of the brain."As part of the study, the team also imaged the children's brains using MRI technology. They found that the content of the microbial community at 1 year was associated with the size of the amygdala, which is part of the brain involved in making quick decisions about potential threats.Connecting the dots suggests that the microbiome may influence how the amygdala develops and operates. That's one of many interesting possibilities uncovered by this new study, which the team is currently working to replicate. Knickmeyer is also preparing to start up new lines of inquiry with new collaborations at IQ, asking new questions that she's excited to answer."We have a great opportunity to support neurological health early on," she said.

"Our long-term goal is that we'll learn what we can do to foster healthy growth and development.".

Kamagra oral jelly what is it used for

AbstractBrazil is Who can buy levitra currently home to the kamagra oral jelly what is it used for largest Japanese population outside of Japan. In Brazil today, Japanese-Brazilians are considered to be successful members of Brazilian society. This was not always the case, however, and Japanese immigrants to Brazil endured kamagra oral jelly what is it used for much hardship to attain their current level of prestige.

This essay explores this communityâs trajectory towards the formation of the Japanese-Brazilian identity and the issues of mental health that arise in this immigrant community. Through the analysis of Japanese-Brazilian novels, TV shows, film and public health studies, I seek to disentangle the themes of gender and modernisation, and how these themes concurrently grapple with Japanese-Brazilian mental health issues. These fictional narratives provide a lens into the experience of the Japanese-Brazilian community that is unavailable in traditional medical studies about their mental health.filmliterature and medicinemental health caregender studiesmedical humanitiesData availability statementData kamagra oral jelly what is it used for are available in a public, open access repository.Introduction and philosophical backgroundWork in the medical humanities has noted the importance of the âmedical gazeâ and how it may âseeâ the patient in ways which are specific, while possessing broad significance, in relation to developing medical knowledge.

To diagnosis. And to the social position of the medical profession.1 Some authors have emphasised that vision is a distinctive modality of perception which merits its own consideration, and which may have a particular role to play in medical education and understanding.2 3 The clothing we wear kamagra oral jelly what is it used for has a strong impact on how we are perceived. For example, commentary in this journal on the âwhite coatâ observes that while it may rob the medical doctor of individuality, it nonetheless grants an elevated status4.

In contrast, the patient hospital gown may rob patients of individuality in a way that stigmatises them,5 reducing their status in the ward, and ultimately dehumanises them, in conflict with the humanistic approaches seen as central to the best practice in the care of older patients, and particularly those living with dementia.6The broad context of our concern is the visibility of patients and their needs. We draw on observations made during an ethnographic study of the everyday care of people living with dementia within acute hospital wards, to consider how patientsâ clothing may impact on the way they kamagra oral jelly what is it used for were perceived by themselves and by others. Hence, we draw on this ethnography to contribute to discussion of the âmedical gazeâ in a specific and informative context.The acute setting illustrates a situation in which there are great many biomedical, technical, recording, and timetabled routine task-oriented demands, organised and delivered by different staff members, together with demands for care and attention to particular individuals and an awareness of their needs.

Within this ward setting, we focus on patients who are living with dementia, since this group may be particularly vulnerable to a dehumanising gaze.6 We frame our discussion within the broader context of the general philosophical question of how we acquire knowledge of different types, and the moral consequences of this, particularly knowledge through visual perception.Debates throughout the history of philosophy raise questions about the nature and sources of our knowledge. Contrasts are often drawn between more reliable or less kamagra oral jelly what is it used for reliable knowledge. And between knowledge that is more technical or âobjectiveâ, and knowledge that is more emotionally based or more âsubjectiveâ.

A frequent point of discussion is the reliability and characteristics of perception as kamagra oral jelly what is it used for a source of knowledge. This epistemological discussion is mostly focused on vision, indicating its particular importance as a mode of perception to humans.7Likewise, in ethics, there is discussion of the origin of our moral knowledge and the particular role of perception.8 There is frequent recognition that the observer has some significant role in acquiring moral knowledge. Attention to qualities of the moral observer is not in itself a denial of moral reality.

Indeed, it kamagra oral jelly what is it used for is the very essence of an ethical response to the world to recognise the deep reality of others as separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways. The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine.

Work that examines different ways of processing information, and of interacting with and being in the world, can be found in kamagra oral jelly what is it used for Iain McGilchristâs The Master and His Emissary,10 where he draws on neurological discoveries and applies his ideas to the development of human culture. McGilchrist has recently expanded on the relevance of understanding two different approaches to knowledge for the practice of medicine.11 He argues that task-oriented perception, and a wider, more emotionally attuned awareness of the environment are necessary partners, but may in some circumstances compete, with the competitive edge often being given to the narrower, task-based attention.There has been critique of McGilchristâs arguments as well as much support. We find his work a useful framework for understanding important debates in the ethics of medicine and of nursing about relationships of staff kamagra oral jelly what is it used for to patients.

In particular, it helps to illuminate the consequences of patientsâ dress and personal appearance for how they are seen and treated.Dementia and personal appearanceOur work focuses on patients living with dementia admitted to acute hospital wards. Here, they are a large group, present alongside older patients unaffected by dementia, as well as younger patients. This mixed population provides a useful setting to consider the impact kamagra oral jelly what is it used for of personal appearance on different patient groups.The role of appearance in the presentation of the self has been explored extensively by TseÃ«lon,12 13 drawing on Goffmanâs work on stigma5 and the presentation of the self14 using interactionist approaches.

Drawing on the experiences on women in the UK, TseÃ«lon argues Goffmanâs interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it. TseÃ«lon suggests that understandings in this area, in the role appearance and clothing have in the presentation of the self, have been restricted by the perceived trivialities of the topic and limited to the field of fashion studies.15The personal appearance of older patients, and patients living with dementia in particular, has, more recently, been shown to be worthy of attention and of particular significance. Older people are often assumed to be left out of fashion, yet a concern with appearance remains.16 17 Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or dementia, and so conversely, attention to appearance kamagra oral jelly what is it used for is one way of combatting the stigma associated with dementia.

Our observations lend support to Kontosâ hypothesis.Much of this previous work has considered clothing in the everyday life of people living with dementia in the context of community or long-term residential care.18 Here, we look at the visual impact of clothing and appearance in the different setting of the hospital ward and consider the consequent implications for patient care. This setting enables us to consider how the short-term and unfamiliar environments of the acute ward, together with the contrast between personal and institutional attire, impact on the perception of the patient by self and by others.There is a body of literature that examines the work of restoring the appearance of residents within long-term community kamagra oral jelly what is it used for care settings, for instance Ward et alâs work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-TÃ¤hkÃ¤vuori25 examines the usage of garments designed for long-term care settings, exploring the conflict between clothing used to prevent undressing or facilitate the delivery of care, and the distress such clothing can cause, being powerfully symbolic of lower social status and associated with reduced autonomy.26 27Within this literature, there has also been a significant focus on the role of clothing, appearance and the tasks of personal care surrounding it, on the older female body. A corpus of feminist literature has examined the ageing process and the use of clothing to conceal ageing, the presentation of a younger self, or a âcertainâ age28 It argues that once the ability to conceal the ageing process through clothing and grooming has been lost, the aged person must instead conceal themselves, dressing to hide themselves and becoming invisible in the process.29 This paper will explore how institutional clothing within hospital wards affects both the male and female body, the presentation of the ageing body and its role in reinforcing the invisibility of older people, at a time when they are paradoxically most visible, unclothed and undressed, or wearing institutional clothing within the hospital ward.Institutional clothing is designed and used to fulfil a practical function.

Its use may therefore perhaps incline us towards a âtask-basedâ mode of attention, which as McGilchrist argues,10 while having a vital place in our understanding of the world, may on occasion interfere with the forms of attention that may be needed to deliver good person-oriented care responsive to individual needs.MethodsEthnography involves the in-depth study of peopleâs actions and accounts within their natural everyday setting, collecting relatively unstructured data from a range of sources.30 Importantly, it can take into account the perspectives of patients, carers and hospital staff.31 Our approach to ethnography is informed by the symbolic interactionist research tradition, which aims to provide an interpretive understanding of the social world, with an emphasis on interaction, focusing on understanding how action and meaning are constructed within a setting.32 The value of this approach is the depth of understanding and theory generation it can provide.33The goal of ethnography is to identify social processes within the data. There are multiple complex and nuanced interactions within these clinical settings that are capable of âcommunicating many messages at once, even of subverting on one level what it appears to be âsayingâ on anotherâ.34 Thus, it is kamagra oral jelly what is it used for important to observe interaction and performance. How everyday care work is organised and delivered.

By obtaining observational data from within each institution on the everyday work of kamagra oral jelly what is it used for hospital wards, their family carers and the nursing and healthcare assistants (HCAs) who carry out this work, we can explore the ways in which hospital organisation, procedures and everyday care impact on care during a hospital admission. It remedies a common weakness in many qualitative studies, that what people say in interviews may differ from what they do or their private justifications to others.35Data collection (observations and interviews) and analysis were informed by the analytic tradition of grounded theory.36 There was no prior hypothesis testing and we used the constant comparative method and theoretical sampling whereby data collection (observation and interview data) and analysis are inter-related,36 37 and are carried out concurrently.38 39 The flexible nature of this approach is important, because it can allow us to increase the âanalytic incisivenessâ35 of the study. Preliminary analysis of data collected from individual sites informed the focus of later stages of sampling, data collection and analysis in other sites.Thus, sampling requires a flexible, pragmatic approach and purposive and maximum variation sampling (theoretical sampling) was used.

This included five hospitals selected to represent a kamagra oral jelly what is it used for range of hospitals types, geographies and socioeconomic catchments. Five hospitals were purposefully selected to represent a range of hospitals types. Two large university teaching hospitals, two medium-sized general hospitals and one smaller general hospital.

This included one urban, two inner city and two hospitals covering a mix of rural and kamagra oral jelly what is it used for suburban catchment areas, all situated within England and Wales.These sites represented a range of expertise and interventions in caring for people with dementia, from no formal expertise to the deployment of specialist dementia workers. Fractures, nutritional disorders, urinary tract and pneumonia40 41 are among the principal causes of admission to acute hospital settings among people with dementia. Thus, we kamagra oral jelly what is it used for focused observation within trauma and orthopaedic wards (80 days) and medical assessment units (MAU.

75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types. Observations were carried out by two researchers, each working in clusters of 2â4 days over a 6-week period at each kamagra oral jelly what is it used for site.

A single day of observation could last a minimum of 2âhours and a maximum of 12âhours. A total of 684âhours of observation were conducted for this study. This produced approximately kamagra oral jelly what is it used for 600â000 words of observational fieldnotes that were transcribed, cleaned and anonymised (by KF and AN).

We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group. This allowed us to question what they are doing and why, and what are the caring practices of ward staff when interacting with people living with kamagra oral jelly what is it used for dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient records and board data with the assistance of ward staff. Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data.

When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was this advisory group that informed us of the need of a better understanding of the impacts of kamagra oral jelly what is it used for the everyday care received by people living with dementia in acute hospital settings. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study.

