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Johnson recalled five aerosol sunscreen products in July after testing found low levels of benzene, a carcinogen in the four Neutrogena products, and one Aveeno product. Click here to sign up for Daily Voice's free daily emails and news alerts.Sandra Lee, the celebrity chef and former longtime girlfriend of soon-to-be-former New York Gov. Andrew Cuomo, is engaged, according to a new report.The New York Post reported that multiple sources confirmed that Lee, age 55, is engaged to Ben Youcef and was seen in Paris wearing an engagement ring. Youcef, age 42, is an actor and producer, who has appeared in TV shows and films such as Munich, which was directed by Steven Spielberg.

The news outlet reported that Lee met Youcef after she moved to Malibu, California. The news comes days after Cuomo announced his resignation following an investigation from Attorney General Letitia James that found he sexually harassed 11 women. Cuomo said he plans to step down as governor of New York on Tuesday, Aug. 24.Lee confirmed her split with Cuomo in September of 2019.

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AbstractBrazil is viagra side effects blood pressure currently home to the 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 much hardship to attain their current level of prestige viagra side effects blood pressure.

This essay explores this community’s 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 are available in a public, open access repository.Introduction and philosophical backgroundWork in the medical humanities has noted the importance of the ‘medical gaze’ viagra side effects blood pressure and how it may ‘see’ 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 has a strong viagra side effects blood pressure impact on how we are perceived. For example, commentary in this journal on the ‘white coat’ 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 viagra side effects blood pressure study of the everyday care of people living with dementia within acute hospital wards, to consider how patients’ clothing may impact on the way they were perceived by themselves and by others. Hence, we draw on this ethnography to contribute to discussion of the ‘medical gaze’ 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 reliable viagra side effects blood pressure knowledge. And between knowledge that is more technical or ‘objective’, and knowledge that is more emotionally based or more ‘subjective’.

A frequent point of discussion is the viagra side effects blood pressure reliability and characteristics of 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 viagra side effects blood pressure 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 viagra side effects blood pressure examines different ways of processing information, and of interacting with and being in the world, can be found in Iain McGilchrist’s 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 McGilchrist’s 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 viagra side effects blood pressure to patients.

In particular, it helps to illuminate the consequences of patients’ 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 viagra side effects blood pressure of appearance in the presentation of the self has been explored extensively by Tseëlon,12 13 drawing on Goffman’s work on stigma5 and the presentation of the self14 using interactionist approaches.

Drawing on the experiences on women in the UK, Tseëlon argues Goffman’s interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it. Tseëlon 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 viagra side effects blood pressure 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 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, while also viagra side effects blood pressure constraining and enabling elements of care within long-term community settings.16–19 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,20–22 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 Kontos’ 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 care settings, for instance Ward et al’s work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-Tähkävuori25 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 viagra side effects blood pressure 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 ‘certain’ 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 ‘task-based’ 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 people’s 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 ‘communicating many messages viagra side effects blood pressure at once, even of subverting on one level what it appears to be “saying” on another’.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, viagra side effects blood pressure 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 ‘analytic incisiveness’35 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 viagra side effects blood pressure hospitals selected to represent a 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 and interventions in caring for people viagra side effects blood pressure 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 trauma and orthopaedic wards viagra side effects blood pressure (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 2–4 days over viagra side effects blood pressure a 6-week period at each site.

A single day of observation could last a minimum of 2 hours and a maximum of 12 hours. A total of 684 hours of observation were conducted for this study. This produced approximately 600 000 words of viagra side effects blood pressure 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 dementia.Patients within these settings with a diagnosis of dementia were identified viagra side effects blood pressure 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 viagra side effects blood pressure 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, viagra side effects blood pressure 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 people living with dementia viagra side effects blood pressure. 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 viagra side effects blood pressure 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 clothing was typically connected to fewer personal items on display or within reach of the patient, with any items tidied away out of viagra side effects blood pressure 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 ‘get well soon’ 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 viagra side effects blood pressure observed that some patients within these wards were much more ‘visible’ 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 viagra side effects blood pressure 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, ‘Wow, look at you!.

€™ The patient looked pleased as she sat and combed her hair [site 3 day 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 ‘invisible’. Here, the ethnographer is observing a four-bed bay occupied by male patients viagra side effects blood pressure 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 viagra side effects blood pressure come and see 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 she’ll 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 viagra side effects blood pressure explaining to him, ‘You need to sit in the chair for a bit’. 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 him, and puts a viagra side effects blood pressure blanket over his legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, ‘The problem is this is a really unstimulating environment’, then says to the patient, ‘All done, let’s have a bit of a tidy up,’ 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 viagra side effects blood pressure are open, and 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 doesn’t 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 player which is at the doorway near the viagra side effects blood pressure 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 viagra side effects blood pressure bed 19 quietly sings along to the songs. €˜I am going to see my baby when I go home on victory day…’At ten thirty, the nurse goes off on her break. The rest of the team are spread viagra side effects blood pressure around the 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 chair tapping his feet viagra side effects blood pressure 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 viagra side effects blood pressure 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 hasn’t touched his tea, and is viagra side effects blood pressure 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 hasn’t 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 viagra side effects blood pressure 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 a jolt to viagra side effects blood pressure the room. She turns and looks at me and says, ‘Sorry were you listening to it?. €™ 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 viagra side effects blood pressure 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 viagra side effects blood pressure tapping their toes again. The music plays on. €˜There’ll be bluebirds over the white cliffs viagra side effects blood pressure of Dover, just you wait and see…’[Site 3 day 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 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 ‘higher’ 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 viagra side effects blood pressure 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 to them as the person they were so viagra side effects blood pressure 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 admission—he has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hue—it 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 and daughter of the patient in bed viagra side effects blood pressure 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. €˜I am like a bird viagra side effects blood pressure I want to fly away…’ plays softly in the radio in the bay. I sit with them for a bit and we chat—his 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 viagra side effects blood pressure because she does not drive. He isn’t wearing his glasses and his daughter tells me that they can’t find them.

We look viagra side effects blood pressure in the bedside cabinet. She has never seen her dad without his glasses. €˜He doesn’t look like my dad without his glasses’ [Site 2 day 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 from the relatives of discharged viagra side effects blood pressure 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 patient’s 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 gaze, in gazing back, and hence helps to ground meaningful and reciprocal viagra side effects blood pressure relationships of recognition. This may be one factor behind the distress of relatives in finding their loved ones’ 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 viagra side effects blood pressure able to verbalise their understandings of the impacts of wearing institutional clothing.

