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    Après les monuments dolois à l'effigie de Louis Pasteur, c'est au tour des sites arboisiens !
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    First-of-its-kind study, based on a mouse model, finds living in a polluted environment could be comparable to eating a high-fat diet, leading to a pre-diabetic state CLEVELAND—Air pollution is the world’s leading environmental risk factor, and causes more than nine million deaths can you buy yasmin over the counter usa per year. New research published in the Journal of Clinical Investigation shows air pollution may play a role in the development of cardiometabolic diseases, such as diabetes. Importantly, the can you buy yasmin over the counter usa effects were reversible with cessation of exposure. Researchers found that air pollution was a “risk factor for a risk factor” that contributed to the common soil of other fatal problems like heart attack and stroke.

    Similar to how an unhealthy diet and lack of exercise can lead to disease, exposure to air pollution could be added to this risk factor list as well. “In this study, we created an environment that mimicked a polluted day in New Delhi can you buy yasmin over the counter usa or Beijing,” said Sanjay Rajagopalan, MD, first author on the study, Chief of Cardiovascular Medicine at University Hospitals Harrington Heart and Vascular Institute, and Director of the Case Western Reserve University Cardiovascular Research Institute. €œWe concentrated fine particles of air pollution, called PM2.5 (particulate matter component <. 2.5 microns) can you buy yasmin over the counter usa.

    Concentrated particles like this develop from human impact on the environment, such as automobile exhaust, power generation and other fossil fuels.” These particles have been strongly connected to risk factors for disease. For example, cardiovascular effects of air pollution can lead to heart attack and stroke. The research team has can you buy yasmin over the counter usa shown exposure to air pollution can increase the likelihood of the same risk factors that lead to heart disease, such as insulin resistance and type 2 diabetes. In the mouse model study, three groups were observed.

    A control group receiving clean filtered air, a group exposed to polluted air for 24 weeks, and a group fed a high-fat diet. Interestingly, the researchers found that being exposed to air pollution was comparable to can you buy yasmin over the counter usa eating a high-fat diet. Both the air pollution and high-fat diet groups showed insulin resistance and abnormal metabolism – just like one would see in a pre-diabetic state. These changes were associated with changes in the epigenome, a layer of control that can masterfully turn on and can you buy yasmin over the counter usa turn off thousands of genes, representing a critical buffer in response to environmental factors.

    This study is the first-of-its-kind to compare genome-wide epigenetic changes in response to air pollution, compare and contrast these changes with that of eating an unhealthy diet, and examine the impact of air pollution cessation on these changes.“The good news is that these effects were reversible, at least in our experiments” added Dr. Rajagopalan. €œOnce the air can you buy yasmin over the counter usa pollution was removed from the environment, the mice appeared healthier and the pre-diabetic state seemed to reverse.” Dr. Rajagopalan explains that if you live in a densely polluted environment, taking actions such as wearing an N95 mask, using portable indoor air cleaners, utilizing air conditioning, closing car windows while commuting, and changing car air filters frequently could all be helpful in staying healthy and limiting air pollution exposure.Next steps in this research involve meeting with a panel of experts, as well as the National Institutes of Health, to discuss conducting clinical trials that compare heart health and the level of air pollution in the environment.

    For example, if someone has a heart attack, should they be wearing an N95 mask or using a portable air filter at home during recovery?. Dr can you buy yasmin over the counter usa. Rajagopalan and his team believe that it is important to address the environment as a population health risk factor and continue to diligently research these issues. The authors can you buy yasmin over the counter usa also note that these findings should encourage policymakers to enact measures aimed at reducing air pollution.Shyam Biswal, PhD, Professor in the Department of Environmental Health and Engineering at Johns Hopkins University School of Public Health, is the joint senior author on the study.

    Drs. Rajagopalan and Biswal are co-PIs on the NIH grant that supported this work.###Rajagopalan, S., Biswal, S., et al. €œMetabolic effects of air pollution exposure and reversibility.” Journal of Clinical can you buy yasmin over the counter usa Investigation. DOI.

    10.1172/JCI137315. This work was supported by the National Institute of Environmental Health Sciences TaRGET II Consortium grant U01ES026721, as well as grants R01ES015146 and R01ES019616.About one in five women experience some form of depression during pregnancy, with poorly understood effects on the fetus. Prenatal depression is linked to behavioural and developmental issues in children as well as an increased risk for depression as young adults. But how prenatal depression leads to these changes remains unclear.

    UCalgary researcher Dr. Catherine Lebel, PhD, is helping understand what may be happening in the developing brains of these children. The research team has shown that young children whose mothers experienced more numerous symptoms of depression in pregnancy have weakened connectivity in brain pathways involved in emotion. These structural changes can be related to increased hyperactivity and aggression in boys.

    The research is based on diffusion magnetic resonance imaging, an imaging technique that probes the strength of structural connections between brain regions. The findings are published in The Journal of Neuroscience. Catherine Lebel, senior author and investigator. Riley Brandt, University of Calgary “The results help us understand how depression can have multigenerational impacts, and speaks to the importance of helping mothers who may be experiencing depression during pregnancy,” says Lebel, an associate professor at the Cumming School of Medicine, and researcher in the Alberta Children’s Hospital Research Institute.

    She holds the Canada Research Chair in Paediatric Neuroimaging. Lebel and her team studied 54 Calgary mothers and their children. They were enrolled from the ongoing, prospective study called the Alberta Pregnancy Outcomes and Nutrition study. Mothers answered a survey about their depression symptoms at several points during their pregnancy.

    Their children were followed after birth and undertook an MRI scan at the Alberta Children’s Hospital at around age four. As well, the children’s behaviour was assessed within six months of their MRI scan. The team found a significant reduction in structural brain connectivity between the amygdala, a structure essential for emotional processing, and the frontal cortex. Weakened connectivity between the amygdala and frontal cortex is associated with disruptive behaviours and vulnerability to depression.

    The first author on the study, Dr. Rebecca Hay, MD, stresses the importance of recognition of depression and intervention in prenatal health. €œThese results suggest complex associations between the prenatal environment and children’s brain development, and may help us to understand why children of depressed mothers are more vulnerable to depression themselves,” says Hay, a resident physician in paediatrics and recent Cumming School of Medicine graduate. The main clinical takeaway from this is to emphasize the importance of recognizing, treating prenatal depression and supporting mothers, both for better maternal outcomes and to help future child development.

    Rebecca Hay, the study's first author. Courtesy Rebecca Hay Current study looks at stress during pandemic Lebel and her research team are currently trying to understand how stress and mental health are affecting pregnant women during the COVID-19 pandemic. She is examining how factors such as social supports might mitigate stress, and how this may influence pregnancy and birth outcomes. If you are interested, you can get involved here in the Pregnancy During the COVID-19 Pandemic study at the University of Calgary.