The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data analysis was complete, the advisory group commented on our initial kamagra oral jelly what is it used for findings and recommendations. During and on completion of the analysis, a series of public consultation events were held with people living with dementia and family carers to ensure their involvement in discussing, informing and refining our analysis.FindingsWithin this paper, we focus on exploring the medical gaze through the embedded institutional cultures of patient clothing, and the implications this have for patients living with dementia within acute hospital wards.

These findings kamagra oral jelly what is it used for emerged from our wider analysis of our ethnographic study examining ward cultures of care and the experiences of people living with dementia. Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress. We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress.

Within many wards, it was typical for all older patients to be dressed in hospital-issued institutional gowns and pyjamas (typically in pastel blue, pink, green or peach), paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip grip soles, while in other wards, it was standard practice for kamagra oral jelly what is it used for people to be supported to dress in their own clothes. Across all these wards, we observed that younger patients (middle aged/working age) were more likely to be able to wear their own clothes while admitted to a ward, than older patients and those with a dementia diagnosis.Among key signifiers of social status and individuality are the material things around the person, which in these hospital wards included the accoutrements around the bedside. Significantly, it was observed that people living with dementia were more likely to be wearing an institutional hospital gown or institutional pyjamas, and to have little to individuate the person at the bedside, on either their cabinet or the mobile tray table at their bedside.

The wearing of kamagra oral jelly what is it used for institutional clothing was typically connected to fewer personal items on display or within reach of the patient, with any items tidied away out of sight. In contrast, younger working age patients often had many personal belongings, cards, gadgets, books, media players, with young adults also often having a range of âget well soonâ gifts, balloons and so on from the hospital gift shop) on display. This both afforded some elements of familiarity, but also marked the person out as someone with individuality and a certain social standing and place.Visibility of patients on a wardThe significance of the obscurity or invisibility of the patient in artworks depicting doctors has been commented on.4 Likewise, we observed that some patients within these wards were much more âvisibleâ to kamagra oral jelly what is it used for staff than others.

It was often apparent how the wearing of personal clothing could make the patient and their needs more readily visible to others as a person. This may be especially so given the contrast in appearance clothing may produce in this particular setting. On occasion, this may be remarked on by staff, and the kamagra oral jelly what is it used for resulting attention received favourably by the patient.A member of the bay team returned to a patient and found her freshly dressed in a white tee shirt, navy slacks and black velvet slippers and exclaimed aloud and appreciatively, âWow, look at you!.

Â The patient looked pleased as she sat and combed her hair [site 3âday 1].Such a simple act of recognition as someone with a socially approved appearance takes on a special significance in the context of an acute hospital ward, and for patients living with dementia whose personhood may be overlooked in various ways.46This question of visibility of patients may also be particularly important when people living with dementia may be less able to make their needs and presence known. In this example, a whole bay of patients was seemingly âinvisibleâ. Here, the ethnographer is observing a four-bed bay occupied by male patients living with kamagra oral jelly what is it used for dementia.The man in bed 17 is sitting in his bedside chair.

He is dressed in green hospital issue pyjamas and yellow grip socks. At 10 a.m., the physiotherapy team come and see kamagra oral jelly what is it used for him. The physiotherapist crouches down in front of him and asks him how he is.

He says he is unhappy, and the physiotherapist explains that sheâll be back later to see him again. The nurse checks on him, asks him if he wants a pillow, and puts it behind his head explaining to kamagra oral jelly what is it used for him, âYou need to sit in the chair for a bitâ. She pulls his bedside trolley near to him.

With the help of a Healthcare Assistant they make the bed. The Healthcare Assistant chats to him, puts cake out for kamagra oral jelly what is it used for him, and puts a blanket over his legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, âThe problem is this is a really unstimulating environmentâ, then says to the patient, âAll done, letâs have a bit of a tidy up,â before wheeling the equipment out.The neighbouring patient in bed 18, is now sitting in his bedside chair, wearing (his own) striped pyjamas.

His eyes are open, and he kamagra oral jelly what is it used for is looking around. After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains.

He says he doesnât want to sit, and they say kamagra oral jelly what is it used for that is fine unless the doctors tell them otherwise.The nurse puts music on an old radio with a CD player which is at the doorway near the ward entrance. It sounds like music from a musical and the ward it is quite noisy suddenly. She turns down the volume a bit, but it is very jaunty and upbeat.

The man in bed 19 quietly sings along to the kamagra oral jelly what is it used for songs. ÂI am going to see my baby when I go home on victory dayâ¦âAt ten thirty, the nurse goes off on her break. The rest of the team are spread around the other bays and side kamagra oral jelly what is it used for rooms.

There are long distances between bays within this ward. After all the earlier activity it is now very calm and peaceful in the bay. Patient 20 is sitting in the chair tapping his feet kamagra oral jelly what is it used for to the music.

He has taken out a large hessian shopping bag out of his cabinet and is sorting through the contents. There is a lot of paperwork in it which he is reading through closely and kamagra oral jelly what is it used for sorting.Opposite, patient 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down the chair.

His head is in his hands and he suddenly looks in pain. He hasnât touched his tea, and is talking to himself kamagra oral jelly what is it used for. The junior medic was aware that 17 was not comfortable, and it had looked like she was going to get some advice, but she hasnât come back.

18 drinks his tea and looks at a wool twiddle mitt sleeve, puts it down, and dozes. 19 has finished all his coffee and manages to put the cup down on the kamagra oral jelly what is it used for trolley.Everyone is tapping their feet or wiggling their toes to the music, or singing quietly to it, when a student nurse, who is working at the computer station in the corridor outside the room, comes in. She has a strong purposeful stride and looks irritated as she switches the music off.

It feels like kamagra oral jelly what is it used for a jolt to the room. She turns and looks at me and says, âSorry were you listening to it?. Â I tell her that I think these gentlemen were listening to it.She suddenly looks very startled and surprised and looks at the men in the room for the first time.

They have all stopped tapping their toes and stopped kamagra oral jelly what is it used for singing along. She turns it back on but asks me if she can turn it down. She leaves and goes back to her paperwork outside.

Once it kamagra oral jelly what is it used for is turned back on everyone starts tapping their toes again. The music plays on. ÂThereâll be bluebirds over the white cliffs of Dover, just you wait and seeâ¦â[Site 3âday 3]The music was played by staff to help combat the drab and unstimulating environment of this hospital ward for the patients, the very people kamagra oral jelly what is it used for the ward is meant to serve.

Yet for this member of ward staff the music was perceived as a nuisance, the men for whom the music was playing seemingly did not register to her awareness. Only an individual of âhigherâ status, the researcher, sitting at the end of this room was visible to her. This example illustrates the general question of the visibility or otherwise of kamagra oral jelly what is it used for patients.

His is not wearing his glasses, which are missing, and his daughters find this very difficult. Even though he looks very different following his admissionâhe has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hueâit is his glasses which are a key concern for the family in their recognition of their father:As I enter the corridor to go back to the ward, I meet the wife kamagra oral jelly what is it used for and daughter of the patient in bed 2 in the hall and walk with them back to the ward. Their father looks very frail, his head is back, and his face is immobile, his eyes are closed, and his mouth is open.

His skin looks darker than before, and his cheekbones and eye sockets are extremely prominent from weight loss. ÂI am like a bird I want to fly awayâ¦â plays softly in the radio in kamagra oral jelly what is it used for the bay. I sit with them for a bit and we chatâhis wife holds his hand as we talk.

His wife has to take two busses to get to the hospital and we talk about the potential care home they expect her husband will be discharged to. They hope it will be close because she does kamagra oral jelly what is it used for not drive. He isnât wearing his glasses and his daughter tells me that they canât find them.

We look kamagra oral jelly what is it used for in the bedside cabinet. She has never seen her dad without his glasses. ÂHe doesnât look like my dad without his glassesâ [Site 2âday 15].It was often these small aspects of personal clothing and grooming that prompted powerful responses from visiting family members.

Missing glasses kamagra oral jelly what is it used for and missing teeth were notable in this regard (and with the follow-up visits from the relatives of discharged patients trying to retrieve these now lost objects). The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a patientâs identity, such as wallets or keys, and particularly, for female patients, handbags, could be a prominent source of distress for individuals. These accessories to personal clothing were notable on these wards by their everyday absence, hidden away in bedside cupboards or simply not brought in with the patient at admission, and by the frequency with which patients requested and called out for them or tried to look for them, often in repetitive cycles that indicated their underlying anxiety about these belongings, but which would become invisible to staff, becoming an everyday background intrusion to the work of the wards.When considering the visibility and recognition of individual persons, missing glasses, especially glasses for distance vision, have a particular significance, for without them, a person may be less able to recognise and interact visually with others.

Their presence facilitates the subject of the kamagra oral jelly what is it used for gaze, in gazing back, and hence helps to ground meaningful and reciprocal relationships of recognition. This may be one factor behind the distress of relatives in finding their loved onesâ glasses to be absent.Clothing as a source of distressAcross all sites, we observed patients living with dementia who exhibited obvious distress at aspects of their institutional apparel and at the absence of their own personal clothing. Some older patients were clearly able to verbalise their understandings kamagra oral jelly what is it used for of the impacts of wearing institutional clothing.

One patient remarked to a nurse of her hospital blue tracksuit. ÂI look like an Olympian or Wentworth prison in this outfit!. The latter I expectâ¦â The staff laughed as they walked her kamagra oral jelly what is it used for out of the bay (site 3âday 1).Institutional clothing may be a source of distress to patients, although they may be unable to express this verbally.

Kontos has shown how people living with dementia may retain an awareness at a bodily level of the demands of etiquette.20 Likewise, in our study, a man living with dementia, wearing a very large institutional pyjama top, which had no collar and a very low V neck, continually tried to pull it up to cover his chest. The neckline was particularly low, because the pyjamas were far too large for him. He continued to kamagra oral jelly what is it used for fiddle with his very low-necked top even when his lunch tray was placed in front of him.

He clearly felt very uncomfortable with such clothing. He continued using his hands to try to pull kamagra oral jelly what is it used for it up to cover his exposed chest, during and after the meal was finished (site 3âday 5).For some patients, the communication of this distress in relation to clothing may be liable to misinterpretation and may have further impacts on how they are viewed within the ward. Here, a patient living with dementia recently admitted to this ward became tearful and upset after having a shower.

Where are my trousers?. I want them, Iâve lost them.â The healthcare assistant repeats the explaination that her clothes are dirty, and kamagra oral jelly what is it used for asks her, âDo you want your dirty ones?. Â She is very teary âNo, I want my clean ones.â The carer again explains that they are dirty.The cleaner who always works in the ward arrives to clean the floor and sweeps around the patient as she sits in her chair, and as he does this, he says âHelloâ to her.

She is very teary and explains that she has kamagra oral jelly what is it used for lost her clothes. The cleaner listens sympathetically as she continues âI am all confused. I have lost my clothes.

I am all kamagra oral jelly what is it used for confused. How am I going to go to the shops with no clothes on!. Â (site 5âday 5).This person experienced significant distress because of her absent clothes, but this would often be simply attributed to confusion, seen as a feature of her dementia.

This then may solidify kamagra oral jelly what is it used for staff perceptions of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse. The absence of her own familiar clothing contributes significantly to her distress and disorientation kamagra oral jelly what is it used for.

