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    Nightmares that occurred twice a week or more were linked with cardiovascular disease in relatively young military veterans, even after controlling for post-traumatic stress disorder (PTSD), a cross-sectional study showed.Frequent distressing dreams were associated with hypertension (OR 1.51, 95% CI 1.28-1.78), heart problems (OR 1.50, 95% CI 1.11-2.02), and myocardial infarction (OR 2.32, 95% CI 1.18-4.54), after buy kamagra next day delivery adjusting for age, race, and sex, reported Christi Ulmer, PhD, of the Durham VA Health Services Research and Development ADAPT Center and Duke University Medical Center, both in North Carolina."After also adjusting for PTSD, depression, and current smoking, severely distressing dreams continued to be associated kamagra oral with heart problems, hypertension, and other heart trouble," Ulmer said in a presentation at virtual SLEEP 2020, a joint meeting of the American Academy of Sleep Medicine (AASM) and the Sleep Research Society."Research on heart rate variability supports the likelihood of abnormal autonomic function during sleep among those with PTSD. However, we haven't taken a look at what role nightmares specifically might play in contributing to increased risk in this population," Ulmer noted."While some have suggested that buy kamagra next day delivery the association between PTSD and cardiovascular disease is solely due to poor health behaviors among those with PTSD, our findings suggest an important role for sleep and that there may be an independent role for nightmares, in particular for conferring cardiovascular disease," she said.In this analysis, Ulmer and colleagues studied 3,468 U.S. Military veterans with an average age of 38 buy kamagra next day delivery who served since Sept. 11, 2001 buy kamagra next day delivery.

    The majority (73.5%) had one or two tours buy kamagra next day delivery of duty and most (77.4%) were men. Most (65.0%) had moderate-to-heavy combat exposure.The researchers assessed nightmare frequency and severity with the buy kamagra next day delivery Davidson Trauma Scale. Nightmares were classified as frequent if they occurred two or more times per week and moderate-to-severe if they were at least buy kamagra next day delivery moderately distressing. Self-reported medical buy kamagra next day delivery issues were assessed using the National Vietnam Veterans Readjustment Study questionnaire and other measures.

    Diagnoses of PTSD and depression were established through structured clinical interviews.About a third of veterans in the study reported nightmares in the past week, and 41% had poor sleep quality scores as measured by buy kamagra next day delivery the Pittsburgh Sleep Quality Index. In total, 31% of the veterans met criteria for current PTSD and 32.7% reported at least one cardiovascular condition.Diagnosed depression was more buy kamagra next day delivery common in the PTSD group. Veterans with PTSD served more tours of duty, had greater combat exposure, poorer sleep quality, and more frequent and more severe distressing dreams.After controlling for depression, PTSD, and current smoking, risks for hypertension (OR 1.43, 95% 1.17-1.73) and heart problems (OR 1.43, 95% CI 1.00-2.05) persisted among veterans with frequent nightmares.The findings set the stage for future research examining the buy kamagra next day delivery possibility that nightmares may confer cardiovascular disease risks beyond those conferred by PTSD diagnosis alone, Ulmer noted."If longitudinal research demonstrates a causal role for nightmares in cardiovascular disease risk, nightmare treatment could be a strategy for improving cardiovascular health," she said. Judy George covers neurology and neuroscience news buy kamagra next day delivery for MedPage Today, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more.

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    Nightmares that occurred twice a week or more were linked with cardiovascular disease in relatively young military veterans, even after controlling for post-traumatic stress disorder (PTSD), a where to buy kamagra cross-sectional study showed.Frequent distressing dreams were associated with hypertension (OR 1.51, 95% CI 1.28-1.78), heart problems (OR 1.50, 95% CI 1.11-2.02), and myocardial infarction (OR 2.32, 95% CI 1.18-4.54), after adjusting for age, race, and sex, reported Christi Ulmer, PhD, of the Durham VA Health Services Research and Development ADAPT Center and Duke University Medical Center, both in North Carolina."After also adjusting for PTSD, depression, and current smoking, severely distressing dreams continued to be associated with heart problems, hypertension, and other heart trouble," Ulmer said in a presentation at virtual SLEEP 2020, a joint meeting of the American Academy of Sleep Medicine (AASM) and the Sleep Research Society."Research on heart rate variability worldwide pharmacy kamagra supports the likelihood of abnormal autonomic function during sleep among those with PTSD. However, we haven't taken a look at what role nightmares specifically might play in contributing to increased risk in this population," Ulmer noted."While some have suggested that the association between PTSD and cardiovascular disease is solely due to poor health behaviors among those with PTSD, our findings suggest an important role for sleep and that there may be an independent role for nightmares, in particular for conferring cardiovascular disease," she where to buy kamagra said.In this analysis, Ulmer and colleagues studied 3,468 U.S. Military veterans with an average age of 38 where to buy kamagra who served since Sept. 11, 2001 where to buy kamagra. The majority (73.5%) had where to buy kamagra one or two tours of duty and most (77.4%) were men.

