Zithromax cost no insurance

Zithromax cost no insurance

So remember that time Tori and I posted our first TWTT? Well, we’re back in action! Katherine, Julia and I wanted to share a few quick photos we snapped at our team picnic from yesterday. Some weeks we may have a fun craft, recipe or adventure to share so you can all keep up with us in our personal lives in between the brilliant sessions and weddings we will be posting! I am so excited about these two girls and the stories their hearts have to share. It was so fun meeting at Longs Park, collaborating a fun little meal, talking about photography/the business and just chatting about life and what’s going on for all of us. I’m also so glad the weather is deciding to take a break from the rain and give us some nice sunshine!

Enjoy our little picnic while I head back to editing for the day!

Meagan Nicole

 photo blog001-33.jpg photo blog002-32.jpg photo blog003-29.jpg photo blog004-27.jpg

Zithromax cost no insurance

Zithromax cost no insurance

The past week has seen an explosion of media commentary about whether children in the UK should go back zithromax cost no insurance to school. Since ‘lockdown’ (23 March 2020) began schools have been open to vulnerable children and young people, and to the children of ‘key zithromax cost no insurance workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools.

Viner et al1 produced a rapid systematic review that concludes that zithromax cost no insurance school closures have less impact on rate and mortality than other social distancing measures. Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’. This was conveyed to the population of the UK on 10 May by the UK zithromax cost no insurance prime minister, Boris Johnson.

He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken by various groups, including a preprint (not peer-reviewed) zithromax cost no insurance modelling exercise by Zhang et al.3Mr Johnson announced that there would be a phased return (in England) of some children to school from 1 June. There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools.

In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a zithromax cost no insurance vital part of restarting the UK economy, but they have concerns about the safety and welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision. Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there are children out there that have not zithromax cost no insurance spoken or played with another child their own age for the last two months.

They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest children will be the ones who fall further behind if we keep zithromax cost no insurance school gates closed. This phased return is in line with what other European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets and news articles identifying problems in enacting the government plan zithromax cost no insurance and the illogical nature of Williamson’s statement.

The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school. This has caused concern about the attainment gap, but as Quinn6 points out fewer children from disadvantaged backgrounds are likely to return to school than those from more affluent backgrounds.Government ministers and spokespeople reiterated zithromax cost no insurance that scientific evidence and observation of other European countries where schools had reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit.

Is that zithromax cost no insurance correct?. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’. This provoked zithromax cost no insurance a great deal of disquiet.

Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the zithromax cost no insurance risk to children of developing antibiotics disease. The second is the risk to others of children transmitting antibiotics disease, either while being symptomatic or asymptomatic.

Here are some of the available zithromax cost no insurance evidence.Morbidity and mortality in children from antibiotics diseaseChildren appear to be less likely to acquire antibiotics disease in various nations.9–11 Barton et al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications). Of these 8113 paediatric cases, 14% required hospital admission. The admission rate to critical care was zithromax cost no insurance 2.2% of confirmed cases (7.2% of admitted children).

Death was reported zithromax cost no insurance in 15 cases (0.18%). This adds to other evidence suggesting that children are at a relatively low risk from the zithromax, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the zithromax.15There are concerns that children who have been infected with the zithromax can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for buy antibiotics, and in the absence of effective community testing it will be impossible to know if they are carrying the zithromax. Children also can have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In short, it is difficult to determine without much more extensive testing if a child can transmit the .Arav et al18 found that the contact route was much more important than the airborne route, which they zithromax cost no insurance concluded had a negligible contribution.

They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is zithromax cost no insurance a case for reopening schools to limited numbers of pupils—the risk to pupils and the adults they come into contact with seems to be small, and the potential gains for children may outweigh them. There is a big proviso with this however, and that is that the overall incidence of buy antibiotics has fallen below specified threshold.

This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of decreasing to manageable levels.Ensuring that personal protective equipment supply can meet demand.Being confident that any adjustments would not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the information that the government and their scientific advisors are sharing zithromax cost no insurance. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy. Decisions about whether to reopen schools are taken on a national level with a distance from personal concerns and zithromax cost no insurance fears.

Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is a difficult path to navigate zithromax cost no insurance. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation.

Parents were being asked to believe that MMR was a safe treatment in the face of a massive and emotive campaign that promoted the ‘risk’ of having the treatment zithromax cost no insurance above all else. This situation is even more complex than that as we have increased access to opinion and difficulty in understanding if or how much that information zithromax cost no insurance is biased. It is no wonder that decision-making is difficult.

It is likely that evidence will continue to emerge and gradually the choice will become easier to make zithromax cost no insurance. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach. By working to identify a consensus position, researchers can report findings on a specific question (or set of questions) that are based on the zithromax cost no insurance knowledge and experience of experts in their field.However, there are challenges to this approach.

For example, what should be done when consensus cannot be reached?. How can experts be engaged in a way zithromax cost no insurance that allows them to consider objectively the views of others and—where appropriate—change their own opinions in response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus.

Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, so that the methods employed “…appear to be more conducive to independent thought on the part of the experts and to aid them in the gradual formation of a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to zithromax cost no insurance other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline. First, the overarching approach is based on a series of ‘rounds’, where a set of experts are asked their opinions zithromax cost no insurance on a particular issue.

The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses. Finally, the findings of each round are always shared zithromax cost no insurance with the broader group anonymously. This avoids any zithromax cost no insurance bias that might result from participants being concerned about their own views being viewed negatively or from their own opinions being biased by personal factors.

This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged. For example, a study zithromax cost no insurance of human factors that contributed to nursing errors used only two rounds. The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could.

Analysis of responses resulted in a list of 28 potential reasons—this list was sent back to the same group of experts for the second round, asking them to score each one for zithromax cost no insurance importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round 1, draft competencies were developed from the findings of zithromax cost no insurance a survey of NP beliefs, knowledge and level of implementation of advance care planning.

Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made based on the original feedback, and a third round was conducted where 15 of the original zithromax cost no insurance NP participants confirmed their consensus with the final document. The final document includes four competencies, each with several elements.

Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses of Delphi studiesThe Delphi technique offers a flexible approach to gathering the zithromax cost no insurance views of experts on an area of interest. The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups. The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from dominant or high-profile members of the group are given extra credence.5However, Delphi studies can—by their very nature—be zithromax cost no insurance complex and time consuming.

The need for participants to complete multiple rounds can lead zithromax cost no insurance to high drop-out rates which impacts on validity of the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword. It provides those taking part with the opportunity to reflect and reconsider their position in zithromax cost no insurance response to additional information, which is an important part of nursing practice.

Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’. Even with the level of flexibility and reflexivity present in Delphi studies, it is still zithromax cost no insurance unlikely that a group of experts will demonstrate 100% agreement on issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached.

This is where there is inconsistency across studies and authors, with the suggested level of consensus ranging from 51% to 100%.2 In addition, it has been identified that in zithromax cost no insurance some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore related to the quality of evidence, with expert opinion viewed as providing a poor zithromax cost no insurance basis for making judgements on healthcare interventions.7 This does not mean that the findings of Delphi studies are intrinsically unreliable or invalid.

It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts. It allows for reflection among participants, who are able to nuance and reconsider their opinion based zithromax cost no insurance on the anonymised opinions of others. However, researchers must take steps to enhance robustness of the studies.

It is important to try and prevent participants from simply resorting to agreeing with the majority view zithromax cost no insurance. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

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More than 2,800 scientists from 130 countries gathered on Friday (January 15) in a virtual forum hosted by the World Health Organization (WHO) to identify knowledge gaps and set research priorities for treatments against fish zithromax antibiotics, the zithromax that causes buy antibiotics.They discussed the safety and efficacy of existing treatments and new candidates, ways to optimize limited supply, and the need for additional safety studies.“The development and approval of several safe and effective treatments less than a year after this zithromax was isolated and sequenced is an astounding scientific accomplishment,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, in his opening remarks. €œThe approval of the first few treatments does not mean the job fish zithromax is done. Far from it. More treatments are in the pipeline, which must be evaluated to ensure we have enough fish zithromax doses to vaccinate everyone.”More than 30 million treatment doses have already been administered in 47 mostly high-income countries. But the global treatment rollout has exposed glaring inequalities in access to this life-saving tool.

€œThe spirit of collaboration has to prevail fish zithromax in these challenging times as we seek to understand this zithromax,” said Dr John Nkengasong, Director of the Africa Centres for Disease Control and Prevention. €œWe have to be mindful of the inequalities and we must deliberately promote investment in regional capacities to level the playing field and have meaningful collaboration to begin to address some of the challenges.”Experts agreed the need for critical research on administering treatments in different target populations, as well as on vaccination delivery strategies and schedules. This includes trials, modelling and observational studies, all of which would help to inform policy.They discussed the impact of emerging antibiotics variants on the efficacy of treatments, the impact of treatments on transmission fish zithromax of , and the need to develop the next generation of treatment platforms. €œThe world needs multiple treatments that work in different populations in order to meet global demand and end the buy antibiotics outbreak. Ideally, those will be single-dose treatments that do not require cold chain, could be delivered without a needle and syringe fish zithromax and are amenable to large-scale manufacture,” said Professor Mike Levine, Director of the Center for treatment Development at the University of Maryland.The meeting concluded with agreement to establish a WHO-hosted platform for global sharing and coordination of emerging treatment research information on efficacy and safety.

The forum would enable scientists to share and discuss unpublished and published data and research protocols to further our collective understanding of antibiotics treatments.“The WHO will regularly convene experts from around the world, promote collaborative research, provide standard protocols and develop a platform for sharing the latest knowledge in the field,” said Dr Soumya Swaminathan, WHO Chief Scientist..

More than 2,800 scientists from 130 countries gathered on Friday (January 15) in a virtual forum hosted by the World Health Organization (WHO) to identify knowledge gaps and set research priorities for treatments against antibiotics, the zithromax that causes buy antibiotics.They discussed the safety and efficacy of existing treatments and new candidates, ways to optimize limited supply, and the zithromax cost no insurance need for additional safety studies.“The development and approval of several safe and effective treatments less than a year after this zithromax was isolated and sequenced is an astounding scientific accomplishment,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, in his opening remarks. €œThe approval of the first few treatments does not mean the zithromax cost no insurance job is done. Far from it.

More treatments are in the pipeline, which must be evaluated to ensure we have enough doses to vaccinate everyone.”More than 30 million treatment doses have already been administered in 47 mostly high-income zithromax cost no insurance countries. But the global treatment rollout has exposed glaring inequalities in access to this life-saving tool. €œThe spirit of collaboration has to prevail in these challenging times as we seek to understand this zithromax,” said Dr John Nkengasong, Director of the Africa Centres for Disease Control and zithromax cost no insurance Prevention.

€œWe have to be mindful of the inequalities and we must deliberately promote investment in regional capacities to level the playing field and have meaningful collaboration to begin to address some of the challenges.”Experts agreed the need for critical research on administering treatments in different target populations, as well as on vaccination delivery strategies and schedules. This includes trials, modelling and observational studies, all of which would zithromax cost no insurance help to inform policy.They discussed the impact of emerging antibiotics variants on the efficacy of treatments, the impact of treatments on transmission of , and the need to develop the next generation of treatment platforms. €œThe world needs multiple treatments that work in different populations in order to meet global demand and end the buy antibiotics outbreak.

Ideally, those will be single-dose treatments that do not require cold zithromax cost no insurance chain, could be delivered without a needle and syringe and are amenable to large-scale manufacture,” said Professor Mike Levine, Director of the Center for treatment Development at the University of Maryland.The meeting concluded with agreement to establish a WHO-hosted platform for global sharing and coordination of emerging treatment research information on efficacy and safety. The forum would enable scientists to share and discuss unpublished and published data and research protocols to further our collective understanding of antibiotics treatments.“The WHO will regularly convene experts from around the world, promote collaborative research, provide standard protocols and develop a platform for sharing the latest knowledge in the field,” said Dr Soumya Swaminathan, WHO Chief Scientist..

