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    Date published buy etodolac over the counter. August 26, 2020On this page BackgroundCOVID-19 is an infectious disease caused by the SARS-CoV-2 coronavirus. The World Health Organization declared a global pandemic in March 2020, and the Minister of Health signed the Interim Order Respecting the Importation and Sale of Medical Devices for buy etodolac over the counter Use in Relation to COVID-19 on March 18, 2020. The Interim Order (IO) allows us to quickly address large-scale public health emergencies.This IO allows for faster authorization of Class I-IV medical devices for COVID-19.This document presents the criteria for safety and effectiveness that apply to test swabs used for COVID-19 sampling. It also provides guidance on how to meet these criteria in an application under the IO pathway.

    Diagnostic testing is a buy etodolac over the counter key element in both. identifying cases of infection preventing the spread of the coronavirus A test swab may be used to collect a sample for either Polymerase Chain Reaction (PCR) laboratory testing or point-of-care testing. Point-of-care testing can be done directly in a hospital or doctor’s office. Once the sample has buy etodolac over the counter been taken, the swab is either placed in a preserving liquid and sent to a laboratory for testing, or placed directly in a testing device (point-of-care).Swabs may be packaged in a variety of virus transport media (VTM). Specifications for individual VTMs are beyond the scope of this document.

    Swabs play a role in the accuracy of COVID-19 diagnostic testing. For example, false negatives buy etodolac over the counter can occur in PCR tests if. the swab material inhibits the test reaction or the swab design doesn’t provide enough surface area to obtain a sufficient sample Test swabs that are not safe and effective may cause or lead to harm. For example. A swab that breaks during sample collection can cause physical injury buy etodolac over the counter a non-sterile swab that produces an incorrect test result can lead to harmHealth Canada has published a guidance document to support the preparation of applications submitted under the IO.

    It should be read in conjunction with this document. We are processing applications as quickly as possible. To avoid buy etodolac over the counter delays, please ensure you have completed your application properly.Medical Devices Regulations (MDR) classification In the Canadian regulatory framework, Class I devices present the lowest potential risk and Class IV the highest. Swabs are classified according to their labelling and intended use. For example, if a swab is labelled for nasopharyngeal (NP) or oropharyngeal (OP) use only, it will be classified as a Class I medical device according to Classification Rule 2(2) of the MDR.

    If a swab is not exclusively for use in oral or nasal cavities, or its use is not explicitly stated, it will buy etodolac over the counter be classified as a Class II device by Rule 2(1). These swabs belong to a higher risk class because their use in other body orifices for the collection of tissue samples (for example, to test for chlamydia or ureaplasma) is associated with greater risk. Rule 2 Subject to subrules (2) to (4), all invasive devices that penetrate the body through buy etodolac over the counter a body orifice or that come into contact with the surface of the eye are classified as Class II. A device described in subrule (1) that is intended to be placed in the oral or nasal cavities as far as the pharynx or in the ear canal up to the ear drum is classified as Class I.Regulatory pathways for COVID-19 devicesManufacturers of Class I swabs may seek authorization to import and sell their products under either. A Medical Device Establishment Licence (MDEL) MDEL is an establishment oversight framework that is not product-specific and not designed to assess safety and effectiveness an IO authorization information on safety and effectiveness are required as part of the application Health Canada is encouraging a sub-group of swab manufacturers to use the IO authorization pathway for Class I swabs, especially if they are.

    New to the manufacturing of swabs and manufacturing in Canada (such as a company that has re-tooled to manufacture), or using a new manufacturing process or design for swabs (such as 3D printing or honeycomb design)IO applications for swabs should include the following information.Device description The buy etodolac over the counter device description should include. A picture and/or engineering drawing identification of all materials used in the production of the swab the intended use(s) (for example, NP swabs)Quality manufacturingManufacturers must either. demonstrate compliance with Quality Manufacturing Systems (for example, ISO 13485 certificate) applicable to the swab, or provide a clear description of the planned quality manufacturing systems that are consistent with similar existing manufacturing systemsDesign verificationProvide swab design verification (bench testing) data in a summary report. It should show that the essential minimum buy etodolac over the counter design characteristics are met. These data should be based on test samples representative of finished swabs that have undergone sterilization prior to bench testing.Dimensions Swabs should have minimum length specifications and minimum and maximum head diameter specifications in order to be safe and effective.

    Minimum length specification for example, adult NP swabs require ≥14 cm to reach the posterior nasopharynx minimum and maximum head diameter specification for example, adult NP swabs require 1–4 mm to pass into the mid-inferior portion of the inferior turbinate and maneuver well FlexibilitySwab flexibility is assessed through. Durability for example, tolerate 20 rough repeated insertions into a 4 mm inner diameter clear plastic tube curved back on itself with a curve radius of 3 cm bendability for example, bend tip and neck 90º without breaking ability to maintain initial form for example, restore to initial form following 45º bending Manufacturers may describe the test performed, buy etodolac over the counter the number of samples, and a summary of the results.Strength/Breakpoint (failure) To limit the potential for patient harm, the minimum breakpoint distance should be approximately 8 to 9 cm from the nasopharynx. However, no breaks or fractures should occur following reasonable manipulation. Applicants should submit a rationale for the design of the breakpoint distance from the swab tip. It should demonstrate that the buy etodolac over the counter breakpoint length can be accommodated by commercially available swab/media tubes.Surface propertiesThe swab surface should be free of.

    processing aids (such as disinfectants) foreign materials degreasers mold release agents For injection molded swabs, no burrs, flashing, or sharp edges should be present. Design validationProvide swab validation (performance) data in a summary report that demonstrates that the swab. can acquire samples comparable to a commercially available swab control, buy etodolac over the counter and will not inhibit the PCR reactionThese data should be based on test samples representative of finished swabs that have undergone sterilization prior to testing.Comparable sample acquisition to a control, and PCR compatibilityThe manufacturer should demonstrate test swab cycle threshold (Ct) recovery values (RT-PCR) that are statistically comparable to those obtained from a commercially available swab control using SARS-CoV-2 (or a scientifically justified surrogate).Pass/Fail criteria. Values ≥ 2Cts indicate significantly less efficient ribonucleic acid collection and/or elution.Clinical feasibility/suitability simulationManufacturers should submit either. A clinical test report or previous clinical data Clinical test reportThe clinical test report should describe the use of the proposed finished swab (sterilized) in a sufficient number of individuals by trained healthcare professionals in a minimum of 30 patients that have tested positive for SARS-CoV-2, buy etodolac over the counter or a scientifically justified surrogate virus.

    Include comparisons of the proposed swab against a flocked swab commercially available in Canada with respect to. flexibility fit ability to navigate to the nasopharynx (or other areas specified in the indications) ability to collect a specimen/respiratory epithelial cells for example, using the RNase P housekeeping gene test results agreement for example, ≥ 90% positive % agreement using a composite control (positive % agreement calculation that includes all positive findings from control and test swabs) Clinical testing considerations A scientifically justified surrogate virus may be used if COVID-positive patients are not available. Positive % agreement should buy etodolac over the counter not be determined using high Ct samples. One-half (1/2) to two-thirds (2/3) of COVID-positive samples should have a high viral loads (Cts <. 30).

    Report agreement between control and test swabs in terms of quantitative (Ct) and qualitative buy etodolac over the counter (+/- test) values with appropriate descriptive statistics. Include patient symptomatology for samples. For example, days from symptom onset, known vs. Suspected COVID buy etodolac over the counter status. Use of different VTM/universal transport media (V/UTM) across COVID-positive samples may contribute to Ct variability.

    Ensure consistency by using the same media/tubes for each specimen within a clinical evaluation. Validate the buy etodolac over the counter chosen V/UTM media/tubes to show they will not interfere with the PCR test results. For example, allowing 7 days of swab positive specimen incubation with the chosen media/vial is considered a worst-case transportation scenario to evaluate maximal leaching/interaction potential). Use a single PCR test platform throughout each clinical evaluation. The platform should have been previously authorized by HC or another buy etodolac over the counter jurisdiction.

    Location (for example, left vs right nostril) and order of sampling (for example, control vs. Test swab) can affect specimen quality and results variability. Location and swab sampling order should be randomized.For additional information on collecting, handling, and testing COVID-19 specimens, please refer to the Centers for Disease Control and Prevention buy etodolac over the counter (CDC) Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19.Previous clinical dataPreviously obtained clinical data may be submitted in lieu of clinical testing. Those data should demonstrate the safe and effective use of a swab of identical design and materials in human subjects. The proposed swab should be compared against a flocked buy etodolac over the counter swab commercially available in Canada with respect to.

    flexibility fit ability to navigate to the nasopharynx (or other areas specified in the indications) ability to collect a specimen/respiratory epithelial cells for example, using the RNase P housekeeping gene test results agreement for example, ≥ 90% positive % agreement) using a composite control (positive % agreement calculation that includes all positive findings from control and test swabs) Sterility Provide sterilization validation data in a summary report. It should demonstrate that the chosen sterilization method will achieve a minimum Sterility Assurance Level (SAL) of 10-6 for the proposed swab, using an appropriate biological indicator (BI) organism (see below). If the swab will be sterilized using an ethylene oxide (EtO) method, buy etodolac over the counter you should demonstrate that EtO and ethylene chlorohydrin (ECH) residuals meet the tolerable contact limits (TCL) specified in ISO 10993-7. Commonly used swab materials, compatible sterilization methods, and appropriate biological indicators are described below. Sterilization Method Swab Materials EtO(for example, ISO 11135) Gamma Irradiation(ISO 11137) Polystyrene handle, polyester bicomponent fiber tipFootnote * X(for example, Puritan 25-3316-H/U) Not applicable Polystyrene handle, nylon flocked fiber tipFootnote * X(for example, Copan 503CS01) X(for example, BD 220252) Footnote * The CDC provides guidance on the types of swabs that should be used for optimal specimen collection for PCR testing.

    They include swabs that are made of polyester buy etodolac over the counter (for example, Dacron), rayon, or nylon-flocked. Cotton-tipped or calcium alginate swabs are not acceptable because residues present in those materials inhibit the PCR reaction. Return to footnote * referrer Appropriate BIIf ionizing radiation will be used to sterilize the swab. Bacillus pumilus spores buy etodolac over the counter are recommended for doses of 25 kGy Bacillus cereus or Bacillus sphaericus spores are recommended for doses of >. 25 kGy (World Health Organization, The International Pharmacopoeia, 9th Ed., 2019) Sterilization Process Spore (Indicator Organism) Steam Geobacillus stearothermophilus(formerly Bacillus stearothermophilus) Dry Heat Bacillus atrophaeus (formerly Bacillus subtilis var.

    Niger) Ethlylene Oxide Bacillus atrophaeus (formerly Bacillus subtilis var. Niger) Hydrogen Peroxide Geobacillus stearothermophilus(formerly buy etodolac over the counter Bacillus stearothermophilus) Source. US Food and Drug Administration, "Biological Indicator (BI) Premarket Notification [510(k)] Submissions," October 2007. [Online].Packaging validation Provide packaging validation data in a summary report. It should buy etodolac over the counter demonstrate that the swab packaging system will maintain a sterile environment across the labelled shelf life (for example, ASTM F1980).

    without leakage (for example, ASTM D3078-02) with adequate seal strength (for example, ASTM F88/EN 868-5)Test packaging samples should be representative of finished swab packages that have undergone sterilization prior to testing.Biocompatibility Provide biocompatibility data in a summary report. It should demonstrate compliance with biocompatibility tests recommended for devices in limited contact (≤24 hrs) with mucosal membranes, as per ISO 10993-1. These include buy etodolac over the counter. cytotoxicity sensitization irritation/intracutaneous reactivityThese data should be based on test samples representative of finished swabs that have undergone sterilization prior to testing.LabellingSwabs should be individually packaged and labelled. The application must include the swab buy etodolac over the counter label, which must include.

    The name and model number of the device the term ‘sterile’, along with the sterilization method (EtO = ethylene oxide. R = gamma irradiation), if the swab is intended to be sold in a sterile condition the name and address of the manufacturer manufacturing and expiry datesIf swabs are not sterile but must be sterilized at the user facility, then the sterilization parameters and method should be clearly described in accompanying instructions for use documentation.Post-market requirementsAs stated in Section 12 of the IO, within 10 days of becoming aware of an incident in Canada, all IO authorization holders must. report the incident specify the nature of the incident buy etodolac over the counter specify the circumstances surrounding the incidentOn this page About face shields Personal protective equipment (PPE) can help prevent potential exposure to infectious disease. They are considered medical devices in Canada and therefore must follow the requirements outlined in the Medical Devices Regulations. Medical devices are classified into 4 groups (Class I, II, III and IV) based on their risk to health and safety.

    Class I devices, such as gauze bandages, pose buy etodolac over the counter the lowest potential risk, while Class IV devices, such as pacemakers, pose the greatest potential risk. In Canada, face shields are Class I medical devices. A face shield has a transparent window or visor that shields the face and associated mucous membranes (eyes, nose and mouth). It protects buy etodolac over the counter the wearer against exposure from splashes and sprays of body fluids. Face shields are made of shatterproof plastic, fit over the face and are held in place by head straps or caps.