One patient remarked to a nurse of her hospital blue tracksuit. €˜I look like an Olympian or Wentworth prison in this outfit!. The latter I expect…’ The staff laughed as they walked her out of the bay (site 3 day 1).Institutional clothing may be a source of distress to patients, although they may be unable to viagra side effects blood pressure 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 viagra side effects blood pressure 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 it up to cover his exposed chest, during and after the meal was finished (site 3 day 5).For some patients, the communication of this distress in relation to clothing may be liable viagra side effects blood pressure 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.‘I want my trousers, where is my bra, I’ve got no bra on.’ It is clear she doesn’t feel right without her own clothes on. The one-to-one healthcare assistant assigned to this patient tells her, ‘Your bra is dirty, do you viagra side effects blood pressure want to wear that?. €™ She replies, ‘No I want a clean one.

Where are my trousers?. I want them, I’ve lost them.’ The healthcare assistant repeats the explaination that her clothes are dirty, and asks her, ‘Do you want your dirty ones? viagra side effects blood pressure. €™ She is very teary ‘No, I want my clean ones.’ 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 ‘Hello’ to her.

She is very teary and explains that she has lost her viagra side effects blood pressure clothes. The cleaner listens sympathetically as she continues ‘I am all confused. I have lost my clothes.

I am all viagra side effects blood pressure confused. How am I going to go to the shops with no clothes on!. €™ (site 5 day 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 staff perceptions of viagra side effects blood pressure 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 viagra side effects blood pressure distress 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 ‘optional extra’. 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 viagra side effects blood pressure in our consideration of clothing, we observed other aspects of 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 ‘self-care’ 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 bed or bedside chair.It is important to consider the impact of appearance and of personal care in the context of an acute ward viagra side effects blood pressure.

Kontos’ 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 viagra side effects blood pressure of how an individual relates to a wider group. In Kontos’ 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 people’s appearance viagra side effects blood pressure in 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 ‘feed’ a person living with dementia, viagra side effects blood pressure when she gives up and leave the bedside (this woman living with dementia has resisted her attempts and explicitly says ‘no’), 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 viagra side effects blood pressure apparel that is demeaning to an individual’s social status. This example also contrasts poignantly with examples from Kontos’ 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 ‘right’ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes ‘placed her hand on her chest, to prevent her blouse from touching the food as she leaned over her plate’.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 ‘Matthew effect’ viagra side effects blood pressure to be frequently in operation. 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 ‘lounge view’ where visitors would see them, using residents to ‘create a visual product for others’ sometimes to the detriment of residents’ 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, viagra side effects blood pressure 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 viagra side effects blood pressure limited opportunities to participate in 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 viagra side effects blood pressure 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 ‘resistance’ to care.50 This included ‘resistance’ 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 any patients removing their own clothing viagra side effects blood pressure.

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 viagra side effects blood pressure by ward staff as a patient’s ‘resistance’ 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 viagra side effects blood pressure 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 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 person’s 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 viagra side effects blood pressure an escalation of distress in the person. This was important, because the recording of ‘refusal of care’, or presumed ‘confusion’ 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 husband’s stroke, he could no longer care for her).

Across the previous evening and morning shift, viagra side effects blood pressure she 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 2 hours.

When she does talk, she is very loud and high pitched, but this viagra side effects blood pressure 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 ‘on suicide watch’ and another is ‘refusing their medication’ (but does not have a diagnosis of dementia). At 15:10 patient 1 begins to remove viagra side effects blood pressure 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 viagra side effects blood pressure 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, ‘Hello,’ when she viagra side effects blood pressure walks past 1’s bed.

1 looks across and smiles back at her. The nurse in charge explains to her that she needs viagra side effects blood pressure 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 hasn’t been viagra side effects blood pressure and she does not believe the nurse.15:25. I overhear the nurse in charge question, under her breath to herself, ‘Why 1 has been left on the unit?.

€™ 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 viagra side effects blood pressure come and talk to her.15:30. 1 has once again kicked her sheets off of her legs.

A social viagra side effects blood pressure worker comes onto the unit. 1 shouts, ‘Excuse me’ to her. The social worker replies, ‘Sorry I’m not staff, I don’t work here’ and leaves the bay.15:40.

1 keeps kicking sheets off her bed, otherwise the viagra side effects blood pressure unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unit’s door. 1 is the only elderly patient on the unit.

Again, the nurse in charge is heard sympathizing viagra side effects blood pressure 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 viagra side effects blood pressure 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, ‘See you later’, and leaves the unit.16:40. 1 attempts to talk to the new nurse assigned viagra side effects blood pressure to the unit.

She goes over to 1 and says, ‘What’s up my darling?. €™ It’s hard to follow 1 now as she sounds very upset. The RN’s first instinct, like with the doctor viagra side effects blood pressure and the nurse in charge, is to cover up 1 s 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 won’t come and visit viagra side effects blood pressure 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 viagra side effects blood pressure 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 patient’s 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 ‘undressing’, 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 viagra side effects blood pressure the example above where distress over loss of familiar clothing may be interpreted as an aspect of confusion, yet lead to, or exacerbate, distress and disorientation. So ‘deviant’ 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 viagra side effects blood pressure 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 Buse’s work16–19 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 viagra side effects blood pressure 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 McGilchrist’s 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 viagra side effects blood pressure 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 ‘task’ 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 appearance—self-perception and perception by others—may 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 viagra side effects blood pressure 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 ‘resisting care’ 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 patient’s 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 viagra side effects blood pressure 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 ‘dignitas’ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to viagra side effects blood pressure 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 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 viagra side effects blood pressure (2013). €œLiving into the imagined body.

How the diagnostic image confronts the lived body.” Medical Humanities. Medhum-2012–010286.2. Joyce Zazulak et al.

(2017). "The art of medicine. Arts-based training in observation and mindfulness for fostering the empathic response in medical residents.” Medical Humanities.

Medhum-2016-011180.3. E Forde (2018). "Using photography to enhance GP trainees’ reflective practice and professional development." Medical Humanities.

Medhum-2017-011203.4. Caroline Wellbery and Melissa Chan (2014) “White coat, patient gown.” Medical Humanities. Medhum-2013–0 10 463.5.

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Blackwell.9. S Weil (1953). Gravity and Grace.

U of Nebraska Press.10. I McGilchrist (2009). The Master and his Emissary.