Personal grooming was notable by its absence beyond the necessary cleaning required for reasons of immediate hygiene and clinical need (such as the prevention of pressure ulcers). Older patients, and particular those living with dementia who were unable to carry out âself-careâ independently and were not able to request support with personal grooming, could, over their admission, become visibly unkempt and scruffy, hair could be left unwashed, uncombed and unstyled, while men could become hirsute through a lack of shaving. The simple act of a visitor dressing and grooming a patient as they prepared for discharge could transform their appearance and leave that patient looking more alert, appear to having increased capacity, than when sitting ungroomed in their kamagra oral jelly what is it used for bed or bedside chair.It is important to consider the impact of appearance and of personal care in the context of an acute ward.

Kontosâ work examining life in a care home, referred to earlier, noted that people living with dementia may be acutely aware of transgressions in grooming and appearance, and noted many acts of self-care with personal appearance, such as stopping to apply lipstick, and conformity with high standards of table manners. Clothing, etiquette and personal grooming are important indicators of social class and hence an aspect of belonging and identity, and of how an individual relates to kamagra oral jelly what is it used for a wider group. In Kontosâ findings, these rituals and standards of appearance were also observed in negative reactions, such as expressions of disgust, towards those residents who breached these standards.

Hence, even in cases where an individual may be assessed as having considerable cognitive impairment, the importance of personal appearance must not be overlooked.For some patients within these wards, routine practices of everyday care at the bedside can increase the potential to influence whether they feel and appear socially acceptable. The delivery of routine timetabled care at the bedside can impact on peopleâs appearance in ways that may mark them out as failing to achieve accepted standards of embodied personhood kamagra oral jelly what is it used for. The task-oriented timetabling of mealtimes may have significance.

It was a typical observed feature of this routine, when a mealtime has ended, that people living with dementia were left with visible signs and features of the mealtime through spillages on faces, clothes, bed sheets and bedsides, that leave them at risk of being assessed as less socially acceptable and marked as having reduced independence. For example, a volunteer attempts to âfeedâ a person living with dementia, when she gives up and kamagra oral jelly what is it used for leave the bedside (this woman living with dementia has resisted her attempts and explicitly says ânoâ), remnants of the food is left spread around her mouth (site E). In a different ward, the mealtime has ended, yet a large white plastic bib to prevent food spillages remains attached around the neck of a person living with dementia who is unable to remove it (site X).Of note, an adult would not normally wear a white plastic bib at home or in a restaurant.

It signifies a task-based apparel that is demeaning kamagra oral jelly what is it used for to an individualâs social status. This example also contrasts poignantly with examples from Kontosâ work,20 such as that of a female who had little or no ability to verbalise, but who nonetheless would routinely take her pearl necklace out from under her bib at mealtimes, showing she retained an acute awareness of her own appearance and the ârightâ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes âplaced her hand on her chest, to prevent her blouse from touching the food as she leaned over her plateâ.20Patients who are less robust, who have cognitive impairments, who may be liable to disorientation and whose agency and personhood are most vulnerable are thus those for whom appropriate and familiar clothing may be most advantageous.

However, we found the âMatthew effectâ to be frequently in operation kamagra oral jelly what is it used for. To those who have the least, even that which they have will be taken away.48 Although there may be institutional and organisational rationales for putting a plastic cover over a patient, leaving it on for an extended period following a meal may act as a marker of dehumanising loss of social status. By being able to maintain familiar clothing and adornment to visually display social standing and identity, a person living with dementia may maintain a continuity of selfhood.However, it is also possible that dressing and grooming an older person may itself be a task-oriented institutional activity in certain contexts, as discussed by Lee-Treweek49 in the context of a nursing home preparing residents for âlounge viewâ where visitors would see them, using residents to âcreate a visual product for othersâ sometimes to the detriment of residentsâ needs.

Our observations regarding the importance of patient appearance must therefore be considered as part of the care of the whole person and a significant feature of the institutional culture.Patient kamagra oral jelly what is it used for status and appearanceWithin these wards, a new grouping of class could become imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs. Those in the lowest classes may have limited opportunities to participate in society, and we observed the ways in which this applied to the people living with dementia kamagra oral jelly what is it used for within these acute wards.

The differential impact of clothing as signifiers of social status has also been observed in a comparison of the white coat and the patient gown.4 It has been argued that while these both may help to mask individuality, they have quite different effects on social status on a ward. One might say that the white coat increases visibility as a person of standing and the attribution of agency, the patient gown diminishes both of these. (Within these wards, although white coats were not to be found, the dress code of medical staff kamagra oral jelly what is it used for did make them stand out.

For male doctors, for example, the uniform rarely strayed beyond chinos paired with a blue oxford button down shirt, sleeves rolled up, while women wore a wider range of smart casual office wear.) Likewise, we observed that the same arrangement of attire could be attributed to entirely different meanings for older patients with or without dementia.Removal of clothes and exposureWithin these wards, we observed high levels of behaviour perceived by ward staff as people living with dementia displaying âresistanceâ to care.50 This included âresistanceâ towards institutional clothing. This could include pulling up or removing hospital gowns, removing institutional pyjama trousers or pulling up gowns, and standing with gowns untied and exposed at the back (although this last example is an unavoidable design feature of the clothing itself). Importantly, the removal of clothing was limited to institutional gowns and pyjamas and we did not see kamagra oral jelly what is it used for any patients removing their own clothing.

This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts could and was often interpreted by ward staff as a kamagra oral jelly what is it used for patientâs âresistanceâ to care. There was some variation in this interpretation.

However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within these wards such as shouting or crying out, the removal of bedsheets and the subsequent bodily exposure would always kamagra oral jelly what is it used for be immediately corrected, the sheet replaced and the patient covered by either the nurse or HCA. The act of removal was typically interpreted by ward staff as representing a feature of the personâs dementia and staff responses were framed as an issue of patient dignity, or the dignity and embarrassment of other patients and visitors to the ward.

However, such responses to removal could lead to further cycles kamagra oral jelly what is it used for of removal and replacement, leading to an escalation of distress in the person. This was important, because the recording of ârefusal of careâ, or presumed âconfusionâ associated with this, could have significant impacts on the care and discharge pathways available and prescribed for the individual patient.Consider the case of a woman living with dementia who is 90 years old (patient 1), in the example below. Despite having no immediate medical needs, she has been admitted to the MAU from a care home (following her husbandâs stroke, he could no longer care for her).

Across the previous evening and morning shift, she was shouting, refusing all kamagra oral jelly what is it used for food and care and has received assistance from the specialist dementia care worker. However, during this shift, she has become calmer following a visit from her husband earlier in the day, has since eaten and requested drinks. Her care home would not readmit her, which meant she was not able to be discharged from the unit (an overflow unit due to a high number of admissions to the emergency department during a patch of exceptionally hot weather) until alternative arrangements could be made by social services.During our observations, she remains calm for the first 2âhours.

When she does talk, she is very loud and high pitched, but kamagra oral jelly what is it used for this is normal for her and not a sign of distress. For staff working on this bay, their attention is elsewhere, because of the other six patients on the unit, one is âon suicide watchâ and another is ârefusing their medicationâ (but does not have a diagnosis of dementia). At 15:10 kamagra oral jelly what is it used for patient 1 begins to remove her sheets:15:10.

The unit seems chaotic today. Patient 1 has begun to loudly drum her fingers on the tray table. She still has not been brought more milk, which she requested from the kamagra oral jelly what is it used for HCA an hour earlier.

The bay that patient 1 is admitted to is a temporary overflow unit and as a result staff do not know where things are. 1 has moved her sheets off her legs, her bare knees peeking out over the top of piled sheets.15:15. The nurse in charge says, âHello,â when kamagra oral jelly what is it used for she walks past 1âs bed.

1 looks across and smiles back at her. The nurse in charge explains to her kamagra oral jelly what is it used for that she needs to shuffle up the bed. 1 asks the nurse about her husband.

The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow. 1 says that he kamagra oral jelly what is it used for hasnât been and she does not believe the nurse.15:25. I overhear the nurse in charge question, under her breath to herself, âWhy 1 has been left on the unit?.

Â 1 has started asking for somebody to come and see her. The nurse in charge tells 1 that she needs to do some jobs first and then will come and talk kamagra oral jelly what is it used for to her.15:30. 1 has once again kicked her sheets off of her legs.

A social worker comes kamagra oral jelly what is it used for onto the unit. 1 shouts, âExcuse meâ to her. The social worker replies, âSorry Iâm not staff, I donât work hereâ and leaves the bay.15:40.

1 keeps kicking sheets off her kamagra oral jelly what is it used for bed, otherwise the unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unitâs door. 1 is the only elderly patient on the unit.

Again, the nurse in charge is heard sympathizing that this is not the kamagra oral jelly what is it used for right place for her.16:30. A doctor approaches 1, tells her that she is on her list of people to say hello to, she is quite friendly. 1 tells her that she has been here for 3 kamagra oral jelly what is it used for days, (the rest is inaudible because of pitch).

The doctor tries to cover 1 up, raising her bed sheet back over the bed, but 1 loudly refuses this. The doctor responds by ending the interaction, âSee you laterâ, and leaves the unit.16:40. 1 attempts kamagra oral jelly what is it used for to talk to the new nurse assigned to the unit.

She goes over to 1 and says, âWhatâs up my darling?. Â Itâs hard to follow 1 now as she sounds very upset. The RNâs first instinct, like with the doctor and the kamagra oral jelly what is it used for nurse in charge, is to cover up 1âs legs with her bed sheet.

When 1 reacts to this she talks to her and they agree to cover up her knees. 1 is talking about kamagra oral jelly what is it used for how her husband wonât come and visit her, and still sounds really upset about this. [Site 3, Day 13]Of note is that between days 6 and 15 at this site, observed over a particularly warm summer, this unit was uncomfortably hot and stuffy.

The need to be uncovered could be viewed as a reasonable response, and in fact was considered acceptable for patients without a classification of dementia, provided they were otherwise clothed, such as the hospital gown patient 1 was wearing. This is an example of an aspect of care where the choice and autonomy granted to patients assessed as having (or assumed to have) cognitive capacity is not available kamagra oral jelly what is it used for to people who are considered to have impaired cognitive capacity (a diagnosis of dementia) and carries the additional moral judgements of the appropriateness of behaviour and bodily exposure. In the example given above, the actions were linked to the patientâs resistance to their admission to the hospital, driven by her desire to return home and to be with her husband.

Throughout observations over this 10-day period, patients perceived by staff as rational agents were allowed to strip down their bedding for comfort, whereas patients living with dementia who responded in this way were often viewed by staff as âundressingâ, which would be interpreted as a feature of their condition, to be challenged and corrected by staff.Note how the same visual data triggered opposing interpretations of personal autonomy. Just as in the example above where distress over loss of familiar kamagra oral jelly what is it used for clothing may be interpreted as an aspect of confusion, yet lead to, or exacerbate, distress and disorientation. So âdeviantâ bedding may be interpreted, for some patients only, in ways that solidify notions of lack of agency and confusion, is another example of the Matthew effect48 at work through the organisational expectations of the clothed appearance of patients.Within wards, it is not unusual to see patients, especially those with a diagnosis of dementia or cognitive impairment, walking in the corridor inadvertently in some state of undress, typically exposed from behind by their hospital gowns.