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Swallow tablets whole with a full glass of water. Azithromycin tablets can be taken with or without food. Take your doses at regular intervals. Do not take your medicine more often than directed. Finish the full course prescribed by your prescriber or health care professional even if you think your condition is better. Do not stop taking except on your prescriber''s advice. Contact your pediatrician or health care professional regarding the use of Zithromax in children. Special care may be needed. Overdosage: If you think you have taken too much of Zithromax contact a poison control center or emergency room at once. NOTE: Zithromax is only for you. Do not share Zithromax with others.

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The move, announced late on Thursday, comes after a joint report was issued in March by WHO and China into http://emukconsultancy.co.uk/how-to-get-symbicort-in-the-us the origins of the antibiotics..@WHO calls for all governments to depoliticize the situation and cooperate to accelerate the #buy antibiotics19 origins studies, and importantly to work together to develop a common framework for future emerging pathogens of zithromax potential.— Tedros Adhanom Ghebreyesus (@DrTedros) August 12, 2021 Noting that a review of that report had determined that there was “insufficient scientific evidence to rule any of the hypotheses out” about the origins of the new antibiotics, the UN agency insisted that to address the ‘lab hypothesis’, it needed access “to all data” in order to prevent global health threats in future.“WHO calls for all governments to depoliticize the situation and cooperate to accelerate the origins studies, and importantly to work together to develop a common framework for future emerging pathogens of zithromax potential,” it said.“We call on all governments to put differences aside and work together to provide all data zithromax pediatric dose and access required so that the next series of studies can be commenced as soon as possible.”In a detailed statement, WHO explained that it had decided on a new series of scientific studies “that need to be undertaken” into “all hypotheses” about how the previously unknown pathogen crossed from animals to humans.Transparency callA new independent advisory group of experts called the International Scientific Advisory Group for Origins of Novel Pathogens (SAGO) will support the sensitive project by coordinating the studies recommended in the March report, it said.In the interests of transparency, WHO said that it welcomed nominations for the panel from all countries, adding that the experts’ work would resemble previous buy antibiotics missions to China and those launched to hunt for the origins of avian influenza, Lassa zithromax and Ebola zithromax.“This open call aims to ensure that a broad range of scientific skills and expertise are identified to advise WHO on the studies needed to identify the origins of any future emerging or re-emerging pathogen of zithromax potential,” the UN agency said.Scientific endeavourAfter highlighting how difficult it is for scientists to find the origins of any novel pathogen, the agency insisted that the mission “is not and should not be an exercise in attributing blame, finger-pointing or political point-scoring. It is vitally important to know how the buy antibiotics zithromax began, to set an example for zithromax pediatric dose establishing the origins of all future animal-human spill-over events.”With access to sensitive information crucial to the success of the new WHO studies, the UN agency noted that research would need to include “a further examination of the raw data from the earliest cases”, along with blood serum from potentially infected people in 2019, before the antibiotics outbreak was declared a zithromax. © UNICEF/Ismail TaxtaA health worker prepares to administer the buy antibiotics treatment to her colleague at a hospital in Mogadishu, Somalia.Data sharingData from “a number of countries” that reported finding the zithromax in blood samples taken in 2019 has zithromax pediatric dose already been shared with WHO, it noted. This included Italy, where WHO coordinated retesting of pre-zithromax blood samples outside the country.“Sharing raw zithromax pediatric dose data and giving permission for the retesting of samples in labs outside of Italy reflects scientific solidarity at its best and is no different from what we encourage all countries, including China, to support so that we can advance the studies of the origins quickly and effectively,” WHO said, before reiterating that access to data was “critically important for evolving our understanding of science and should not be politicised in any way”..

The move, announced late on Thursday, comes after a joint report was issued in March by WHO and China into the origins of the antibiotics..@WHO calls for all governments to depoliticize the situation and cooperate to accelerate the #buy antibiotics19 origins studies, and importantly to work together to develop a common framework for future emerging zithromax cost no insurance pathogens of zithromax potential.— Tedros Adhanom Ghebreyesus (@DrTedros) August 12, 2021 Noting that a review of that report had determined that there was “insufficient scientific evidence to rule any of the hypotheses out” about the origins of the new antibiotics, the UN agency insisted that to address the ‘lab hypothesis’, it needed access “to all data” in order to prevent global health threats in future.“WHO calls for all governments to depoliticize the situation and cooperate to accelerate the origins studies, and importantly to work together to develop a common framework for future emerging pathogens of zithromax potential,” it said.“We call on all governments to put differences aside and work together to provide all data click here to investigate and access required so that the next series of studies can be commenced as soon as possible.”In a detailed statement, WHO explained that it had decided on a new series of scientific studies “that need to be undertaken” into “all hypotheses” about how the previously unknown pathogen crossed from animals to humans.Transparency callA new independent advisory group of experts called the International Scientific Advisory Group for Origins of Novel Pathogens (SAGO) will support the sensitive project by coordinating the studies recommended in the March report, it said.In the interests of transparency, WHO said that it welcomed nominations for the panel from all countries, adding that the experts’ work would resemble previous buy antibiotics missions to China and those launched to hunt for the origins of avian influenza, Lassa zithromax and Ebola zithromax.“This open call aims to ensure that a broad range of scientific skills and expertise are identified to advise WHO on the studies needed to identify the origins of any future emerging or re-emerging pathogen of zithromax potential,” the UN agency said.Scientific endeavourAfter highlighting how difficult it is for scientists to find the origins of any novel pathogen, the agency insisted that the mission “is not and should not be an exercise in attributing blame, finger-pointing or political point-scoring. It is vitally important to know how the buy antibiotics zithromax began, to set an example for establishing the origins of all future animal-human spill-over events.”With access to sensitive information crucial to the success of the new WHO studies, the UN agency noted that research would need to include “a further examination of the raw data from the earliest cases”, zithromax cost no insurance along with blood serum from potentially infected people in 2019, before the antibiotics outbreak was declared a zithromax. © UNICEF/Ismail TaxtaA health worker prepares to administer the buy antibiotics treatment to her colleague at a hospital in Mogadishu, Somalia.Data sharingData from “a zithromax cost no insurance number of countries” that reported finding the zithromax in blood samples taken in 2019 has already been shared with WHO, it noted.