The divided brain and the making of the western world. New Haven and London, Yale University Press.11. Iain McGilchrist (2011).

€œPaying attention to the bipartite brain.” The Lancet 377 (9771). 1068–1069.12. Efrat Tseëlon (1992).

€œSelf presentation through appearance. A manipulative vs a dramaturgical approach”. Symbolic Interaction, 15(4).

501–514.13. E Tseëlon (1995). The masque of femininity.

The presentation of woman in everyday life. London. Sage.14.

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€œFashion research and its discontents”. Fashion Theory, 5 (4). 435–451.16.

Julia Twigg (2010a). €œClothing and dementia. A neglected dimension?.

€ Journal of Ageing Studies 24(4). 223–230.17. Julia Twigg and Christina E Buse (2013).

€œDress, dementia and the embodiment of identity.” Dementia 12(3). 326–336.18. C.

E Buse and J. Twigg (2015). €œClothing, embodied identity and dementia.

Maintaining the self through dress.” Age, Culture, Humanities (2).19. Christina Buse and Julia Twigg (2018). €œDressing disrupted.

Negotiating care through the materiality of dress in the context of dementia.” Sociology of Health &. Illness, 40(2). 340-352.20.

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C Kontos (2005). €œEmbodied selfhood in Alzheimer's disease. Rethinking person-centred care.” Dementia 4 (4).

Naglie (2007). €œBridging theory and practice. Imagination, the body, and person-centred dementia care.” Dementia 6 (4).

549–569.23. Richard Ward et al. (2016a).

€œâ€˜Gonna make yer gorgeous’. Everyday transformation, resistance and belonging in the care-based hair salon.” Dementia, 15(3). 395–413.24.

Richard Ward, Sarah Campbell, and John Keady (2016b). €œAssembling the salon. Learning from alternative forms of body work in dementia care.” Sociology of Health &.

Illness, 38(8). 1287–1302.25. Sonja Iltanen-Tähkävuori, Minttu Wikberg, and Päivi Topo (2012).

Design and dementia. A case of garments designed to prevent undressing. Dementia, 11(1).

49–59.26. Päivi Topo and Sonja Iltanen-Tähkävuori (2010). €œScripting patienthood with patient clothing.” Social Science &.

Medicine, 70(11). 1682–1689.27. Julia Twigg (2010b).

€œWelfare embodied. The materiality of hospital dress. A commentary on Topo and Iltanen-Tähkävuori”.

Social Science and Medicine, 70(11), 1690–1692.28. Kathleen Woodward (2006). €œPerforming age, performing gender” National Women’s Studies Association (NWSA) Journal 18(1).

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Ix-xxix). Bloomington. Indiana University Press.30.

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London. Routledge34. V Turner and E Bruner (1986).

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Corbin and Anselm Strauss (1990). Grounded theoryrResearch. Procedures, canons, and evaluative criteria.

Grounded theory and the constant comparative method. BMJ (Clinical research ed.), 316 (7137),:1064.39. Roy Suddaby (2006).

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Prospective cohort study of prevalence and mortality”. British Journal of Psychiatry,195(1). 61–66.

Doi:10.1192/bjp.bp.108.05533541. C Pinkert and B Holle (2012). €œPeople with dementia in acute hospitals.

Literature review of prevalence and reasons for hospital admission”. Z. Gerontol.

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The methodological significance of comparison in ethnographic research” Studies in Education Ethnography 6:23–4244. Benjamin Saunders et al. (2018).

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Sage Publications, Inc.46. Paula Boddington and Katie Featherstone (2018). €œThe canary in the coal mine.

Continence care for people with dementia in acute hospital wards as a crisis of dehumanisation”. Bioethics, 32(4). 251–260.47.

Christina Buse et al. (2014). €œLooking “out of place”.

Analysing the spatial and symbolic meanings of dementia care settings through dress.” International Journal of Ageing and Later Life 9 (1). 69–95.48. R.

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The reward and communication systems of science are considered.” Science 159 (3810). 56–63.49. Geraldine Lee-Treweek (1997) “Women, resistance and care.

An ethnographic study of nursing auxiliary work” Work, Employment and Society, 11(1). 47–6350. Katie Featherstone et al.

(2019b). €œRefusal and resistance to care by people living with dementia being cared for within acute hospital wards. An ethnographic study” Health Service and Delivery Research51.

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Dignity and aesthetic values in nursing care” Nursing Philosophy, 14(3). 186–200.

AbstractBrazil is currently home to the largest Japanese population outside of how to buy cheap viagra Japan best place to buy viagra online. 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 best place to buy viagra online attain their current level of prestige. This essay explores this community’s 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 are available in a public, open access repository.Introduction best place to buy viagra online and philosophical backgroundWork in the medical humanities has noted the importance of the ‘medical gaze’ and how it may ‘see’ 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 best place to buy viagra online 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 has a strong impact on how we are perceived. For example, commentary in this journal on the ‘white coat’ 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 patients’ clothing may impact on the best place to buy viagra online way they were perceived by themselves and by others. Hence, we draw on this ethnography to contribute to discussion of the ‘medical gaze’ 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 best place to buy viagra online drawn between more reliable or less reliable knowledge. And between knowledge that is more technical or ‘objective’, and knowledge that is more emotionally based or more ‘subjective’.

A frequent point of discussion is the reliability best place to buy viagra online and characteristics of 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 of others best place to buy viagra online 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 Iain McGilchrist’s The Master and His Emissary,10 where he draws on best place to buy viagra online 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 McGilchrist’s arguments as well as much support. We find his best place to buy viagra online work a 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 patients’ 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 best place to buy viagra online to consider the impact of personal appearance on different patient groups.The role of appearance in the presentation of the self has been explored extensively by Tseëlon,12 13 drawing on Goffman’s work on stigma5 and the presentation of the self14 using interactionist approaches. Drawing on the experiences on women in the UK, Tseëlon argues Goffman’s interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it. Tseëlon 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 best place to buy viagra online impairment or dementia, and so conversely, attention to appearance is one way of 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, while also best place to buy viagra online constraining and enabling elements of care within long-term community settings.16–19 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,20–22 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 Kontos’ 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 care settings, for instance Ward et al’s work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-Tähkävuori25 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 best place to buy viagra online 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 ‘certain’ 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 ‘task-based’ 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 people’s 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 ‘communicating many messages at once, best place to buy viagra online even of subverting on one level what it appears to be “saying” on another’.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 care during a hospital best place to buy viagra online 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 ‘analytic incisiveness’35 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 best place to buy viagra online a 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 and interventions in caring for people with dementia, from no formal expertise to the deployment of best place to buy viagra online 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 best place to buy viagra online 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 2–4 best place to buy viagra online days over a 6-week period at each site. A single day of observation could last a minimum of 2 hours and a maximum of 12 hours. A total of 684 hours of observation were conducted for this study. This produced approximately 600 000 words of observational fieldnotes that best place to buy viagra online 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 dementia.Patients within these settings with a diagnosis of dementia were identified through best place to buy viagra online 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 the everyday care received by people living with dementia in acute hospital settings best place to buy viagra online. 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 best place to buy viagra online 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 people living with dementia best place to buy viagra online. 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 best place to buy viagra online 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 clothing was typically connected to fewer personal items on display or within reach best place to buy viagra online 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 ‘get well soon’ gifts, balloons and so on from the hospital gift shop) on display. This both best place to buy viagra online 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 ‘visible’ 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 best place to buy viagra online 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 and exclaimed aloud and appreciatively, ‘Wow, look at you!.