This exposure in itself is of course, kamagra oral jelly what is it used for an intrinsic functional feature of the design of the flimsy back-opening institutional clothing the patient has been placed in. This task-based clothing does not even fulfil this basic function very adequately. However, this inadvertent exposure could often be interpreted as an overt act of resistance to the ward and towards staff, especially when it led to exposed genitalia or continence products (pads or nappies).We speculate that the interpretation of resistance may be triggered by the visual prompt of disarrayed clothing and the meanings assumed to follow, where lack of decorum in attire is interpreted as indicating more general behavioural incompetence, cognitive impairment and/or standing outside the social order.DiscussionPrevious studies examining the significance of the visual, particularly Twigg and Buseâs work16â19 exploring the materialities of appearance, emphasise its key role in self-presentation, visibility, dignity and autonomy for older people and especially those living with dementia in care home settings.

Similarly, care home studies have demonstrated that institutional clothing, designed to facilitate kamagra oral jelly what is it used for task-based care, can be potentially dehumanising or and distressing.25 26 Our findings resonate with this work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from McGilchristâs work.10 The institutional culture of the wards produces an organisational task-based technical attention, which we found appeared to compete with and reduce the opportunity for ward staff to seek a finer emotional attunement to the person they are caring for and their needs.

Focus on efficiency, pace and record keeping kamagra oral jelly what is it used for that measures individual task completion within a timetable of care may worsen all these effects. Indeed, other work has shown that in some contexts, attention to visual appearance may itself be little more than a âtaskâ to achieve.49 McGilchrist makes clear, and we agree, that both forms of attention are vital, but more needs to be done to enable staff to find a balance.Previous work has shown how important appearance is to older people, and to people living with dementia in particular, both in terms of how they are perceived by others, but also how for this group, people living with dementia, clothing and personal grooming may act as a particularly important anchor into a familiar social world. These twin aspects of clothing and appearanceâself-perception and perception by othersâmay be especially important in the fast-paced kamagra oral jelly what is it used for context of an acute ward environment, where patients living with dementia may be struggling with the impacts of an additional acute medical condition within in a highly timetabled and regimented and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways.

We have seen above, for instance, how behaviour in relation to appearance may be seen as âresisting careâ in one group of patients, but as the natural expression of personal preference in patients viewed as being without cognitive impairments. Likewise, personal grooming might impact favourably on a patientâs alertness, visibility and status within the ward.Prior work has demonstrated the importance of the medical gaze for the perceptions of the patient. Other work has also shown how older people, and in particular people living with dementia, may be thought to be kamagra oral jelly what is it used for beyond concern for appearance, yet this does not accurately reflect the importance of appearance we found for this patient group.

Indeed, we argue that our work, along with the work of others such as Kontos,20 21 shows that if anything, visual appearance is especially important for people living with dementia particularly within clinical settings. In considering the task of washing the patient, Pols53 considered âdignitasâ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to dignitas in the form of appearance may be a way of facilitating the treatment by others of a person with humanitas, and helping to realise dignity of patients.Data availability kamagra oral jelly what is it used for statementNo data are available.

Data are unavailable to protect anonymity.Ethics statementsPatient consent for publicationNot required.Ethics approvalEthics committee approval for the study was granted by the NHS Research Ethics Service (15/WA/0191).AcknowledgmentsThe authors acknowledge funding support from the NIHR.Notes1. Devan Stahl kamagra oral jelly what is it used for (2013). ÂLiving into the imagined body.

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ÂWelfare embodied. The materiality of hospital dress. A commentary on Topo and Iltanen-TÃ¤hkÃ¤vuoriâ.

Social Science and Medicine, 70(11), 1690â1692.28. Kathleen Woodward (2006). ÂPerforming age, performing genderâ National Womenâs Studies Association (NWSA) Journal 18(1).

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AbstractBrazil is currently home to the largest http://adamlucidi.com/who-can-buy-levitra/ Japanese buy kamagra online no prescription population outside of Japan. In Brazil today, Japanese-Brazilians are considered to be successful members of Brazilian society. This was not always the case, however, and Japanese immigrants to Brazil endured much hardship to attain their current level of prestige buy kamagra online no prescription. This essay explores this communityâs trajectory towards the formation of the Japanese-Brazilian identity and the issues of mental health that arise in this immigrant community. Through the analysis of Japanese-Brazilian novels, TV shows, film and public health studies, I seek to disentangle the themes of gender and modernisation, and how these themes concurrently grapple with Japanese-Brazilian mental health issues.

These fictional narratives provide a lens into the experience of buy kamagra online no prescription the Japanese-Brazilian community that is unavailable in traditional medical studies about their mental health.filmliterature and medicinemental health caregender studiesmedical humanitiesData availability statementData are available in a public, open access repository.Introduction and philosophical backgroundWork in the medical humanities has noted the importance of the âmedical gazeâ and how it may âseeâ the patient in ways which are specific, while possessing broad significance, in relation to developing medical knowledge. To diagnosis. And to the social position of the medical profession.1 Some authors have emphasised that vision is a distinctive modality of perception which merits its own consideration, and which may buy kamagra online no prescription have a particular role to play in medical education and understanding.2 3 The clothing we wear has a strong impact on how we are perceived. For example, commentary in this journal on the âwhite coatâ observes that while it may rob the medical doctor of individuality, it nonetheless grants an elevated status4. In contrast, the patient hospital gown may rob patients of individuality in a way that stigmatises them,5 reducing their status in the ward, and ultimately dehumanises them, in conflict with the humanistic approaches seen as central to the best practice in the care of older patients, and particularly those living with dementia.6The broad context of our concern is the visibility of patients and their needs.

We draw on observations made during an ethnographic study of the everyday care of people living with dementia within acute hospital wards, to consider how patientsâ clothing may impact on the way they were perceived by themselves and by others buy kamagra online no prescription. Hence, we draw on this ethnography to contribute to discussion of the âmedical gazeâ in a specific and informative context.The acute setting illustrates a situation in which there are great many biomedical, technical, recording, and timetabled routine task-oriented demands, organised and delivered by different staff members, together with demands for care and attention to particular individuals and an awareness of their needs. Within this ward setting, we focus on patients who are living with dementia, since this group may be particularly vulnerable to a dehumanising gaze.6 We frame our discussion within the broader context of the general philosophical question of how we acquire knowledge of different types, and the moral consequences of this, particularly knowledge through visual perception.Debates throughout the history of philosophy raise questions about the nature and sources of our knowledge. Contrasts are buy kamagra online no prescription often drawn between more reliable or less reliable knowledge. And between knowledge that is more technical or âobjectiveâ, and knowledge that is more emotionally based or more âsubjectiveâ.

A frequent point of discussion is the reliability and characteristics of buy kamagra online no prescription perception as a source of knowledge. This epistemological discussion is mostly focused on vision, indicating its particular importance as a mode of perception to humans.7Likewise, in ethics, there is discussion of the origin of our moral knowledge and the particular role of perception.8 There is frequent recognition that the observer has some significant role in acquiring moral knowledge. Attention to qualities of the moral observer is not in itself a denial of moral reality. Indeed, it is the very essence of an ethical response to the world to recognise the deep reality buy kamagra online no prescription of others as separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways.

The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine. Work that examines different ways of processing information, and of interacting with and buy kamagra online no prescription being in the world, can be found in Iain McGilchristâs The Master and His Emissary,10 where he draws on neurological discoveries and applies his ideas to the development of human culture. McGilchrist has recently expanded on the relevance of understanding two different approaches to knowledge for the practice of medicine.11 He argues that task-oriented perception, and a wider, more emotionally attuned awareness of the environment are necessary partners, but may in some circumstances compete, with the competitive edge often being given to the narrower, task-based attention.There has been critique of McGilchristâs arguments as well as much support. We find his work a buy kamagra online no prescription useful framework for understanding important debates in the ethics of medicine and of nursing about relationships of staff to patients. In particular, it helps to illuminate the consequences of patientsâ dress and personal appearance for how they are seen and treated.Dementia and personal appearanceOur work focuses on patients living with dementia admitted to acute hospital wards.

Here, they are a large group, present alongside older patients unaffected by dementia, as well as younger patients. This mixed population provides a useful setting to consider the impact of personal appearance on different patient groups.The role of appearance in the presentation of the self has been buy kamagra online no prescription explored extensively by TseÃ«lon,12 13 drawing on Goffmanâs work on stigma5 and the presentation of the self14 using interactionist approaches. Drawing on the experiences on women in the UK, TseÃ«lon argues Goffmanâs interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it. TseÃ«lon suggests that understandings in this area, in the role appearance and clothing have in the presentation of the self, have been restricted by the perceived trivialities of the topic and limited to the field of fashion studies.15The personal appearance of older patients, and patients living with dementia in particular, has, more recently, been shown to be worthy of attention and of particular significance. Older people are often assumed to be left out of fashion, yet a concern with appearance remains.16 17 Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or dementia, and so conversely, attention to appearance is one way of buy kamagra online no prescription combatting the stigma associated with dementia.

Families and carers may also feel the importance of personal appearance. The significant body of work by Twigg and Buse in this field in particular draws attention to the role clothing has on preserving the identity and dignity or people living with dementia, buy kamagra online no prescription while also constraining and enabling elements of care within long-term community settings.16â19 Within this paper, we examine the ways in which these phenomena can be even more acutely felt within the impersonal setting of the acute hospital.Work has also shown how people living with dementia strongly retain a felt, bodily appreciation for the importance of personal appearance. The comfort and sensuous feel of familiar clothing may remain, even after cognitive capacities such as the ability to recognise oneself in a mirror, or verbal fluency, are lost.18 More strongly still, Kontos,20â22 drawing on the work of Merleau-Ponty and of Bourdieu, has convincingly argued that this attention to clothing and personal appearance is an important aspect of the maintenance of a bodily sense of self, which is also socially mediated, in part via such attention to appearance. Our observations lend support to Kontosâ hypothesis.Much of this previous work has considered clothing in the everyday life of people living with dementia in the context of community or long-term residential care.18 Here, we look at the visual impact of clothing and appearance in the different setting of the hospital ward and consider the consequent implications for patient care. This setting enables us to consider how the short-term and unfamiliar environments of the acute ward, together with the contrast between personal and institutional attire, impact on the perception of the patient by buy kamagra online no prescription self and by others.There is a body of literature that examines the work of restoring the appearance of residents within long-term community care settings, for instance Ward et alâs work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-TÃ¤hkÃ¤vuori25 examines the usage of garments designed for long-term care settings, exploring the conflict between clothing used to prevent undressing or facilitate the delivery of care, and the distress such clothing can cause, being powerfully symbolic of lower social status and associated with reduced autonomy.26 27Within this literature, there has also been a significant focus on the role of clothing, appearance and the tasks of personal care surrounding it, on the older female body.