This included Italy, where WHO coordinated retesting of pre-zithromax blood samples outside the country.“Sharing raw data and giving permission for the retesting of samples in labs outside of Italy reflects scientific solidarity at its best and is no different from what we encourage all countries, including China, to support so that we can advance the studies of the origins quickly and effectively,” WHO said, before reiterating that access to data was “critically important for evolving our zithromax cost no insurance understanding of science and should not be politicised in any way”..

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Shutterstock A bipartisan coalition of 23 attorneys general recently sent a letter to the Food and Drug Administration zithromax pill (FDA) urging the agency to Antabuse price immediately ban menthol cigarettes. €œState attorneys general have on numerous occasions commented on tobacco-related topics to the FDA, reported violations to the FDA, and recommended that the FDA take steps to protect their citizens from the dangers of tobacco use and exposure to tobacco products,” the letter said. €œState attorneys general have zithromax pill also urged the FDA to ban flavored tobacco products…. This letter is a further attempt to urge the FDA to act in the interest of public health by promptly banning menthol cigarettes because the evidence shows these products cause harm to our citizens.”The attorneys general said that banning the cigarettes would save thousands of lives.

Menthol smoking disproportionately impacts youth and minority zithromax pill populations. It has been attributed as the top reason youths become addicted to smoking. In addition, menthol cigarettes are a barrier to smoking cessation and reducing smoking-related health conditions.An estimated 46.7 percent of middle and high school-aged smokers use menthol cigarettes, according to 2019 data, and 89 percent of African-American zithromax pill smokers smoke menthol cigarettes. Only 26 percent of white smokers use menthol..

Shutterstock A bipartisan coalition of 23 attorneys general recently sent a letter to zithromax cost no insurance the Food and Drug Administration (FDA) urging the agency to immediately ban menthol cigarettes. €œState attorneys general have on numerous occasions commented on tobacco-related topics to the FDA, reported violations to the FDA, and recommended that the FDA take steps to protect their citizens from the dangers of tobacco use and exposure to tobacco products,” the letter said. €œState attorneys general have also urged the FDA to ban zithromax cost no insurance flavored tobacco products…. This letter is a further attempt to urge the FDA to act in the interest of public health by promptly banning menthol cigarettes because the evidence shows these products cause harm to our citizens.”The attorneys general said that banning the cigarettes would save thousands of lives.

Menthol smoking disproportionately impacts youth zithromax cost no insurance and minority populations. It has been attributed as the top reason youths become addicted to smoking. In addition, menthol cigarettes are a barrier to smoking cessation and reducing smoking-related health conditions.An zithromax cost no insurance estimated 46.7 percent of middle and high school-aged smokers use menthol cigarettes, according to 2019 data, and 89 percent of African-American smokers smoke menthol cigarettes. Only 26 percent of white smokers use menthol..

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An award from the Health Resources and Services Administration will how to buy zithromax online increase underrepresented minorities in medicine and support student work in areas of mental health, http://www.em-holtzheim.ac-strasbourg.fr/fournitures-scolaires/ opioid addiction and primary care in rural areas. Written by Kevin StorrMedia contact. Adam PopeAn award from the Health Resources and Services Administration will increase underrepresented minorities in medicine how to buy zithromax online and support student work in areas of mental health, opioid addiction and primary care in rural areas.(Photography. Andrea Mabry and Lexi Coon)The Health Resources and Services Administration has awarded a $1,492,465 grant to the University of Alabama at Birmingham Physician Assistant Studies program to expand mental health training for students, increase the number of underrepresented minorities in medicine and extend clinical care to more underserved patient populations.In Alabama, 62 of the 67 counties fall under the federal definition of Health Professional Shortage Areas. More than one-third of recent UAB physician assistant graduates work in medically underserved areas, but everyone how to buy zithromax online recognizes that number needs to rise even more.

€œI grew up in a rural county in Alabama, and I have seen firsthand the devastating impact on a community when health care options continue to disappear,” said Kathy Nugent, Ph.D., chair of Department of Clinical and Diagnostic Sciences and director of the UAB Harbert Institute of Innovation and Entrepreneurship. €œI am excited that our PA students are being given more opportunities to reverse this disturbing trend and deliver more care to those in the most how to buy zithromax online need.”The HRSA grant is part of the program’s “PA Training Enhancement Initiative” and goes through 2026. It will enhance student training in opioid and other substance use disorders by delivering a specialized addiction medicine elective rotation that will be offered to five UAB PA students. In addition, this new elective rotation will also be offered to how to buy zithromax online five physician assistant students from other PA programs across the nation, on an annual basis for the next five years. €œThe substance use disorder — especially opioid addiction — is a zithromax in the United States,” said Wei Li, Ph.D., the grant’s principal investigator and an associate professor in the UAB PA program.

€œThis grant will help us prepare PA students from how to buy zithromax online our program, as well as other programs, in fighting this zithromax. Physician assistant students from other PA programs are welcome to apply for an opportunity to complete an elective in our newly developed addiction medicine rotation, with corresponding expenses being covered by this grant as a scholarship.” As part of the new initiatives, the HRSA grant will provide the UAB PA program an opportunity to enhance their behavioral medicine didactic curriculum. New curriculum — including training in the courses Mental Health First Aid, Applied Suicide Intervention Skills Training, and Screening, Brief Intervention and Referral to Treatment — will be how to buy zithromax online added to further develop student skills in recognizing and treating patients in the area of mental health.The National Alliance on Mental Health reports one in five U.S. Adults experiences mental illness. Considering the average primary care facility sees 20 patients per day, the physician assistant could encounter around four people experiencing mental illness daily.