€™ The patient looked pleased as she sat and combed her hair [site 3 day 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 ‘invisible’. Here, the ethnographer is best place to buy viagra online observing a four-bed 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 best place to buy viagra online see 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 she’ll be back later to see him again. The nurse checks on him, asks him if he wants a pillow, best place to buy viagra online and puts it behind his head explaining to him, ‘You need to sit in the chair for a bit’. She pulls his bedside trolley near to him. With the help of a Healthcare Assistant they make the bed.

The Healthcare Assistant chats to best place to buy viagra online him, puts cake out 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, ‘The problem is this is a really unstimulating environment’, then says to the patient, ‘All done, let’s have a bit of a tidy up,’ 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 is looking best place to buy viagra online around. After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains.

He says he doesn’t want to sit, and they say that is fine unless the doctors tell them otherwise.The nurse puts best place to buy viagra online 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 best place to buy viagra online songs. €˜I am going to see my baby when I go home on victory day…’At ten thirty, the nurse goes off on her break.

The rest of the team are best place to buy viagra online spread around the 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 best place to buy viagra online 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 he is reading through closely and sorting.Opposite, patient 17 looks very best place to buy viagra online 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 hasn’t touched his tea, best place to buy viagra online and 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 hasn’t 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 best place to buy viagra online 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 a jolt to best place to buy viagra online the room. She turns and looks at me and says, ‘Sorry were you listening to it?.

€™ 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 best place to buy viagra online 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 best place to buy viagra online everyone starts tapping their toes again.

The music plays on. €˜There’ll be bluebirds over the white cliffs of Dover, just you wait and see…’[Site 3 day 3]The music was played by staff to help combat the drab and unstimulating environment of this hospital ward for the patients, the very best place to buy viagra online 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 ‘higher’ 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 best place to buy viagra online 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 best place to buy viagra online visible 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 admission—he has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hue—it is his glasses which best place to buy viagra online 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. €˜I am like a bird I best place to buy viagra online want to fly away…’ plays softly in the radio in the bay. I sit with them for a bit and we chat—his 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 best place to buy viagra online does not drive. He isn’t wearing his glasses and his daughter tells me that they can’t find them. We look in the bedside best place to buy viagra online cabinet. She has never seen her dad without his glasses. €˜He doesn’t look like my dad without his glasses’ [Site 2 day 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 from the relatives of discharged patients best place to buy viagra online 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 patient’s 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 best place to buy viagra online 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 ones’ 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 impacts best place to buy viagra online of wearing institutional clothing. One patient remarked to a nurse of her hospital blue tracksuit. €˜I look like an Olympian or Wentworth prison in this outfit!. The latter I expect…’ The staff laughed as they walked her out best place to buy viagra online of the bay (site 3 day 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 best place to buy viagra online 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 it best place to buy viagra online up to cover his exposed chest, during and after the meal was finished (site 3 day 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.‘I want my trousers, where is my bra, I’ve got no bra on.’ It is clear she doesn’t feel right without her own clothes on. The one-to-one healthcare assistant assigned to this patient tells her, ‘Your bra best place to buy viagra online is dirty, do you want to wear that?. €™ She replies, ‘No I want a clean one. Where are my trousers?. I want them, I’ve lost them.’ The healthcare assistant repeats the explaination that her clothes are dirty, and best place to buy viagra online asks her, ‘Do you want your dirty ones?.

€™ She is very teary ‘No, I want my clean ones.’ 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 ‘Hello’ to her. She is very teary and explains that she has lost her best place to buy viagra online clothes. The cleaner listens sympathetically as she continues ‘I am all confused. I have lost my clothes. I am best place to buy viagra online all confused.

How am I going to go to the shops with no clothes on!. €™ (site 5 day 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 staff perceptions best place to buy viagra online 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 best place to buy viagra online to her distress 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 ‘optional extra’. However, for those patients most at risk of disorientation and distress within an unfamiliar environment, it could be a best place to buy viagra online valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed other aspects of 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 ‘self-care’ 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 best place to buy viagra online 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 bed or bedside chair.It is important to consider the impact of appearance and of personal care in the context of an acute ward. Kontos’ 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 a best place to buy viagra online wider group. In Kontos’ 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 best place to buy viagra online routine timetabled care at the bedside can impact on people’s appearance in 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 ‘feed’ a person living with dementia, when she gives up and leave the bedside (this woman living with dementia has resisted her attempts and explicitly says ‘no’), remnants of the food best place to buy viagra online 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 best place to buy viagra online that is demeaning to an individual’s social status. This example also contrasts poignantly with examples from Kontos’ 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 ‘right’ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes ‘placed her hand on her chest, to prevent her blouse from touching the food as she leaned over her plate’.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 ‘Matthew effect’ best place to buy viagra online to be frequently in operation. 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 ‘lounge view’ where visitors would see them, using residents to ‘create a visual product for others’ sometimes to the detriment of residents’ 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 best place to buy viagra online 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 best place to buy viagra online 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 wards, although white coats were not to be found, the dress code best place to buy viagra online 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 ‘resistance’ to care.50 This included ‘resistance’ 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 any patients removing best place to buy viagra online their own clothing.