    They may be made of polycarbonate, propionate, acetate, polyvinyl chloride, or polyethylene terephthalate. They are usually worn with other PPE, such as a medical mask, respirator or eyewear buy etodolac over the counter. Health Canada strongly advises against the use of plastic bags as an alternative to face shields. Standards and requirements for face shields Organizations that are manufacturing face shields are advised to consult some or all of the following standards throughout the design and testing stages. ANSI/ISEA Z.87.1 (2015), American National Standard for Occupational and Educational Personal Eye and Face Protection Devices CSA buy etodolac over the counter Z94.3 (2020), Eye and Face Protectors CSA Z94.3.1 (2016), Guideline for Selection, Use, and Care of Eye and Face Protectors BS EN 166 (2002), Personal Eye Protection.

    Specifications. Minimum specifications must be incorporated into the design and verification stages to ensure safe and effective face shields. Provide adequate buy etodolac over the counter coverage (CSA Z94.3 Sections 0.2.1/10.2.2/10.3/10.4). The size of the face shield is important because it must protect the face and front part of the head. This includes the eyes, forehead, cheeks, nose, mouth, and chin.

    Protection may also need buy etodolac over the counter to extend to the front of the neck in situations with flying particles and sprays of hazardous liquids. Fit snugly to afford a good seal to the forehead area and to prevent slippage of the device Footnote 1. Be made of optically clear, distortion-free, lightweight buy etodolac over the counter materials (CSA Z94.3.1-16 and Footnote 1). Be free of visible defects or flaws that would impede vision (ANSI Z87.1 Section 9.4). Be comfortable and easy to assemble, use and remove by health care professionals.

    Provide adequate space between the wearer’s face and the inner surface of the visor to allow for the use of ancillary equipment (for example, medical mask, buy etodolac over the counter respirator, eyewear) Footnote 1. The characteristics and performance requirements of face shields must not be altered when attaching shields to other protective equipment, such as hats or caps. Display anti-fog characteristics on inside and outside of shield (CSA Z94.3.1-16). For face buy etodolac over the counter shields that are not fog resistant, anti-fog spray must be provided. Provide user-contacting materials that have adequate material biocompatibility (skin sensitivity and cytotoxic testing) (ISO 10993-5, 10).

    Other items to take note of include. Face shields used for protection in buy etodolac over the counter hospital settings do not have to be impact- or flame- resistant. If the device is specifically designed to withstand impact from sharp or fast projectiles, it must comply with set-out standards (ANSI Z87.1, sections 9.2 and 9.3, CSA Z94.3, section 10.1). For reuse, manufacturers must provide validated cleaning instructions. Sterilization procedures must not compromise the shield in any way, such buy etodolac over the counter as deformation or cracking.

    Regulatory authorization Most PPE, including face shields, are Class I medical devices if they are manufactured, sold or represented for use for reducing the risk of or preventing the user from infection. This includes COVID-19. Face shields may be authorized for sale or import into Canada through the following regulatory pathways buy etodolac over the counter. Pathway 1. Interim order authorization to import and sell medical devices related to COVID-19.

    Pathway 2 buy etodolac over the counter. Expedited review and issuance of Medical Device Establishment Licences (MDEL) related to COVID-19. MDEL holders that import and sell face shields should take measures to buy etodolac over the counter ensure they are safe and effective. Pathway 3. Exceptional importation and sale of certain non-compliant medical devices related to COVID-19.

    Note that a sale generally requires the transfer of ownership of a device buy etodolac over the counter from one party to another and does not necessitate any transfer of money. Applicants should carefully review the pathways and select the most appropriate authorization route for their product. For more information, see Personal protective equipment (COVID-19). How to buy etodolac over the counter get authorization. If you intend to manufacture 3D print face shields in response to the COVID-19 crisis, see.

    3D printing and other manufacturing of personal protective equipment in response to COVID-19 Feedback If you have any questions or comments about this notice, contact the Medical Devices Directorate at hc.meddevices-instrumentsmed.sc@canada.ca R. J. Roberge, "Face shields for infection control. A review," Journal of Occupational and Environmental Hygiene, pp. 235-242, 2016.

    Related links FootnotesFootnote 1 R. J. Roberge, "Face shields for infection control. A review," Journal of Occupational and Environmental Hygiene, pp. 235-242, 2016.Return to footnote 1 referrer.

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    How to where to buy etodolac pills cite this article:Singh OP. The need for routine psychiatric assessment of COVID-19 survivors. Indian J Psychiatry 2020;62:457-8COVID-19 pandemic where to buy etodolac pills is expected to bring a Tsunami of mental health issues.

    Public health emergencies may affect the well-being, safety, and security of both individuals and communities, which lead to a range of emotional reactions, unhealthy behavior, and noncompliance, with public health directives (such as home confinement and vaccination) in people who contact the disease as well as in the general population.[1] Thus far, there has been an increased emphasis on psychosocial factors such as loneliness, effect of quarantine, uncertainty, vulnerability to COVID-19 infection, economic factors, and career difficulties, which may lead to increased psychiatric morbidity.Time has now come to pay attention to the direct effect of the virus on brain and psychiatric adverse symptoms, resulting from the treatment provided. Viral infections where to buy etodolac pills are known to be associated with psychiatric disorders such as depression, bipolar disorder, obsessive–compulsive disorder (OCD), or schizophrenia. There was an increased incidence of psychiatric disorders following the Influenza Pandemic.

    Karl Menninger described 100 cases of influenza presenting with psychiatric sequelae, which could mainly be categorized as dementia praecox, where to buy etodolac pills delirium, other psychoses, and unclassified subtypes. Dementia praecox constituted the largest number among all these cases.[2] Neuroinflammation is now known as the key factor in genesis and exacerbation of psychiatric disorders, particularly depression and bipolar disorders.Emerging evidence points toward the neurotropic properties of the SARS-CoV-2 virus. Loss of where to buy etodolac pills smell and taste as an initial symptom points toward early involvement of olfactory bulb.

    The rapid spread to brain has been demonstrated through retrograde axonal transport.[3] The virus can enter the brain through endothelial cells lining the blood–brain barrier and also through other nerves such as the vagus nerve.[4] Cytokine storm, a serious immune reaction to the virus, can activate brain glial cells, leading to delirium, depression, bipolar disorder, and OCD.Studies examining psychiatric disorders in acute patients suffering from COVID-19 found almost 40% of such patients suffering from anxiety, depression, and posttraumatic stress disorder.[5] The data on long-term psychiatric sequelae in patients who have recovered from acute illness are limited. There are anecdotal reports of psychosis and mania occurring in patients of COVID-19 following discharge from hospital. This may where to buy etodolac pills be either due to the direct effect of the virus on the brain or due to the neuropsychiatric effects of drugs used to treat the infection or its complications.

    For example, behavioral toxicity of high-dose corticosteroids which are frequently used during the treatment of severe cases to prevent and manage cytokine storm.The patients with COVID-19 can present with many neuropsychiatric disorders, which may be caused by direct inflammation, central nervous system effects of cytokine storm, aberrant epigenetic modifications of stress-related genes, glial activation, or treatment emergent effects.[6] To assess and manage various neuropsychiatric complications of COVID-19, the psychiatric community at large should equip itself with appropriate assessment tools and management guidelines to effectively tackle this unprecedented wave of psychiatric ailments. References 1.Pfefferbaum B, North where to buy etodolac pills CS. Mental health and the COVID-19 pandemic.

    N Engl J Med where to buy etodolac pills 2020;383:510-2. 2.Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of where to buy etodolac pills unknown etiology in Wuhan, China.

    The mystery and the miracle. J Med Virol 2020;92:401-2. 3.Fodoulian L, where to buy etodolac pills Tuberosa J, Rossier D, Landis BN, Carleton A, Rodriguez I.

    SARS-CoV-2 receptor and entry genes are expressed by sustentacular cells in the human olfactory neuroepithelium. BioRxiv 2020.03.31.013268 where to buy etodolac pills. Doi.

    Https://doi.org/10.1101/2020.03.31.013268. 4.Lochhead JJ, Thorne RG. Intranasal delivery of biologics to the central nervous system.

    Adv Drug Deliv Rev 2012;64:614-28. 5.Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections.

    A systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020;7:611-27. 6.Steardo L Jr., Steardo L, Verkhratsky A.

    Psychiatric face of COVID-19. Transl Psychiatry 2020;10:261. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

    None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1169_2Abstract The COVID-19 pandemic has emerged as a major stressor of a global scale, affecting all aspects of our lives, and is likely to contribute to a surge of mental ill health.

    Ancient Hindu scriptures, notably the Bhagavad Gita, have a wealth of insights that can help approaches to build psychological resilience for individuals at risk, those affected, as well as for caregivers. The path of knowledge (Jnana yoga) promotes accurate awareness of nature of the self, and can help reframe our thinking from an “I” to a “we mode,” much needed for collectively mitigating the spread of the coronavirus. The path of action (Karma yoga) teaches the art of selfless action, providing caregivers and frontline health-care providers a framework to continue efforts in the face of uncertain consequences.

    Finally, the path of meditation (Raja yoga) offers a multipronged approach to healthy lifestyle and mindful meditation, which may improve resilience to the illness and its severe consequences. While more work is needed to empirically examine the potential value of each of these approaches in modern psychotherapy, the principles herein may already help individuals facing and providing care for the COVID-19 pandemic.Keywords. Bhagavad Gita, Covid-19, YogaHow to cite this article:Keshavan MS.

    Building resilience in the COVID-19 era. Three paths in the Bhagavad Gita. Indian J Psychiatry 2020;62:459-61The COVID-19 crisis has changed our world in just a matter of months, thrusting us into danger, uncertainty, fear, and of course social isolation.

    At the time of this writing, over 11 million individuals have been affected worldwide (India is fourth among all countries, 674,515) and over half a million people have died. The COVID-19 pandemic has been an unprecedented global stressor, not only because of the disease burden and mortality but also because of economic upheaval. The very fabric of the society is disrupted, affecting housing, personal relationships, travel, and all aspects of lifestyle.

    The overwhelmed health-care system is among the most major stressors, leading to a heightened sense of vulnerability. No definitive treatments or vaccine is on the horizon yet. Psychiatry has to brace up to an expected mental health crisis resulting from this global stressor, not only with regard to treating neuropsychiatric consequences but also with regard to developing preventive approaches and building resilience.Thankfully, there is a wealth of wisdom to help us in our ancient scriptures such as the Bhagavad Gita[1] for building psychological resilience.

    The Bhagavad Gita is a dialog between the Pandava prince Arjuna and his charioteer Krishna in the epic Mahabharata, the great tale of the Bharata Dynasty, authored by Sage Vyasa (c. 4–5 B.C.E.). The dialog occurs in the 6th chapter of the epic and has over 700 verses.

    In this epic story, Arjuna, the righteous Pandava hero was faced with the dilemma of waging a war against his cousins, the Kauravas, for territory. Arjuna is confused and has no will to initiate the war. In this context, Krishna, his charioteer and spiritual mentor, counsels him.

    The key principles of this spiritual discourse in the Gita are embodied in the broad concept of yoga, which literally means “Yog” or “to unite.” Applying three tenets of yoga can greatly help developing resilience at individual, group, and societal levels. A fourth path, Bhakti yoga, is a spiritual approach in the Gita which emphasizes loving devotion toward a higher power or principle, which may or may not involve a personal god. In this editorial, I focus on three paths that have considerable relevance to modern approaches to reliance-focused psychotherapy that may be especially relevant in the COVID-19 era.

    Path of Knowledge The first concept in the Gita is the path of knowledge (Jnana Yoga, chapter 2). The fundamental goal of Jnana yoga is to liberate oneself from the limited view of the individual ego, and to develop the awareness of one's self as part of a larger, universal self. Hindu philosophers were among the earliest to ask the question of “who am I” and concluded that the self is not what it seems.

    The self as we all know is a collection of our physical, mental, and social attributes that we create for ourselves with input from our perceptions, and input by our families and society. Such a world view leads to a tendency to crave for the “I” and for what is mine, and not consider the “We.” As Krishna in the Bhagavad Gita points out, the person who sees oneself in others, and others in oneself, really “sees.” Such awareness, which guides action in service of self as well as others, is critically important in our goals of collectively preventing the spread of the coronavirus. A glaring example is the use of face masks, known to effectively slow the viral infection.

    Using the mask is as important to protecting oneself from the virus as well as protecting others from oneself. Nations such as the USA (and their leaders), who have given mixed messages to the public about the need to wear masks, have been showing a strikingly high number of cases as well as mortality. Unfortunately, such reluctance to wear masks (and thus model protective hygiene for the population), as in the case of the US leader, has stemmed from ego or vanity-related issues (i.e., how he would appear to other leaders!.

    ). This factor may at least partly underlie the worse COVID-19 outcome in the USA. The simple lesson here is that it is important to first flatten the ego if one wants to flatten the pandemic curve!.

    Path of Action The second key concept is the path of action (Karma yoga, chapter 3). Karma yoga is all about taking action without thinking, “what's in it for me.” As such, it seeks to mainly let go of one's ego. In the Bhagavad Gita, Arjuna is ambivalent about fighting because of the conflict regarding the outcome brought on by waging the war, i.e., having to kill some of his own kith and kin.

    Krishna reminds him that he should not hesitate, because it is his nature and duty (or Dharma), as a warrior, to protect the larger good, though it will have some downside consequences. The frontline health-care worker caring for severely ill patients with COVID-19 is likely to have a similar emotional reaction as Arjuna, facing a lack of adequate treatments, high likelihood of mortality and of unpredictable negative outcomes, and risk to him/herself. Compounding this, especially when resources such as ventilators are limited, the doctor may have to make tough decisions of whose life to save and whose not.