    Most (65.0%) where to buy kamagra had moderate-to-heavy combat exposure.The researchers assessed nightmare frequency and severity with the Davidson Trauma Scale. Nightmares were classified as frequent if they occurred two where to buy kamagra or more times per week and moderate-to-severe if they were at least moderately distressing. Self-reported medical issues were where to buy kamagra assessed using the National Vietnam Veterans Readjustment Study questionnaire and other measures. Diagnoses of PTSD and depression were established through structured clinical interviews.About a third of veterans in the study reported nightmares where to buy kamagra in the past week, and 41% had poor sleep quality scores as measured by the Pittsburgh Sleep Quality Index. In total, 31% of the veterans met criteria for current PTSD and 32.7% reported at least one cardiovascular condition.Diagnosed depression was where to buy kamagra more common in the PTSD group.

    Veterans with PTSD served more tours of duty, had greater combat exposure, poorer sleep quality, and more frequent and more severe distressing dreams.After controlling for depression, PTSD, and current smoking, risks for hypertension (OR 1.43, 95% 1.17-1.73) and heart problems (OR 1.43, 95% CI 1.00-2.05) persisted among veterans with frequent nightmares.The findings set the stage for future research examining the possibility that nightmares may where to buy kamagra confer cardiovascular disease risks beyond those conferred by PTSD diagnosis alone, Ulmer noted."If longitudinal research demonstrates a causal role for nightmares in cardiovascular disease risk, nightmare treatment could be a strategy for improving cardiovascular health," she said. Judy George covers neurology and neuroscience news for MedPage Today, writing about brain aging, Alzheimer’s, dementia, where to buy kamagra MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more. Follow Disclosures The study was where to buy kamagra supported by the Department of Veterans VISN 6 MIRECC and ADAPT Centers at the Durham VA Health Care System..

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    Lauren Gambill, MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee on Child http://www.amisdepasteur.fr/kamagra-online-paypal/ and Adolescent HealthExecutive Board Member, Texas buy kamagra tablets Pediatric SocietyDoctors are community leaders. This role has become even more important during the COVID-19 pandemic. As patients navigate our new reality, they are looking to us to determine what is safe, how to protect their families, and the buy kamagra tablets future of their health care. As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net.

    The U.S. Census helps determine funding for those resources, and that is buy kamagra tablets why it is of the upmost importance that each and every Texan, no matter address, immigration status, or age, respond to the 2020 U.S. Census. The deadline has been buy kamagra tablets cut short one month and now closes Sept.

    30.COVID-19 has only increased the importance of completing the census to help our local communities and economies recover. The novel coronavirus has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more. Schools also buy kamagra tablets have been stretched thin, with teachers scrambling to teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago.

    Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the pandemic’s fallout. Therefore, it buy kamagra tablets is vital that all Texans be counted.The federal dollars Texas receives generally depends on our population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example. Federal funds pay for 60% of the state’s program, which provides health coverage for two out of five Texas children, one in three individuals with disabilities, and 53% buy kamagra tablets of all births.

    The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars. If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance buy kamagra tablets Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, but not enough to afford quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census.

    Texas also uses this federal funding to study and respond to maternal mortality and perinatal buy kamagra tablets depression.Food and housing As unemployment rises and families struggle financially, many live with uncertainty as to where they will find their next meal. Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the pandemic continues. The Central buy kamagra tablets Texas Food Bank saw a 206% rise in clients in March.

    Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census. Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their homes during this economic crisis have better hope of finding buy kamagra tablets shelter while our communities recover. Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by coronavirus, more parents are taking on roles as breadwinner, parent, teacher, and caretaker.