This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts best place to buy viagra online could and was often interpreted by ward staff as a patient’s ‘resistance’ 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 best place to buy viagra online 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 person’s 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 best place to buy viagra online to an escalation of distress in the person. This was important, because the recording of ‘refusal of care’, or presumed ‘confusion’ 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 husband’s stroke, he could no longer care for her). Across the previous evening and morning shift, she was shouting, refusing all best place to buy viagra online 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 2 hours. When she does talk, she best place to buy viagra online is very loud and high pitched, but 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 ‘on suicide watch’ and another is ‘refusing their medication’ (but does not have a diagnosis of dementia). At 15:10 patient 1 begins best place to buy viagra online 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, best place to buy viagra online 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, ‘Hello,’ best place to buy viagra online when she walks past 1’s bed. 1 looks across and smiles back at her. The nurse in charge explains to her that she needs to shuffle up the bed best place to buy viagra online. 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 hasn’t been and she best place to buy viagra online does not believe the nurse.15:25. I overhear the nurse in charge question, under her breath to herself, ‘Why 1 has been left on the unit?. €™ 1 has started asking for somebody to come and see her. The nurse in best place to buy viagra online charge tells 1 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 worker comes onto best place to buy viagra online the unit. 1 shouts, ‘Excuse me’ to her. The social worker replies, ‘Sorry I’m not staff, I don’t work here’ and leaves the bay.15:40. 1 keeps kicking sheets off best place to buy viagra online her bed, otherwise the unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unit’s door.

1 is the only elderly patient on the unit. Again, the nurse in charge is heard best place to buy viagra online sympathizing 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 best place to buy viagra online her that she has been here for 3 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, ‘See you later’, and leaves the unit.16:40. 1 attempts to talk to the new nurse assigned to best place to buy viagra online the unit. She goes over to 1 and says, ‘What’s up my darling?. €™ It’s hard to follow 1 now as she sounds very upset. The RN’s first instinct, like with the doctor and the nurse in charge, is to cover up 1 s legs best place to buy viagra online 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 best place to buy viagra online her husband won’t 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 to people who are considered to have impaired cognitive capacity best place to buy viagra online (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 patient’s 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 ‘undressing’, 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 best place to buy viagra online where distress over loss of familiar clothing may be interpreted as an aspect of confusion, yet lead to, or exacerbate, distress and disorientation. So ‘deviant’ 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, an intrinsic functional feature of the design of the best place to buy viagra online 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 Buse’s work16–19 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 of their care.Our ethnographic best place to buy viagra online 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 McGilchrist’s 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 best place to buy viagra online efficiency, pace and record keeping 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 ‘task’ 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 appearance—self-perception and perception by others—may 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 unfamiliar environment of best place to buy viagra online 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 ‘resisting care’ 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 patient’s 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 best place to buy viagra online people, and in particular people living with dementia, may be thought to be 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 ‘dignitas’ 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 best place to buy viagra online 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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There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals. For many, viagra 25mg the world is not suddenly on fire. It has long been burning.The present viagra lays bare systemic prejudice against the most vulnerable among us.

We at Medical Humanities, with our focus on global health and social justice, welcome discussion about how the crisis has disproportionately affected racial and fiscal minorities, those from the disabled community, those who are LGBTQA+ and other vulnerable groups. What we focus on here, now, can lead to greater accessibility and equity in the future.In this expanded issue, we offer some of the incredible work being done across the field of medical humanities prior to the viagra 25mg erectile dysfunction treatment crisis, and we are already reviewing articles on the role of health humanities during the viagra. The process of academic publishing tends not to lend itself to immediacy, however, and the challenges of viagra means greater pressure on everyone, from the authors to the reviewers and readers.To remedy this, we at Medical Humanities have been increasing the work on our blog platform, a place where content can be quickly updated, and where conversations can occur among readers and writers.

We openly invite submissions concerning the viagra, as well as topics relevant viagra 25mg to our wider CFP (call for posts/papers) this year on social justice and health, to both blog and journal. We will do our best to expedite. Finally, we have also been addressing social justice and access in our podcast, where we interviewed disability activist Alice Wong and most recently Dr Oni Blackstock, primary care physician and HIV specialist in New York.

We hope to have many more viagra 25mg on these critical subjects.We wish all of you good health and safety and know that many of you are yet on the front lines. Thank you for being part of the community of Medical Humanities.IntroductionMinecraft is a computer game with no specific goals to accomplish. The gameworld consists of three-dimensional (3D) cubes and viagra 25mg objects which the player (Steve) can mine and build into infinitely complex (and logically impossible) structures.

Steve sometimes encounters other characters (‘mobs’), such as animals and hostile creatures. He can ‘spawn’ and destroy them. While it looks like a harmless game of logical construction, viagra 25mg it conveys some worryingly delusive ideas about the real world.

The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification in mental health has had various forms throughout history. Mack and colleagues set out a history of psychiatric classification beginning in 2600 BC with Egyptian references to melancholia and hysteria viagra 25mg. Through the Ancient Greeks with Hippocrates’ phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease.

Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some viagra 25mg common trends such as the labels ‘melancholia’ and ‘hysteria’ which have survived millennia, the label ‘depression’ is relatively new. The earliest usage noted by Snaith is from 1899.

€˜in simple pathological depression…the patient exhibits a growing indifference to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf viagra 25mg Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge. This did not happen until the middle of the 20th century. With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate.

In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the viagra 25mg evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical quarrels around categorisation of mental disorders. DSM I and DSM II have been described as products of an American Psychiatric Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories. €˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision viagra 25mg of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state.

Zimbardo, who described psychiatric care as a controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’. Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists viagra 25mg classify as a depression is constructed differently in other cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science.

In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are opposing stances in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility. The nominalism–realism debate is illustrated using as metaphor three different stances viagra 25mg a cricket umpire might take on calling strikes and balls. The discussion sets out two of these as extreme views.

€˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who is characterised as holding particularly extreme views, is named as viagra 25mg an archetypal solipsist. There is implied to be a degree of arrogance associated with this view in the illustrative example in which the umpire states ‘there are no balls and there are no strikes until I call them’.

Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as viagra 25mg I see them’, other than to focus on its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’. The natural conclusion the reader is invited to reach is that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’. Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’.

The prototypical approach viagra 25mg is again put forward as a clinically useful middle ground. Illustrations are drawn from natural science. €˜a triangle and a square are never the viagra 25mg same’, inciting the reader to consider science as value-free.

The prototypical approach emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification. Doing so is more viagra 25mg like playing Minecraft than cricket.