A corpus of feminist literature has examined the ageing process and the use of clothing to conceal ageing, the presentation of a younger self, or a âcertainâ age28 It argues that once the ability to conceal the ageing process through clothing and grooming has been lost, the aged person must instead conceal themselves, dressing to hide themselves and becoming invisible in the process.29 This paper will explore how institutional clothing within hospital wards affects both the male and female body, the presentation of the ageing body and its role in reinforcing the invisibility of older people, at a time when they are paradoxically most visible, unclothed and undressed, or wearing institutional clothing within the hospital ward.Institutional clothing is designed and used to fulfil a practical function. Its use may therefore perhaps incline us towards a âtask-basedâ mode of attention, which as McGilchrist argues,10 while having a vital place in our understanding of the world, may on occasion interfere with the forms of attention that may be needed to deliver good person-oriented care responsive to individual needs.MethodsEthnography involves the in-depth study of peopleâs actions and accounts within their natural everyday setting, collecting relatively unstructured data from a range of sources.30 Importantly, it can take into account the perspectives of patients, carers and hospital staff.31 Our approach to ethnography is informed by the symbolic interactionist research tradition, which aims to provide an interpretive understanding of the social world, with an emphasis on interaction, focusing on understanding how action and meaning are constructed within a setting.32 The value of this approach is the depth of understanding and theory generation it can provide.33The goal of ethnography is to identify social processes within the data. There are multiple complex and nuanced interactions buy kamagra online no prescription within these clinical settings that are capable of âcommunicating many messages at once, even of subverting on one level what it appears to be âsayingâ on anotherâ.34 Thus, it is important to observe interaction and performance. How everyday care work is organised and delivered. By obtaining observational data from within each institution on the everyday work of hospital wards, their family carers and the nursing and healthcare assistants (HCAs) who carry out this work, we can explore the ways in which hospital organisation, procedures and everyday care impact on buy kamagra online no prescription care during a hospital admission.

It remedies a common weakness in many qualitative studies, that what people say in interviews may differ from what they do or their private justifications to others.35Data collection (observations and interviews) and analysis were informed by the analytic tradition of grounded theory.36 There was no prior hypothesis testing and we used the constant comparative method and theoretical sampling whereby data collection (observation and interview data) and analysis are inter-related,36 37 and are carried out concurrently.38 39 The flexible nature of this approach is important, because it can allow us to increase the âanalytic incisivenessâ35 of the study. Preliminary analysis of data collected from individual sites informed the focus of later stages of sampling, data collection and analysis in other sites.Thus, sampling requires a flexible, pragmatic approach and purposive and maximum variation sampling (theoretical sampling) was used. This included five hospitals selected to represent a buy kamagra online no prescription range of hospitals types, geographies and socioeconomic catchments. Five hospitals were purposefully selected to represent a range of hospitals types. Two large university teaching hospitals, two medium-sized general hospitals and one smaller general hospital.

This included one urban, two inner city and two hospitals covering a mix of rural and suburban catchment areas, all situated within England and Wales.These sites represented a range of expertise buy kamagra online no prescription and interventions in caring for people with dementia, from no formal expertise to the deployment of specialist dementia workers. Fractures, nutritional disorders, urinary tract and pneumonia40 41 are among the principal causes of admission to acute hospital settings among people with dementia. Thus, we focused observation within buy kamagra online no prescription trauma and orthopaedic wards (80 days) and medical assessment units (MAU. 75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types.

Observations were carried buy kamagra online no prescription out by two researchers, each working in clusters of 2â4 days over a 6-week period at each site. A single day of observation could last a minimum of 2âhours and a maximum of 12âhours. A total of 684âhours of observation were conducted for this study. This produced approximately 600â000 words of observational fieldnotes that were transcribed, cleaned and anonymised (by KF and buy kamagra online no prescription AN). We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group.

This allowed us to question what they are doing and why, and buy kamagra online no prescription what are the caring practices of ward staff when interacting with people living with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient records and board data with the assistance of ward staff. Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data. When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was this advisory group that informed us of the need of a better understanding buy kamagra online no prescription of the impacts of the everyday care received by people living with dementia in acute hospital settings. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study.

The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data buy kamagra online no prescription analysis was complete, the advisory group commented on our initial findings and recommendations. During and on completion of the analysis, a series of public consultation events were held with people living with dementia and family carers to ensure their involvement in discussing, informing and refining our analysis.FindingsWithin this paper, we focus on exploring the medical gaze through the embedded institutional cultures of patient clothing, and the implications this have for patients living with dementia within acute hospital wards. These findings emerged from our wider analysis of our ethnographic study examining ward cultures of care and the experiences of buy kamagra online no prescription people living with dementia. Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress.

We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress. Within many wards, it was typical for all older patients to buy kamagra online no prescription be dressed in hospital-issued institutional gowns and pyjamas (typically in pastel blue, pink, green or peach), paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip grip soles, while in other wards, it was standard practice for people to be supported to dress in their own clothes. Across all these wards, we observed that younger patients (middle aged/working age) were more likely to be able to wear their own clothes while admitted to a ward, than older patients and those with a dementia diagnosis.Among key signifiers of social status and individuality are the material things around the person, which in these hospital wards included the accoutrements around the bedside. Significantly, it was observed that people living with dementia were more likely to be wearing an institutional hospital gown or institutional pyjamas, and to have little to individuate the person at the bedside, on either their cabinet or the mobile tray table at their bedside. The wearing of institutional buy kamagra online no prescription clothing was typically connected to fewer personal items on display or within reach of the patient, with any items tidied away out of sight.

In contrast, younger working age patients often had many personal belongings, cards, gadgets, books, media players, with young adults also often having a range of âget well soonâ gifts, balloons and so on from the hospital gift shop) on display. This both afforded some elements buy kamagra online no prescription of familiarity, but also marked the person out as someone with individuality and a certain social standing and place.Visibility of patients on a wardThe significance of the obscurity or invisibility of the patient in artworks depicting doctors has been commented on.4 Likewise, we observed that some patients within these wards were much more âvisibleâ to staff than others. It was often apparent how the wearing of personal clothing could make the patient and their needs more readily visible to others as a person. This may be especially so given the contrast in appearance clothing may produce in this particular setting. On occasion, this may be remarked on by staff, and the resulting attention received favourably by the patient.A member of the bay team returned to a patient and found her freshly dressed in a white tee shirt, navy slacks and black velvet slippers buy kamagra online no prescription and exclaimed aloud and appreciatively, âWow, look at you!.

Â The patient looked pleased as she sat and combed her hair [site 3âday 1].Such a simple act of recognition as someone with a socially approved appearance takes on a special significance in the context of an acute hospital ward, and for patients living with dementia whose personhood may be overlooked in various ways.46This question of visibility of patients may also be particularly important when people living with dementia may be less able to make their needs and presence known. In this example, a whole bay of patients was seemingly âinvisibleâ. Here, the ethnographer is observing a four-bed buy kamagra online no prescription bay occupied by male patients living with dementia.The man in bed 17 is sitting in his bedside chair. He is dressed in green hospital issue pyjamas and yellow grip socks. At 10 a.m., the physiotherapy team come and see buy kamagra online no prescription him.

The physiotherapist crouches down in front of him and asks him how he is. He says he is unhappy, and the physiotherapist explains that sheâll be back later to see him again. The nurse checks on him, asks him if he wants a pillow, and buy kamagra online no prescription puts it behind his head explaining to him, âYou need to sit in the chair for a bitâ. She pulls his bedside trolley near to him. With the help of a Healthcare Assistant they make the bed.

The Healthcare Assistant chats to him, puts cake out for buy kamagra online no prescription him, and puts a blanket over his legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, âThe problem is this is a really unstimulating environmentâ, then says to the patient, âAll done, letâs have a bit of a tidy up,â before wheeling the equipment out.The neighbouring patient in bed 18, is now sitting in his bedside chair, wearing (his own) striped pyjamas. His eyes are open, and buy kamagra online no prescription he is looking around. After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains.

He says he doesnât want to sit, and they say that is fine unless the doctors tell them otherwise.The nurse puts music on an old radio with a CD buy kamagra online no prescription player which is at the doorway near the ward entrance. It sounds like music from a musical and the ward it is quite noisy suddenly. She turns down the volume a bit, but it is very jaunty and upbeat. The man buy kamagra online no prescription in bed 19 quietly sings along to the songs. ÂI am going to see my baby when I go home on victory dayâ¦âAt ten thirty, the nurse goes off on her break.

The rest of the team are spread around the buy kamagra online no prescription other bays and side rooms. There are long distances between bays within this ward. After all the earlier activity it is now very calm and peaceful in the bay. Patient 20 is sitting in the buy kamagra online no prescription chair tapping his feet to the music. He has taken out a large hessian shopping bag out of his cabinet and is sorting through the contents.

There is a lot of paperwork in it which buy kamagra online no prescription he is reading through closely and sorting.Opposite, patient 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down the chair. His head is in his hands and he suddenly looks in pain. He hasnât touched his tea, and buy kamagra online no prescription is talking to himself. The junior medic was aware that 17 was not comfortable, and it had looked like she was going to get some advice, but she hasnât come back.

18 drinks his tea and looks at a wool twiddle mitt sleeve, puts it down, and dozes. 19 has finished all his coffee and manages to put the cup down on the trolley.Everyone is tapping their feet or wiggling their toes to the music, or singing quietly to it, when a student nurse, who is working at the computer station in the corridor outside buy kamagra online no prescription the room, comes in. She has a strong purposeful stride and looks irritated as she switches the music off. It feels like a jolt to buy kamagra online no prescription the room. She turns and looks at me and says, âSorry were you listening to it?.

Â I tell her that I think these gentlemen were listening to it.She suddenly looks very startled and surprised and looks at the men in the room for the first time. They have buy kamagra online no prescription all stopped tapping their toes and stopped singing along. She turns it back on but asks me if she can turn it down. She leaves and goes back to her paperwork outside. Once it is turned back on everyone starts tapping their toes buy kamagra online no prescription again.

The music plays on. ÂThereâll be bluebirds over the white cliffs of Dover, just you wait and seeâ¦â[Site 3âday 3]The music was played by staff to help combat the drab and unstimulating environment of this hospital ward for the patients, the buy kamagra online no prescription very people the ward is meant to serve. Yet for this member of ward staff the music was perceived as a nuisance, the men for whom the music was playing seemingly did not register to her awareness. Only an individual of âhigherâ status, the researcher, sitting at the end of this room was visible to her. This example illustrates buy kamagra online no prescription the general question of the visibility or otherwise of patients.

Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the example below, a mother and two adult daughters visit the father of the family, who is not visible buy kamagra online no prescription to them as the person they were so familiar with. His is not wearing his glasses, which are missing, and his daughters find this very difficult. Even though he looks very different following his admissionâhe has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hueâit is his glasses buy kamagra online no prescription which are a key concern for the family in their recognition of their father:As I enter the corridor to go back to the ward, I meet the wife and daughter of the patient in bed 2 in the hall and walk with them back to the ward.

Their father looks very frail, his head is back, and his face is immobile, his eyes are closed, and his mouth is open. His skin looks darker than before, and his cheekbones and eye sockets are extremely prominent from weight loss. ÂI am like a buy kamagra online no prescription bird I want to fly awayâ¦â plays softly in the radio in the bay. I sit with them for a bit and we chatâhis wife holds his hand as we talk. His wife has to take two busses to get to the hospital and we talk about the potential care home they expect her husband will be discharged to.

They hope it will be close because she does buy kamagra online no prescription not drive. He isnât wearing his glasses and his daughter tells me that they canât find them. We look buy kamagra online no prescription in the bedside cabinet. She has never seen her dad without his glasses. ÂHe doesnât look like my dad without his glassesâ [Site 2âday 15].It was often these small aspects of personal clothing and grooming that prompted powerful responses from visiting family members.