    So far, approximately 7,500 women from across Canada are enrolled and supplying information through questionnaires. €œIt is critical to appropriately recognize and treat prenatal maternal mental health problems, both for the mothers and to improve child outcomes,” says Lebel. €œNow more than ever, with increased stress, anxiety and depression during the COVID-19 pandemic, we should do more to support mothers to positively impact the health of their children.” Lebel is an associate professor in the Department of Radiology at the Cumming School of Medicine, adjunct associate professor in the Werklund School of Education and a member of The Mathison Centre for Mental Health Research &. Education, Owerko Centre at ACHRI, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute.

    The study was funded by the Canadian Institute of Health Research, Alberta Innovates - Health Solutions, the Alberta Children's Hospital Foundation, the National Institute of Environmental Health Sciences, the Mach-Gaensslen Foundation, and an Eyes High University of Calgary Postdoctoral Scholar. Led by the Hotchkiss Brain Institute, Brain and Mental Health is one of six research strategies guiding the University of Calgary toward its Eyes High goals. The strategy provides a unifying direction for brain and mental health research at the university..

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    Despite PAHs being the first class of chemicals identified can you buy yasmin over the counter usa as cancer-causing, little is known about the carcinogenic potential of the more than 1,500 PAHs. Part of the challenge is that PAHs usually occur as a mixture of chemicals, making it difficult to tease apart roles of individual chemicals in the mixture. The OSU researchers, led by Susan Tilton, an associate professor in the Department of Environmental and Molecular Toxicology in the College of Agricultural Sciences, have been studying PAHs for over six years. They previously developed a system can you buy yasmin over the counter usa to predict whether tumors formed in mice exposed to certain PAHs.

    The current research translates that approach using human bronchial cells. The researchers treated the cells with individual PAHs and then used computational analysis to look at changes across thousands of genes simultaneously to identify gene signatures. They then looked for gene can you buy yasmin over the counter usa signatures consistent across the different chemicals with similar carcinogenic potential. €œThose with similar carcinogenic potential are the ones we can focus on,” Tilton said.

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    Exponential growth yasmin halawa is difficult for people to grasp. But that is what has happened to sales of Albert Camus’s The Plague, first published in 1947. According to Jacqueline yasmin halawa Rose, it is ‘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 for Rose, and for us, is that a key theme of Camus is that ‘the pestilence is at once blight and yasmin halawa revelation. It brings the hidden truth of a corrupt world to the surface’. In the same way, the pandemic yasmin halawa 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 yasmin halawa 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 COVID-19 and inequalities in the social conditions that lead to inequalities in health more generally.It was yasmin halawa 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 yasmin halawa many people 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. €¦INTRODUCTIONOver the past few weeks, there have been claims in yasmin halawa the media that coronavirus disease 2019 (COVID-19) is uniting societies and countries in shared experience. €˜we are all in 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 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 yasmin halawa 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 yasmin halawa 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 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 yasmin halawa the COVID-19 pandemic. The study commenced on 21 March 2020, with recruitment ongoing. The study involves online weekly yasmin halawa 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 yasmin halawa who had previously consented to be involved in health research across the UK), print and digital media coverage, and social media. Second, more 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 yasmin halawa 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 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 yasmin halawa (n=14 309. 58.7% of 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 yasmin halawa 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 each week yasmin halawa. 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 yasmin halawa had been unable to pay bills. Three questions assessed adversity relating to basic needs. Whether participants had lost their accommodation, they had yasmin halawa 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 yasmin halawa had suspected 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 yasmin halawa (ie, once experienced 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, £16 000–£30 000, £30 000–£60 000, £60 000–£90 000, £90 000+), (2) highest qualification (General Certificate of Secondary Education (GCSE) or yasmin halawa 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 (white, non-white).AnalysisWe assessed experienced adversities according to SEP by estimating Poisson models for each of the 3 weeks separately. First, we extracted yasmin halawa 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 each week of data. Analyses were adjusted for age, gender, ethnicity and marital yasmin halawa 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 time. To account for the non-random nature of yasmin halawa 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 yasmin halawa 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 yasmin halawa was 0.08, indicating an adequate fit.23 We split the latent 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 yasmin halawa paid work, we repeated each 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 this table:Table 1 Descriptive sample statistics weighted according to ONS dataSupplemental materialThe prevalence of adversities overall and by week is shown in yasmin halawa 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 losing work yasmin halawa. 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 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 yasmin halawa 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 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 yasmin halawa past 7 days. SEP, socioeconomic position." 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 yasmin halawa 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 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 yasmin halawa 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 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 yasmin halawa 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. SEP, socioeconomic position." data-icon-position data-hide-link-title="0">Figure 2 Predicted probability of yasmin halawa 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 than our low SEP index (Supplementary Figures 2 and 3).

    When excluding suspected/diagnosed COVID-19 from the total adversity measure, results showed yasmin halawa 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 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 yasmin halawa 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 yasmin halawa 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 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 yasmin halawa 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, 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 yasmin halawa to SEP, and so may also have affected analyses. Moreover, our 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 yasmin halawa may have been underpowered to detect clear effects.

    This also applies to losing accommodation, which occurred for less than 0.2% of the sample. Therefore, our findings yasmin halawa 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 measures on socioeconomic factors and experienced adversities during COVID-19. However, there are yasmin halawa 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 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 yasmin halawa 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 have continued to provide data since, merely outside the window of the dates we focused on for these analyses) yasmin halawa. 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 yasmin halawa 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 yasmin halawa aspects of SEP in sensitivity analyses, but we 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 yasmin halawa enough 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 yasmin halawa 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 been no empirical analyses.What this study addsThis study confirms that there was a clear gradient across the number of yasmin halawa 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 can you buy yasmin over the counter usa difficult for people to 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 ‘an upsurge strangely in line with the graphs that daily chart can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa at once blight and revelation.

    It brings the hidden truth of a corrupt world to the surface’. In the same way, the pandemic of COVID-19 exposes and amplifies inequalities can you buy yasmin over the counter usa in society. The myth of the pandemic as the great leveller was given air when early cases included elites. A prince, a can you buy yasmin over the counter usa prime minister, a 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 COVID-19 and inequalities in the social conditions that lead to inequalities can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa many people 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. €¦INTRODUCTIONOver the past few weeks, there have been claims in the media that coronavirus disease 2019 (COVID-19) is uniting societies and countries in can you buy yasmin over the counter usa shared experience.

    €˜we are all in 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 challenges for more disadvantaged groups due to individuals facing difficulties in accessing healthcare in certain countries, being less able to can you buy yasmin over the counter usa 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 adversity can you buy yasmin over the counter usa.

    (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 can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa 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 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 can you buy yasmin over the counter usa 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 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 can you buy yasmin over the counter usa (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). We excluded participants with missing data on any variable used in this study (n=1782. 12.45% of can you buy yasmin over the counter usa balanced panel. 3.21% missing weights, 9.67% missing SEP measures and 0.01% missing outcome measure). This provided can you buy yasmin over the counter usa a final analytical sample of 12 527 participants.MeasuresAdversitiesQuestions 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 can you buy yasmin over the counter usa 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, can you buy yasmin over the counter usa they 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 or diagnosed COVID-19, somebody close to them can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa 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, £16 000–£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 can you buy yasmin over the counter usa.