The National Institute for Health and Care Excellence (NICE) guideline for depression is taken as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, specifically subcategories of persistent forms of depression. As well as serving a clinical purpose, diagnosis in medicine is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within viagra 25mg the National Health Service. The consequences for recipients of healthcare are therefore significant.

Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression. €˜further-line’ treatment of viagra 25mg depression (equivalent to TRD), CD and ‘depression with co-morbidities’. The latter is subdivided into treatments for ‘complex depression’ and ‘psychotic depression’.

These categories and subcategories introduce an unfortunate sense of certainty as though these labels represent viagra 25mg real things. An analysis follows of how these definitions play out in terms of grouping of randomised controlled trials in the NICE evidence review. Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years.

Dysthymia and double depression viagra 25mg (MDD superimposed on dysthymia) were included. If 75% of the trial population met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point. If 80% of the viagra 25mg trial participants met these criteria, it was reviewed in the TRD category.13 Complex depression was defined as ‘depression co-existing with personality disorder’.

To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there is a potential problem with attempting to categorise trial populations into just one of these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information. The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the category of further-line viagra 25mg treatments (TRD), 64 trials were reviewed.

Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’. In drilling down by way of illustration, this analysis considers the 51 trials in the augmentation viagra 25mg strategy evidence review. Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs.

Fonagy 2015 and Kocsis 200915). About half of the trials (23/51) did not report the mean duration of episode, meaning that it is not possible to know what percentage of participants also met the criteria for CD viagra 25mg. Of trials that did report episode duration, 17 reported a mean duration longer than 24 months.

While the standard deviations varied in size or were unreported, the mean indicates a good likelihood that a significant proportion of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by viagra 25mg NICE. For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations. Only 14 of 51 trials report employment data.

Of those viagra 25mg that do, unemployment ranges from 12% to 56% across trial samples. None of the trials report trauma history. About half of the trials (26/51) excluded people who were considered a suicide viagra 25mg risk.

The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity. Of these, 18 did not exclude any diagnoses, while 12 excluded some (but not all) disorders. The most common diagnoses excluded were psychotic disorders, substance or alcohol abuse, and bipolar viagra 25mg disorder (excluded in 26, 25 and 23 trials, respectively).

Only 7 of 51 trials clearly stated that all axis 1 diagnoses were excluded. This leaves only viagra 25mg 13 studies providing any data about comorbidity. Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD.

Many stated PD as an exclusion criterion but without defining a threshold for exclusion. For example, viagra 25mg PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’. Some excluded certain PDs (such as antisocial or borderline) and not others but without reporting the prevalence of those not excluded.

In the five trials where prevalence was clear, prevalence ranged viagra 25mg from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample (Town 201715). Two studies reported the mean number of PDs. 2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The majority of trials (43/51) did not report the prevalence of physical illness.

Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be viagra 25mg interpreted in different ways. For example, illness could be excluded if it was ‘unstable’, ‘serious’, helpful hints ‘significant’, ‘relevant’, or would ‘contraindicate’ or ‘impact’ the medication. Of the eight trials reporting information about physical health, there was viagra 25mg a wide variation.

Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used scales of physical health. Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this viagra 25mg would be a clinically useful classification for general practitioners.

NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials which use more than one of these measures reveals problems in the algorithm. Of the 51 trials, there are 6 instances in which the study population falls into NICE’s more severe category according to viagra 25mg one measure and into the less severe category according to another. In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715).

The other two trials were designated more severe (Barbee 2011, Dunner 200715). Only 17 of 51 trials reported two or more depression scale measures, leaving much unknown viagra 25mg about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?. A key philosophical error in science is to confuse an absence of knowledge with knowledge of absence.

It is likely that some of the study populations deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity viagra 25mg. Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm). The information may be non-existent as it was not collected.

It may be somewhere in the viagra 25mg publication pipeline. Or it may be sitting in a database with a research team that has run out of funds for supplementary analyses. Wherever those data are or are not, their absence from published articles does not define the phenomenology viagra 25mg of depression for the patients who took part.

As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial also meets the guideline criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published cut-off scores). NICE categorised this population as less viagra 25mg severe TRD, not CD and not complex.Notes1.

Avram H. Mack et viagra 25mg al. (1994), “A Brief History of Psychiatric Classification.

From the Ancients to DSM-IV,” Psychiatric Clinics 17, no. 3. 515–9.2.

R. P. Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no.

3. 387.3. Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &.

Gerald N. Grob (1991), “Origins of DSM-I. A Study in Appearance and Reality,” The American Journal of Psychiatry.

421–31.5. Wilson M. Compton and Samuel B.

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

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

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

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

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

208–15.10. Allen Frances et al. (1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy.

A Forum for Bioethics and Philosophy of Medicine 19, no. 3. 207–18.11.

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

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

Ibid., 351–62.14. Ibid., 597.15. Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used.

See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16. National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management.

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

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

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

Jacqui Thornton (2018), “Depression in Adults. Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361. K2681..

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Paul thorn viagra

When we took the editorship check my site of Evidence-Based Mental Health (EBMH) at the end of 2013, we paul thorn viagra set two main objectives. To promote and embed an paul thorn viagra evidence-based medicine (EBM) approach into daily mental health clinical practice, and to get an impact factor (IF) for EBMH. Both aims have been big paul thorn viagra challenges and we have learnt a lot.EBM has been around for about 30 years now, shaping and changing the way we practice medicine.

When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains. The best available evidence, the clinical state and circumstances, and patient’s preferences and values paul thorn viagra. EBM and EBMH have since continuously evolved to deepen our understanding of these three domains.The best available evidenceWe keep complaining paul thorn viagra about the poor quality of studies in mental health.

To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily paul thorn viagra …IntroductionQuality-adjusted life years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse than death). QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal paul thorn viagra decisions.The representative method to evaluate QALYs is the generic, preference-based measure of health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the UK.

While the responsiveness of such generic measures to various mental conditions, especially severe mental paul thorn viagra illnesses, has been questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms. Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled paul thorn viagra trials of internet cognitive-behavioural therapies (iCBT) for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously.

This study, therefore, attempts to link the depression-specific measure onto the generic measure of health in order to paul thorn viagra enable estimation of QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if they had missing paul thorn viagra data in either of the two scales at baseline or at endpoint.

We excluded studies that focused on patients with general medical disorders paul thorn viagra (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do. This produces 3ˆ5=243 different health states, ranging from paul thorn viagra no problem at all in any dimension (11111) to severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population.