The buy antibiotics zithromax has had a profound impact on the lives how to buy zithromax online of many Americans across the country, especially regarding their mental and emotional health. “Unfortunately, there are not enough psychiatrists or psychologists to screen, evaluate, treat and manage this growing population of patients,” said M. Tosi Gilford, M.D., how to buy zithromax online PA-C, the grant’s co-investigator and director of the UAB Physician Assistant Studies program. €œUltimately, the burden of care will lie heavily on clinicians practicing in primary care and in the setting of urgent care and emergency medicine. €œTo ensure our students are prepared to meet the needs of these patients in a how to buy zithromax online competent and compassionate manner, we are proud to be given an opportunity to expand our didactic and clinical training to equip students with the tools needed to assist in identifying, treating and counseling patients with mental illness.

And decrease the stigma of mental illness, in an effort to improve the cognitive, behavioral and emotional well-being of the patient population in which they will ultimately serve,” Gilford said. Recent diversity efforts from the Physician Assistant Studies program have resulted in a double-digit increase over the past two years in the number how to buy zithromax online of students underrepresented in medicine accepted to their incoming cohorts. The HRSA grant will support an expansion of the recruiting and retention efforts of these students, to surpass the national average for physician assistant programs. Furthermore, the UAB PA program will intensify their efforts how to buy zithromax online to facilitate the education of U.S. Military veterans to honor their service and the history of the program.

UAB PA is the second-oldest program how to buy zithromax online in the nation and was founded by military veterans in 1968.This is the second HRSA grant for the UAB Physician Assistant Studies program, which is housed in the School of Health Professions. In 2004, the program was awarded a grant to conduct risk assessments for sexually transmitted diseases and HIV. That grant resulted in the development of curriculum on recognizing risk behaviors in patients, and the training was also offered to visiting PA students from other programs across the country..

An award zithromax cost no insurance from the Health Resources and Services Administration will increase underrepresented minorities in medicine and support student work in areas of mental site link health, opioid addiction and primary care in rural areas. Written by Kevin StorrMedia contact. Adam PopeAn award from the Health Resources and Services Administration will increase underrepresented minorities in medicine and support student work in areas of mental health, opioid addiction and primary care in rural zithromax cost no insurance areas.(Photography. Andrea Mabry and Lexi Coon)The Health Resources and Services Administration has awarded a $1,492,465 grant to the University of Alabama at Birmingham Physician Assistant Studies program to expand mental health training for students, increase the number of underrepresented minorities in medicine and extend clinical care to more underserved patient populations.In Alabama, 62 of the 67 counties fall under the federal definition of Health Professional Shortage Areas. More than one-third zithromax cost no insurance of recent UAB physician assistant graduates work in medically underserved areas, but everyone recognizes that number needs to rise even more.

€œI grew up in a rural county in Alabama, and I have seen firsthand the devastating impact on a community when health care options continue to disappear,” said Kathy Nugent, Ph.D., chair of Department of Clinical and Diagnostic Sciences and director of the UAB Harbert Institute of Innovation and Entrepreneurship. €œI am excited that our PA students are being given more opportunities to reverse this disturbing trend and deliver more care to those in the most need.”The HRSA grant is part of the zithromax cost no insurance program’s “PA Training Enhancement Initiative” and goes through 2026. It will enhance student training in opioid and other substance use disorders by delivering a specialized addiction medicine elective rotation that will be offered to five UAB PA students. In addition, this zithromax cost no insurance new elective rotation will also be offered to five physician assistant students from other PA programs across the nation, on an annual basis for the next five years. €œThe substance use disorder — especially opioid addiction — is a zithromax in the United States,” said Wei Li, Ph.D., the grant’s principal investigator and an associate professor in the UAB PA program.

€œThis grant will help us prepare PA students from our program, zithromax cost no insurance as well as other programs, in fighting this zithromax. Physician assistant students from other PA programs are welcome to apply for an opportunity to complete an elective in our newly developed addiction medicine rotation, with corresponding expenses being covered by this grant as a scholarship.” As part of the new initiatives, the HRSA grant will provide the UAB PA program an opportunity to enhance their behavioral medicine didactic curriculum. New curriculum — including training in the courses Mental Health First Aid, Applied Suicide Intervention Skills Training, and Screening, Brief Intervention and Referral to Treatment zithromax cost no insurance — will be added to further develop student skills in recognizing and treating patients in the area of mental health.The National Alliance on Mental Health reports one in five U.S. Adults experiences mental illness. Considering the average primary care facility sees 20 patients per http://826la.org/la-galaxy-soccer-team-helps-826la-barnacles-bookworms-students-take-on-sports-writing/ day, the physician assistant could encounter around four people experiencing mental illness daily.

The buy antibiotics zithromax has had a profound impact on the lives of many Americans across zithromax cost no insurance the country, especially regarding their mental and emotional health. “Unfortunately, there are not enough psychiatrists or psychologists to screen, evaluate, treat and manage this growing population of patients,” said M. Tosi Gilford, M.D., PA-C, the grant’s co-investigator and director zithromax cost no insurance of the UAB Physician Assistant Studies program. €œUltimately, the burden of care will lie heavily on clinicians practicing in primary care and in the setting of urgent care and emergency medicine. €œTo ensure our students are prepared to meet the needs of these patients in a competent and compassionate manner, we are proud to be given an opportunity to expand our didactic and clinical training to equip students with the tools needed to assist in identifying, treating and counseling patients with zithromax cost no insurance mental illness.