    >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 (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 can you buy yasmin over the counter usa 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 each week of data. Analyses were adjusted for age, gender, can you buy yasmin over the counter usa 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 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 can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa SEP index, 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, can you buy yasmin over the counter usa indicating an adequate fit.23 We split the latent 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 to adults who were employed at baseline.RESULTSDescriptive statisticsDescriptive statistics for the sample are shown in table can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa participants reported a major cut in ousehold income and either them or their partner 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 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 can you buy yasmin over the counter usa 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 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 can you buy yasmin over the counter usa. SEP, socioeconomic position." 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 can you buy yasmin over the counter usa 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 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 can you buy yasmin over the counter usa 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 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 can you buy yasmin over the counter usa 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." data-icon-position data-hide-link-title="0">Figure 2 Predicted probability of experiencing specific adversities by week and SEP, from can you buy yasmin over the counter usa 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 than our low SEP index (Supplementary Figures 2 and 3). When excluding suspected/diagnosed COVID-19 from the total adversity measure, results can you buy yasmin over the counter usa 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 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 can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa 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 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 can you buy yasmin over the counter usa 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, our data cannot be taken to represent actual inequalities in cases.

    Differences in recognition of symptoms are likely to be related to health literacy can you buy yasmin over the counter usa and thus to SEP, and so may also have affected analyses. Moreover, our 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 can you buy yasmin over the counter usa have been underpowered to detect clear effects. This also applies to losing accommodation, which occurred for less than 0.2% of 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 can you buy yasmin over the counter usa.

    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 measures on socioeconomic factors and experienced adversities during COVID-19. However, there are several can you buy yasmin over the counter usa limitations. The study is not nationally representative, although it does have good stratification across all 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 inequalities shown can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa not reflect a drop-out rate for the study as some participants 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 on adversities relating to finances, basic needs and can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa SEP in sensitivity analyses, but we 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 can you buy yasmin over the counter usa 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 to food, medication and accommodation), and the experience of financial loss can you buy yasmin over the counter usa.

    There has been concern that the COVID-19 pandemic could expose and widen existing inequalities within societies. Yet, there can you buy yasmin over the counter usa 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 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..

    Yasmin ocp

    How to yasmin ocp cite this article:Singh OP. The need for routine psychiatric assessment of COVID-19 survivors. Indian J Psychiatry 2020;62:457-8COVID-19 yasmin ocp pandemic 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 are known to be associated yasmin ocp 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 yasmin ocp 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 initial symptom yasmin ocp 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 yasmin ocp 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 yasmin ocp B, North CS. Mental health and the COVID-19 pandemic.

    N Engl yasmin ocp J Med 2020;383:510-2. 2.Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of yasmin ocp unknown etiology in Wuhan, China. The mystery and the miracle. J Med Virol 2020;92:401-2.

    3.Fodoulian L, Tuberosa J, Rossier D, Landis BN, yasmin ocp 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 yasmin ocp. 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. 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 this article:Singh OP can you buy yasmin over the counter usa. The need for routine psychiatric assessment of COVID-19 survivors. Indian J Psychiatry 2020;62:457-8COVID-19 pandemic is expected to bring a Tsunami of mental health can you buy yasmin over the counter usa 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 be associated with psychiatric disorders such as depression, bipolar disorder, obsessive–compulsive disorder (OCD), or schizophrenia can you buy yasmin over the counter usa. 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 can you buy yasmin over the counter usa 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 initial symptom points toward can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa B, North CS. Mental health and the COVID-19 pandemic. N Engl can you buy yasmin over the counter usa J Med 2020;383:510-2.

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

    3.Fodoulian L, Tuberosa J, Rossier D, Landis BN, Carleton can you buy yasmin over the counter usa 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 can you buy yasmin over the counter usa. 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.

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    If you receive a call from someone offering can you buy yasmin over the counter usa to enrol you for a “health record”, do not provide any personal information, hang up the call and report it to scamwatch.gov.au.The Australian Digital Health Agency will not telephone you with an offer to enrol you for a My Health Record. For more information on how to register for a My Health can you buy yasmin over the counter usa Record, visit myhealthrecord.gov.au.If you have shared your Medicare number with an unknown caller, report this to Services Australia who will place your details on a watch list to monitor for any compromise or misuse of your Medicare record. Email [email protected] or phone 1800 941 126.

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    If you have shared personal information and believe you may be at risk, you can contact IDCARE, a not for profit organisation can you buy yasmin over the counter usa that provides assistance and support to victims of identity theft and other cybercrime. Visit idcare.org or telephone 1800 595 160.The Office of the Australian Information Commissioner provides information about identity fraud including what to do if your identity has been stolen.For additional information about scams, visit scamwatch.gov.au – you can also subscribe to a free alert service to receive updates about the latest scams.The Australian Cyber Security Centre also provides advice for individuals, a free alert service to help you understand the latest online threats and the ability to report online crimes via the ReportCyber page..

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    COVID-19 has evolved rapidly into a pandemic buy yasmin online with global impacts. However, as the buy yasmin online pandemic has developed, it has become increasingly evident that the risks of COVID-19, both in terms of infection rates and particularly of severe complications, are not equal across all members of society. While general risk factors for hospital admission with COVID-19 infection include age, male sex and specific comorbidities (eg, cardiovascular disease, hypertension and diabetes), there is increasing evidence that people identifying with Black, Asian and Minority Ethnic (BAME) groupsi have disproportionately higher risks of being adversely affected by COVID-19 in the UK and the USA. The ethnic disparities include overall numbers of cases, as well as the relative numbers of critical care admissions and deaths.1In the area of mental health, for people from BAME groups, even before the current pandemic there were already significant mental health inequalities.2 These inequalities have been increased by buy yasmin online the pandemic in several ways. The constraints of quarantine have made access to traditional face-to-face support from mental health services more difficult in general.

    This difficulty will increase pre-existing inequalities where there are challenges to engaging people in care buy yasmin online and in providing early access to services. The restrictions may also reduce the flexibility of care offers, given the need for social isolation, limiting non-essential travel and closure of routine clinics. The service impacts are compounded by constraints on the use of non-traditional or alternative routes to care and support.In addition, there is growing evidence of specific mental health consequences from significant COVID-19 infection, with increased rates of not only post-traumatic stress disorder, anxiety and depression, but also specific neuropsychiatric symptoms.3 Given the higher risks of mental illnesses and complex care needs among ethnic minorities and also in deprived inner city areas, COVID-19 seems to buy yasmin online deliver a double blow. Physical and mental health vulnerabilities are inextricably linked, especially as a significant proportion of healthcare workers (including in mental health services) in the UK are from BAME groups.Focusing on mental health, there is very little COVID-19-specific guidance on the needs of patients in the BAME group. The risk to staff in general healthcare (including mental healthcare) is a buy yasmin online particular concern, and in response, the Royal College of Psychiatrists and NHS England have produced a report on the impact of COVID-19 on BAME staff in mental healthcare settings, with guidance on assessment and management of risk using an associated risk assessment tool for staff.4 5However, there is little formal guidance for the busy clinician in balancing different risks for individual mental health patients and treating appropriately.