    Adding to this are personal emotions when facing with the death of patients, having to deliver bad news, and dealing with grieving relatives.[2] All these are likely to result in emotional anguish and guilt, leading to burnout and a war “neurosis.”So, what should the frontline health-care provider should do?. Krishna's counsel would be that the doctor should continue to perform his/her own dharma, but do so without desire or attachment, thereby performing action in the spirit of Karma yoga. Such action would be with detachment, without a desire for personal gain and being unperturbed by success or failure.

    Such “Nishkaama Karma” (or selfless action) may help doctors working today in the COVID outbreak to carry forward their work with compassion, and accept the results of their actions with equanimity and without guilt. Krishna points out that training one's mind to engage in selfless action is not easy but requires practice (Abhyasa). Krishna is also emphatic about the need to protect oneself, in order to be able to effectively carry out one's duties.

    Path of Meditation The third core concept in the Gita is the path of meditation and self-reflection (Raja yoga, or Dhyana yoga, chapter 6). It is considered the royal path (Raja means royal) for attaining self-realization, and often considered the 8-fold path of yoga (Ashtanga yoga) designed to discipline lifestyle, the body and mind toward realizing mindfulness and self-reflection. These techniques, which originated in India over two millennia ago, have evolved over recent decades and anticipate several approaches to contemplative psychotherapy, including dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based stress reduction.[3] These approaches are of particular relevance for stress reduction and resilience building in individuals faced by COVID-19-related emotional difficulties as well as health-care providers.[4]The majority of people affected by the COVID-19 virus recover, but about 20% have severe disease, and the mortality is around 5%.

    Older individuals, those with obesity and comorbid medical illnesses such as diabetes and lung disease, are particularly prone to developing severe disease. It is possible that a state of chronic low-grade inflammation which underlies each of these conditions may increase the risk of disproportionate host immune reactions (with excessive release of cytokines), characterizing severe disease in those with COVID-19.[4] With this in mind, it is important to note that exercise, some forms of meditation, anti-inflammatory and antioxidant diet (such as turmeric and melatonin), and yoga have known benefits in reducing inflammation.[5],[6],[7],[8],[9] Sleep loss also elevates inflammatory cytokines. Healthy sleep may reduce inflammation.[10] Clearly, a healthy lifestyle, including healthy sleep, exercise, and diet, may be protective against developing COVID-19-related severe complications.

    These principles of healthy living are beautifully summarized in the Bhagavad Gita.Yuktahara-viharasya yukta-cestasya karmasuYukta-svapnavabodhasya yogo bhavati duhkha-haHe who is temperate in his habits of eating, sleeping, working and recreation can mitigate all sorrows by practicing the yoga system.–Bhagavad Gita, Chapter 6, verse 17.The relevance of the Bhagavad Gita for modern psychotherapy has been widely reviewed.[11],[12] However, relatively little empirical literature exists on the effectiveness of versus spiritually integrated psychotherapy incorporating Hindu psychotherapeutic insights. Clearly, more work is needed, and COVID-19 may provide an opportunity for conducting further empirical research.[13] In the meantime, using the principles outlined here may already be of benefit in helping those in need, and may be rapidly enabled in the emerging era of telehealth and digital health.[14]Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Pandurangi AK, Shenoy S, Keshavan MS.

    Psychotherapy in the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8. 2.Arango C.

    Lessons learned from the coronavirus health crisis in Madrid, Spain. How COVID-19 has changed our lives in the last 2 weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry 2020;26:S0006-3223 (20) 31493-1.

    3.Keshavan MS, Gangadhar GN, Hinduism PA. In. Spirituality and Mental Health Across Cultures, Evidence-Based Implications for Clinical Practice.

    Oxford, England. Oxford University Press. In Press.

    4.Habersaat KB, Betsch C, Danchin M, Sunstein CR, Böhm R, Falk A, et al. Ten considerations for effectively managing the COVID-19 transition. Nat Hum Behav 2020;4:677-87.

    Doi. 10.1038/s41562-020-0906-x. Epub 2020 Jun 24.

    5.Kumar K. Building resilience to Covid-19 disease severity. J Med Res Pract 2020;9:1-7.

    6.Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and Yoga practices as potential adjunctive treatment of SARS-CoV-2 infection and COVID-19. A brief overview of key subjects [published online ahead of print, 2020 Jun 22].

    J Altern Complement Med 2020;26:10.1089/acm. 2020.0177. [doi.

    10.1089/acm. 2020.0177]. 7.Gupta H, Gupta M, Bhargava S.

    Potential use of turmeric in COVID-19 [published online ahead of print, 2020 Jul 1]. Clin Exp Dermatol. 2020;10.1111/ced.14357.

    Doi:10.1111/ced.14357. 8.Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological implications of physical inactivity among older adults during the COVID-19 pandemic [published online ahead of print, 2020 Jun 25].

    Gerontology 2020:26;1-8. [doi. 10.1159/000509216].

    9.El-Missiry MA, El-Missiry ZM, Othman AI. Melatonin is a potential adjuvant to improve clinical outcomes in individuals with obesity and diabetes with coexistence of Covid-19 [published online ahead of print, 2020 Jun 29]. Eur J Pharmacol 2020;882:173329.

    10.Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010;24:775-84.

    11.Balodhi JP, Keshavan MS. Bhagavad Gita and psychotherapy. Asian J Psychiatr 2011;4:300-2.

    12.Bhatia SC, Madabushi J, Kolli V, Bhatia SK, Madaan V. The Bhagavad Gita and contemporary psychotherapies. Indian J Psychiatry 2013;55:S315-21.

    13.Keshavan MS. Pandemics and psychiatry. Repositioning research in context of COVID-19 [published online ahead of print, 2020 May 7].

    Asian J Psychiatr 2020;51:102159. [doi. 10.1016/j.ajp.

    2020.102159]. 14.Torous J, Keshavan M. COVID-19, mobile health and serious mental illness.

    Schizophr Res 2020;218:36-7. Correspondence Address:Matcheri S KeshavanRoom 542, Massachusetts Mental Health Center, 75 Fenwood Road, Boston, MA 02115 USASource of Support. None, Conflict of Interest.

    NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_829_20.

    How to cite buy etodolac over the counter this article:Singh OP. The need for routine psychiatric assessment of COVID-19 survivors. Indian J Psychiatry 2020;62:457-8COVID-19 pandemic is expected to buy etodolac over the counter bring a Tsunami of mental health issues. Public health emergencies may affect the well-being, safety, and security of both individuals and communities, which lead to a range of emotional reactions, unhealthy behavior, and noncompliance, with public health directives (such as home confinement and vaccination) in people who contact the disease as well as in the general population.[1] Thus far, there has been an increased emphasis on psychosocial factors such as loneliness, effect of quarantine, uncertainty, vulnerability to COVID-19 infection, economic factors, and career difficulties, which may lead to increased psychiatric morbidity.Time has now come to pay attention to the direct effect of the virus on brain and psychiatric adverse symptoms, resulting from the treatment provided.

    Viral infections are known to buy etodolac over the counter be associated with psychiatric disorders such as depression, bipolar disorder, obsessive–compulsive disorder (OCD), or schizophrenia. There was an increased incidence of psychiatric disorders following the Influenza Pandemic. Karl Menninger buy etodolac over the counter described 100 cases of influenza presenting with psychiatric sequelae, which could mainly be categorized as dementia praecox, delirium, other psychoses, and unclassified subtypes. Dementia praecox constituted the largest number among all these cases.[2] Neuroinflammation is now known as the key factor in genesis and exacerbation of psychiatric disorders, particularly depression and bipolar disorders.Emerging evidence points toward the neurotropic properties of the SARS-CoV-2 virus.

    Loss of smell and taste as an buy etodolac over the counter initial symptom points toward early involvement of olfactory bulb. The rapid spread to brain has been demonstrated through retrograde axonal transport.[3] The virus can enter the brain through endothelial cells lining the blood–brain barrier and also through other nerves such as the vagus nerve.[4] Cytokine storm, a serious immune reaction to the virus, can activate brain glial cells, leading to delirium, depression, bipolar disorder, and OCD.Studies examining psychiatric disorders in acute patients suffering from COVID-19 found almost 40% of such patients suffering from anxiety, depression, and posttraumatic stress disorder.[5] The data on long-term psychiatric sequelae in patients who have recovered from acute illness are limited. There are anecdotal reports of psychosis and mania occurring in patients of COVID-19 following discharge from hospital. This may be either due to the direct effect of the virus on the brain or due to the neuropsychiatric effects of drugs used to treat the infection buy etodolac over the counter or its complications.

    For example, behavioral toxicity of high-dose corticosteroids which are frequently used during the treatment of severe cases to prevent and manage cytokine storm.The patients with COVID-19 can present with many neuropsychiatric disorders, which may be caused by direct inflammation, central nervous system effects of cytokine storm, aberrant epigenetic modifications of stress-related genes, glial activation, or treatment emergent effects.[6] To assess and manage various neuropsychiatric complications of COVID-19, the psychiatric community at large should equip itself with appropriate assessment tools and management guidelines to effectively tackle this unprecedented wave of psychiatric ailments. References 1.Pfefferbaum B, North buy etodolac over the counter CS. Mental health and the COVID-19 pandemic. N Engl J buy etodolac over the counter Med 2020;383:510-2.

    2.Lu H, Stratton CW, Tang YW. Outbreak of buy etodolac over the counter pneumonia of unknown etiology in Wuhan, China. The mystery and the miracle. J Med Virol 2020;92:401-2.

    3.Fodoulian L, Tuberosa J, Rossier D, buy etodolac over the counter Landis BN, Carleton A, Rodriguez I. SARS-CoV-2 receptor and entry genes are expressed by sustentacular cells in the human olfactory neuroepithelium. BioRxiv 2020.03.31.013268 buy etodolac over the counter. Doi.

    Https://doi.org/10.1101/2020.03.31.013268. 4.Lochhead JJ, Thorne RG. Intranasal delivery of biologics to the central nervous system. Adv Drug Deliv Rev 2012;64:614-28.

    5.Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections. A systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry 2020;7:611-27.

    6.Steardo L Jr., Steardo L, Verkhratsky A. Psychiatric face of COVID-19. Transl Psychiatry 2020;10:261. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

    None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1169_2Abstract The COVID-19 pandemic has emerged as a major stressor of a global scale, affecting all aspects of our lives, and is likely to contribute to a surge of mental ill health. Ancient Hindu scriptures, notably the Bhagavad Gita, have a wealth of insights that can help approaches to build psychological resilience for individuals at risk, those affected, as well as for caregivers.

    The path of knowledge (Jnana yoga) promotes accurate awareness of nature of the self, and can help reframe our thinking from an “I” to a “we mode,” much needed for collectively mitigating the spread of the coronavirus. The path of action (Karma yoga) teaches the art of selfless action, providing caregivers and frontline health-care providers a framework to continue efforts in the face of uncertain consequences. Finally, the path of meditation (Raja yoga) offers a multipronged approach to healthy lifestyle and mindful meditation, which may improve resilience to the illness and its severe consequences. While more work is needed to empirically examine the potential value of each of these approaches in modern psychotherapy, the principles herein may already help individuals facing and providing care for the COVID-19 pandemic.Keywords.

    Bhagavad Gita, Covid-19, YogaHow to cite this article:Keshavan MS. Building resilience in the COVID-19 era. Three paths in the Bhagavad Gita. Indian J Psychiatry 2020;62:459-61The COVID-19 crisis has changed our world in just a matter of months, thrusting us into danger, uncertainty, fear, and of course social isolation.

    At the time of this writing, over 11 million individuals have been affected worldwide (India is fourth among all countries, 674,515) and over half a million people have died. The COVID-19 pandemic has been an unprecedented global stressor, not only because of the disease burden and mortality but also because of economic upheaval. The very fabric of the society is disrupted, affecting housing, personal relationships, travel, and all aspects of lifestyle. The overwhelmed health-care system is among the most major stressors, leading to a heightened sense of vulnerability.

    No definitive treatments or vaccine is on the horizon yet. Psychiatry has to brace up to an expected mental health crisis resulting from this global stressor, not only with regard to treating neuropsychiatric consequences but also with regard to developing preventive approaches and building resilience.Thankfully, there is a wealth of wisdom to help us in our ancient scriptures such as the Bhagavad Gita[1] for building psychological resilience. The Bhagavad Gita is a dialog between the Pandava prince Arjuna and his charioteer Krishna in the epic Mahabharata, the great tale of the Bharata Dynasty, authored by Sage Vyasa (c. 4–5 B.C.E.).

    The dialog occurs in the 6th chapter of the epic and has over 700 verses. In this epic story, Arjuna, the righteous Pandava hero was faced with the dilemma of waging a war against his cousins, the Kauravas, for territory. Arjuna is confused and has no will to initiate the war. In this context, Krishna, his charioteer and spiritual mentor, counsels him.

    The key principles of this spiritual discourse in the Gita are embodied in the broad concept of yoga, which literally means “Yog” or “to unite.” Applying three tenets of yoga can greatly help developing resilience at individual, group, and societal levels. A fourth path, Bhakti yoga, is a spiritual approach in the Gita which emphasizes loving devotion toward a higher power or principle, which may or may not involve a personal god. In this editorial, I focus on three paths that have considerable relevance to modern approaches to reliance-focused psychotherapy that may be especially relevant in the COVID-19 era. Path of Knowledge The first concept in the Gita is the path of knowledge (Jnana Yoga, chapter 2).