Missing glasses and missing teeth were notable in this regard (and with the follow-up visits buy kamagra online no prescription from the relatives of discharged patients trying to retrieve these now lost objects). The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a patientâs identity, such as wallets or keys, and particularly, for female patients, handbags, could be a prominent source of distress for individuals. These accessories to personal clothing were notable on these wards by their everyday absence, hidden away in bedside cupboards or simply not brought in with the patient at admission, and by the frequency with which patients requested and called out for them or tried to look for them, often in repetitive cycles that indicated their underlying anxiety about these belongings, but which would become invisible to staff, becoming an everyday background intrusion to the work of the wards.When considering the visibility and recognition of individual persons, missing glasses, especially glasses for distance vision, have a particular significance, for without them, a person may be less able to recognise and interact visually with others. Their presence buy kamagra online no prescription facilitates the subject of the gaze, in gazing back, and hence helps to ground meaningful and reciprocal relationships of recognition. This may be one factor behind the distress of relatives in finding their loved onesâ glasses to be absent.Clothing as a source of distressAcross all sites, we observed patients living with dementia who exhibited obvious distress at aspects of their institutional apparel and at the absence of their own personal clothing.

Some older patients were clearly able to verbalise their understandings of the buy kamagra online no prescription impacts of wearing institutional clothing. One patient remarked to a nurse of her hospital blue tracksuit. ÂI look like an Olympian or Wentworth prison in this outfit!. The latter I expectâ¦â buy kamagra online no prescription The staff laughed as they walked her out of the bay (site 3âday 1).Institutional clothing may be a source of distress to patients, although they may be unable to express this verbally. Kontos has shown how people living with dementia may retain an awareness at a bodily level of the demands of etiquette.20 Likewise, in our study, a man living with dementia, wearing a very large institutional pyjama top, which had no collar and a very low V neck, continually tried to pull it up to cover his chest.

The neckline was particularly low, because the pyjamas were far too large for him. He continued to fiddle with his very low-necked top even when his lunch tray was placed in buy kamagra online no prescription front of him. He clearly felt very uncomfortable with such clothing. He continued using his hands to try to pull it up to cover his exposed chest, during and after the meal was finished (site buy kamagra online no prescription 3âday 5).For some patients, the communication of this distress in relation to clothing may be liable to misinterpretation and may have further impacts on how they are viewed within the ward. Here, a patient living with dementia recently admitted to this ward became tearful and upset after having a shower.

She had no fresh clothes, and so the team had provided her with a pink hospital gown to wear.âI want my trousers, where is my bra, Iâve got no bra on.â It is clear she doesnât feel right without her own clothes on. The one-to-one healthcare assistant buy kamagra online no prescription assigned to this patient tells her, âYour bra is dirty, do you want to wear that?. Â She replies, âNo I want a clean one. Where are my trousers?. I want them, Iâve lost buy kamagra online no prescription them.â The healthcare assistant repeats the explaination that her clothes are dirty, and asks her, âDo you want your dirty ones?.

Â She is very teary âNo, I want my clean ones.â The carer again explains that they are dirty.The cleaner who always works in the ward arrives to clean the floor and sweeps around the patient as she sits in her chair, and as he does this, he says âHelloâ to her. She is very teary and buy kamagra online no prescription explains that she has lost her clothes. The cleaner listens sympathetically as she continues âI am all confused. I have lost my clothes. I am buy kamagra online no prescription all confused.

How am I going to go to the shops with no clothes on!. Â (site 5âday 5).This person experienced significant distress because of her absent clothes, but this would often be simply attributed to confusion, seen as a feature of her dementia. This then may buy kamagra online no prescription solidify staff perceptions of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse. The absence of her own familiar clothing contributes significantly to her distress buy kamagra online no prescription and disorientation.

Others have argued that people with limited verbal capacity and limited cognitive comprehension will have a direct appreciation of the grounding familiarity of wearing their own clothes, which give a bodily felt notion of comfort and familiarity.18 47 Familiar clothing may then be an essential prop to anchor the wearer within a recognisable social and meaningful space. To simply see clothing from a task-oriented point of view, as fulfilling a simply mechanical function, and that all clothing, whether personal or institutional have the same value and role, might be to interpret the desire to wear familiar clothing as an âoptional extraâ. However, for those patients most at risk of disorientation and distress within an unfamiliar environment, it could be a valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed other aspects of buy kamagra online no prescription the role of personal grooming. Personal grooming was notable by its absence beyond the necessary cleaning required for reasons of immediate hygiene and clinical need (such as the prevention of pressure ulcers). Older patients, and particular those living with dementia who were unable to carry out âself-careâ independently and were not able to request support with personal grooming, could, over their admission, become visibly unkempt and scruffy, hair could be left unwashed, uncombed and unstyled, while men could become hirsute through a lack of shaving.

The simple act of a visitor dressing and grooming a patient as they prepared for discharge could transform buy kamagra online no prescription their appearance and leave that patient looking more alert, appear to having increased capacity, than when sitting ungroomed in their bed or bedside chair.It is important to consider the impact of appearance and of personal care in the context of an acute ward. Kontosâ work examining life in a care home, referred to earlier, noted that people living with dementia may be acutely aware of transgressions in grooming and appearance, and noted many acts of self-care with personal appearance, such as stopping to apply lipstick, and conformity with high standards of table manners. Clothing, etiquette and personal grooming are important indicators of social class and hence an aspect of belonging and identity, and of how an individual relates buy kamagra online no prescription to a wider group. In Kontosâ findings, these rituals and standards of appearance were also observed in negative reactions, such as expressions of disgust, towards those residents who breached these standards. Hence, even in cases where an individual may be assessed as having considerable cognitive impairment, the importance of personal appearance must not be overlooked.For some patients within these wards, routine practices of everyday care at the bedside can increase the potential to influence whether they feel and appear socially acceptable.

The delivery of routine timetabled care at the bedside can impact on peopleâs appearance in buy kamagra online no prescription ways that may mark them out as failing to achieve accepted standards of embodied personhood. The task-oriented timetabling of mealtimes may have significance. It was a typical observed feature of this routine, when a mealtime has ended, that people living with dementia were left with visible signs and features of the mealtime through spillages on faces, clothes, bed sheets and bedsides, that leave them at risk of being assessed as less socially acceptable and marked as having reduced independence. For example, a volunteer attempts to âfeedâ a person living with dementia, when she gives buy kamagra online no prescription up and leave the bedside (this woman living with dementia has resisted her attempts and explicitly says ânoâ), remnants of the food is left spread around her mouth (site E). In a different ward, the mealtime has ended, yet a large white plastic bib to prevent food spillages remains attached around the neck of a person living with dementia who is unable to remove it (site X).Of note, an adult would not normally wear a white plastic bib at home or in a restaurant.

It signifies a task-based buy kamagra online no prescription apparel that is demeaning to an individualâs social status. This example also contrasts poignantly with examples from Kontosâ work,20 such as that of a female who had little or no ability to verbalise, but who nonetheless would routinely take her pearl necklace out from under her bib at mealtimes, showing she retained an acute awareness of her own appearance and the ârightâ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes âplaced her hand on her chest, to prevent her blouse from touching the food as she leaned over her plateâ.20Patients who are less robust, who have cognitive impairments, who may be liable to disorientation and whose agency and personhood are most vulnerable are thus those for whom appropriate and familiar clothing may be most advantageous. However, we found the âMatthew effectâ to be frequently in operation buy kamagra online no prescription. To those who have the least, even that which they have will be taken away.48 Although there may be institutional and organisational rationales for putting a plastic cover over a patient, leaving it on for an extended period following a meal may act as a marker of dehumanising loss of social status.

By being able to maintain familiar clothing and adornment to visually display social standing and identity, a person living with dementia may maintain a continuity of selfhood.However, it is also possible that dressing and grooming an older person may itself be a task-oriented institutional activity in certain contexts, as discussed by Lee-Treweek49 in the context of a nursing home preparing residents for âlounge viewâ where visitors would see them, using residents to âcreate a visual product for othersâ sometimes to the detriment of residentsâ needs. Our observations regarding the importance of patient appearance must therefore be considered as part of the care of the whole person and a significant feature of the institutional culture.Patient status and appearanceWithin these wards, a new grouping of class could become buy kamagra online no prescription imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs. Those in the lowest classes may have limited opportunities to participate in buy kamagra online no prescription society, and we observed the ways in which this applied to the people living with dementia within these acute wards. The differential impact of clothing as signifiers of social status has also been observed in a comparison of the white coat and the patient gown.4 It has been argued that while these both may help to mask individuality, they have quite different effects on social status on a ward.

One might say that the white coat increases visibility as a person of standing and the attribution of agency, the patient gown diminishes both of these. (Within these buy kamagra online no prescription wards, although white coats were not to be found, the dress code of medical staff did make them stand out. For male doctors, for example, the uniform rarely strayed beyond chinos paired with a blue oxford button down shirt, sleeves rolled up, while women wore a wider range of smart casual office wear.) Likewise, we observed that the same arrangement of attire could be attributed to entirely different meanings for older patients with or without dementia.Removal of clothes and exposureWithin these wards, we observed high levels of behaviour perceived by ward staff as people living with dementia displaying âresistanceâ to care.50 This included âresistanceâ towards institutional clothing. This could include pulling up or removing hospital gowns, removing institutional pyjama trousers or pulling up gowns, and standing with gowns untied and exposed at the back (although this last example is an unavoidable design feature of the clothing itself). Importantly, the removal of clothing was limited to institutional gowns and pyjamas and we did not buy kamagra online no prescription see any patients removing their own clothing.

This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts could buy kamagra online no prescription and was often interpreted by ward staff as a patientâs âresistanceâ to care. There was some variation in this interpretation. However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within buy kamagra online no prescription these wards such as shouting or crying out, the removal of bedsheets and the subsequent bodily exposure would always be immediately corrected, the sheet replaced and the patient covered by either the nurse or HCA.

The act of removal was typically interpreted by ward staff as representing a feature of the personâs dementia and staff responses were framed as an issue of patient dignity, or the dignity and embarrassment of other patients and visitors to the ward. However, such responses to removal could lead to further cycles of removal and replacement, leading to an escalation of buy kamagra online no prescription distress in the person. This was important, because the recording of ârefusal of careâ, or presumed âconfusionâ associated with this, could have significant impacts on the care and discharge pathways available and prescribed for the individual patient.Consider the case of a woman living with dementia who is 90 years old (patient 1), in the example below. Despite having no immediate medical needs, she has been admitted to the MAU from a care home (following her husbandâs stroke, he could no longer care for her). Across the previous evening and morning shift, she buy kamagra online no prescription was shouting, refusing all food and care and has received assistance from the specialist dementia care worker.

However, during this shift, she has become calmer following a visit from her husband earlier in the day, has since eaten and requested drinks. Her care home would not readmit her, which meant she was not able to be discharged from the unit (an overflow unit due to a high number of admissions to the emergency department during a patch of exceptionally hot weather) until alternative arrangements could be made by social services.During our observations, she remains calm for the first 2âhours. When she does talk, she is very loud and high pitched, but this is normal for buy kamagra online no prescription her and not a sign of distress. For staff working on this bay, their attention is elsewhere, because of the other six patients on the unit, one is âon suicide watchâ and another is ârefusing their medicationâ (but does not have a diagnosis of dementia). At 15:10 buy kamagra online no prescription patient 1 begins to remove her sheets:15:10.