    This stress highlights buy kamagra tablets the desperate need for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families. The good news is you still have time to complete the census. Visit 2020census.gov to take it buy kamagra tablets.

    It takes less than five minutes to complete. Then talk to your buy kamagra tablets family, neighbors, and colleagues about doing the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the pandemic. Thank you for helping Texas heal and for supporting these essential safety net programs.(L to R).

    UTHSA medical students Swetha Maddipudi, Brittany Hansen, Charles Wang, Carson buy kamagra tablets Cortino, faculty advisor Kaparaboyna Kumar, MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz, and Frank Jung pose with the TMA Be Wise Immunize banner. Photo courtesy by Ryan WealtherRyan WealtherMedical Student, UT Health San Antonio Long School of MedicineStudent Member, Texas Medical AssociationEditor’s Note. August is National Immunization Awareness Month. This article is part of a Me&My Doctor series buy kamagra tablets highlighting and promoting the use of vaccinations.“Can the flu shot give you the flu?.

    €â€œIs it dangerous for pregnant women to get a flu shot?. €â€œCan vaccines cause buy kamagra tablets autism?. €These were questions women at Alpha Home, a residential substance abuse rehabilitation center in San Antonio, asked my fellow medical students and me during a flu vaccine discussion. It is easy to see why these questions were asked, as vaccine misinformation is common today.UTHSA medical student Frank Jing (left) gets a vaccine fromKaparaboyna Kumar, MD, (right).Photo courtesy of Ryan Wealther“No” is the answer to all the questions.

    These were exactly the types of myths we set out to dispel at our vaccination drive.UT Health San Antonio Long School buy kamagra tablets of Medicine medical students (under the supervision of Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the vaccine drive at Alpha Home with the support of TMA’s Be Wise – Immunize℠ program, a public health initiative that aims to increase vaccinations and vaccine awareness through shot clinics and education. Our program consisted of a vaccination drive and an interactive, educational presentation that addressed influenza, common flu shot questions, and general vaccine myths. The Alpha Home residents could ask us questions during the program.We were interested to see if our educational program could answer Alpha Home residents’ questions about vaccinations and allay their hesitations buy kamagra tablets about getting a flu vaccination. To gauge this, we created a brief survey.(Before I discuss the results of the survey, I should define vaccine hesitancy.

    Vaccine hesitancy is a concept defined by the World Health Organization. It relates to when patients do not vaccinate despite buy kamagra tablets having access to vaccines. Vaccine hesitancy is a problem because it prevents individuals from receiving their vaccinations. That makes them more susceptible to getting sick from vaccine-preventable diseases.)We surveyed the residents’ opinions about vaccinations before and after our educational program.

    While opinions about shots improved with each survey question, we saw the most buy kamagra tablets significant attitude change reflected in answers to the questions “I am concerned that vaccinations might not be safe,” and “How likely are you to receive a flu shot today?. € We had informed the residents and improved their understanding and acceptance of immunizations.Post-survey results show more residents at the Alpha Home shifted to more positive attitudes about vaccines, after learning more about their effectiveness by trusted members of the medical community. Graph by Ryan WealtherWhy is buy kamagra tablets this important?. First, our findings confirm what we already knew.

    Education by a trusted member of the medical community can effect change. In fact, it is widely known that physician recommendation of buy kamagra tablets vaccination is one of the most critical factors affecting whether patients receive an influenza vaccination. Perhaps some added proof to this is that a few of the Alpha Home residents were calling me “Dr. Truth” by the end of the evening.Second, our findings add to buy kamagra tablets our understanding of adult vaccine hesitancy.

    This is significant because most of what we know about vaccine hesitancy is limited to parental attitudes toward their children’s vaccinations. Some parents question shots for their children, and many of the most deadly diseases we vaccinate against are given in childhood, including polio, tetanus, measles, and whooping cough shots. However, adults need some vaccinations buy kamagra tablets as well, like the yearly influenza vaccine. After taking part in the UTHSA educational program, more residents at the Alpha Home shared more willingness to receive the flu vaccine.