    Thus, for example, an inpatient clinician may want to know whether a patient who is older, has additional comorbidities and is from an ethnic background, should be started on one antipsychotic medication or another, or whether treatments such as vitamin D prophylaxis or treatment and venous thromboembolism prevention should be started earlier in the context of the COVID-19 pandemic. While syntheses of the existing guidelines are available about COVID-19 and mental health,6 7 there is nothing specific about the healthcare needs of patients from ethnic minorities during the buy yasmin online pandemic.To fill this gap, we propose three core actions that may help:Ensure good information and psychoeducation packages are made available to those with English as a second language, and ensure health beliefs and knowledge are based on the best evidence available. Address culturally grounded explanatory models and illness perceptions to allay fears and worry, and ensure timely access to testing and care if needed.Maintain levels of service, flexibility in care packages, buy yasmin online and personal relationships with patients and carers from ethnic minority backgrounds in order to continue existing care and to identify changes needed to respond to worsening of mental health.Consider modifications to existing interventions such as psychological therapies and pharmacotherapy. Have a high index of suspicion to take into account emerging physical health problems and the greater risk of serious consequences of COVID-19 in ethnic minority people with pre-existing chronic conditions and vulnerability factors.These actions are based on clinical common sense, but guidance in this area should be provided on the basis of good evidence. There has already been a call for urgent research in the area of COVID-19 and mental buy yasmin online health8 and also a clear need for specific research focusing on the post-COVID-19 mental health needs of people from the BAME group.

    Research also needs to recognise the diverse range of different people, with different needs and vulnerabilities, who are grouped under the multidimensional term BAME, including people from different generations, first-time migrants, people from Africa, India, the Caribbean and, more recently, migrants from Eastern Europe. Application of a race equality impact assessment to all research questions and methodology has recently been proposed as a first step in this process.2 At this early stage, the guidance for assessing risks of COVID-19 for health professionals is also useful for patients, until more refined decision support and buy yasmin online prediction tools are developed. A recent Public Health England report on ethnic minorities and COVID-199 recommends better recording of ethnicity data in health and social care, and goes further to suggest this should also apply to death certificates. Furthermore, the report recommends more participatory and experience-based research to understand causes and consequences of pre-existing multimorbidity and COVID-19 infection, integrated care systems that work well for susceptible and marginalised groups, culturally competent health promotion, prevention and occupational risk assessments, and recovery strategies to mitigate the risks of widening inequalities as we come out of restrictions.Primary data collection buy yasmin online will need to cover not only hospital admissions but also data from primary care, linking information on mental health, COVID-19 and ethnicity. We already have research and specific guidance emerging on other risk factors, such as age and gender.

    Now we also need to focus buy yasmin online on an equally important aspect of vulnerability. As clinicians, we need to balance the relative risks for each of our patients, so that we can act promptly and proactively in response to their individual needs.10 For this, we need evidence-based guidance to ensure we are balancing every risk appropriately and without bias.Footnotei While we have used the term ‘people identifying with BAME groups’, we recognise that this is a multidimensional group and includes vast differences in culture, identity, heritage and histories contained within this abbreviated term..

    COVID-19 has evolved rapidly into a pandemic with global can you buy yasmin over the counter usa impacts. However, as the pandemic has developed, it has become increasingly evident that the risks of COVID-19, both in terms of infection rates and particularly can you buy yasmin over the counter usa of severe complications, are not equal across all members of society. While general risk factors for hospital admission with COVID-19 infection include age, male sex and specific comorbidities (eg, cardiovascular disease, hypertension and diabetes), there is increasing evidence that people identifying with Black, Asian and Minority Ethnic (BAME) groupsi have disproportionately higher risks of being adversely affected by COVID-19 in the UK and the USA. The ethnic can you buy yasmin over the counter usa disparities include overall numbers of cases, as well as the relative numbers of critical care admissions and deaths.1In the area of mental health, for people from BAME groups, even before the current pandemic there were already significant mental health inequalities.2 These inequalities have been increased by the pandemic in several ways.

    The constraints of quarantine have made access to traditional face-to-face support from mental health services more difficult in general. This difficulty will increase pre-existing inequalities where there are challenges to engaging people in care and in providing early can you buy yasmin over the counter usa access to services. The restrictions may also reduce the flexibility of care offers, given the need for social isolation, limiting non-essential travel and closure of routine clinics. The service impacts are compounded by constraints on the use of non-traditional or alternative routes to care and support.In addition, there is growing evidence of specific mental health consequences from significant COVID-19 infection, with increased rates of not only post-traumatic stress disorder, anxiety and depression, but also specific neuropsychiatric symptoms.3 Given the higher risks of mental illnesses and complex care needs among ethnic minorities and also in deprived inner city areas, COVID-19 seems can you buy yasmin over the counter usa to deliver a double blow.

    Physical and mental health vulnerabilities are inextricably linked, especially as a significant proportion of healthcare workers (including in mental health services) in the UK are from BAME groups.Focusing on mental health, there is very little COVID-19-specific guidance on the needs of patients in the BAME group. The risk to staff in general healthcare (including mental healthcare) is a particular concern, and in response, the Royal College of Psychiatrists and NHS can you buy yasmin over the counter usa England have produced a report on the impact of COVID-19 on BAME staff in mental healthcare settings, with guidance on assessment and management of risk using an associated risk assessment tool for staff.4 5However, there is little formal guidance for the busy clinician in balancing different risks for individual mental health patients and treating appropriately. Thus, for example, an inpatient clinician may want to know whether a patient who is older, has additional comorbidities and is from an ethnic background, should be started on one antipsychotic medication or another, or whether treatments such as vitamin D prophylaxis or treatment and venous thromboembolism prevention should be started earlier in the context of the COVID-19 pandemic. While syntheses of the existing guidelines are available about COVID-19 and can you buy yasmin over the counter usa mental health,6 7 there is nothing specific about the healthcare needs of patients from ethnic minorities during the pandemic.To fill this gap, we propose three core actions that may help:Ensure good information and psychoeducation packages are made available to those with English as a second language, and ensure health beliefs and knowledge are based on the best evidence available.

    Address culturally grounded explanatory models and illness perceptions to allay fears and worry, and ensure timely access to testing and care if needed.Maintain levels of service, flexibility in care packages, and personal relationships with patients and carers from ethnic minority backgrounds in order to continue existing care and to identify changes needed to respond to worsening of mental health.Consider modifications can you buy yasmin over the counter usa to existing interventions such as psychological therapies and pharmacotherapy. Have a high index of suspicion to take into account emerging physical health problems and the greater risk of serious consequences of COVID-19 in ethnic minority people with pre-existing chronic conditions and vulnerability factors.These actions are based on clinical common sense, but guidance in this area should be provided on the basis of good evidence. There has already been a call for urgent research in the area of COVID-19 and mental health8 can you buy yasmin over the counter usa and also a clear need for specific research focusing on the post-COVID-19 mental health needs of people from the BAME group. Research also needs to recognise the diverse range of different people, with different needs and vulnerabilities, who are grouped under the multidimensional term BAME, including people from different generations, first-time migrants, people from Africa, India, the Caribbean and, more recently, migrants from Eastern Europe.