The unit seems chaotic today. Patient 1 has begun to loudly drum her fingers on the tray table. She still buy kamagra online no prescription has not been brought more milk, which she requested from the HCA an hour earlier. The bay that patient 1 is admitted to is a temporary overflow unit and as a result staff do not know where things are. 1 has moved her sheets off her legs, her bare knees peeking out over the top of piled sheets.15:15.

The nurse in charge says, âHello,â when she walks past 1âs buy kamagra online no prescription bed. 1 looks across and smiles back at her. The nurse in charge explains buy kamagra online no prescription to her that she needs to shuffle up the bed. 1 asks the nurse about her husband. The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow.

1 says that he hasnât been and she does buy kamagra online no prescription not believe the nurse.15:25. I overhear the nurse in charge question, under her breath to herself, âWhy 1 has been left on the unit?. Â 1 has started asking for somebody to come and see her. The nurse in charge tells 1 buy kamagra online no prescription that she needs to do some jobs first and then will come and talk to her.15:30. 1 has once again kicked her sheets off of her legs.

A social buy kamagra online no prescription worker comes onto the unit. 1 shouts, âExcuse meâ to her. The social worker replies, âSorry Iâm not staff, I donât work hereâ and leaves the bay.15:40. 1 keeps buy kamagra online no prescription kicking sheets off her bed, otherwise the unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unitâs door.

1 is the only elderly patient on the unit. Again, the nurse in charge is heard sympathizing buy kamagra online no prescription that this is not the right place for her.16:30. A doctor approaches 1, tells her that she is on her list of people to say hello to, she is quite friendly. 1 tells her that she has been here for 3 days, (the rest is inaudible because of buy kamagra online no prescription pitch). The doctor tries to cover 1 up, raising her bed sheet back over the bed, but 1 loudly refuses this.

The doctor responds by ending the interaction, âSee you laterâ, and leaves the unit.16:40. 1 attempts to talk to buy kamagra online no prescription the new nurse assigned to the unit. She goes over to 1 and says, âWhatâs up my darling?. Â Itâs hard to follow 1 now as she sounds very upset. The RNâs first instinct, like with the doctor and the buy kamagra online no prescription nurse in charge, is to cover up 1âs legs with her bed sheet.

When 1 reacts to this she talks to her and they agree to cover up her knees. 1 is talking about how her husband wonât come and buy kamagra online no prescription visit her, and still sounds really upset about this. [Site 3, Day 13]Of note is that between days 6 and 15 at this site, observed over a particularly warm summer, this unit was uncomfortably hot and stuffy. The need to be uncovered could be viewed as a reasonable response, and in fact was considered acceptable for patients without a classification of dementia, provided they were otherwise clothed, such as the hospital gown patient 1 was wearing. This is an example of an aspect of care where the choice and autonomy buy kamagra online no prescription granted to patients assessed as having (or assumed to have) cognitive capacity is not available to people who are considered to have impaired cognitive capacity (a diagnosis of dementia) and carries the additional moral judgements of the appropriateness of behaviour and bodily exposure.

In the example given above, the actions were linked to the patientâs resistance to their admission to the hospital, driven by her desire to return home and to be with her husband. Throughout observations over this 10-day period, patients perceived by staff as rational agents were allowed to strip down their bedding for comfort, whereas patients living with dementia who responded in this way were often viewed by staff as âundressingâ, which would be interpreted as a feature of their condition, to be challenged and corrected by staff.Note how the same visual data triggered opposing interpretations of personal autonomy. Just as in the example above where distress over loss of familiar clothing may be interpreted as an buy kamagra online no prescription aspect of confusion, yet lead to, or exacerbate, distress and disorientation. So âdeviantâ bedding may be interpreted, for some patients only, in ways that solidify notions of lack of agency and confusion, is another example of the Matthew effect48 at work through the organisational expectations of the clothed appearance of patients.Within wards, it is not unusual to see patients, especially those with a diagnosis of dementia or cognitive impairment, walking in the corridor inadvertently in some state of undress, typically exposed from behind by their hospital gowns. This exposure in itself buy kamagra online no prescription is of course, an intrinsic functional feature of the design of the flimsy back-opening institutional clothing the patient has been placed in.

This task-based clothing does not even fulfil this basic function very adequately. However, this inadvertent exposure could often be interpreted as an overt act of resistance to the ward and towards staff, especially when it led to exposed genitalia or continence products (pads or nappies).We speculate that the interpretation of resistance may be triggered by the visual prompt of disarrayed clothing and the meanings assumed to follow, where lack of decorum in attire is interpreted as indicating more general behavioural incompetence, cognitive impairment and/or standing outside the social order.DiscussionPrevious studies examining the significance of the visual, particularly Twigg and Buseâs work16â19 exploring the materialities of appearance, emphasise its key role in self-presentation, visibility, dignity and autonomy for older people and especially those living with dementia in care home settings. Similarly, care home studies have demonstrated that institutional clothing, designed to facilitate task-based care, can be potentially dehumanising or and distressing.25 26 Our findings resonate with this work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity buy kamagra online no prescription of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from McGilchristâs work.10 The institutional culture of the wards produces an organisational task-based technical attention, which we found appeared to compete with and reduce the opportunity for ward staff to seek a finer emotional attunement to the person they are caring for and their needs.

Focus on efficiency, pace and record keeping that measures individual task completion within a timetable of care may worsen all these buy kamagra online no prescription effects. Indeed, other work has shown that in some contexts, attention to visual appearance may itself be little more than a âtaskâ to achieve.49 McGilchrist makes clear, and we agree, that both forms of attention are vital, but more needs to be done to enable staff to find a balance.Previous work has shown how important appearance is to older people, and to people living with dementia in particular, both in terms of how they are perceived by others, but also how for this group, people living with dementia, clothing and personal grooming may act as a particularly important anchor into a familiar social world. These twin aspects of clothing and appearanceâself-perception and perception by othersâmay be especially important in the fast-paced context of an acute ward environment, where patients living with dementia may be struggling with the impacts of an additional acute medical condition within in a highly timetabled and regimented and buy kamagra online no prescription unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways. We have seen above, for instance, how behaviour in relation to appearance may be seen as âresisting careâ in one group of patients, but as the natural expression of personal preference in patients viewed as being without cognitive impairments. Likewise, personal grooming might impact favourably on a patientâs alertness, visibility and status within the ward.Prior work has demonstrated the importance of the medical gaze for the perceptions of the patient.

Other work has also shown how older people, and in particular people living with dementia, may be thought to be beyond concern for appearance, yet this does not accurately reflect buy kamagra online no prescription the importance of appearance we found for this patient group. Indeed, we argue that our work, along with the work of others such as Kontos,20 21 shows that if anything, visual appearance is especially important for people living with dementia particularly within clinical settings. In considering the task of washing the patient, Pols53 considered âdignitasâ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to dignitas in the form of buy kamagra online no prescription appearance may be a way of facilitating the treatment by others of a person with humanitas, and helping to realise dignity of patients.Data availability statementNo data are available. Data are unavailable to protect anonymity.Ethics statementsPatient consent for publicationNot required.Ethics approvalEthics committee approval for the study was granted by the NHS Research Ethics Service (15/WA/0191).AcknowledgmentsThe authors acknowledge funding support from the NIHR.Notes1.

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Kamagra que es

Food insecurityâthe economic and social condition of limited or uncertain access to adequate foodâis high on the agenda.1 In Europe, estimates from Eurostat in 2020 show that 7% of households with children are food insecure.2 There is a worry that the corresponding figures for 2021 may be even higher as the kamagra que es erectile dysfunction treatment kamagra has led to increased unemployment and economic uncertainty, processes that likely exacerbate food insecurity.3 4 The fact that so many children experience insecure access to food is important in its own right, but food insecurity is also associated with long-term adverse outcomes related to, for example, education and nutrition.5 6In a timely new study, Men et al7 examine the association between food insecurity and mental health problems among children Kamagra oral jelly price and young adults. Using large-scale Canadian survey data on more than 55â000 individuals, they document that food insecurity is associated with worse mental health, and that the association is graded with more severe food insecurity associated with progressively worse health. The study includes overall measures of mental health, but also more specific measures related to depression, anxiety and suicidal ideation.Beyond the immediate relevance of the topic, Men et al7 address dimensions of disadvantage that go beyond standard measures of socioeconomic status such as income and poverty, and it is also interesting to see such patterns in a country with universal healthcare and a safety kamagra que es net meant to buffer some of the disadvantages of poor income. Men et al7 also found a strong association between food insecurity and risk of mental health problems, net of household income and other socioeconomic factors. This highlights kamagra que es an additional point.

Even though childhood food insecurity is closely linked to poverty, food insecurity may be high even among families above poverty thresholds.Men and colleagues mention social disorganisation within the family as a potential explanation of why the relationship between household insecurity and mental health exists even after controlling for income. Other factors, such as high cost of living in certain areas (ie, large cities), may kamagra que es make it difficult to get by even with a decent income. As such geography may be a relevant factor. Parental unemployment and other abrupt changes such kamagra que es as divorce, or disability among family members, are additional factors that could contribute to food insecurity. Importantly, these risk factors are much more likely to affect low-income families.8 Even among those entitled to benefits, there might be delays in receiving these, with consequences for a familyâs food security.

Typically, family poverty is often measured annually, but such aggregated measures might not capture the income volatility experienced by many low-income families.A key limitation of the study is the kamagra que es cross-sectional nature of the data, which makes the interpretation open to reverse causation. For example, prior research has revealed a plethora of factors that predict food insecurity, such as motherâs health, substance abuse, family instability and immigrant background.5 Thus, the path from food insecurity to mental health might not be as straightforward as we might expect, as there could be other factorsâoften less easily measuredâthat account for part of the association. However, the kamagra que es authors acknowledge this, and one study can only do so much. Instead, future research should also apply (quasi)experimental approaches to get closer to causal estimates.Future research could also benefit from a comparative perspective. The rate of food insecurity varies considerably across countries, kamagra que es but we know less about whether the consequences of food insecurity for children and youth also differ across countries.

Previous research has shown that the relationship between parental income and childrenâs adult attainments and intergenerational mobility varies across countries, with less adverse consequences in more egalitarian and universal welfare states.9 For the current topic, the primary goal of welfare states should be to limit the prevalence of food insecurity among children. However, it is important to know whether welfare states also cushion the negative repercussions among those children who still face insecure access to food while growing up.Ethics statementsPatient consent for publicationNot required.Recent evidence of continuing inequalities by educational level in disability in Europe is disappointing. Further socioeconomic measures might reveal greater kamagra que es inequalities. Conclusions are limited by differences in wording used to establish disability. Assuming that there is inequity kamagra que es behind these inequalities, this, along with the adverse effects of the erectile dysfunction treatment kamagra, reinforces the need for multisectoral action, collaboration and cooperation.Rubio Valverde et al1 show us that inequalities in disabilities in Europe have not improved between 2002 and 2017.