    The fundamental goal of Jnana yoga is to liberate oneself from the limited view of the individual ego, and to develop the awareness of one's self as part of a larger, universal self. Hindu philosophers were among the earliest to ask the question of “who am I” and concluded that the self is not what it seems. The self as we all know is a collection of our physical, mental, and social attributes that we create for ourselves with input from our perceptions, and input by our families and society. Such a world view leads to a tendency to crave for the “I” and for what is mine, and not consider the “We.” As Krishna in the Bhagavad Gita points out, the person who sees oneself in others, and others in oneself, really “sees.” Such awareness, which guides action in service of self as well as others, is critically important in our goals of collectively preventing the spread of the coronavirus.

    A glaring example is the use of face masks, known to effectively slow the viral infection. Using the mask is as important to protecting oneself from the virus as well as protecting others from oneself. Nations such as the USA (and their leaders), who have given mixed messages to the public about the need to wear masks, have been showing a strikingly high number of cases as well as mortality. Unfortunately, such reluctance to wear masks (and thus model protective hygiene for the population), as in the case of the US leader, has stemmed from ego or vanity-related issues (i.e., how he would appear to other leaders!.

    ). This factor may at least partly underlie the worse COVID-19 outcome in the USA. The simple lesson here is that it is important to first flatten the ego if one wants to flatten the pandemic curve!. Path of Action The second key concept is the path of action (Karma yoga, chapter 3).

    Karma yoga is all about taking action without thinking, “what's in it for me.” As such, it seeks to mainly let go of one's ego. In the Bhagavad Gita, Arjuna is ambivalent about fighting because of the conflict regarding the outcome brought on by waging the war, i.e., having to kill some of his own kith and kin. Krishna reminds him that he should not hesitate, because it is his nature and duty (or Dharma), as a warrior, to protect the larger good, though it will have some downside consequences. The frontline health-care worker caring for severely ill patients with COVID-19 is likely to have a similar emotional reaction as Arjuna, facing a lack of adequate treatments, high likelihood of mortality and of unpredictable negative outcomes, and risk to him/herself.

    Compounding this, especially when resources such as ventilators are limited, the doctor may have to make tough decisions of whose life to save and whose not. Adding to this are personal emotions when facing with the death of patients, having to deliver bad news, and dealing with grieving relatives.[2] All these are likely to result in emotional anguish and guilt, leading to burnout and a war “neurosis.”So, what should the frontline health-care provider should do?. Krishna's counsel would be that the doctor should continue to perform his/her own dharma, but do so without desire or attachment, thereby performing action in the spirit of Karma yoga. Such action would be with detachment, without a desire for personal gain and being unperturbed by success or failure.

    Such “Nishkaama Karma” (or selfless action) may help doctors working today in the COVID outbreak to carry forward their work with compassion, and accept the results of their actions with equanimity and without guilt. Krishna points out that training one's mind to engage in selfless action is not easy but requires practice (Abhyasa). Krishna is also emphatic about the need to protect oneself, in order to be able to effectively carry out one's duties. Path of Meditation The third core concept in the Gita is the path of meditation and self-reflection (Raja yoga, or Dhyana yoga, chapter 6).

    It is considered the royal path (Raja means royal) for attaining self-realization, and often considered the 8-fold path of yoga (Ashtanga yoga) designed to discipline lifestyle, the body and mind toward realizing mindfulness and self-reflection. These techniques, which originated in India over two millennia ago, have evolved over recent decades and anticipate several approaches to contemplative psychotherapy, including dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based stress reduction.[3] These approaches are of particular relevance for stress reduction and resilience building in individuals faced by COVID-19-related emotional difficulties as well as health-care providers.[4]The majority of people affected by the COVID-19 virus recover, but about 20% have severe disease, and the mortality is around 5%. Older individuals, those with obesity and comorbid medical illnesses such as diabetes and lung disease, are particularly prone to developing severe disease. It is possible that a state of chronic low-grade inflammation which underlies each of these conditions may increase the risk of disproportionate host immune reactions (with excessive release of cytokines), characterizing severe disease in those with COVID-19.[4] With this in mind, it is important to note that exercise, some forms of meditation, anti-inflammatory and antioxidant diet (such as turmeric and melatonin), and yoga have known benefits in reducing inflammation.[5],[6],[7],[8],[9] Sleep loss also elevates inflammatory cytokines.

    Healthy sleep may reduce inflammation.[10] Clearly, a healthy lifestyle, including healthy sleep, exercise, and diet, may be protective against developing COVID-19-related severe complications. These principles of healthy living are beautifully summarized in the Bhagavad Gita.Yuktahara-viharasya yukta-cestasya karmasuYukta-svapnavabodhasya yogo bhavati duhkha-haHe who is temperate in his habits of eating, sleeping, working and recreation can mitigate all sorrows by practicing the yoga system.–Bhagavad Gita, Chapter 6, verse 17.The relevance of the Bhagavad Gita for modern psychotherapy has been widely reviewed.[11],[12] However, relatively little empirical literature exists on the effectiveness of versus spiritually integrated psychotherapy incorporating Hindu psychotherapeutic insights. Clearly, more work is needed, and COVID-19 may provide an opportunity for conducting further empirical research.[13] In the meantime, using the principles outlined here may already be of benefit in helping those in need, and may be rapidly enabled in the emerging era of telehealth and digital health.[14]Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Pandurangi AK, Shenoy S, Keshavan MS.

    Psychotherapy in the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8. 2.Arango C. Lessons learned from the coronavirus health crisis in Madrid, Spain.

    How COVID-19 has changed our lives in the last 2 weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry 2020;26:S0006-3223 (20) 31493-1. [doi. 10.1016/j.biopsych.

    2020.04.003]. 3.Keshavan MS, Gangadhar GN, Hinduism PA. In. Spirituality and Mental Health Across Cultures, Evidence-Based Implications for Clinical Practice.

    Oxford, England. Oxford University Press. In Press. 4.Habersaat KB, Betsch C, Danchin M, Sunstein CR, Böhm R, Falk A, et al.

    Ten considerations for effectively managing the COVID-19 transition. Nat Hum Behav 2020;4:677-87. Doi. 10.1038/s41562-020-0906-x.

    Epub 2020 Jun 24. 5.Kumar K. Building resilience to Covid-19 disease severity. J Med Res Pract 2020;9:1-7.

    6.Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and Yoga practices as potential adjunctive treatment of SARS-CoV-2 infection and COVID-19. A brief overview of key subjects [published online ahead of print, 2020 Jun 22]. J Altern Complement Med 2020;26:10.1089/acm.

    7.Gupta H, Gupta M, Bhargava S. Potential use of turmeric in COVID-19 [published online ahead of print, 2020 Jul 1]. Clin Exp Dermatol. 2020;10.1111/ced.14357.

    Doi:10.1111/ced.14357. 8.Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological implications of physical inactivity among older adults during the COVID-19 pandemic [published online ahead of print, 2020 Jun 25]. Gerontology 2020:26;1-8.

    [doi. 10.1159/000509216]. 9.El-Missiry MA, El-Missiry ZM, Othman AI. Melatonin is a potential adjuvant to improve clinical outcomes in individuals with obesity and diabetes with coexistence of Covid-19 [published online ahead of print, 2020 Jun 29].

    Eur J Pharmacol 2020;882:173329. 10.Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010;24:775-84.

    11.Balodhi JP, Keshavan MS. Bhagavad Gita and psychotherapy. Asian J Psychiatr 2011;4:300-2. 12.Bhatia SC, Madabushi J, Kolli V, Bhatia SK, Madaan V.

    The Bhagavad Gita and contemporary psychotherapies. Indian J Psychiatry 2013;55:S315-21. 13.Keshavan MS. Pandemics and psychiatry.

    Repositioning research in context of COVID-19 [published online ahead of print, 2020 May 7]. Asian J Psychiatr 2020;51:102159. [doi. 10.1016/j.ajp.

    2020.102159]. 14.Torous J, Keshavan M. COVID-19, mobile health and serious mental illness. Schizophr Res 2020;218:36-7.

    Correspondence Address:Matcheri S KeshavanRoom 542, Massachusetts Mental Health Center, 75 Fenwood Road, Boston, MA 02115 USASource of Support. None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_829_20.

    What is the medicine etodolac used for

    Exponential growth is difficult for people to what is the medicine etodolac used for grasp. But that is what has happened to sales of Albert Camus’s The Plague, first published in 1947. According to Jacqueline Rose, it is what is the medicine etodolac used for ‘an upsurge strangely in line with the graphs that daily chart the toll of the sick and the dead’.

    She reports that, from the start of the COVID-19 pandemic, sales had grown 1000%.1 It may not be worth dwelling on those statistics. More interesting what is the medicine etodolac used for for Rose, and for us, is that a key theme of Camus is that ‘the pestilence is at once blight and revelation. It brings the hidden truth of a corrupt world to the surface’.

    In the same what is the medicine etodolac used for way, the pandemic of COVID-19 exposes and amplifies inequalities in society. The myth of the pandemic as the great leveller was given air when early cases included elites. A prince, a prime minister, a what is the medicine etodolac used for Premier League football manager and the actor Tom Hanks.

    It was, and is, most likely that as the pandemic took hold and society responded we would see familiar inequalities, of two sorts. Inequalities in what is the medicine etodolac used for COVID-19 and inequalities in the social conditions that lead to inequalities in health more generally.It was not always thus with epidemics. The plague came to Northern Italy in 1630, killing 35% of the population, including 38% in Bergamo, and an astonishing 59% in Padua.

    One effect of killing so many people what is the medicine etodolac used for was a temporary slowdown in what had been a steep rise in economic inequality in Italy. In the aftermath of the plague, work was plentiful—so many workers had died—and real wages increased. Property was available at relatively low what is the medicine etodolac used for cost, given how many potential purchasers had also gone, making it easier for lower strata of the population to acquire property.

    It did not last. By 1650, inequality was again on its relentless rise in Venice, Northern Italy and Italy as a whole.2Serious as is COVID-19, the what is the medicine etodolac used for worst-case scenario, with no intervention, was perhaps 400 000 deaths in the UK. Terrible as is premature death coming to 0.6% of the population, it is not 35%.

    The effect of COVID-19 on inequality is likely to be adverse what is the medicine etodolac used for and severe.Loosely following Camus, we suggest that COVID-19 exposes the fault lines in society and amplifies inequalities. In the UK, the myth of the great equaliser has been dispelled by the publication by the Office for National Statistics (ONS) of COVID-19 mortality rates according to level of deprivation.3 It shows a clear social gradient. The more deprived the what is the medicine etodolac used for area the higher the mortality.

    The gradient suggests that the ‘fault line’ is not quite accurate. It is not ‘them’ at high risk and the rest of ‘us’ at acceptable risk, but a gradient of what is the medicine etodolac used for disadvantage. The argument that we are seeing COVID-19 imposed on pre-existing health inequalities is supported by the ONS figures showing that the gradient, by area deprivation, for all-cause mortality is similar to that for COVID-19.The case that we are seeing a general phenomenon of health inequalities is shown further by a graph (figure 1) produced by the Nuffield Trust (https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-covid-19-kills-the-most-deprived-at-double-the-rate-of-affluent-people-like-other-conditions).

    For shorthand, rather than the gradient, what is the medicine etodolac used for it shows mortality in the most deprived 10% and that in the least deprived 10% of areas. Remarkably, the twofold increase is consistent across a range of causes of death, including COVID-19. In the past, what is the medicine etodolac used for observing this general phenomenon, one of us (MM) speculated about general susceptibility to illness following the social gradient, perhaps linked to psychosocial processes.4 There may be elements of that.

    But the susceptibility may also be happening at the social level, being relatively disadvantaged puts you at higher risk of a range of specific causes of illness—the causes of the causes.Mortality rate in most deprived areas." data-icon-position data-hide-link-title="0">Figure 1 Mortality rate in most deprived areas.The inequalities that the pandemic exposed had been building in the UK for at least a decade. Health Equity in England. The Marmot Review 10 Years On documented what is the medicine etodolac used for three worrying trends, since 2010.

    A slowdown in increase in life expectancy, a continuing increase in inequalities in life expectancy between more and less deprived areas and increased regional differences, and a decline in life expectancy in women in the most deprived areas outside London.5 The recent report examined five of the six domains that had formed the basis of the 2010 Marmot Review6. Early child development, education, employment and working conditions, having at least the minimum income necessary for a healthy life, what is the medicine etodolac used for and healthy and sustainable places to live and work.Our conclusion was that it was highly likely that policies of austerity had contributed to the grim and unequal health picture. To take just one example, highly relevant to what is happening during the COVID-19 pandemic, the crisis of adult social care.

    Spending on adult social care what is the medicine etodolac used for was reduced by about 7% from 2010, but in a highly regressive way. In the least deprived 20% of local authorities, the spending reduction was 3%. In the what is the medicine etodolac used for most deprived it was 16%.

    The UK came into the pandemic with weakened social and health services.We drew attention to ethnic inequalities in health, but lamented that data were insufficient to give the kind of comprehensive attention we had given to socioeconomic inequalities.5 In the pandemic, the high mortality of some ethnic groups is of particular concern. There is no need, as some commentators are likely to do, to invoke genetic what is the medicine etodolac used for or cultural explanations. ONS analyses suggest that about half of the excess—in people of African, Pakistani and Bangladeshi background—can be attributed to the index of multiple deprivation.7 It may well be that this index does not capture differences in crowding that come with multigenerational households or occupational exposures.Considering the amplification of inequalities, it is the societal response—lockdown and social distancing—that will both increase inequalities in exposure to the virus and inequalities in the social determinants of health.