And decrease the stigma of mental illness, in an effort to improve the cognitive, behavioral and emotional well-being of the patient population in which they will ultimately serve,” Gilford said. Recent diversity efforts from the Physician Assistant Studies program have resulted in zithromax cost no insurance a double-digit increase over the past two years in the number of students underrepresented in medicine accepted to their incoming cohorts. The HRSA grant will support an expansion of the recruiting and retention efforts of these students, to surpass the national average for physician assistant programs. Furthermore, the UAB PA program will intensify their efforts to zithromax cost no insurance facilitate the education of U.S. Military veterans to honor their service and the history of the program.

UAB PA is the second-oldest program in the zithromax cost no insurance nation and was founded by military veterans in 1968.This is the second HRSA grant for the UAB Physician Assistant Studies program, which is housed in the School of Health Professions. In 2004, the program was awarded a grant to conduct risk assessments for sexually transmitted diseases and HIV. That grant resulted in the development of curriculum on recognizing risk behaviors in patients, and the training was also offered to visiting PA students from other programs across the country..

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AbstractBrazil is currently home to the largest zithromax liquid price Japanese population outside of Japan. In Brazil today, Japanese-Brazilians are considered to be successful members of Brazilian society. This was zithromax liquid price not always the case, however, and Japanese immigrants to Brazil endured much hardship to 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 zithromax liquid price 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’ 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price recognise the deep reality of others as separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways.

The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine. Work that examines different ways of processing information, and of interacting with and being in the world, can be found in Iain McGilchrist’s The Master and His Emissary,10 where he draws on zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price has on preserving the identity and dignity or people living with dementia, while also 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 zithromax liquid price 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 zithromax liquid price that are capable of ‘communicating many messages 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 zithromax liquid price 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 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 a range zithromax liquid price 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 zithromax liquid price 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 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 (80 days) and medical assessment zithromax liquid price 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 a 6-week period at each site zithromax liquid price. 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 zithromax liquid price approximately 600 000 words of observational fieldnotes that were transcribed, cleaned and anonymised (by KF and AN). We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group.

This allowed us to question what they are doing and why, and what are the caring practices of ward staff when interacting with people living with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient zithromax liquid price 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 zithromax liquid price 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. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study.

The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data analysis was complete, the advisory group zithromax liquid price 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 zithromax liquid price. 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 zithromax liquid price 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 of the patient, with any items tidied away out of sight zithromax liquid price.

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 observed that zithromax liquid price 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 received favourably by the patient.A member of the bay team returned to a patient and found her freshly dressed in a zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price physiotherapy team 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 explaining to him, ‘You need to sit in the chair for a bit’ zithromax liquid price. 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 blanket over his zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 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 songs zithromax liquid price. €˜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 around zithromax liquid price 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 zithromax liquid price is sitting in the 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 uncomfortable zithromax liquid price. 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, zithromax liquid price 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 zithromax liquid price coffee and manages to put the cup down on the trolley.Everyone is tapping their feet or wiggling their toes to the music, or singing quietly to it, when a student nurse, who is working at the computer station in the corridor outside 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 the room zithromax liquid price. 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 tapping their toes and zithromax liquid price 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 zithromax liquid price back on everyone starts tapping their toes again.

The music plays on. €˜There’ll be bluebirds over the white cliffs of Dover, just you wait zithromax liquid price 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 zithromax liquid price general question of the visibility or otherwise of patients.

Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the example below, a mother and two adult daughters visit the father of the family, who zithromax liquid price is not 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 are a key concern for the family in their recognition of their zithromax liquid price 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 want to fly away…’ plays zithromax liquid price 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 does zithromax liquid price not drive. He isn’t wearing his glasses and his daughter tells me that they can’t find them. We look in zithromax liquid price 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 zithromax liquid price follow-up visits from the relatives of discharged patients trying to retrieve these now lost objects). The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a 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 zithromax liquid price 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 of wearing institutional zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 is dirty, do you want to wear zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price teary and explains that she has lost her clothes. The cleaner listens sympathetically as she continues ‘I am all confused. I have lost my clothes. I am all confused zithromax liquid price.

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 zithromax liquid price solidify staff perceptions of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse. The absence of her own familiar clothing contributes significantly zithromax liquid price 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 zithromax liquid price most at risk of disorientation and distress within an unfamiliar environment, it could be a valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed other aspects of 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 zithromax liquid price 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 wider zithromax liquid price 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 in ways that may mark them out as failing to achieve accepted zithromax liquid price 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 zithromax liquid price ‘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 apparel that is demeaning to an individual’s social zithromax liquid price 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’ to zithromax liquid price 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 become imposed on patients zithromax liquid price. 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 zithromax liquid price the lowest classes may have limited opportunities to participate in society, and we observed the ways in which this applied to the people living with dementia 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 zithromax liquid price 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 zithromax liquid price see any patients removing their own clothing.

This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts could and was often interpreted by ward staff as a patient’s ‘resistance’ zithromax liquid price to care. There was some variation in this interpretation. However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within these wards such as shouting or crying out, the removal of bedsheets and the subsequent bodily exposure would always be immediately corrected, the zithromax liquid price 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 an escalation of distress in the zithromax liquid price 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 zithromax liquid price 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, zithromax liquid price 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 to remove zithromax liquid price 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 zithromax liquid price 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, zithromax liquid price ‘Hello,’ when she walks past 1’s bed. 1 looks across and smiles back at her. The nurse zithromax liquid price in charge explains to her that she needs to shuffle up the bed. 1 asks the nurse about her husband. The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow.

1 says zithromax liquid price that he hasn’t been 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price sheets off 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 zithromax liquid price 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 her that she has zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 zithromax liquid price 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 the example above zithromax liquid price 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 flimsy back-opening institutional zithromax liquid price 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 zithromax liquid price work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from 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 may worsen all zithromax liquid price 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 zithromax liquid price 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 this does not accurately reflect the importance of appearance we found zithromax liquid price 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 zithromax liquid price 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.

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€œUsing signs and symbols to identify hospital patients with a dementia diagnosis. Help or hindrance to recognition and care?. € Narrative Inquiry in Bioethics53. Jeannette Pols (2013). €œWashing the patient.