In TTO, respondents are asked to give the relative length paul thorn viagra of time in full health that they would be willing to sacrifice for the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health and 0=death to paul thorn viagra minus values=worse than death bounded by −1. The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults.

Over the years, value sets for EQ-5D-3L paul thorn viagra have been produced for many countries/regions.2 3 7Depression severity scalesWe included any validated depression severity measures. The scale scores were converted into the most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, paul thorn viagra each rated on a scale between 0 and 3, making the total score range 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness.

The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 and 20- paul thorn viagra for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their changes, to establish if the linking is justified. Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then applied the equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks paul thorn viagra and allows for a nominal translation from PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation paul thorn viagra and with the Helsinki Declaration of 1975, as revised in 2008.

Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1). Three studies included only paul thorn viagra patients with major depressive disorder (MDD), one only patients with subthreshold depression and the remaining three included both. All the studies paul thorn viagra administered EQ-5D-3L.

PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total paul thorn viagra scores at baseline and at endpoint. Figure 2 shows the same between paul thorn viagra their change scores.

Table 1 summarises the correspondences between the two paul thorn viagra scales.PHQ-9 and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions. PHQ-9, PatientHealth Questionnaire-9." data-icon-position data-hide-link-title="0">Figure paul thorn viagra 1 PHQ-9 and EQ-5D total scores at baseline and endpoint.

EQ-5D,Euro-Qol Five Dimensions paul thorn viagra. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol paul thorn viagra Five Dimensions.

PHQ-9, Patient Health Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 change paul thorn viagra scores and EQ-5D change scores. EQ-5D,Euro-Qol Five paul thorn viagra Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores.

To summarise, subthreshold depression paul thorn viagra corresponded with EQ-5D-3L index values of 0.9–0.8, mild major depression with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean (SD) utilities paul thorn viagra based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression. The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression.

One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies (IAPT) cohort7 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56 paul thorn viagra. Our results are largely in line with these aforementioned studies.There was a consistent difference of about paul thorn viagra 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer.

It is, therefore, reasonable to use the conversion table at baseline for relatively new cases of depression and that at end of treatment for more chronic cases (table 1).An effect size paul thorn viagra to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the average SD of PHQ-9 in the studies was about 6, an effect size of 0.3 corresponds to a difference by two points on PHQ-9 paul thorn viagra. The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 paul thorn viagra and 0.13, producing an approximate average of 0.1 EQ-5D scores.

If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to paul thorn viagra 0.05 QALY. (See figure paul thorn viagra 3 for a schematic drawing to help understand the calculation of QALYs based on changing EQ-5D scores.

In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less. If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 sessions of psychotherapy cost US$1600–3200 dollars, paul thorn viagra both therapies would be deemed largely cost-effective. An individual’s decision, by contrast, will and should paul thorn viagra be more variable and no one can categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies.

A patient may start with PHQ-9 of 20, corresponding with paul thorn viagra EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain paul thorn viagra in QALY per year would be equal to 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY paul thorn viagra. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be paul thorn viagra similar.

EQ-5D, Euro-Qol Five paul thorn viagra Dimensions. PHQ-9, Patient paul thorn viagra Health Questionnaire-9. QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies.

A patient may start with PHQ-9 of 20, corresponding with EQ-5D paul thorn viagra index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed paul thorn viagra line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.

If we assume paul thorn viagra that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic paul thorn viagra drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.

EQ-5D,Euro-Qol Five paul thorn viagra Dimensions. PHQ-9, PatientHealth paul thorn viagra Questionnaire-9. QALY, quality-adjustedlife years.Several caveats should be paul thorn viagra considered when interpreting the results.

First, our sample was limited to participants of trials of iCBT. It may be argued that the results, therefore, would not apply to patients with depression undergoing paul thorn viagra other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in PHQ-9 scores at baseline because some studies required minimum depression paul thorn viagra scores.

However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were able to compare PHQ-9 to paul thorn viagra EQ-5D-3L only. The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder paul thorn viagra conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion values.Our study also has several important strengths.

First, our sample included patients with subthreshold depression and major depression and from the community or workplace and the primary care paul thorn viagra. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in our sample paul thorn viagra received iCBT or control interventions including care as usual.

Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken into consideration when evaluating their impacts, but our estimates, arguably independent of paul thorn viagra major side effects, can better inform such considerations. Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable fine-grained paul thorn viagra assessment of burden of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request.

The overall database used for this IPD is restricted due to data sharing agreements with the research institutes where the studies were conducted paul thorn viagra. IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

When we took the editorship of Evidence-Based Mental Health (EBMH) best place to buy viagra online at the end of 2013, we set two main objectives. To promote and embed an evidence-based medicine (EBM) approach into daily mental health clinical practice, best place to buy viagra online and to get an impact factor (IF) for EBMH. Both aims have been big challenges and best place to buy viagra online we have learnt a lot.EBM has been around for about 30 years now, shaping and changing the way we practice medicine. When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains.

The best available evidence, the clinical state and circumstances, and patient’s preferences best place to buy viagra online and values. EBM and EBMH have best place to buy viagra online since continuously evolved to deepen our understanding of these three domains.The best available evidenceWe keep complaining about the poor quality of studies in mental health. To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily …IntroductionQuality-adjusted life years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse best place to buy viagra online than death).

QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure best place to buy viagra online of health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the UK. While the responsiveness of such generic measures to various mental conditions, especially severe best place to buy viagra online mental illnesses, has been questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms. Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled trials of internet cognitive-behavioural therapies (iCBT) for best place to buy viagra online depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously.

This study, therefore, attempts to link the depression-specific measure onto the generic measure of health in order to enable estimation of best place to buy viagra online QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if they had missing data in either of the two scales at baseline best place to buy viagra online or at endpoint. We excluded studies that focused on patients with general medical disorders (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe best place to buy viagra online EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do.

This produces 3ˆ5=243 different health states, ranging from no problem at best place to buy viagra online all in any dimension (11111) to severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population. In TTO, respondents are asked to give the relative length of time in best place to buy viagra online full health that they would be willing to sacrifice for the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health and 0=death to minus values=worse than death bounded by best place to buy viagra online −1.

The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults. Over the years, value sets for EQ-5D-3L have been produced for best place to buy viagra online many countries/regions.2 3 7Depression severity scalesWe included any validated depression severity measures. The scale scores were converted into the most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range best place to buy viagra online 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness.