They included a wide age range (30â79 years) and 26 countries. They used two surveys, the European Union Statistics on Income and Living (EU-SILC) and the European Social kamagra que es Survey. The disability measure was the Global Activity Limitation Indicator (GALI), a self-report of being limited in activities âpeople usually doâ in the past 6 months.2 The former survey indicated an increase in gap between low and high education groups, with the more educated experiencing reduced prevalence of disability, and the latter survey no discernible trend. Inequalities have been the subject of discussion for decades so it is disappointing to find this.Three aspects of the paper caught my attention kamagra que es. This is one of a long series of analyses by Mackenbach and his team which use education as the socioeconomic indicator.

Their reasons for doing kamagra que es this are that they judge educational measures to be most comparable across countries, that it may be a starting point for several pathways and reverse causation is unlikely.3 However, it may not be the socioeconomic indicator most strongly related to disability and may underestimate the importance of socioeconomic status. For example, in the English Longitudinal Study of Ageing, absolute differences in healthy life expectancy were greater for wealth categories than for education or social class whereas in the USAâs Health and Retirement Study both wealth and education were strong.4 Marmotâs example of a Glasgow male shows how education, occupation and material resource all play a part.5Marmot is also talking about âequityâ whereas Rubio Valverdeâs paper refers to inequality. To know kamagra que es that there are these inequalities is the starting point but the prompt to action is inequity. Not a new topic, of course, but one that has become highly visible with the erectile dysfunction treatment kamagra. The WHO report judges that âfailure to anticipate and avoid the resulting unwanted scenarios in the short and medium terms has led to a major risk both of exacerbating health, social and economic kamagra que es inequities in the long term and of giving rise to new vulnerabilities within the populationâ6 (p 1).

People with learning and other disabilities have been at higher risk of death. In England, as of November 2020, 60% of erectile dysfunction treatment deaths were to people with disabilities.7 erectile dysfunction treatment is leaving some people kamagra que es with reduced long-term health which may lead to reduced earning capacity or mobility6 (p 33). Also, new hardship is arising because of the economic and social restrictions. The corollary of the two-way impact of socioeconomic inequities on the kamagra and the kamagra on the inequities is the need for multisectoral policies affecting peopleâs access to essential care and health services, providing economic security and ensuring that decision-making is an inclusive process6 (p 14). We need âcommitment to social justice and putting equity of health and wellbeing at the kamagra que es heart of all policy makingâ8 (p 64).

Marmot is addressing socioeconomic inequity and those relating to ethnicity, age and gender.The third aspect of the paper is the variability between countries and between surveys in the graphs of disability prevalence over time. Both the kamagra que es levels and shapes vary. Rubio Valverde et al highlight this and, not finding clear geographical patterns, fall back on overall averages. Some of this heterogeneity arises from variation in the GALI wording used in EU-SILC and they have tried kamagra que es to take some account of this. There are now several multicountry studies and families of cohort studies which aim to harmonise measures within their group.

Methods are kamagra que es being developed to harmonise when measures are different9 but Rubio Valverdeâs paper highlights how differences in measurement can hamper conclusions about risks. Being self-report, and depending on what people consider to be usual, one can expect some variation by culture and age and gender. However, it is likely that some of it arises from the context in which kamagra que es people live. Their countryâs health services, policy and environment. It would kamagra que es be instructive to learn more about this and see what we can learn from each other.

During the kamagra, countries have taken very different paths to deal with the erectile dysfunction kamagra and its effects. Collaborative research is common in epidemiology kamagra que es. In the economic and political world, sometimes it feels as if the terms âcooperationâ and âcollaborationâ are undervalued. My wish is to see them given greater prominence.Ethics statementsPatient consent for publicationNot required..

Food insecurityâthe economic and social condition of limited or uncertain access to adequate foodâis high on the agenda.1 In Europe, estimates from Eurostat in 2020 show that 7% of households with children are food insecure.2 There is a worry that the corresponding figures for 2021 may be even higher as the erectile dysfunction treatment kamagra has led to increased unemployment and economic uncertainty, processes that likely exacerbate food insecurity.3 4 The fact that so many children experience insecure access to food is important in its own right, but http://www.findlayillinois.net/kamagra-oral-jelly-price/ food insecurity buy kamagra online no prescription is also associated with long-term adverse outcomes related to, for example, education and nutrition.5 6In a timely new study, Men et al7 examine the association between food insecurity and mental health problems among children and young adults. Using large-scale Canadian survey data on more than 55â000 individuals, they document that food insecurity is associated with worse mental health, and that the association is graded with more severe food insecurity associated with progressively worse health. The study includes overall measures of mental health, but also more specific measures related to depression, anxiety and suicidal ideation.Beyond the immediate relevance of the topic, Men et al7 address dimensions of disadvantage that go beyond standard measures of buy kamagra online no prescription socioeconomic status such as income and poverty, and it is also interesting to see such patterns in a country with universal healthcare and a safety net meant to buffer some of the disadvantages of poor income. Men et al7 also found a strong association between food insecurity and risk of mental health problems, net of household income and other socioeconomic factors.

This highlights an additional buy kamagra online no prescription point. Even though childhood food insecurity is closely linked to poverty, food insecurity may be high even among families above poverty thresholds.Men and colleagues mention social disorganisation within the family as a potential explanation of why the relationship between household insecurity and mental health exists even after controlling for income. Other factors, buy kamagra online no prescription such as high cost of living in certain areas (ie, large cities), may make it difficult to get by even with a decent income. As such geography may be a relevant factor.

Parental unemployment and other abrupt changes such as divorce, or disability among family members, are additional factors that could contribute to food buy kamagra online no prescription insecurity. Importantly, these risk factors are much more likely to affect low-income families.8 Even among those entitled to benefits, there might be delays in receiving these, with consequences for a familyâs food security. Typically, family poverty is often measured annually, but such aggregated measures might not capture the income volatility experienced by many low-income families.A key limitation of the study is the cross-sectional nature of the data, buy kamagra online no prescription which makes the interpretation open to reverse causation. For example, prior research has revealed a plethora of factors that predict food insecurity, such as motherâs health, substance abuse, family instability and immigrant background.5 Thus, the path from food insecurity to mental health might not be as straightforward as we might expect, as there could be other factorsâoften less easily measuredâthat account for part of the association.

However, the authors acknowledge this, and one study can only do so buy kamagra online no prescription much. Instead, future research should also apply (quasi)experimental approaches to get closer to causal estimates.Future research could also benefit from a comparative perspective. The rate of food insecurity varies considerably across countries, but we know less buy kamagra online no prescription about whether the consequences of food insecurity for children and youth also differ across countries. Previous research has shown that the relationship between parental income and childrenâs adult attainments and intergenerational mobility varies across countries, with less adverse consequences in more egalitarian and universal welfare states.9 For the current topic, the primary goal of welfare states should be to limit the prevalence of food insecurity among children.

However, it is important to know whether welfare states also cushion the negative repercussions among those children who still face insecure access to food while growing up.Ethics statementsPatient consent for publicationNot required.Recent evidence of continuing inequalities by educational level in disability in Europe is disappointing. Further socioeconomic buy kamagra online no prescription measures might reveal greater inequalities. Conclusions are limited by differences in wording used to establish disability. Assuming that there is inequity behind these inequalities, buy kamagra online no prescription this, along with the adverse effects of the erectile dysfunction treatment kamagra, reinforces the need for multisectoral action, collaboration and cooperation.Rubio Valverde et al1 show us that inequalities in disabilities in Europe have not improved between 2002 and 2017.

They included a wide age range (30â79 years) and 26 countries. They used two surveys, the European Union Statistics on Income and buy kamagra online no prescription Living (EU-SILC) and the European Social Survey. The disability measure was the Global Activity Limitation Indicator (GALI), a self-report of being limited in activities âpeople usually doâ in the past 6 months.2 The former survey indicated an increase in gap between low and high education groups, with the more educated experiencing reduced prevalence of disability, and the latter survey no discernible trend. Inequalities have buy kamagra online no prescription been the subject of discussion for decades so it is disappointing to find this.Three aspects of the paper caught my attention.

This is one of a long series of analyses by Mackenbach and his team which use education as the socioeconomic indicator. Their reasons for doing this are that they judge educational measures to be most comparable across countries, that it may be a starting point for several pathways and reverse causation is unlikely.3 However, it buy kamagra online no prescription may not be the socioeconomic indicator most strongly related to disability and may underestimate the importance of socioeconomic status. For example, in the English Longitudinal Study of Ageing, absolute differences in healthy life expectancy were greater for wealth categories than for education or social class whereas in the USAâs Health and Retirement Study both wealth and education were strong.4 Marmotâs example of a Glasgow male shows how education, occupation and material resource all play a part.5Marmot is also talking about âequityâ whereas Rubio Valverdeâs paper refers to inequality. To know that there buy kamagra online no prescription are these inequalities is the starting point but the prompt to action is inequity.

Not a new topic, of course, but one that has become highly visible with the erectile dysfunction treatment kamagra. The WHO report judges that âfailure to anticipate and avoid the resulting unwanted scenarios in the short and medium terms has led to a major risk both of exacerbating buy kamagra online no prescription health, social and economic inequities in the long term and of giving rise to new vulnerabilities within the populationâ6 (p 1). People with learning and other disabilities have been at higher risk of death. In England, as of buy kamagra online no prescription November 2020, 60% of erectile dysfunction treatment deaths were to people with disabilities.7 erectile dysfunction treatment is leaving some people with reduced long-term health which may lead to reduced earning capacity or mobility6 (p 33).

Also, new hardship is arising because of the economic and social restrictions. The corollary of the two-way impact of socioeconomic inequities on the kamagra and the kamagra on the inequities is the need for multisectoral policies affecting peopleâs access to essential care and health services, providing economic security and ensuring that decision-making is an inclusive process6 (p 14). We need âcommitment to social justice and putting equity of health and buy kamagra online no prescription wellbeing at the heart of all policy makingâ8 (p 64). Marmot is addressing socioeconomic inequity and those relating to ethnicity, age and gender.The third aspect of the paper is the variability between countries and between surveys in the graphs of disability prevalence over time.

Both the levels buy kamagra online no prescription and shapes vary. Rubio Valverde et al highlight this and, not finding clear geographical patterns, fall back on overall averages. Some of this heterogeneity arises from variation in the GALI wording used buy kamagra online no prescription in EU-SILC and they have tried to take some account of this. There are now several multicountry studies and families of cohort studies which aim to harmonise measures within their group.

Methods are being developed to harmonise buy kamagra online no prescription when measures are different9 but Rubio Valverdeâs paper highlights how differences in measurement can hamper conclusions about risks. Being self-report, and depending on what people consider to be usual, one can expect some variation by culture and age and gender. However, it buy kamagra online no prescription is likely that some of it arises from the context in which people live. Their countryâs health services, policy and environment.

It would be instructive to learn more about this and see what we buy kamagra online no prescription can learn from each other. During the kamagra, countries have taken very different paths to deal with the erectile dysfunction kamagra and its effects. Collaborative research buy kamagra online no prescription is common in epidemiology. In the economic and political world, sometimes it feels as if the terms âcooperationâ and âcollaborationâ are undervalued.

My wish is to see them given greater prominence.Ethics statementsPatient consent for publicationNot required..