    A most basic requirement of living in what is the medicine etodolac used for a society is that people should be able to eat. The Food Foundation’s survey reveals that 5.1 million adults in families with children have experienced food insecurity since the start of lockdown. 2 million what is the medicine etodolac used for children in those households have been food insecure (https://foodfoundation.org.uk/vulnerable_groups/food-foundation-polling-third-survey-five-weeks-into-lockdown/).The advice is to work from home.

    The lower people’s income, the less likely are they to be in jobs where working from home is possible. For example, ONS reported that before the lockdown only 10% of workers what is the medicine etodolac used for in accommodation and food could work from home. 53% of workers in communication and information could work from home.

    ONS showed high COVID-19 mortality in ‘front-line’ occupations such as workers in social what is the medicine etodolac used for care, drivers, chefs and sales and retail assistants.8The paper in this issue of JECH by Fancourt and colleagues looks at experience of adversity in the UK since the start of lockdown. They show that for loss of income and employment, and for difficulties in accessing food and medicines, there is a clear social gradient—the lower the socioeconomic position the greater the adversity.Our recent report called for a national commitment to reduce social and economic inequalities and thereby achieve greater health equity.5 As we emerge from the pandemic, such societal commitment will become ever more important.INTRODUCTIONOver the past few weeks, there have been claims in the media that coronavirus disease 2019 (COVID-19) is uniting societies and countries in shared experience. €˜we are all in what is the medicine etodolac used for this together’.

    However, scientific papers are beginning to emerge arguing that COVID-19 is disproportionately affecting vulnerable populations. Much of this research has focused on inequalities in cases and fatalities, citing what is the medicine etodolac used for challenges for more disadvantaged groups due to individuals facing difficulties in accessing healthcare in certain countries, being less able to adhere to protective social distancing measures due to living in more overcrowded areas, having a higher burden of pre-existing diseases and risk factors, being disproportionally affected by misinformation and miscommunication, and not being able to afford to lose income from missing work.1–4 Nevertheless, there has also been concern that the virus could expose and widen existing inequalities within societies.25–7 This is particularly problematic as it could trigger a vicious cycle of increasing inequalities that weaken economic structures within societies and also exacerbate the spread of the virus, leading to the labelling of COVID-19 as a ‘pandemic of inequality’.4 5 7Studies from previous epidemics such as severe acute respiratory syndrom (SARS), Middle East respiratory syndrome (MERS) and Ebola have suggested that people can experience a range of adversities during and in the aftermath of epidemics.8 These can include adversities related to the virus itself (such as infection or bereavement), as well as challenges meeting basic needs (such as access to food, medication and accommodation),9–11 and the experience of financial loss (including loss of employment and income).11–16 The wider health literature suggests that people from lower socioeconomic backgrounds are less resilient to shocks such as ill-health, experiencing greater financial burden, and hardship.17 This suggests there is likely to be a social gradient in these experiences during COVID-19, but so far there has been limited empirical investigation of inequalities in experience of adversity during the pandemic. Nevertheless, these experiences of burden and hardship are vital to understand as studies of previous epidemics have found a relationship between experience of adversity and psychological consequences including post-traumatic stress and depression.16 This echoes wider literature on the strong relationship between adversities relating to finances, basic needs, and ill-health, and poor mental and physical health outcomes.18–21Therefore, this study explored the changing patterns of adversity relating to the COVID-19 pandemic by socioeconomic position (SEP) during the first few weeks of lockdown in the UK.

    We focused on three types of what is the medicine etodolac used for adversity. (1) financial stressors (loss of work, partner’s loss of work, cut in household income or inability to pay bills), (2) challenges relating to basic needs (including food, medications and accommodation) and (3) experience of the virus itself (including contracting the virus, a close person being hospitalised and a close person dying). We sought to explore the nature of the relationship between SEP and (1) number of adversities experienced, (2) type of adversity experienced, and (3) how the relationship evolved over the first 3 weeks of lockdown.METHODSParticipantsData were drawn from the University College London (UCL) COVID-19 Social Study—a large panel study of the psychological and social experiences of what is the medicine etodolac used for over 70 000 adults (aged 18+) in the UK during the COVID-19 pandemic.

    The study commenced on 21 March 2020, with recruitment ongoing. The study what is the medicine etodolac used for involves online weekly data collection from participants during the COVID-19 pandemic in the UK. While not random, the study has a well-stratified sample that was recruited using three primary approaches.

    First, snowballing was used, including promoting the study through existing networks and mailing lists (including large databases of adults who had previously consented to be involved in health research across the UK), print and digital media coverage, and social media. Second, more what is the medicine etodolac used for targeted recruitment was undertaken focusing on (1) individuals from a low-income background, (2) individuals with no or few educational qualifications, and (3) individuals who were unemployed. Third, the study was promoted via partnerships with third sector organisations to vulnerable groups, including adults with pre-existing mental illness, older adults and carers.

    The study was approved by what is the medicine etodolac used for the UCL Research Ethics Committee (12467/005) and all participants gave informed consent.Questionnaire items related to newly experienced adversities were available from 25 March 2020— 1 day after legal enforcement of lockdown commenced. We used data from the 3 weeks following this date (25 March–14 April 2020), limiting our analysis to a balanced panel of participants who were interviewed in all of these weeks (n=14 309. 58.7% of individuals interviewed between 25 and 31 March 2020) what is the medicine etodolac used for.

    We excluded participants with missing data on any variable used in this study (n=1782. 12.45% of what is the medicine etodolac used for balanced panel. 3.21% missing weights, 9.67% missing SEP measures and 0.01% missing outcome measure).

    This provided a final analytical sample of 12 527 participants.MeasuresAdversitiesQuestions what is the medicine etodolac used for on 10 separate adversities were recorded each week. Four of these assessed financial adversity. Whether participants had lost their job or been unable to work, their partner had lost their job or was unable to work, they had experienced a major cut in household income (data available from the second week) or they had been unable to what is the medicine etodolac used for pay bills.

    Three questions assessed adversity relating to basic needs. Whether participants had lost their accommodation, they what is the medicine etodolac used for had been unable to access sufficient food, or they had been unable to access required medication. Finally, three questions assessed adversity directly relating to the virus.

    Whether in the past week the participant had suspected what is the medicine etodolac used for or diagnosed COVID-19, somebody close to them was hospitalised, or they had lost somebody close to them. We constructed a weekly total adversity measure by summing the number of adversities present in a given week (range 0–10). For adversities that were considered to be cumulative (ie, once experienced what is the medicine etodolac used for in 1 week, their effects would likely last into future weeks), we also counted them on subsequent waves after they had first occurred.

    This applied to experiencing suspected/diagnosed COVID-19, the loss of work for a participant or their partner, a major cut in household income, and the loss of somebody close to the participant.Socioeconomic positionWe measured SEP using five variables collected at baseline interview. (1) annual household income (<£16 000, £16 what is the medicine etodolac used for 000–£30 000, £30 000–£60 000, £60 000–£90 000, £90 000+), (2) highest qualification (General Certificate of Secondary Education (GCSE) or lower (qualifications at age 16), A-Levels or vocational training (qualifications at age 18), undergraduate degree, postgraduate degree), (3) employment status (employed, inactive and unemployed), (4) housing tenure (own outright, own with mortgage, rent/live rent-free) and (5) household overcrowding (binary. >1 person per room).

    From these variables, we constructed a Low SEP index measure by counting indications what is the medicine etodolac used for of low SEP (income <£16 000, educational qualifications of GCSE or lower, unemployed, living in rented or rent-free accommodation, and living in overcrowded accommodation), collapsing into 0, 1 and 2+ indications of low SEP to attain adequate sample sizes for each category.CovariatesTo account for broad demographic differences that could confound the association between SEP and adversity experiences, we also included variables for gender (male, female), age (18–24, 25–34, 35–49, 50–64, 65+), marital status (cohabiting with partner, living away from partner, single, divorced/widowed) and ethnicity (white, non-white).AnalysisWe assessed experienced adversities according to SEP by estimating Poisson models for each of the 3 weeks separately. First, we extracted the predicted number of adversities according to SEP using average marginal effects and plotted the estimates to test whether social gradients were present and whether they changed in size by week. Second, we repeated this exercise for each adversity separately what is the medicine etodolac used for by estimating logit models for each adversity and each week of data.

    Analyses were adjusted for age, gender, ethnicity and marital status. Third, we compared estimated differences in the what is the medicine etodolac used for prevalence of adversities between highest and lowest SEP groups in weeks 1 and 3 to explore if there was any evidence of change in inequalities over time. To account for the non-random nature of the sample, all data were weighted to the proportions of gender, age, ethnicity, education and country of living obtained from the Office for National Statistics.22We carried out several sensitivity analyses to test the robustness of our results.

    First, to test whether findings were an artefact of our chosen statistical method, we repeated the Poisson regressions using negative binomial and zero-inflated Poisson models. Second, to test whether findings were driven by our type of SEP index, what is the medicine etodolac used for we repeated analyses using the individual SEP variables directly and deriving an alternative SEP measure using confirmatory factor analysis (CFA). The CFA used weighted least square mean, and given the discrete nature of the SEP indicators, the variance adjusted (WLSMV) estimator was implemented.

    The root mean square error of approximation of the CFA model was 0.08, indicating an adequate fit.23 We split the latent factor into five groups using natural breaks in the factor what is the medicine etodolac used for values. Third, as the reporting of COVID-19 symptoms is likely biased due to asymptomatic cases or differences in recognition of symptoms, the latter of which is likely to be related to health literacy and thus to SEP, we excluded suspected/diagnosed COVID-19 from the total adversity measure. Finally, as several of the adversities considered here are related to loss of employment or paid work, we repeated each what is the medicine etodolac used for analysis restricting the sample to adults who were employed at baseline.RESULTSDescriptive statisticsDescriptive statistics for the sample are shown in table 1.

    Once weighting had been applied, our sample closely matched population averages on gender, age, ethnicity, education and country of living. Unweighted figures are shown in Supplementary table 1.View what is the medicine etodolac used for this table:Table 1 Descriptive sample statistics weighted according to ONS dataSupplemental materialThe prevalence of adversities overall and by week is shown in table 2. Average number of adversities increased over the follow-up period, as did variability.

    Within the first 3 weeks, one in six participants reported a major cut in ousehold income and either them or their what is the medicine etodolac used for partner losing work. Numbers experiencing symptoms of COVID-19, or losing people close to them also increased. Conversely, numbers of participants what is the medicine etodolac used for being unable to access food or medication fell week by week.View this table:Table 2 Weighted descriptive statistics, total and individual adversitiesAdversity by SEPWhen applying our low SEP index, the number of adverse events experienced each week showed a clear social gradient (figure 1).

    Regression results showed a significant difference in the number of adverse events according to the SEP index score among those with scores of 1 and 2+ compared with those with scores of 0 (Supplementary Table 2). When comparing the change in experience in adversities over time by SEP, these inequalities were maintained each week, with no decreases what is the medicine etodolac used for evident over time (Supplementary Table 4).Predicted mean number of adversities experienced by week and SEP, derived from fully adjusted Poisson model. NB dates show the week in which adversities were reported, with reporting being on experiences in the past 7 days.

    SEP, socioeconomic position." what is the medicine etodolac used for data-icon-position data-hide-link-title="0">Figure 1 Predicted mean number of adversities experienced by week and SEP, derived from fully adjusted Poisson model. NB dates show the week in which adversities were reported, with reporting being on experiences in the past 7 days.SEP, socioeconomic position.When exploring the patterns for each type of adversity individually, there was a clear social gradient across all financial measures and across factors relating to basic needs (figure 2). People of lower SEP what is the medicine etodolac used for were 1.5 times more likely to experience loss of work compared with people of higher SEP, and their partners were twice as likely to experience loss of work (Supplementary Table 3).

    They were also 7.2 times more likely to be unable to pay bills in week 1 (rising to 8.7 times more likely by week 3), 4.1 times more likely to be unable to access sufficient food in week 1 (rising to 4.9 times more likely be week 3) and 2.5 times more likely to be unable to access required medication. However, there was little evidence of what is the medicine etodolac used for a gradient in experiences directly relating to the virus, with no significant differences between groups. In comparing the change in experience of each specific adversity over time by SEP, the inequalities present in each individual adversity were maintained each week, with no evidence of improvement over time (Supplementary Table 4).Predicted probability of experiencing specific adversities by week and SEP, from fully adjusted logit models.

    NB dates show the week in what is the medicine etodolac used for which adversities were reported, with reporting being on experiences in the past 7 days. SEP, socioeconomic position." data-icon-position data-hide-link-title="0">Figure 2 Predicted probability of experiencing specific adversities by week and SEP, from fully adjusted logit models. NB dates show the week in which adversities were reported, with reporting being on experiences in the past 7 days.SEP, what is the medicine etodolac used for socioeconomic position.Sensitivity analysesWhen using alternative regression analyses, results were materially unaffected (Supplementary Figure 1), as were results when using CFA rather than our low SEP index (Supplementary Figures 2 and 3).

    When excluding suspected/diagnosed COVID-19 from the total adversity measure, results showed no meaningful differences (Supplementary Figure 4). Similarly, when restricting the what is the medicine etodolac used for analysis to those employed at baseline, results were qualitatively similar but with a stronger social gradient (Supplementary Figure 5).DISCUSSIONThis study explored the patterns of adversities in the early weeks of lockdown in the UK due to COVID-19, showing a clear social gradient in experiences. This gradient was evident across the overall number of adversities experienced and specifically across financial stressors and challenges relating to basic needs (including food, medications and accommodation).