    Application of a race equality impact assessment to all research questions and methodology has recently been proposed as a first step in this process.2 At this early stage, the guidance for can you buy yasmin over the counter usa assessing risks of COVID-19 for health professionals is also useful for patients, until more refined decision support and prediction tools are developed. A recent Public Health England report on ethnic minorities and COVID-199 recommends better recording of ethnicity data in health and social care, and goes further to suggest this should also apply to death certificates. Furthermore, the report recommends more participatory and experience-based research to understand causes and consequences of pre-existing multimorbidity and COVID-19 infection, integrated care systems can you buy yasmin over the counter usa that work well for susceptible and marginalised groups, culturally competent health promotion, prevention and occupational risk assessments, and recovery strategies to mitigate the risks of widening inequalities as we come out of restrictions.Primary data collection will need to cover not only hospital admissions but also data from primary care, linking information on mental health, COVID-19 and ethnicity. We already have research and specific guidance emerging on other risk factors, such as age and gender.

    Now we also need to focus on an equally important aspect can you buy yasmin over the counter usa of vulnerability. As clinicians, we need to balance the relative risks for each of our patients, so that we can act promptly and proactively in response to their individual needs.10 For this, we need evidence-based guidance to ensure we are balancing every risk appropriately and without bias.Footnotei While we have used the term ‘people identifying with BAME groups’, we recognise that this is a multidimensional group and includes vast differences in culture, identity, heritage and histories contained within this abbreviated term..

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    Under the stewardship of the MidMichigan Health Foundation, this year, 23 area students will received how to get yasmin in the us scholarship awards from the Tolfree Scholarship, the Dr. George Schaiberger, how to get yasmin in the us Sr., Dr. Howard VanOosten and Dr.

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    Those receiving the Tolfree Scholarship are. Allie Morand, how to get yasmin in the us Nicholas Morse, Anna Erickson, Emily Terry and Andrew Waack. Lastly, awardees receiving the Paul A.Poling Memorial Scholarship are Emily Terry, Anna Erickson, Nicholas Morse, Allie Morand and Andrew Waack.“The intent of our generous donors in creating these scholarships is to provide our rural counties, particularly those served by MidMichigan Medical Center – West Branch, with future generations of excellent health care professionals,” said Nicole Potter, director, MidMichigan Health Foundation.

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    Those interested in how to get yasmin in the us reviewing the eligibility guidelines, including a scholarship application, may visit www.midmichigan.org/scholarships or call (989) 343-3694.Growers donate produce to staff and patients at MidMichigan Health Park – Bay.Residents in the Bay area have an additional opportunity to embrace healthy lifestyles near MidMichigan Health Park – Bay. Produce by the Park, a community garden that began late last year with a donation from MidMichigan Health Foundation, is flourishing, allowing patients, friends and neighbors to literally enjoy the fruits of their labor.Brenda Turner, director, MidMichigan Physicians Group, has a farming background and dreamt of a garden for her community for years. When the Health Park was built with ample property behind and support from the Foundation, that dream was brought to life.“We are so pleased to be able to support this project as it represents very well MidMichigan Health’s purpose of building healthy communities – together,” said Denise O’Keefe, executive director, MidMichigan Health how to get yasmin in the us Foundation.Other local organizations came on board to offer help.

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    €œWe congratulate all of this year’s recipients, as well as the parents and teachers who help them arrive at this major milestone in can you buy yasmin over the counter usa these students’ lives. We wish each one of them the best of success and hope to see them back again in a few years serving the people of their own hometown.”Examples of the health professions being pursued by these individuals include physical therapy, pre-medicine, nursing, health administration, sports medicine, neuroscience and human biology.Applications for the 2021-2022 school year will be accepted from Dec. 1, 2020, can you buy yasmin over the counter usa through March 1, 2021. Those interested in reviewing the eligibility guidelines, including a scholarship application, may visit www.midmichigan.org/scholarships or call (989) 343-3694.Growers donate produce to staff and patients at MidMichigan Health Park – Bay.Residents in the Bay can you buy yasmin over the counter usa area have an additional opportunity to embrace healthy lifestyles near MidMichigan Health Park – Bay.

    Produce by the Park, a community garden that began late last year with a donation from MidMichigan Health Foundation, is flourishing, allowing patients, friends and neighbors to literally enjoy the fruits of their labor.Brenda Turner, director, MidMichigan Physicians Group, has a farming background and dreamt of a garden for her community for years. When the Health Park was built with ample property behind and support from the Foundation, that dream was brought to life.“We are so pleased to be able to support this project as it represents very well MidMichigan Health’s purpose of building healthy communities – together,” can you buy yasmin over the counter usa said Denise O’Keefe, executive director, MidMichigan Health Foundation.Other local organizations came on board to offer help. Tri-County Equipment of Saginaw donated dirt, and the Agriscience classes at John Glenn High School volunteered to get plots prepared for gardening. The Building can you buy yasmin over the counter usa Trades program at Bay Arenac ISD built and installed a tool shed.

    Woodchips from Weiler Tree Service were donated to cut down on weeding, and Nature’s Own Landscaping and Irrigation hooked up a spigot in a central location so that all gardeners could access it easily.“During our first season, we had just a few plots of our two-acre garden assigned and less than ten participants,” said Ashleigh Palmer, practice manager, MidMichigan Health Park – Bay. €œThis year, we have all plots can you buy yasmin over the counter usa filled with more than 40 participants. We have couples, families and can you buy yasmin over the counter usa individuals who share their experience, produce and recipes with each other. It’s a lot of fun to see the friendships that have developed among our gardeners.

    The ground is fertile, so produce is thriving, and excess vegetables are being donated to patients of can you buy yasmin over the counter usa the facility.”Jarod Morse, 21, saw the garden information on Facebook and is excited to be participating. €œMy whole family - brother, sister and her fiancé, mom, and Papa - are working on the garden together,” Morse stated. A few of the items they are growing are cabbage, can you buy yasmin over the counter usa cauliflower and a variety of peppers. €œThe best part,” he added, “is getting to share knowledge and smiles with other members of the garden.”Rows of produce growing in the community garden, Produce by the Park.MidMichigan Health staffers Shelby Kuch and Kellie Picard do much of the organizing, serving as “garden ambassadors.” They are excited to see it thriving.“It has been fun to see how each person has their own unique approach to gardening and harvesting,” said Kuch.