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

AbstractBrazil is currently http://cm-supply.com/can-you-get-ventolin-over-the-counter/ home to the zithromax cost no insurance 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 zithromax cost no insurance endured much hardship to 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 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 zithromax cost no insurance 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 zithromax cost no insurance 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 zithromax cost no insurance 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 zithromax cost no insurance 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 and zithromax cost no insurance 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 zithromax cost no insurance very essence of an ethical response to the world to recognise the deep reality of others as separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways.

The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine. Work that examines different zithromax cost no insurance 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 zithromax cost no insurance 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 to consider the impact of personal appearance on different patient zithromax cost no insurance 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 zithromax cost no insurance concern with appearance remains.16 17 Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or dementia, and so conversely, attention to appearance is one way of 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 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 zithromax cost no insurance 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 zithromax cost no insurance 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 zithromax cost no insurance settings that are capable of ‘communicating many messages 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 zithromax cost no insurance 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 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 a range of hospitals types, geographies and zithromax cost no insurance 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 zithromax cost no insurance 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 zithromax cost no insurance focused observation within trauma and orthopaedic wards (80 days) and medical assessment units (MAU. 75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types.

Observations were carried out zithromax cost no insurance by two researchers, each working in clusters of 2–4 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 zithromax cost no insurance 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 zithromax cost no insurance when interacting with people living with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient records and board data with the assistance of ward staff. Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data. When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was this advisory group zithromax cost no insurance 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. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study.

The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data analysis was complete, the advisory group zithromax cost no insurance 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 zithromax cost no insurance examining ward cultures of care and the experiences of people living with dementia. Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress.

We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress. Within many wards, it was typical for all zithromax cost no insurance older patients to be dressed in hospital-issued institutional gowns and pyjamas (typically in pastel blue, pink, green or peach), paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip grip soles, while in other wards, it was standard practice for 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 zithromax cost no insurance 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 zithromax cost no insurance 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 staff, and the resulting attention received favourably by the patient.A member of zithromax cost no insurance 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 living with dementia.The man in zithromax cost no insurance 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 zithromax cost no insurance 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 zithromax cost no insurance on him, asks him if he wants a pillow, 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 zithromax cost no insurance to 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 zithromax cost no insurance 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 zithromax cost no insurance 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 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 songs zithromax cost no insurance. €˜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 zithromax cost no insurance the team are 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 zithromax cost no insurance the 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 zithromax cost no insurance in it which he is reading through closely and sorting.Opposite, patient 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down the chair. His head is in his hands and he suddenly looks in pain. He hasn’t touched his zithromax cost no insurance tea, 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 music, or singing quietly to it, when a student zithromax cost no insurance 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 the room zithromax cost no insurance. 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 tapping their toes zithromax cost no insurance 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 zithromax cost no insurance is turned back on 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 zithromax cost no insurance 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 zithromax cost no insurance visibility or otherwise of patients.

Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the zithromax cost no insurance 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 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 zithromax cost no insurance 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 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 zithromax cost no insurance a bird 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 because she zithromax cost no insurance does not drive. He isn’t wearing his glasses and his daughter tells me that they can’t find them. We look zithromax cost no insurance 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 zithromax cost no insurance (and with the follow-up visits from the relatives of discharged patients trying to retrieve these now lost objects). The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a 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 zithromax cost no insurance 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 zithromax cost no insurance 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 zithromax cost no insurance 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 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 zithromax cost no insurance to 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 zithromax cost no insurance 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 is dirty, zithromax cost no insurance 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 asks her, ‘Do you want zithromax cost no insurance 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 zithromax cost no insurance lost her clothes. The cleaner listens sympathetically as she continues ‘I am all confused. I have lost my clothes. I am zithromax cost no insurance 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 zithromax cost no insurance perceptions of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse. The absence of her zithromax cost no insurance own familiar clothing contributes significantly 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 zithromax cost no insurance 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 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 zithromax cost no insurance 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 zithromax cost no insurance social class and hence an aspect of belonging and identity, and 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 in ways that may mark them zithromax cost no insurance 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’ zithromax cost no insurance 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 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 zithromax cost no insurance a task-based 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’ to be frequently zithromax cost no insurance 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 zithromax cost no insurance of class could become imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs. Those in the lowest classes may have limited opportunities to participate in society, and we observed the ways in which this applied to the people living with dementia within these acute zithromax cost no insurance 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 zithromax cost no insurance 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 zithromax cost no insurance own clothing.

This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts could and zithromax cost no insurance 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 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 zithromax cost no insurance 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 zithromax cost no insurance lead to further cycles of removal and replacement, leading 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 food and care and has received assistance from zithromax cost no insurance 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, zithromax cost no insurance 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 to remove her sheets:15:10 zithromax cost no insurance.

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

The nurse in charge says, ‘Hello,’ when she walks zithromax cost no insurance past 1’s bed. 1 looks across and smiles back at her. The nurse in charge explains zithromax cost no insurance to her that she needs to shuffle up the bed. 1 asks the nurse about her husband. The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow.

1 says that he zithromax cost no insurance hasn’t been 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 come zithromax cost no insurance and talk to her.15:30. 1 has once again kicked her sheets off of her legs.

A social worker comes onto zithromax cost no insurance 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 zithromax cost no insurance kicking sheets off her bed, otherwise the unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unit’s door.

1 is the only elderly patient on the unit. Again, the nurse zithromax cost no insurance in charge is heard 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 her that she has been here zithromax cost no insurance 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 the unit zithromax cost no insurance. 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 with her zithromax cost no insurance 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 her, and still sounds zithromax cost no insurance 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 zithromax cost no insurance 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 the example above zithromax cost no insurance 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 zithromax cost no insurance 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 zithromax cost no insurance that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from 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 zithromax cost no insurance 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 the ward, and where staff perceptions of them may feed into clinical assessments zithromax cost no insurance 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 zithromax cost no insurance 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 of facilitating the treatment by others of a person with zithromax cost no insurance 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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"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. E Goffman (1990a).