    Inequalities were maintained with no reductions in differences between socioeconomic groups over time.Notably, this experience of inequalities in financial stressors occurred in the wake of measures announced by what is the medicine etodolac used for government and banks in the UK such as mortgage holidays and furlough schemes aimed at reducing the financial shocks of COVID-19.24 While these financial measures implemented may have reduced the discrepancy in experiences between the wealthiest and poorest to a certain extent (it is not possible to test what the alternative scenario might have been), the data presented here show that they did not remove it. This may be because benefits of the schemes did not come into effect immediately within the first month of lockdown (eg, for receipt of furlough payments to be made) or it may indicate that measures were insufficient and individuals of lower SEP still experienced greater financial burden during the pandemic. Even if these initial financial shocks are reduced over time as schemes come into effect and as more measures are taken, they are still concerning, given the well-researched link between experience of adversities and poor mental health outcomes, poor physical health outcomes and suicides.18–21 In planning ahead for anticipated upcoming stages in the fallout from the pandemic, such as a possible future recession, this suggests that more steps need to be taken urgently to reduce further adverse effects for individuals of lower SEP before further negative effects occur.18 Further, in terms of preparedness for future pandemics, these results suggest that even more ambitious measures are required early to reduce immediate financial shocks if efforts are to be made to try to avoid widening economic disparities.Our findings were related to access to basic needs such as food substantiate concerns voiced by academic-practitioners working in food insecurity, food systems and inequality early in the outbreak of COVID-19.25 While the data presented here may suggest that although challenges in accessing food decreased in the early weeks following lockdown being implemented in the UK, inequalities in that access remained.

    It is clearly important that such inequalities are addressed, as there is the potential for both second waves of the virus that might trigger repeat lockdowns, and what is the medicine etodolac used for for further challenges in the functioning of food systems. Planning for the potential of future pandemics should consider how such inequalities could be reduced through early implementation of interventions such as further financial and business support to low-income households, to food charities and food banks, to food producers and to supermarkets, shops and delivery companies.25It is notable that the findings presented here did not show such a clear gradient in experiences of the virus itself within the UK. There is evidence of patterns of inequality in the experience of symptoms of COVID-19 in other literature.1–4 However, given that many cases of the virus what is the medicine etodolac used for are asymptomatic, and low levels of population testing mean that exact infections rates cannot be estimated, our data cannot be taken to represent actual inequalities in cases.

    Differences in recognition of symptoms are likely to be related to health literacy and thus to SEP, and so may also have affected analyses. Moreover, our questions about experience of bereavement due to what is the medicine etodolac used for COVID-19 or a close family member being hospitalised were asked early in the pandemic when prevalence was low. Our study may have been underpowered to detect clear effects.

    This also applies to losing accommodation, which occurred for less than 0.2% of what is the medicine etodolac used for the sample. Therefore, our findings do not necessarily imply an absence of inequalities for these experiences and it remains to be seen if inequalities do start to emerge over time. It is also likely that this finding will vary by country depending what is the medicine etodolac used for on the measures taken to reduce the spread of the virus.This study has several strengths, including its large sample size, its longitudinal tracking of participants and its rich inclusion of measures on socioeconomic factors and experienced adversities during COVID-19.

    However, there are several limitations. The study is not nationally representative, although it does have good stratification across all major socio-demographic groups and analyses were weighted on what is the medicine etodolac used for the basis of population estimates of core demographics (gender, age, ethnicity, education and country of living). While the recruitment strategy included deliberately targeting individuals of low educational attainment and low household income groups, it is possible that more extreme experiences were not adequately captured.

    So the inequalities shown in this paper may what is the medicine etodolac used for be underestimations. Further, individuals experiencing particularly high levels of adversity may have withdrawn from the study early, and therefore not been included in our longitudinal sample in these analyses. We lacked follow-up data for 40% of participants (although this does not reflect a drop-out rate for the study as some participants have continued to provide data since, merely outside what is the medicine etodolac used for the window of the dates we focused on for these analyses).

    Although our use of survey weights may have partly guarded against the effects of selective dropout, it is nonetheless possible that our data present underestimations of inequalities. Additionally, this what is the medicine etodolac used for paper focused exclusively on adversities relating to finances, basic needs and experience of the virus. However, other inequalities have also been noted such as in educational opportunities for children during school closures.26 These remain to be explored further in future studies.

    Finally, our study used two different SEP indices and further tested specific aspects of SEP in sensitivity analyses, but we restricted measurement of what is the medicine etodolac used for SEP to a finite list of factors. Other measures of SEP such as social status or area deprivation and how they relate to adversities experienced remain to be explored further.The results presented here suggest that there were clear inequalities in adverse experiences during the COVID-19 pandemic in the early weeks of lockdown in the UK. This is notable given that several measures were taken to try to reduce such adverse events, and suggests that such measures did not go far enough in tackling inequality what is the medicine etodolac used for.

    Further, it is likely that such inequalities in experience will be even greater in low-income countries as the pandemic continues.7 The findings from this paper therefore support calls for each country to continually assess which members of society are vulnerable throughout the COVID-19 pandemic to take action to support those at highest risk, and also for planning for future pandemics to include more extensive measures to reduce disproportionate experiences of adversity among lower socioeconomic groups.7What is already known on this subjectA recently published rapid review of the literature on the effects of isolation and quarantine suggested that people can experience a range of adversities during and in the aftermath of the epidemic. These can include adversities related to the virus itself (such as infection or bereavement), as what is the medicine etodolac used for well as challenges meeting basic needs (such as access to food, medication and accommodation), and the experience of financial loss. There has been concern that the COVID-19 pandemic could expose and widen existing inequalities within societies.

    Yet, there have what is the medicine etodolac used for been no empirical analyses.What this study addsThis study confirms that there was a clear gradient across the number of adverse events experienced each week by SEP during lockdown in the UK. This was most clearly seen for adversities relating to finances and basic needs (including access to food and medications) but less for experiences directly relating to the virus. The findings from this paper suggest that individuals of lower SEP are experiencing more adverse events due to COVID-19 and supports calls for each country to continually assess which members of society are vulnerable throughout the COVID-19 pandemic to take action to support those at highest risk..

    Exponential growth is difficult for people to grasp buy etodolac over the counter. But that is what has happened to sales of Albert Camus’s The Plague, first published in 1947. According to Jacqueline Rose, it is ‘an upsurge strangely in line with the graphs that daily chart buy etodolac over the counter the toll of the sick and the dead’. She reports that, from the start of the COVID-19 pandemic, sales had grown 1000%.1 It may not be worth dwelling on those statistics.

    More interesting for Rose, and for us, is that a key theme of Camus is that ‘the pestilence is at once blight and buy etodolac over the counter revelation. It brings the hidden truth of a corrupt world to the surface’. In the buy etodolac over the counter same way, the pandemic of COVID-19 exposes and amplifies inequalities in society. The myth of the pandemic as the great leveller was given air when early cases included elites.

    A prince, a prime minister, a Premier League football manager and the actor Tom buy etodolac over the counter Hanks. It was, and is, most likely that as the pandemic took hold and society responded we would see familiar inequalities, of two sorts. Inequalities in COVID-19 and inequalities in the social conditions that lead to inequalities in health more buy etodolac over the counter generally.It was not always thus with epidemics. The plague came to Northern Italy in 1630, killing 35% of the population, including 38% in Bergamo, and an astonishing 59% in Padua.

    One effect of killing so many people was a buy etodolac over the counter temporary slowdown in what had been a steep rise in economic inequality in Italy. In the aftermath of the plague, work was plentiful—so many workers had died—and real wages increased. Property was available at relatively low cost, given how many potential buy etodolac over the counter purchasers had also gone, making it easier for lower strata of the population to acquire property. It did not last.

    By 1650, inequality was again on its relentless rise in Venice, Northern Italy and Italy as buy etodolac over the counter a whole.2Serious as is COVID-19, the worst-case scenario, with no intervention, was perhaps 400 000 deaths in the UK. Terrible as is premature death coming to 0.6% of the population, it is not 35%. The effect of COVID-19 on inequality is likely to be adverse and severe.Loosely following Camus, we suggest that COVID-19 exposes the fault lines in buy etodolac over the counter society and amplifies inequalities. In the UK, the myth of the great equaliser has been dispelled by the publication by the Office for National Statistics (ONS) of COVID-19 mortality rates according to level of deprivation.3 It shows a clear social gradient.

    The more deprived the area the higher buy etodolac over the counter the mortality. The gradient suggests that the ‘fault line’ is not quite accurate. It is not ‘them’ at high risk and the rest of ‘us’ at acceptable risk, but a buy etodolac over the counter gradient of disadvantage. The argument that we are seeing COVID-19 imposed on pre-existing health inequalities is supported by the ONS figures showing that the gradient, by area deprivation, for all-cause mortality is similar to that for COVID-19.The case that we are seeing a general phenomenon of health inequalities is shown further by a graph (figure 1) produced by the Nuffield Trust (https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-covid-19-kills-the-most-deprived-at-double-the-rate-of-affluent-people-like-other-conditions).

    For shorthand, rather than the gradient, it shows mortality in the most deprived 10% and that buy etodolac over the counter in the least deprived 10% of areas. Remarkably, the twofold increase is consistent across a range of causes of death, including COVID-19. In the buy etodolac over the counter past, observing this general phenomenon, one of us (MM) speculated about general susceptibility to illness following the social gradient, perhaps linked to psychosocial processes.4 There may be elements of that. But the susceptibility may also be happening at the social level, being relatively disadvantaged puts you at higher risk of a range of specific causes of illness—the causes of the causes.Mortality rate in most deprived areas." data-icon-position data-hide-link-title="0">Figure 1 Mortality rate in most deprived areas.The inequalities that the pandemic exposed had been building in the UK for at least a decade.

    Health Equity in England. The Marmot Review buy etodolac over the counter 10 Years On documented three worrying trends, since 2010. A slowdown in increase in life expectancy, a continuing increase in inequalities in life expectancy between more and less deprived areas and increased regional differences, and a decline in life expectancy in women in the most deprived areas outside London.5 The recent report examined five of the six domains that had formed the basis of the 2010 Marmot Review6. Early child development, education, employment and working conditions, having at least the minimum income necessary for a healthy life, and healthy and sustainable places to buy etodolac over the counter live and work.Our conclusion was that it was highly likely that policies of austerity had contributed to the grim and unequal health picture.

    To take just one example, highly relevant to what is happening during the COVID-19 pandemic, the crisis of adult social care. Spending on adult social care was reduced buy etodolac over the counter by about 7% from 2010, but in a highly regressive way. In the least deprived 20% of local authorities, the spending reduction was 3%. In the most deprived it was buy etodolac over the counter 16%.

    The UK came into the pandemic with weakened social and health services.We drew attention to ethnic inequalities in health, but lamented that data were insufficient to give the kind of comprehensive attention we had given to socioeconomic inequalities.5 In the pandemic, the high mortality of some ethnic groups is of particular concern. There is no need, as some commentators are buy etodolac over the counter likely to do, to invoke genetic or cultural explanations. ONS analyses suggest that about half of the excess—in people of African, Pakistani and Bangladeshi background—can be attributed to the index of multiple deprivation.7 It may well be that this index does not capture differences in crowding that come with multigenerational households or occupational exposures.Considering the amplification of inequalities, it is the societal response—lockdown and social distancing—that will both increase inequalities in exposure to the virus and inequalities in the social determinants of health. A most basic requirement of living in a society is that people should be able buy etodolac over the counter to eat.

    The Food Foundation’s survey reveals that 5.1 million adults in families with children have experienced food insecurity since the start of lockdown. 2 million children in buy etodolac over the counter those households have been food insecure (https://foodfoundation.org.uk/vulnerable_groups/food-foundation-polling-third-survey-five-weeks-into-lockdown/).The advice is to work from home. The lower people’s income, the less likely are they to be in jobs where working from home is possible. For example, ONS reported that before the lockdown only 10% of workers in accommodation buy etodolac over the counter and food could work from home.

    53% of workers in communication and information could work from home. ONS showed high COVID-19 mortality in ‘front-line’ occupations such as workers in social care, drivers, chefs and sales buy etodolac over the counter and retail assistants.8The paper in this issue of JECH by Fancourt and colleagues looks at experience of adversity in the UK since the start of lockdown. They show that for loss of income and employment, and for difficulties in accessing food and medicines, there is a clear social gradient—the lower the socioeconomic position the greater the adversity.Our recent report called for a national commitment to reduce social and economic inequalities and thereby achieve greater health equity.5 As we emerge from the pandemic, such societal commitment will become ever more important.INTRODUCTIONOver the past few weeks, there have been claims in the media that coronavirus disease 2019 (COVID-19) is uniting societies and countries in shared experience. €˜we are all in this together’ buy etodolac over the counter.