    €œThere are can you buy yasmin over the counter usa so many things being grown. Cabbage, corn, can you buy yasmin over the counter usa potatoes, broccoli, tomatoes, and beautiful sunflowers. You wouldn’t believe the variety and the willingness to share what is harvested with other gardeners, members of the community and patients.”Picard is pleased to see elderly residents becoming involved. €œMany don’t have the room to plant where they live,” she can you buy yasmin over the counter usa explained.

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    The past week has seen an explosion of media commentary about whether children in the UK should go back yasmin birth control generic to school. Since ‘lockdown’ (23 March 2020) began schools yasmin birth control generic have been open to vulnerable children and young people, and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools. Viner et al1 produced a rapid systematic review that concludes that school closures have yasmin birth control generic less impact on infection rate and mortality than other social distancing measures.

    Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’. This was conveyed to the population of the UK on 10 yasmin birth control generic May by the UK prime minister, Boris Johnson. He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken by various groups, including a yasmin birth control generic preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson announced that there would be a phased return (in England) of some children to school from 1 June.

    There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools. In a yasmin birth control generic joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a vital part of restarting the UK economy, but they have concerns about the safety and welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision. Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there are children out there that have not spoken or played with another child their own yasmin birth control generic age for the last two months.

    They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest children will be the ones who fall further behind if we keep school yasmin birth control generic gates closed. This phased return is in line with what other European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets and news articles identifying problems in enacting yasmin birth control generic the government plan and the illogical nature of Williamson’s statement. The Institute for Fiscal Studies has produced a briefing note on children’s experiences of learning during lockdown.5 This is being widely cited as a rationale for reopening schools because children from vulnerable backgrounds are disproportionately affected by not being able to attend school.

    This has caused concern about the attainment yasmin birth control generic gap, but as Quinn6 points out fewer children from disadvantaged backgrounds are likely to return to school than those from more affluent backgrounds.Government ministers and spokespeople reiterated that scientific evidence and observation of other European countries where schools had reopened demonstrated their decision was the correct one. However, there were no links provided to the scientific evidence and unions were quick to seize on this (eg, NASUWT7).The chief scientific advisor to the Department for Education, Osama Rahman, made a statement in a parliamentary science and technology committee meeting on 13 May that:There is a low degree of confidence in evidence that [children] might transmit it less.Carol Monaghan, the Scottish National Party education spokesperson, replied:We’re putting together hundreds of potential vectors that can then go on and transmit. Is that yasmin birth control generic correct?. Osama Rahman responded:Possibly, depending on school sizes.His final statement contains layers of complexity but can be interpreted simply as ‘we don’t know’.

    This provoked yasmin birth control generic a great deal of disquiet. Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the risk to children yasmin birth control generic of developing coronavirus disease. The second is the risk to others of children transmitting coronavirus disease, either while being symptomatic or asymptomatic.

    Here are some of the available evidence.Morbidity and yasmin birth control generic mortality in children from coronavirus diseaseChildren appear to be less likely to acquire coronavirus disease in various nations.9–11 Barton et al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications). Of these 8113 paediatric cases, 14% required hospital admission. The admission rate to critical care was 2.2% of confirmed cases (7.2% of admitted children) yasmin birth control generic. Death was reported in yasmin birth control generic 15 cases (0.18%).

    This adds to other evidence suggesting that children are at a relatively low risk from the virus, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the virus.15There are concerns that children who have been infected with the virus can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for COVID-19, and in the absence of effective community testing it will be impossible to know if they are carrying the virus. Children also can have normal or abnormal signs (eg, chest imaging) yasmin birth control generic when they have tested positive.17 In short, it is difficult to determine without much more extensive testing if a child can transmit the infection.Arav et al18 found that the contact route was much more important than the airborne route, which they concluded had a negligible contribution. They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of infection suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is a case for reopening schools to limited numbers of pupils—the risk to pupils and the adults they come into contact with yasmin birth control generic seems to be small, and the potential gains for children may outweigh them.

    There is a big proviso with this however, and that is that the overall incidence of COVID-19 has fallen below specified threshold. This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of infection decreasing to manageable levels.Ensuring that personal protective equipment supply can meet demand.Being confident that any adjustments would not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education yasmin birth control generic and health in the information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy. Decisions about whether to reopen schools are taken on yasmin birth control generic a national level with a distance from personal concerns and fears.

    Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is a difficult yasmin birth control generic path to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation. Parents were being asked to believe that MMR was a safe yasmin birth control generic vaccine in the face of a massive and emotive campaign that promoted the ‘risk’ of having the vaccine above all else.

    This situation yasmin birth control generic is even more complex than that as we have increased access to opinion and difficulty in understanding if or how much that information is biased. It is no wonder that decision-making is difficult. It is likely that evidence will continue to emerge and gradually the choice will yasmin birth control generic become easier to make. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach.

    By working to identify yasmin birth control generic a consensus position, researchers can report findings on a specific question (or set of questions) that are based on the knowledge and experience of experts in their field.However, there are challenges to this approach. For example, what should be done when consensus cannot be reached?. How can experts be engaged in a yasmin birth control generic way that allows them to consider objectively the views of others and—where appropriate—change their own opinions in response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus.

    Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, so that the methods employed “…appear to be more conducive to independent thought on the part of the experts and to aid them in the gradual formation of a considered opinion”.1 Though the original Delphi study was linked to the defence industry, the technique has spread to other research areas, including yasmin birth control generic nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline. First, the overarching approach is based on a series of ‘rounds’, where yasmin birth control generic a set of experts are asked their opinions on a particular issue. The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses.

    Finally, the findings of each round are always shared with yasmin birth control generic the broader group anonymously. This avoids any bias that might result from participants being concerned about their own views being yasmin birth control generic viewed negatively or from their own opinions being biased by personal factors. This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged. For example, a study of human yasmin birth control generic factors that contributed to nursing errors used only two rounds.

    The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could. Analysis of responses resulted in a list of 28 potential reasons—this list was sent back to the same group of experts for the second round, asking them to score each yasmin birth control generic one for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round 1, draft competencies were developed from the findings of a survey of NP beliefs, knowledge and level of implementation of advance care yasmin birth control generic planning.

    Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made yasmin birth control generic based on the original feedback, and a third round was conducted where 15 of the original NP participants confirmed their consensus with the final document. The final document includes four competencies, each with several elements. Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses of Delphi studiesThe Delphi technique offers a flexible approach to gathering the views of experts on an area of interest yasmin birth control generic.

    The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups. The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from dominant or high-profile members of the group are given extra credence.5However, Delphi studies can—by their very yasmin birth control generic nature—be complex and time consuming. The need for participants to complete multiple rounds yasmin birth control generic can lead to high drop-out rates which impacts on validity of the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword.

    It provides those taking part with the opportunity to reflect and reconsider their position in response yasmin birth control generic to additional information, which is an important part of nursing practice. Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’. Even with yasmin birth control generic the level of flexibility and reflexivity present in Delphi studies, it is still unlikely that a group of experts will demonstrate 100% agreement on issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached.