    Graph by Ryan WealtherAnother reason improving attitudes is important is that receiving a flu shot is even more timely during the COVID-19 pandemic because it decreases illnesses and conserves health care resources. Thousands of people each year are hospitalized from the flu, and with hospitals filling up with coronavirus patients, we could buy kamagra tablets avoid adding dangerously ill flu patients to the mix. Lastly, these findings are important because once a COVID-19 vaccination becomes available, more people might be willing to receive it if their overall attitude toward immunizations is positive. Though the COVID-19 vaccine is buy kamagra tablets still in development, it is not immune to vaccine hesitancy.

    Recent polls have indicated up to one-third of Americans would not receive a COVID-19 vaccine even if it were accessible and affordable. Work is already being done to try to raise awareness and acceptance. In addition, buy kamagra tablets misinformation about the COVID vaccine is circulating widely. (Someone recently asked me if the COVID vaccine will implant a microchip in people, and I have seen the same myth circulating on social media.

    It will not.) This myth, however, illustrates the need for health care professionals to answer patients’ questions and to assuage their concerns.Vaccines work best when buy kamagra tablets many people in a community receive them, and vaccine hesitancy can diminish vaccination rates, leaving people who can't get certain vaccines susceptible to these vaccine-preventable diseases. For example, babies under 6 months of age should not receive a flu shot, so high community vaccination rates protect these babies from getting sick with the flu. Our educational program at Alpha Home is just one example of how health care professionals can increase awareness and acceptance of shots. As the COVID-19 pandemic progresses, we need to ensure buy kamagra tablets children and adults receive their vaccinations as recommended by their physician and the Centers for Disease Control and Prevention.

    I encourage readers who have questions about the vaccinations they or their child may need to talk with their physician. As health care professionals, we’re more than happy to answer your questions..

    Lauren Gambill, what is kamagra tablets MDPediatrician, AustinMember, Texas Medical Association (TMA) Committee where to buy kamagra on Child and Adolescent HealthExecutive Board Member, Texas Pediatric SocietyDoctors are community leaders. This role has become even more important during the COVID-19 pandemic. As patients navigate our new reality, they are looking to us to determine what is safe, how to protect their families, and the where to buy kamagra future of their health care. As more Texans lose their jobs, their health insurance, or even their homes, it is crucial that Texas receives the resources it needs to uphold our social safety net. The U.S.

    Census helps determine funding for those where to buy kamagra resources, and that is why it is of the upmost importance that each and every Texan, no matter address, immigration status, or age, respond to the 2020 U.S. Census. The deadline has been cut short one where to buy kamagra month and now closes Sept. 30.COVID-19 has only increased the importance of completing the census to help our local communities and economies recover. The novel coronavirus has inflicted unprecedented strain on patients and exacerbated inequality as more people are out of work and are many in need of help with food, health care, housing, and more.

    Schools also where to buy kamagra have been stretched thin, with teachers scrambling to teach students online. Yet, the amount of federal funding Texas has available today to help weather this emergency was driven in part by the census responses made a decade ago. Getting an accurate count in 2020 will help Texans prepare for the decade to follow, the first few years of which most certainly will be spent rebuilding from the pandemic’s fallout. Therefore, it is vital that all Texans be counted.The federal dollars Texas receives generally depends on our where to buy kamagra population. A George Washington University study recently found that even a 1% undercount can lead to a $300 million loss in funding.Take Medicaid, for example.

    Federal funds where to buy kamagra pay for 60% of the state’s program, which provides health coverage for two out of five Texas children, one in three individuals with disabilities, and 53% of all births. The complicated formula used to calculate the federal portion of this funding depends on accurate census data. If Texas’ population is undercounted, Texans may appear better off financially than they really are, resulting in Texas getting fewer federal Medicaid dollars. If that happens, lawmakers will have to make up the difference, with cuts in services, program eligibility, or physician and provider payments, any of which are potentially detrimental.The census data also is key to funding other aspects of a community’s social safety net:Health careThe Children’s Health Insurance Program (CHIP) provides low-cost health insurance to children whose parents make too much to qualify for Medicaid, but not enough to afford where to buy kamagra quality coverage. Like Medicaid, how much money the federal government reimburses the state for the program depends in part on the census.Maternal and child health programs that promote public health and help ensure children are vaccinated relies on data from the census.