    However, scientific papers are beginning to emerge arguing that COVID-19 is disproportionately affecting vulnerable populations. Much of this research has focused on inequalities in cases and fatalities, citing challenges for more disadvantaged groups due to individuals facing difficulties in accessing healthcare in certain countries, being less able to adhere to protective social distancing measures due to living in more overcrowded areas, having a higher burden of pre-existing diseases and risk factors, being disproportionally affected by misinformation and miscommunication, and not being able to afford to lose income from missing work.1–4 Nevertheless, there has also been concern that the virus could expose and widen existing inequalities within buy etodolac over the counter societies.25–7 This is particularly problematic as it could trigger a vicious cycle of increasing inequalities that weaken economic structures within societies and also exacerbate the spread of the virus, leading to the labelling of COVID-19 as a ‘pandemic of inequality’.4 5 7Studies from previous epidemics such as severe acute respiratory syndrom (SARS), Middle East respiratory syndrome (MERS) and Ebola have suggested that people can experience a range of adversities during and in the aftermath of epidemics.8 These can include adversities related to the virus itself (such as infection or bereavement), as well as challenges meeting basic needs (such as access to food, medication and accommodation),9–11 and the experience of financial loss (including loss of employment and income).11–16 The wider health literature suggests that people from lower socioeconomic backgrounds are less resilient to shocks such as ill-health, experiencing greater financial burden, and hardship.17 This suggests there is likely to be a social gradient in these experiences during COVID-19, but so far there has been limited empirical investigation of inequalities in experience of adversity during the pandemic. Nevertheless, these experiences of burden and hardship are vital to understand as studies of previous epidemics have found a relationship between experience of adversity and psychological consequences including post-traumatic stress and depression.16 This echoes wider literature on the strong relationship between adversities relating to finances, basic needs, and ill-health, and poor mental and physical health outcomes.18–21Therefore, this study explored the changing patterns of adversity relating to the COVID-19 pandemic by socioeconomic position (SEP) during the first few weeks of lockdown in the UK. We focused buy etodolac over the counter on three types of adversity.

    (1) financial stressors (loss of work, partner’s loss of work, cut in household income or inability to pay bills), (2) challenges relating to basic needs (including food, medications and accommodation) and (3) experience of the virus itself (including contracting the virus, a close person being hospitalised and a close person dying). We sought to explore the nature of the relationship between SEP buy etodolac over the counter and (1) number of adversities experienced, (2) type of adversity experienced, and (3) how the relationship evolved over the first 3 weeks of lockdown.METHODSParticipantsData were drawn from the University College London (UCL) COVID-19 Social Study—a large panel study of the psychological and social experiences of over 70 000 adults (aged 18+) in the UK during the COVID-19 pandemic. The study commenced on 21 March 2020, with recruitment ongoing. The study involves online weekly data collection from participants during the COVID-19 pandemic buy etodolac over the counter in the UK.

    While not random, the study has a well-stratified sample that was recruited using three primary approaches. First, snowballing was used, including promoting the study through existing networks and mailing lists (including large databases of adults who had previously consented to be involved in health research across the UK), print and digital media coverage, and social media. Second, more buy etodolac over the counter targeted recruitment was undertaken focusing on (1) individuals from a low-income background, (2) individuals with no or few educational qualifications, and (3) individuals who were unemployed. Third, the study was promoted via partnerships with third sector organisations to vulnerable groups, including adults with pre-existing mental illness, older adults and carers.

    The study was approved by the UCL Research Ethics Committee (12467/005) and all participants buy etodolac over the counter gave informed consent.Questionnaire items related to newly experienced adversities were available from 25 March 2020— 1 day after legal enforcement of lockdown commenced. We used data from the 3 weeks following this date (25 March–14 April 2020), limiting our analysis to a balanced panel of participants who were interviewed in all of these weeks (n=14 309. 58.7% of buy etodolac over the counter individuals interviewed between 25 and 31 March 2020). We excluded participants with missing data on any variable used in this study (n=1782.

    12.45% of balanced buy etodolac over the counter panel. 3.21% missing weights, 9.67% missing SEP measures and 0.01% missing outcome measure). This provided a final analytical sample of 12 527 participants.MeasuresAdversitiesQuestions on 10 separate adversities were recorded buy etodolac over the counter each week. Four of these assessed financial adversity.

    Whether participants had lost their job or been unable to work, their partner had lost their job or was unable to work, they had buy etodolac over the counter experienced a major cut in household income (data available from the second week) or they had been unable to pay bills. Three questions assessed adversity relating to basic needs. Whether participants had lost their accommodation, they had been buy etodolac over the counter unable to access sufficient food, or they had been unable to access required medication. Finally, three questions assessed adversity directly relating to the virus.

    Whether in the past week the participant had suspected or diagnosed buy etodolac over the counter COVID-19, somebody close to them was hospitalised, or they had lost somebody close to them. We constructed a weekly total adversity measure by summing the number of adversities present in a given week (range 0–10). For adversities that were considered to be cumulative (ie, once experienced in buy etodolac over the counter 1 week, their effects would likely last into future weeks), we also counted them on subsequent waves after they had first occurred. This applied to experiencing suspected/diagnosed COVID-19, the loss of work for a participant or their partner, a major cut in household income, and the loss of somebody close to the participant.Socioeconomic positionWe measured SEP using five variables collected at baseline interview.

    (1) annual household income (<£16 000, £16 000–£30 000, £30 000–£60 000, £60 000–£90 000, £90 000+), buy etodolac over the counter (2) highest qualification (General Certificate of Secondary Education (GCSE) or lower (qualifications at age 16), A-Levels or vocational training (qualifications at age 18), undergraduate degree, postgraduate degree), (3) employment status (employed, inactive and unemployed), (4) housing tenure (own outright, own with mortgage, rent/live rent-free) and (5) household overcrowding (binary. >1 person per room). From these variables, we constructed a Low SEP index measure by counting indications of low SEP (income <£16 000, educational qualifications of GCSE or lower, unemployed, living in rented or rent-free accommodation, and living in overcrowded accommodation), collapsing into 0, 1 and 2+ indications of low SEP to attain adequate sample sizes for each category.CovariatesTo account for broad demographic differences that could confound the association between SEP and adversity experiences, we also included variables for gender (male, female), age (18–24, 25–34, 35–49, 50–64, 65+), marital status (cohabiting with partner, living away from partner, single, divorced/widowed) and ethnicity buy etodolac over the counter (white, non-white).AnalysisWe assessed experienced adversities according to SEP by estimating Poisson models for each of the 3 weeks separately. First, we extracted the predicted number of adversities according to SEP using average marginal effects and plotted the estimates to test whether social gradients were present and whether they changed in size by week.

    Second, we repeated this exercise for each adversity separately by estimating logit models for each adversity and buy etodolac over the counter each week of data. Analyses were adjusted for age, gender, ethnicity and marital status. Third, we compared estimated differences in the prevalence of adversities between highest and lowest SEP groups in weeks 1 and 3 to explore if there was any evidence of change in inequalities over buy etodolac over the counter time. To account for the non-random nature of the sample, all data were weighted to the proportions of gender, age, ethnicity, education and country of living obtained from the Office for National Statistics.22We carried out several sensitivity analyses to test the robustness of our results.

    First, to test whether findings were an artefact of our chosen statistical method, we repeated the Poisson regressions using negative binomial and zero-inflated Poisson models. Second, to test whether findings were driven by our type of SEP index, we repeated analyses using the individual SEP variables directly and deriving an alternative SEP measure using confirmatory factor buy etodolac over the counter analysis (CFA). The CFA used weighted least square mean, and given the discrete nature of the SEP indicators, the variance adjusted (WLSMV) estimator was implemented. The root mean square error of approximation of the CFA model was 0.08, indicating an adequate fit.23 We split the latent buy etodolac over the counter factor into five groups using natural breaks in the factor values.

    Third, as the reporting of COVID-19 symptoms is likely biased due to asymptomatic cases or differences in recognition of symptoms, the latter of which is likely to be related to health literacy and thus to SEP, we excluded suspected/diagnosed COVID-19 from the total adversity measure. Finally, as several of the adversities considered here are related to loss of employment or paid work, we repeated each analysis restricting the sample buy etodolac over the counter to adults who were employed at baseline.RESULTSDescriptive statisticsDescriptive statistics for the sample are shown in table 1. Once weighting had been applied, our sample closely matched population averages on gender, age, ethnicity, education and country of living. Unweighted figures are shown in Supplementary table 1.View this table:Table 1 Descriptive sample statistics buy etodolac over the counter weighted according to ONS dataSupplemental materialThe prevalence of adversities overall and by week is shown in table 2.

    Average number of adversities increased over the follow-up period, as did variability. Within the first 3 weeks, one in six participants reported a major cut in ousehold income and either them or their partner buy etodolac over the counter losing work. Numbers experiencing symptoms of COVID-19, or losing people close to them also increased. Conversely, numbers of participants being unable to access food or medication fell week by week.View this table:Table 2 Weighted descriptive statistics, total and individual adversitiesAdversity buy etodolac over the counter by SEPWhen applying our low SEP index, the number of adverse events experienced each week showed a clear social gradient (figure 1).

    Regression results showed a significant difference in the number of adverse events according to the SEP index score among those with scores of 1 and 2+ compared with those with scores of 0 (Supplementary Table 2). When comparing the change in experience in adversities over time by SEP, these inequalities were maintained each week, with buy etodolac over the counter no decreases evident over time (Supplementary Table 4).Predicted mean number of adversities experienced by week and SEP, derived from fully adjusted Poisson model. NB dates show the week in which adversities were reported, with reporting being on experiences in the past 7 days. SEP, socioeconomic position." data-icon-position data-hide-link-title="0">Figure 1 Predicted mean number of adversities experienced by buy etodolac over the counter week and SEP, derived from fully adjusted Poisson model.

    NB dates show the week in which adversities were reported, with reporting being on experiences in the past 7 days.SEP, socioeconomic position.When exploring the patterns for each type of adversity individually, there was a clear social gradient across all financial measures and across factors relating to basic needs (figure 2). People of lower SEP were 1.5 times more likely to experience buy etodolac over the counter loss of work compared with people of higher SEP, and their partners were twice as likely to experience loss of work (Supplementary Table 3). They were also 7.2 times more likely to be unable to pay bills in week 1 (rising to 8.7 times more likely by week 3), 4.1 times more likely to be unable to access sufficient food in week 1 (rising to 4.9 times more likely be week 3) and 2.5 times more likely to be unable to access required medication. However, there was little evidence of a gradient in buy etodolac over the counter experiences directly relating to the virus, with no significant differences between groups.

    In comparing the change in experience of each specific adversity over time by SEP, the inequalities present in each individual adversity were maintained each week, with no evidence of improvement over time (Supplementary Table 4).Predicted probability of experiencing specific adversities by week and SEP, from fully adjusted logit models. NB dates show the week in which adversities were reported, with reporting being on experiences in the past 7 days buy etodolac over the counter. SEP, socioeconomic position." data-icon-position data-hide-link-title="0">Figure 2 Predicted probability of experiencing specific adversities by week and SEP, from fully adjusted logit models. NB dates show the week in which adversities were reported, with reporting being on experiences in the past 7 days.SEP, socioeconomic position.Sensitivity analysesWhen using alternative regression analyses, results were materially unaffected (Supplementary Figure 1), as were results when using CFA rather buy etodolac over the counter than our low SEP index (Supplementary Figures 2 and 3).

    When excluding suspected/diagnosed COVID-19 from the total adversity measure, results showed no meaningful differences (Supplementary Figure 4). Similarly, when restricting the analysis to those employed at baseline, results were qualitatively similar but with a stronger social gradient (Supplementary Figure 5).DISCUSSIONThis study explored the patterns of adversities in the early weeks of lockdown in the UK buy etodolac over the counter due to COVID-19, showing a clear social gradient in experiences. This gradient was evident across the overall number of adversities experienced and specifically across financial stressors and challenges relating to basic needs (including food, medications and accommodation). Inequalities were maintained with no reductions in differences between socioeconomic groups over time.Notably, this experience of inequalities in financial stressors occurred in the wake of measures announced by government and banks in the UK such as mortgage holidays and furlough schemes aimed at reducing the financial shocks of COVID-19.24 While these financial measures implemented may have reduced the discrepancy in experiences between the wealthiest and poorest to a certain extent (it is not possible to test what the alternative scenario buy etodolac over the counter might have been), the data presented here show that they did not remove it.

    This may be because benefits of the schemes did not come into effect immediately within the first month of lockdown (eg, for receipt of furlough payments to be made) or it may indicate that measures were insufficient and individuals of lower SEP still experienced greater financial burden during the pandemic. Even if these initial financial shocks are reduced over time as schemes come into effect and as more measures are taken, they are still concerning, given the well-researched link between experience of adversities and poor mental health outcomes, poor physical health outcomes and suicides.18–21 In planning ahead for anticipated upcoming stages in the fallout from the pandemic, such as a possible future recession, this suggests that more steps need to be taken urgently to reduce further adverse effects for individuals of lower SEP before further negative effects occur.18 Further, in terms of preparedness for future pandemics, these results suggest that even more ambitious measures are required early to reduce immediate financial shocks if efforts are to be made to try to avoid widening economic disparities.Our findings were related to access to basic needs such as food substantiate concerns voiced by academic-practitioners working in food insecurity, food systems and inequality early in the outbreak of COVID-19.25 While the data presented here may suggest that although challenges in accessing food decreased in the early weeks following lockdown being implemented in the UK, inequalities in that access remained. It is clearly important that buy etodolac over the counter such inequalities are addressed, as there is the potential for both second waves of the virus that might trigger repeat lockdowns, and for further challenges in the functioning of food systems. Planning for the potential of future pandemics should consider how such inequalities could be reduced through early implementation of interventions such as further financial and business support to low-income households, to food charities and food banks, to food producers and to supermarkets, shops and delivery companies.25It is notable that the findings presented here did not show such a clear gradient in experiences of the virus itself within the UK.

    There is evidence of patterns of inequality in the experience of symptoms of COVID-19 in other literature.1–4 However, given that many cases of the virus are asymptomatic, and low levels of population testing mean that exact infections rates cannot be estimated, buy etodolac over the counter our data cannot be taken to represent actual inequalities in cases. Differences in recognition of symptoms are likely to be related to health literacy and thus to SEP, and so may also have affected analyses. Moreover, our buy etodolac over the counter questions about experience of bereavement due to COVID-19 or a close family member being hospitalised were asked early in the pandemic when prevalence was low. Our study may have been underpowered to detect clear effects.