    This is where there is inconsistency across studies and yasmin birth control generic authors, with the suggested level of consensus ranging from 51% to 100%.2 In addition, it has been identified that in some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore related to the quality of evidence, with expert opinion viewed as providing a poor basis for making judgements on healthcare interventions.7 This does not mean that the findings of yasmin birth control generic Delphi studies are intrinsically unreliable or invalid. It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts.

    It allows for reflection among participants, who are able to nuance and yasmin birth control generic reconsider their opinion based on the anonymised opinions of others. However, researchers must take steps to enhance robustness of the studies. It is important to yasmin birth control generic try and prevent participants from simply resorting to agreeing with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

    The past week has seen an explosion of can you buy yasmin over the counter usa media commentary about whether children in the UK should go back to school. Since ‘lockdown’ (23 March 2020) began schools have been open to vulnerable children and young can you buy yasmin over the counter usa people, and to the children of ‘key workers’. Right from the start there have been differing opinions about the necessity or wisdom of closing schools. Viner et can you buy yasmin over the counter usa al1 produced a rapid systematic review that concludes that school closures have less impact on infection rate and mortality than other social distancing measures. Many countries have closed their schools for less time than the UK and have already started to reopen with several protective measures in place.2Concerns about the long-term economic, social and mental impact of lockdown led to the generation of plans to ‘get back to business’.

    This was conveyed to the population of the UK on 10 May can you buy yasmin over the counter usa by the UK prime minister, Boris Johnson. He announced a range of measures to gradually reduce the level of lockdown. This is in keeping with modelling undertaken by various groups, including a preprint (not peer-reviewed) modelling exercise by Zhang et al.3Mr Johnson can you buy yasmin over the counter usa announced that there would be a phased return (in England) of some children to school from 1 June. There are no national guidelines as it is recognised that school have differences that require a flexible approach, but there are a broad set of principles relating to social distancing and hygiene.Government ministers and teachers’ unions have opposing views on the safety of reopening schools. In a joint statement nine unions representing teachers stated that they thought 1 June was too early to be safe.4 They recognise that the opening of schools is a can you buy yasmin over the counter usa vital part of restarting the UK economy, but they have concerns about the safety and welfare of children and others.Meanwhile, the education secretary, Gavin Williamson, spoke at a press conference on 16 May stating that scientific evidence backed their decision.

    Interestingly, much of his statement was not about the scientific evidence but setting out an emotive argument that school was essential for safe and happy children.There is a consequence to this, the longer that schools are closed the more that children miss out. Teachers know that there are children out there that have can you buy yasmin over the counter usa not spoken or played with another child their own age for the last two months. They know there are children from difficult or very unhappy homes for whom school is the happiest moment in their week, and it’s also the safest place for them to be. The poorest children will be the ones who fall further behind can you buy yasmin over the counter usa if we keep school gates closed. This phased return is in line with what other European countries are doing.There ensued an at times ill-tempered debate and a flurry of tweets and news articles identifying problems in enacting the government can you buy yasmin over the counter usa plan and the illogical nature of Williamson’s statement.

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

    This provoked a can you buy yasmin over the counter usa great deal of disquiet. Rahman had already stated that the Scientific Advisory Group for Emergencies (SAGE) was collecting and considering evidence that was new and emerging, and that confidence was low in the evidence relating to transmission because there was very little evidence.8 However, this normal scientific caution in the evidence base was not discussed, and therefore it was assumed that low or moderate confidence in the evidence means a high-risk strategy is being mooted.There appear to be two major concerns about lifting the lockdown for children. First is the can you buy yasmin over the counter usa risk to children of developing coronavirus disease. The second is the risk to others of children transmitting coronavirus disease, either while being symptomatic or asymptomatic. Here are some of the available evidence.Morbidity and mortality in children from coronavirus diseaseChildren appear to be less can you buy yasmin over the counter usa likely to acquire coronavirus disease in various nations.9–11 Barton et al12 found that children account for 1.9% of confirmed cases (data collected from government websites and publications).

    Of these 8113 paediatric cases, 14% required hospital admission. The admission rate to critical care was 2.2% of confirmed cases (7.2% of can you buy yasmin over the counter usa admitted children). Death was can you buy yasmin over the counter usa reported in 15 cases (0.18%). This adds to other evidence suggesting that children are at a relatively low risk from the virus, with other estimates coming in at around 0.01%.13 14 This is likely to be because they appear to have a stronger immune response to the virus.15There are concerns that children who have been infected with the virus can develop a postviral inflammatory reaction (Kawasaki disease) and this can be severe,16 but the research evidence for this is not well developed yet.Transmission by childrenChildren can be asymptomatic and test positive for COVID-19, and in the absence of effective community testing it will be impossible to know if they are carrying the virus. Children also can have normal or abnormal signs (eg, chest imaging) when they have tested positive.17 In can you buy yasmin over the counter usa short, it is difficult to determine without much more extensive testing if a child can transmit the infection.Arav et al18 found that the contact route was much more important than the airborne route, which they concluded had a negligible contribution.

    They suggest protective measures would therefore be good hand hygiene, careful cleaning and avoiding physical contact.Given that there are quite low numbers of symptomatic cases and an unknown quantity of asymptomatic cases, it is very difficult to determine whether children are a significant vector for the disease. Studies cited by the Royal College of Paediatrics and Child Health that explored family clusters of infection suggest that the child was unlikely to be the index case.The riskThis evidence suggests that there is a case for reopening schools to limited numbers of pupils—the risk to pupils and the adults they come into contact with can you buy yasmin over the counter usa seems to be small, and the potential gains for children may outweigh them. There is a big proviso with this however, and that is that the overall incidence of COVID-19 has fallen below specified threshold. This is quite a contentious issue and depends on us meeting the five key tests for easing lockdown.Making sure the National Health Service can cope.A sustained and consistent fall in the daily death rate.Rate of infection decreasing to manageable levels.Ensuring that personal protective equipment supply can meet demand.Being confident that any adjustments would not risk a second peak.These conditions are open to interpretation, and there appears to be a lack of trust by the public and by professionals from education and health in the can you buy yasmin over the counter usa information that the government and their scientific advisors are sharing. An example of this is a group of scientists who have come together to challenge the government about their decision-making.19 The concern about whether the evidence and advice that we are given are biased in any way has also been increased by concerns that a government advisor (Dominic Cummings) has attended what were supposed to be politically independent meetings of the SAGE.Scientific evidence continues to emerge, but weighing up the risks and benefits is not easy.

    Decisions about whether to reopen schools are taken on a can you buy yasmin over the counter usa national level with a distance from personal concerns and fears. Individuals who are making decisions often rely on media translations of the evidence, and there is a level of mistrust in politicians and the media.20 Individuals are often irrational in their risk perception and management (eg, continuing to smoke or drink alcohol despite strong scientific evidence about the risk).21 22Overall, we are information-poor and opinion-rich. It is can you buy yasmin over the counter usa a difficult path to navigate. The debate about whether the benefits outweigh the risks of returning to school reminds me of the post-Wakefield Measles Mumps and Rubella vaccination situation. Parents were being asked to believe that MMR was can you buy yasmin over the counter usa a safe vaccine in the face of a massive and emotive campaign that promoted the ‘risk’ of having the vaccine above all else.