    Texas also uses this federal funding to study and respond to maternal mortality and perinatal depression.Food and housing As unemployment rises and families struggle financially, many live where to buy kamagra with uncertainty as to where they will find their next meal. Already, one in seven Texans experiences food insecurity, and 20% of Texas children experience hunger. Food insecurity is rising in Texas as the pandemic continues. The Central Texas Food Bank saw a 206% rise in clients in March where to buy kamagra. Funding for the Supplemental Nutrition Assistance Program and school lunch programs are both determined by the census.

    Funding for local housing programs also is calculated via the census. An accurate count will help ensure that people who lose their where to buy kamagra homes during this economic crisis have better hope of finding shelter while our communities recover. Homelessness is closely connected with declines in overall physical and mental health.Childcare and educationAs we navigate the new reality brought on by coronavirus, more parents are taking on roles as breadwinner, parent, teacher, and caretaker. This stress highlights the desperate where to buy kamagra need for affordable childcare. The census determines funding for programs like Head Start that provide comprehensive early childhood education to low-income families.

    The good news is you still have time to complete the census. Visit 2020census.gov to where to buy kamagra take it. It takes less than five minutes to complete. Then talk where to buy kamagra to your family, neighbors, and colleagues about doing the same. If you are wondering who counts, the answer is everyone, whether it’s a newborn baby, child in foster care, undocumented immigrant, or an individual experiencing homelessness.Completing the census is one of the best things that you can do for the health of your community, especially during the pandemic.

    Thank you for helping Texas heal and for supporting these essential safety net programs.(L to R). UTHSA medical students Swetha Maddipudi, Brittany Hansen, Charles Wang, Carson where to buy kamagra Cortino, faculty advisor Kaparaboyna Kumar, MD, Ryan Wealther, Sidney Akabogu, Irma Ruiz, and Frank Jung pose with the TMA Be Wise Immunize banner. Photo courtesy by Ryan WealtherRyan WealtherMedical Student, UT Health San Antonio Long School of MedicineStudent Member, Texas Medical AssociationEditor’s Note. August is National Immunization Awareness Month. This article is part of a Me&My Doctor series highlighting and promoting the use of vaccinations.“Can where to buy kamagra the flu shot give you the flu?.

    €â€œIs it dangerous for pregnant women to get a flu shot?. €â€œCan vaccines where to buy kamagra cause autism?. €These were questions women at Alpha Home, a residential substance abuse rehabilitation center in San Antonio, asked my fellow medical students and me during a flu vaccine discussion. It is easy to see why these questions were asked, as vaccine misinformation is common today.UTHSA medical student Frank Jing (left) gets a vaccine fromKaparaboyna Kumar, MD, (right).Photo courtesy of Ryan Wealther“No” is the answer to all the questions. These were exactly the types of myths we set out to dispel at our vaccination drive.UT Health San Antonio Long School of Medicine medical where to buy kamagra students (under the supervision of Kaparaboyna Ashok Kumar, MD, faculty advisor for the Texas Medical Association Medical Student Section at UT Health San Antonio) hosted the vaccine drive at Alpha Home with the support of TMA’s Be Wise – Immunize℠ program, a public health initiative that aims to increase vaccinations and vaccine awareness through shot clinics and education.

    Our program consisted of a vaccination drive and an interactive, educational presentation that addressed influenza, common flu shot questions, and general vaccine myths. The Alpha Home residents could ask us questions during the program.We were interested to see if our educational program could answer Alpha Home residents’ questions about vaccinations and allay their hesitations about where to buy kamagra getting a flu vaccination. To gauge this, we created a brief survey.(Before I discuss the results of the survey, I should define vaccine hesitancy. Vaccine hesitancy is a concept defined by the World Health Organization. It relates to when patients do where to buy kamagra not vaccinate despite having access to vaccines.

    Vaccine hesitancy is a problem because it prevents individuals from receiving their vaccinations. That makes them more susceptible to getting sick from vaccine-preventable diseases.)We surveyed the residents’ opinions about vaccinations before and after our educational program. While opinions about shots improved where to buy kamagra with each survey question, we saw the most significant attitude change reflected in answers to the questions “I am concerned that vaccinations might not be safe,” and “How likely are you to receive a flu shot today?. € We had informed the residents and improved their understanding and acceptance of immunizations.Post-survey results show more residents at the Alpha Home shifted to more positive attitudes about vaccines, after learning more about their effectiveness by trusted members of the medical community. Graph by Ryan WealtherWhy is where to buy kamagra this important?.