    This also applies to losing accommodation, which occurred for less than 0.2% of the sample buy etodolac over the counter. Therefore, our findings do not necessarily imply an absence of inequalities for these experiences and it remains to be seen if inequalities do start to emerge over time. It is also likely that this finding will vary by country depending on the measures taken to reduce the spread of the virus.This study has several strengths, including its large sample size, its longitudinal tracking of participants and its rich inclusion of buy etodolac over the counter measures on socioeconomic factors and experienced adversities during COVID-19. However, there are several limitations.

    The study is not nationally representative, although it does have good stratification across all buy etodolac over the counter major socio-demographic groups and analyses were weighted on the basis of population estimates of core demographics (gender, age, ethnicity, education and country of living). While the recruitment strategy included deliberately targeting individuals of low educational attainment and low household income groups, it is possible that more extreme experiences were not adequately captured. So the buy etodolac over the counter inequalities shown in this paper may be underestimations. Further, individuals experiencing particularly high levels of adversity may have withdrawn from the study early, and therefore not been included in our longitudinal sample in these analyses.

    We lacked follow-up data for 40% of participants (although this does not reflect a drop-out rate for the study as some participants buy etodolac over the counter have continued to provide data since, merely outside the window of the dates we focused on for these analyses). Although our use of survey weights may have partly guarded against the effects of selective dropout, it is nonetheless possible that our data present underestimations of inequalities. Additionally, this paper focused exclusively buy etodolac over the counter on adversities relating to finances, basic needs and experience of the virus. However, other inequalities have also been noted such as in educational opportunities for children during school closures.26 These remain to be explored further in future studies.

    Finally, our study used two different SEP indices and further tested specific aspects of SEP in sensitivity analyses, but we buy etodolac over the counter restricted measurement of SEP to a finite list of factors. Other measures of SEP such as social status or area deprivation and how they relate to adversities experienced remain to be explored further.The results presented here suggest that there were clear inequalities in adverse experiences during the COVID-19 pandemic in the early weeks of lockdown in the UK. This is notable given that several measures were taken to try to reduce such adverse events, and suggests that such measures did not go far enough buy etodolac over the counter in tackling inequality. Further, it is likely that such inequalities in experience will be even greater in low-income countries as the pandemic continues.7 The findings from this paper therefore support calls for each country to continually assess which members of society are vulnerable throughout the COVID-19 pandemic to take action to support those at highest risk, and also for planning for future pandemics to include more extensive measures to reduce disproportionate experiences of adversity among lower socioeconomic groups.7What is already known on this subjectA recently published rapid review of the literature on the effects of isolation and quarantine suggested that people can experience a range of adversities during and in the aftermath of the epidemic.

    These can include adversities related to the virus itself (such as infection or bereavement), as well as challenges meeting basic needs (such as access buy etodolac over the counter to food, medication and accommodation), and the experience of financial loss. There has been concern that the COVID-19 pandemic could expose and widen existing inequalities within societies. Yet, there have been no empirical analyses.What this study addsThis study confirms that there was a clear gradient across the number of adverse events experienced each week by SEP during lockdown in the buy etodolac over the counter UK. This was most clearly seen for adversities relating to finances and basic needs (including access to food and medications) but less for experiences directly relating to the virus.

    The findings from this paper suggest that individuals of lower SEP are experiencing more adverse events due to COVID-19 and supports calls for each country to continually assess which members of society are vulnerable throughout the COVID-19 pandemic to take action to support those at highest risk..

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    Francine Padgett and Michael RoseMidMichigan buy etodolac without a prescription Health’s longtime Chief Financial Officer Francine Padgett will retire at the end of October 2020 after more than 30 years of dedicated service and leadership to the not-for-profit health system. Padgett, who also serves as senior vice president and treasurer for MidMichigan, will transition alongside her newly named successor Michael Rose, C.P.A., M.B.A., previous CFO of SolutionHealth and former president and CEO of Southern New Hampshire Health.“Francine is well respected buy etodolac without a prescription in the health care industry and is one of the most accomplished financial leaders you will ever come to know. No matter the project on the table, she and her team put our patients first at all times,” said Diane Postler-Slattery, Ph.D., FACHE, president and CEO, MidMichigan Health. €œHer tremendous knowledge base and direction has made a significant contribution to the success and buy etodolac without a prescription overall growth of our organization. We will miss her enthusiasm, work ethic and the thoughtfulness she has shown to each and every one of us over the years.”Recipient of the Chief Financial Officer of the Year Award for Healthcare by Crain’s Detroit Business in 2012, during her time with MidMichigan Health, Padgett has played a critical role in several collaboration and growth initiatives.

    These included MidMichigan’s 2013 affiliation with Michigan Medicine, the health care division of the University of Michigan, the health system’s partnership with Alpena buy etodolac without a prescription Regional Medical Center in April 2016 and West Branch Medical Center in April 2018, as well as expansions in Freeland, Bay City, and Mt. Pleasant, to name a few.In addition, Padgett helped to establish strong buy etodolac without a prescription credit ratings and invested carefully, which allowed MidMichigan to execute numerous construction and renovation projects, implement a state-of-the-art electronic medical record system, acquire state-of-the-art technology and provide millions in charity care, community benefits and other compensated care each fiscal year.What’s more, with her guidance, the health system navigated an ever-changing health care industry, with challenges including fluctuating regulations and reimbursements, treatment costs and value-based purchasing. Yet, according to MidMichigan’s leaders, one of her greatest successes was helping to save hundreds of jobs during COVID-19 while also contending with a 500-year flood that impacted the health system’s flagship Medical Center in Midland, amidst the global pandemic.“The challenges we encountered in 2020 are nothing short of unprecedented,” said Postler-Slattery. €œLike most health care systems, buy etodolac without a prescription we forecasted a significant financial impact early on in the crisis. But Francine, along with our entire leadership team, refused to have employees lose their jobs to save our organization dollars.

    As services were temporarily suspended, we implemented a unique buy etodolac without a prescription pandemic PTO (personal time off) program for our employees. The program allowed them to cross-train within other departments when otherwise they may have been laid off. This decision resulted buy etodolac without a prescription in a savings far greater than the bottom line. The decision saved our employees and kept buy etodolac without a prescription them working throughout the pandemic. It helped them in the long-term and that was the important difference.

    We couldn’t have done this without Francine’s foresight.”“Working at MidMichigan Health has been more than rewarding, it has been an honor,” said Padgett, who was named a Junior Achievement of North Central Michigan Business Hall of Fame Laureate in 2019, and a 2019 Healthcare Honoree for the YWCA Women of buy etodolac without a prescription Achievement Awards. €œI have worked alongside the very best and consider my colleagues and team - family. To serve in this capacity and help change buy etodolac without a prescription the lives of our patients, families, our employees and community has been second-to-none. It’s been a privilege and my heartfelt thanks go to all those who gave me the opportunity to carry out my career with MidMichigan.”Succeeding Padgett, Rose has nearly 30 years of health care experience. In his past role as president and CEO of Southern New Hampshire Health and CFO of SolutionHealth, he helped lead the formation of buy etodolac without a prescription SolutionHealth in 2017.

    Through a merger of Southern New Hampshire Health and Elliot Health System, the regional system has revenues in excess buy etodolac without a prescription of $1 billion, approximately 7,000 employees and 700 employed providers.“Michael’s background and experience will be a tremendous asset to MidMichigan Health,” said Padgett. €œHe has experience working with academic medical centers, large physician practice groups, and has created unique partnerships with commercial insurance companies. The depth of his skills buy etodolac without a prescription will have a great impact on the advancement of our health system. We are confident he will continue to position MidMichigan Health for a strong and healthy financial future.”Prior to his time with Southern New Hampshire, Rose was vice president of finance and operations for Cooper University Hospital where he oversaw all financial and operational areas of a $220 million faculty practice with 370 full-time physicians. Before that, he served in various financial leadership positions for Virginia buy etodolac without a prescription Commonwealth University Health Systems from 1992 to 2000.Rose completed his undergraduate degree in accounting from Longwood University and received his master’s degree in in Business Administration from Virginia Commonwealth University.

    He is married with three adult children and enjoys outdoor activities such as skiing, hiking and mountain biking..

    Francine Padgett and Michael RoseMidMichigan Health’s longtime Chief Financial Officer Francine Padgett will retire at the end of October 2020 after more than 30 years of buy etodolac over the counter dedicated service and leadership to the not-for-profit health system. Padgett, who also serves as senior vice president and treasurer for MidMichigan, will transition alongside her newly named successor Michael Rose, C.P.A., M.B.A., previous CFO of SolutionHealth and former buy etodolac over the counter president and CEO of Southern New Hampshire Health.“Francine is well respected in the health care industry and is one of the most accomplished financial leaders you will ever come to know. No matter the project on the table, she and her team put our patients first at all times,” said Diane Postler-Slattery, Ph.D., FACHE, president and CEO, MidMichigan Health.

    €œHer tremendous knowledge base and direction has made a significant contribution buy etodolac over the counter to the success and overall growth of our organization. We will miss her enthusiasm, work ethic and the thoughtfulness she has shown to each and every one of us over the years.”Recipient of the Chief Financial Officer of the Year Award for Healthcare by Crain’s Detroit Business in 2012, during her time with MidMichigan Health, Padgett has played a critical role in several collaboration and growth initiatives. These included MidMichigan’s 2013 affiliation with Michigan Medicine, the health care division of the University of Michigan, the health system’s partnership with Alpena Regional Medical Center in April 2016 and West buy etodolac over the counter Branch Medical Center in April 2018, as well as expansions in Freeland, Bay City, and Mt.

    Pleasant, to name a few.In addition, Padgett helped to establish strong credit ratings and invested carefully, which allowed MidMichigan to execute numerous construction and renovation projects, implement a state-of-the-art electronic medical record system, acquire state-of-the-art technology and provide millions in charity care, community benefits and other compensated care each fiscal year.What’s more, with her guidance, the health system navigated an ever-changing health care industry, with challenges including fluctuating regulations and reimbursements, treatment costs buy etodolac over the counter and value-based purchasing. Yet, according to MidMichigan’s leaders, one of her greatest successes was helping to save hundreds of jobs during COVID-19 while also contending with a 500-year flood that impacted the health system’s flagship Medical Center in Midland, amidst the global pandemic.“The challenges we encountered in 2020 are nothing short of unprecedented,” said Postler-Slattery. €œLike most health care systems, we forecasted a significant financial impact early on in the crisis buy etodolac over the counter.

    But Francine, along with our entire leadership team, refused to have employees lose their jobs to save our organization dollars. As services were temporarily suspended, we implemented a unique pandemic PTO (personal time off) program for our buy etodolac over the counter employees. The program allowed them to cross-train within other departments when otherwise they may have been laid off.

    This decision resulted in buy etodolac over the counter a savings far greater than the bottom line. The decision saved our employees buy etodolac over the counter and kept them working throughout the pandemic. It helped them in the long-term and that was the important difference.

    We couldn’t have done this without Francine’s foresight.”“Working at MidMichigan Health has been more than rewarding, it has been buy etodolac over the counter an honor,” said Padgett, who was named a Junior Achievement of North Central Michigan Business Hall of Fame Laureate in 2019, and a 2019 Healthcare Honoree for the YWCA Women of Achievement Awards. €œI have worked alongside the very best and consider my colleagues and team - family. To serve in this capacity and help change the lives of our patients, buy etodolac over the counter families, our employees and community has been second-to-none.

    It’s been a privilege and my heartfelt thanks go to all those who gave me the opportunity to carry out my career with MidMichigan.”Succeeding Padgett, Rose has nearly 30 years of health care experience. In his past role as president and CEO of Southern New Hampshire Health and CFO of SolutionHealth, he buy etodolac over the counter helped lead the formation of SolutionHealth in 2017. Through a merger of Southern New Hampshire Health and Elliot Health System, the regional system has revenues in excess of $1 billion, approximately 7,000 employees and 700 employed providers.“Michael’s background and experience will be a tremendous asset to MidMichigan buy etodolac over the counter Health,” said Padgett.

    €œHe has experience working with academic medical centers, large physician practice groups, and has created unique partnerships with commercial insurance companies. The depth of his skills will have a great impact on the buy etodolac over the counter advancement of our health system. We are confident he will continue to position MidMichigan Health for a strong and healthy financial future.”Prior to his time with Southern New Hampshire, Rose was vice president of finance and operations for Cooper University Hospital where he oversaw all financial and operational areas of a $220 million faculty practice with 370 full-time physicians.

    Before that, he served in various buy etodolac over the counter financial leadership positions for Virginia Commonwealth University Health Systems from 1992 to 2000.Rose completed his undergraduate degree in accounting from Longwood University and received his master’s degree in in Business Administration from Virginia Commonwealth University. He is married with three adult children and enjoys outdoor activities such as skiing, hiking and mountain biking..

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    Une exposition présentera à la Maison natale des aspects actuels de l'utilisation de la soie, dans les domaines industriels et techniques, dans la création artistique, avec un clin d'oeil aux travaux de Pasteur sur les maladies des vers à soie en...

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    Visite passion

    Pendant les vacances , venez faire la connaissance de Louis PASTEUR, visitez sa maison natale à Dole et la salle scientifique exposant les découvertes de notre grand savant Jurassien.
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