    This situation is even more can you buy yasmin over the counter usa complex than that as we have increased access to opinion and difficulty in understanding if or how much that information is biased. It is no wonder that decision-making is difficult. It is likely that evidence will continue to emerge and gradually the can you buy yasmin over the counter usa choice will become easier to make. For now, however, we can understand the difficulties that parents, teachers and councils face.IntroductionWhenever developing training competencies, tools to support clinical practice or a response to a professional issue, seeking the opinion of experts is a common approach. By working to identify a consensus position, researchers can report findings on a specific question (or set of questions) that are based on the knowledge and experience of experts in their field.However, there are can you buy yasmin over the counter usa challenges to this approach.

    For example, what should be done when consensus cannot be reached?. How can experts be engaged in a way that allows them to consider objectively the views of others can you buy yasmin over the counter usa and—where appropriate—change their own opinions in response?. One approach that attempts to provide a clear method for gathering expert opinion is the Delphi technique.The Delphi technique was first developed in the 1950s by Norman Dalkey and Olaf Helmer in an attempt to gain reliable expert consensus. Specifically, they developed an approach—named after the Ancient Greek Oracle of Delphi, who could predict the future—which promoted anonymity and avoided direct confrontation between experts, so that the methods employed “…appear to be more conducive to independent thought on the part of the experts and to aid them in the gradual formation of a considered opinion”.1 Though the can you buy yasmin over the counter usa original Delphi study was linked to the defence industry, the technique has spread to other research areas, including nursing.2Characteristics of Delphi studiesAs with all research methods, the Delphi technique has evolved since it was first reported on in the 1960s. However, many of the fundamental characteristics of the approach still remain from Dalkey and Helmer’s original outline.

    First, the overarching approach is based on a series of ‘rounds’, where a set of experts are can you buy yasmin over the counter usa asked their opinions on a particular issue. The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings.Second, participants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly.2 This also gives them the opportunity to consider and feedback on what they perceive to be the strengths and weaknesses of other’s responses. Finally, the findings of each round are always can you buy yasmin over the counter usa shared with the broader group anonymously. This avoids any bias that might result can you buy yasmin over the counter usa from participants being concerned about their own views being viewed negatively or from their own opinions being biased by personal factors. This framework of expert opinion rounds, with each round built on previous findings and each allowing for responses to be reconsidered by participants, is designed to allow the development of a consensus view that answers the research question.Within this broad approach, there can be variation in areas such as how many rounds there are, how the questions are delivered and responses collected, and how ‘consensus’ is judged.

    For example, a study of human factors that contributed to can you buy yasmin over the counter usa nursing errors used only two rounds. The first took the form of an online survey asking 25 experts to list all the ‘human’ causes of nursing errors that they could. Analysis of responses resulted in a can you buy yasmin over the counter usa list of 28 potential reasons—this list was sent back to the same group of experts for the second round, asking them to score each one for importance. Analysis of this scoring then allowed for consensus conclusions on the top 10 human factors that contributed to nursing errors (with fatigue, heavy workload and communication problems the top three).3In another example, nurse practitioners (NPs) were recruited to participate in a Delphi study to achieve consensus related to NP advance care planning competencies. In round 1, draft competencies were developed from the findings of a survey of NP beliefs, knowledge and level of can you buy yasmin over the counter usa implementation of advance care planning.

    Round 2 included engagement with 29 NPs who evaluated the draft competencies and their components. Revisions were made based on the original feedback, and a third round was conducted can you buy yasmin over the counter usa where 15 of the original NP participants confirmed their consensus with the final document. The final document includes four competencies, each with several elements. Clinical Practice, Consultation and Communication, Advocacy and Therapeutic Management.4Strengths and weaknesses of Delphi studiesThe can you buy yasmin over the counter usa Delphi technique offers a flexible approach to gathering the views of experts on an area of interest. The ability for participants to reconsider their views in light of the contribution of others allows for an element of reflection that is missing from studies based on single interviews or focus groups.

    The anonymity among the expert groups that underpins Delphi studies promotes honesty among participants and reduces the risk of the ‘halo effect’ where views from dominant or high-profile members of the can you buy yasmin over the counter usa group are given extra credence.5However, Delphi studies can—by their very nature—be complex and time consuming. The need for participants to complete multiple rounds can lead to high drop-out rates which impacts on validity of can you buy yasmin over the counter usa the study. The ability of participants to amend or alter their views at each round is also something of a double-edged sword. It provides those taking part with the opportunity to reflect and reconsider their position in response to additional information, which can you buy yasmin over the counter usa is an important part of nursing practice. Conversely though, there is a danger that this flexibility introduces bias, with participants altering their response to comply with what they view to be the majority view (sometime called the ‘bandwagon effect’).5Delphi studies can be criticised due to a lack of clarity on what is meant by ‘consensus’.

    Even with the level of flexibility and reflexivity present in Delphi studies, it is still unlikely that a group of experts will demonstrate 100% can you buy yasmin over the counter usa agreement on issues. However, because consensus is a requirement of a Delphi study, there does need to be a judgement on when this point is reached. This is where there is inconsistency across studies and authors, with the suggested level of consensus ranging from 51% to 100%.2 can you buy yasmin over the counter usa In addition, it has been identified that in some areas, consensus is not predefined as part of the study method. For example, a review of Delphi studies in nurse education found that fewer than half of the papers appraised included a predefined level at which consensus was judged to have been achieved.6 In addition, the identification of an objective level consensus is only possible when gathering quantifiable data—the judgement on consensus being reached in some qualitative Delphi studies will always be rather more subjective on the part of the researcher, and therefore potentially open to bias.By their nature, Delphi studies often rely purely on expert opinion to generate findings. A further limitation is therefore can you buy yasmin over the counter usa related to the quality of evidence, with expert opinion viewed as providing a poor basis for making judgements on healthcare interventions.7 This does not mean that the findings of Delphi studies are intrinsically unreliable or invalid.

    It does mean that researchers should consider whether their research question is one that can be answered through expert consensus or whether other approaches (such as a systematic review of research evidence) are more appropriate.ConclusionThe Delphi technique is a well-established approach to answering a research question through the identification of a consensus view across subject experts. It allows for reflection among participants, who are able to nuance and reconsider their opinion based can you buy yasmin over the counter usa on the anonymised opinions of others. However, researchers must take steps to enhance robustness of the studies. It is important can you buy yasmin over the counter usa to try and prevent participants from simply resorting to agreeing with the majority view. Studies must also predefine what is meant by ‘consensus’ and how it will be established.With careful and clear design though, Delphi studies can make a valuable contribution to the nursing evidence base by tapping into the profession’s most precious resource—the knowledge and expertise of its practitioners..

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