    First, our findings confirm what we already knew. Education by a trusted member of the medical community can effect change. In fact, it is widely known that physician recommendation of vaccination is one of the most critical factors affecting whether patients where to buy kamagra receive an influenza vaccination. Perhaps some added proof to this is that a few of the Alpha Home residents were calling me “Dr. Truth” by the end of the evening.Second, our findings where to buy kamagra add to our understanding of adult vaccine hesitancy.

    This is significant because most of what we know about vaccine hesitancy is limited to parental attitudes toward their children’s vaccinations. Some parents question shots for their children, and many of the most deadly diseases we vaccinate against are given in childhood, including polio, tetanus, measles, and whooping cough shots. However, adults need some vaccinations as well, like the where to buy kamagra yearly influenza vaccine. After taking part in the UTHSA educational program, more residents at the Alpha Home shared more willingness to receive the flu vaccine. Graph by Ryan WealtherAnother reason improving attitudes is important is that receiving a flu shot is even more timely during the COVID-19 pandemic because it decreases illnesses and conserves health care resources.

    Thousands of people each year are hospitalized from the flu, and with hospitals filling up with coronavirus where to buy kamagra patients, we could avoid adding dangerously ill flu patients to the mix. Lastly, these findings are important because once a COVID-19 vaccination becomes available, more people might be willing to receive it if their overall attitude toward immunizations is positive. Though the COVID-19 vaccine is still where to buy kamagra in development, it is not immune to vaccine hesitancy. Recent polls have indicated up to one-third of Americans would not receive a COVID-19 vaccine even if it were accessible and affordable. Work is already being done to try to raise awareness and acceptance.

    In addition, misinformation about the COVID vaccine is circulating where to buy kamagra widely. (Someone recently asked me if the COVID vaccine will implant a microchip in people, and I have seen the same myth circulating on social media. It will not.) This myth, however, illustrates the need for health care professionals to answer patients’ questions and to assuage their concerns.Vaccines work best when many people in a community receive them, and vaccine hesitancy can diminish vaccination rates, leaving people who can't get certain where to buy kamagra vaccines susceptible to these vaccine-preventable diseases. For example, babies under 6 months of age should not receive a flu shot, so high community vaccination rates protect these babies from getting sick with the flu. Our educational program at Alpha Home is just one example of how health care professionals can increase awareness and acceptance of shots.

    As the where to buy kamagra COVID-19 pandemic progresses, we need to ensure children and adults receive their vaccinations as recommended by their physician and the Centers for Disease Control and Prevention. I encourage readers who have questions about the vaccinations they or their child may need to talk with their physician. As health care professionals, we’re more than happy to answer your questions..

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    Longer, more frequent daytime naps in elderly adults predicted a higher risk of incident Alzheimer's dementia over time, an actigraphy study showed.Elderly people who napped more than once a day had 1.3-fold increased risk in developing future Alzheimer's dementia, reported Peng Li, PhD, of Brigham and Women's Hospital in Boston, and colleagues, kamagra novi sad at the virtual SLEEP 2020, a joint meeting of the American Academy of Sleep Medicine cheap kamagra online uk and the Sleep Research Society."Importantly, these associations were independent from depressive symptoms, vascular diseases, and risk factors, and prescribed medications that may all contribute to sleep," Li said.Studies have shown conflicting messages about links between daytime napping and cognition, he noted. "Some research provided evidence that a short, planned nap may improve cognitive performance, while the others suggested that excessive self-reported daytime napping may be tied to cognitive impairment or more cognitive decline," Li told MedPage Today."Using a longitudinal design and objective measures of daytime napping based on ambulatory actigraphy, this study for the first time showed that longer and more frequent daytime naps were associated with increased future risk of Alzheimer's dementia," he said.The study involved 1,180 people with an kamagra novi sad average age of 81 from the Rush Memory and Aging Project. No participant had kamagra novi sad dementia at baseline, but 264 people had mild cognitive impairment.At baseline, motor activities were recorded with wrist actigraphy for up to 10 days to assess napping characteristics objectively. The researchers defined daytime napping episodes as motor activity segments between 10 a.m.