The cut-offs have been proposed as 0–4, best place to buy viagra online 5–9, 10–14, 15–19 and 20- for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their changes, to establish if the linking is justified. Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 We then applied the equipercentile linking procedure,19 which best place to buy viagra online identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully best place to buy viagra online for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1).

Three studies included only patients with major best place to buy viagra online depressive disorder (MDD), one only patients with subthreshold depression and the remaining three included both. All the studies administered best place to buy viagra online EQ-5D-3L. PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the best place to buy viagra online standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint.

Figure 2 best place to buy viagra online shows the same between their change scores. Table 1 summarises the correspondences between the two scales.PHQ-9 best place to buy viagra online and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions. PHQ-9, PatientHealth Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 1 PHQ-9 and EQ-5D total scores at baseline best place to buy viagra online and endpoint.

EQ-5D,Euro-Qol Five best place to buy viagra online Dimensions. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol best place to buy viagra online Five Dimensions. PHQ-9, Patient Health best place to buy viagra online Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 change scores and EQ-5D change scores.

EQ-5D,Euro-Qol Five best place to buy viagra online Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores. To summarise, subthreshold depression corresponded with EQ-5D-3L index values of 0.9–0.8, mild major depression with 0.8–0.7, moderate depression best place to buy viagra online with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values for depression31 found that the pooled mean (SD) utilities based on studies using the standard best place to buy viagra online gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression.

The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression. One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to best place to buy viagra online Psychological Therapies (IAPT) cohort7 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these aforementioned studies.There was a consistent difference of about 0.07 EQ-5D scores for the best place to buy viagra online same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1). This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer.

It is, best place to buy viagra online therefore, reasonable to use the conversion table at baseline for relatively new cases of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is 0.3. Given that the average SD of PHQ-9 in best place to buy viagra online the studies was about 6, an effect size of 0.3 corresponds to a difference by two points on PHQ-9. The differences best place to buy viagra online in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is between 5 and 15 (table 1), ranges between 0.08 and 0.13, producing an approximate average of 0.1 EQ-5D scores. If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control best place to buy viagra online group, the gain in QALY per year would be equal to 0.05 QALY. (See figure 3 for a schematic drawing to help understand the calculation of QALYs best place to buy viagra online based on changing EQ-5D scores. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less. If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 sessions of psychotherapy cost US$1600–3200 dollars, both therapies would be deemed largely cost-effective best place to buy viagra online.

An individual’s decision, by contrast, will and should be more variable and no one can categorically reject nor best place to buy viagra online require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of 20, best place to buy viagra online corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that best place to buy viagra online the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.

If we assume that the difference best place to buy viagra online would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be best place to buy viagra online more smoothly curvilinear but the calculation will be similar. EQ-5D, Euro-Qol Five best place to buy viagra online Dimensions.

PHQ-9, Patient best place to buy viagra online Health Questionnaire-9. QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start best place to buy viagra online with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D best place to buy viagra online score of 0.8 even if on placebo (dashed line).

If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would best place to buy viagra online eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. Please note that this is a best place to buy viagra online schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.

EQ-5D,Euro-Qol Five best place to buy viagra online Dimensions. PHQ-9, PatientHealth Questionnaire-9 best place to buy viagra online. QALY, quality-adjustedlife years.Several caveats should be best place to buy viagra online considered when interpreting the results. First, our sample was limited to participants of trials of iCBT.

It may be best place to buy viagra online argued that the results, therefore, would not apply to patients with depression undergoing other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking best place to buy viagra online but were somewhat weaker at baseline, probably due to limited variability in PHQ-9 scores at baseline because some studies required minimum depression scores. However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were best place to buy viagra online able to compare PHQ-9 to EQ-5D-3L only.

The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder best place to buy viagra online conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L to examine if we can obtain similar conversion values.Our study also has several important strengths. First, our sample included patients with subthreshold depression and major depression and from the community or workplace and best place to buy viagra online the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in our sample received best place to buy viagra online iCBT or control interventions including care as usual.

Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken into consideration when evaluating their impacts, best place to buy viagra online but our estimates, arguably independent of major side effects, can better inform such considerations. Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments which best place to buy viagra online may bring various degrees of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request. The overall database used best place to buy viagra online for this IPD is restricted due to data sharing agreements with the research institutes where the studies were conducted.

IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

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UNDP Bangladesh/Fahad KaizeCommunity workers, supported by the UN, promote erectile dysfunction prevention awareness and distribute hygiene packages among poor urban households in Bangladesh.…and were reminded about the importance of handwashing as a way to reduce the transmission of diseases. © UNICEF/Alissa EverettTwo siblings study at home in Mathare slum, Nairobi, Kenya, accessing their lessons on the family mobile phone.Students who were not able to go to school had to adapt to a new reality and find ways to keep up with their metoprolol and viagra studies. WFP/Damilola OnafuwaWomen in Nigeria collect food vouchers as part of a programme to support families 
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UN Photo/Evan SchneiderA New York City resident advocates for how he thinks the erectile dysfunction (erectile dysfunction treatment) outbreak should be tackled. As the world enters 2021, the viagra is still raging and, after metoprolol and viagra an apparent mid-year lull in many countries, more s and more deaths are being reported. With more treatments being rolled out, the international community is being urged to work together to stop the spread and follow science-based guidelines.For a more detailed picture of how the world looked in 2020, look out for our UN News end-of-year series of special reports, as the year draws to a close.Resident Coordinator in the country, Niky Fabiancic, is leading these efforts, said UN Spokesperson, Stéphane Dujarric, speaking in New York.

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UN News/Daniel best place to buy viagra online DickinsonA dental office in Brooklyn, New York, posts a grim reminder of the changes brought about by the erectile dysfunction.As erectile dysfunction treatment took hold, countries and cities across the world entered lockdown with the closure of schools, cultural and sports venues and all non-essential businesses. World Bank/Sambrian MbaabuIt's hoped that downtown areas in cities like Nairobi in Kenya, will recover strongly from the erectile dysfunction treatment viagra.Normally bustling city centres, like the Kenyan capital Nairobi, were eerily quiet as people stayed at home. UN Photo/Eskinder DebebeDelegates in the UN General Assembly hall observe social distancing as meetings get underway during the busiest week of the year at the United Nations The United Nations did stay best place to buy viagra online open for business across the world, although most of the key events, like the annual meeting of the new session of the General Assembly in New York, did look very different. Only a small number of delegates were allowed into the chamber as world leaders gave their speeches virtually.

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