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Contemporary Epistemology, John Wiley and Sons.8. D McNaughton (1988). Moral Vision. 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).

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The Presentation of Self in Everyday Life Penguin15. Efrat Tseëlon (2001). €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. PIA C Kontos (2004). Ethnographic reflections on selfhood, embodiment and Alzheimer's disease.

Ageing &. Society, 24(6). 829–849.21. P. C Kontos (2005).

€œEmbodied selfhood in Alzheimer's disease. Rethinking person-centred care.” Dementia 4 (4). 553–570.22. P. C Kontos and G.

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).

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€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).

162–89.29. K.M Woodward (1999). Introduction. In K.M. Woodward (ed.), Figuring Age.

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J Caracelli (2006). Enhancing the policy process through the use of ethnography and other study frameworks. A mixed-method strategy. Research in the Schools, 13(1). 84–92.32.

W Housley and P Atkinson (2003). Interactionism, Sage33. M Hammersley (1987) What's Wrong with Ethnography?. Methodological Explorations. London.

Routledge34. V Turner and E Bruner (1986). The Anthropology of Experience New York. PAJ Publications. 2435.

K Charmaz and RG Mitchell (2001). €˜Grounded theory in ethnography’ in Atkinson P. (Ed) Handbook of Ethnography, 2001. 160-174. Sage.

London36. B Glaser and A Strauss (1967). The Discovery of Grounded Theory. London. Weidenfeld and Nicholson, 24(25).

288–30437. Juliet M. Corbin and Anselm Strauss (1990). Grounded theoryrResearch. Procedures, canons, and evaluative criteria.

Qual. Sociol. 13. 3–21.38. J Green (1998).

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

What grounded theory is not.” Academy of management journal, 49(4). 633–642.40. Elizabeth L Sampson et al. (2009). €œDementia in the acute hospital.

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).

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45. 728–734.42. Robert E Herriott and William A. Firestone (1983) “Multisite qualitative policy research. Optimising description and generalizability”.

Education Research 12:14–1943. F Vogt (2002). €œNo ethnography without comparison. The methodological significance of comparison in ethnographic research” Studies in Education Ethnography 6:23–4244. Benjamin Saunders et al.

(2018). €œSaturation in qualitative research. Exploring its conceptualization and operationalization.” Quality and Quantity 52 (4). 1893–1907.45. A Coffey and P Atkinson (1996).

Making sense of qualitative data. Complementary research strategies. 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).

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Merton (1968). €œThe Matthew effect in science. The reward and communication systems of science are considered.” Science 159 (3810). 56–63.49. Geraldine Lee-Treweek (1997) “Women, resistance and care.

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An ethnographic study” Health Service and Delivery Research51. Katie Featherstone, Andy Northcott, and Jackie Bridges (2019a). €œRoutines of resistance. An ethnography of the care of people living with dementia in acute hospital wards and its consequences.” International Journal of Nursing Studies.52. K Featherstone, A Northcott, and P Boddington (2020).

€œUsing signs and symbols to identify hospital patients with a dementia diagnosis. Help or hindrance to recognition and care?. € Narrative Inquiry in Bioethics53. Jeannette Pols (2013). €œWashing the patient.

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

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Zithromax cost no insurance

A few weeks ago my fiance Caleb and I ordered a custom table for our new, rustic home that sits in the woods. I came across Ben Shea through some mutual friends and immediately fell in love with his work! After I saw the finished product of our table, I was definitely NOT disappointed. Ben is an awesome guy, so easy to work with and he totally made our vision become a reality! It’s exactly what I wanted. Raw, rustic, knots and grain. I’m.. obsessed. Ben is constantly creating lots of amazing wood pieces for homes, offices and gifts! Check out his Facebook fan-page HERE, his Etsy shop HERE, and his website HERE.

Meagan Nicole

 


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Zithromax cost no insurance

This Sunday my mom and sister threw me a surprise bridal shower! I knew I was having the bridal shower, but I had absolutely nothing to do with the planning so I had no clue what to expect or who would be coming (although seeing random pieces of thrifted china and table clothes hidden around the house was getting me very excited!). It was more beautiful than I could’ve imaged and exactly what I hoped for. So many lovely faces came that I wasn’t expecting which made it all the sweeter. The theme was an outdoor garden party! My mom made her famous chicken salad recipe, a blueberry-raspberry-strawberry fruit medley, and greens with an olive oil lemon dressing (the one they use at Tomato Pie) YUM! The vintage dresser held two baskets- everyone brought their favorite kitchen spice or  cleaning item (which went in the awesome, wooden hamper my nana gifted us to the right of the dresser)! I loved the date night jar. Everyone wrote down date ideas on popcycle sticks for Caleb and I. We’ve been enjoying reading everyones recommendations.. especially the hilarious X-rated ones. haha!

If you’re wondering why my face looks so crazy in the opening-gifts photos it’s because we were playing the bubble gum game! Previously my sister had asked Caleb a bunch of random questions that he gave his answers to. While opening gifts, I was asked these questions as well and had to try and answer the same as Caleb did. For every question I got wrong I gad to put a piece of gum in my mouth. I actually did pretty good but still wound up with a few wads of gum, whoops. I never thought I could get tired of bubble gum until Sunday. HA! This was such a fun and exciting day! Huge thank you’s to my mom and sister for pulling it all together and getting so creative.. I know how much work and thought you put into everything to make it perfect for me and it means so much! To each and every lady that came to the party- you all made me feel so loved and blessed! Thank you for celebrating this time in my life; Caleb and I are beyond thankful for all of the amazing gifts and well wishes you showered us with. 🙂

*Beautiful cake by Wendy Hess at Oregon Dairy Bakery!

**All photographs taken by my amazing friend Rebekah of Rebekah Viola Photography! Thank you so much for capturing these memories for me.

Meagan Nicole


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Fish zithromax

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