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    One more nap per day was associated with kamagra novi sad a 19% increase in the risk of Alzheimer's dementia (95% CI 8%-30%, P=0.0003). These associations remained even after adjusting for total sleep time."One of the unique settings of this study is that participants were followed annually with not kamagra tablets next day delivery only clinical assessments, but also motor activity monitoring that allowed objective measurement of daytime napping behavior," Li pointed out.Compared with objective activity assessments, self-reports are highly subjective and may suffer from recall bias, he noted. "So-called 'snoozes' or periods of drowsiness are more likely to be detected by objective algorithm, but left out during self-report."In other research presented at the SLEEP meeting, Li and colleagues reported within-person changes in daytime kamagra novi sad napping. "We found that objective daytime napping became longer and more frequent over time within individuals," he said."Importantly, the speed kamagra novi sad of napping prolongation was accelerated after the diagnosis of mild cognitive impairment, and further after the diagnosis of Alzheimer's dementia," Li said.

    "Altogether, our studies demonstrated a potential bidirectional relationship between daytime napping and Alzheimer's dementia."Study participants had an average baseline age of about 80, and how napping at younger ages relates to late-life cognitive performance, decline, or dementia warrants further study, he added. Judy George covers neurology and neuroscience news for MedPage Today, writing about brain kamagra novi sad aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more. Follow Disclosures This work was supported by the NIH.The 24-hour kamagra novi sad news cycle is just as important to medicine as it is to politics, finance, or sports. At MedPage Today, new information is posted daily, but keeping up can be a challenge.

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    Longer, more frequent daytime naps in elderly adults predicted a higher risk of incident Alzheimer's dementia over time, an actigraphy study showed.Elderly people who napped more than once a day had 1.3-fold increased risk in developing future Alzheimer's dementia, reported Peng Li, PhD, of Brigham and Women's Hospital in Boston, and colleagues, at the virtual SLEEP 2020, a joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society."Importantly, these associations were independent from depressive symptoms, vascular diseases, and risk factors, and prescribed medications that may all contribute to sleep," Li said.Studies have shown conflicting messages about links between daytime napping and cognition, where to buy kamagra he noted. "Some research provided evidence that a short, planned nap may improve cognitive performance, while the others suggested that excessive self-reported daytime napping may be tied to cognitive impairment or more cognitive decline," Li told MedPage Today."Using a longitudinal design and objective measures of daytime napping based on ambulatory actigraphy, where to buy kamagra this study for the first time showed that longer and more frequent daytime naps were associated with increased future risk of Alzheimer's dementia," he said.The study involved 1,180 people with an average age of 81 from the Rush Memory and Aging Project. No participant had dementia at baseline, but 264 people had mild cognitive impairment.At baseline, motor activities were recorded with wrist actigraphy where to buy kamagra for up to 10 days to assess napping characteristics objectively. The researchers defined daytime napping episodes as motor activity segments between 10 a.m. And 7 where to buy kamagra p.m.

    With continuous zero activity for 10 where to buy kamagra minutes or more but less than 1 hour (to avoid off-wrist periods). Segments that were less than 5 minutes apart were merged.On average, participants napped for 38.3 minutes and 1.56 times a day at baseline. In total, 277 participants developed Alzheimer's dementia within 5.74 years.Every 30-minute increase in daily napping duration was associated with a 20% increase in where to buy kamagra the risk of incident Alzheimer's dementia (95% CI 9%-31%, P=0.0002), after adjusting for age, sex, and education. One more nap per where to buy kamagra day was associated with a 19% increase in the risk of Alzheimer's dementia (95% CI 8%-30%, P=0.0003). These associations remained even after adjusting for total sleep time."One of the unique settings of this study is that participants were followed annually with not only clinical assessments, but also motor activity monitoring that allowed objective measurement of daytime napping behavior," Li pointed out.Compared with objective activity assessments, self-reports are highly subjective and may suffer from recall bias, he noted.

    "So-called 'snoozes' or periods of drowsiness are more likely to be detected by objective algorithm, but left out during self-report."In where to buy kamagra other research presented at the SLEEP meeting, Li and colleagues reported within-person changes in daytime napping. "We found that objective daytime napping became longer and more frequent over time within individuals," he said."Importantly, the speed of napping prolongation was accelerated where to buy kamagra after the diagnosis of mild cognitive impairment, and further after the diagnosis of Alzheimer's dementia," Li said. "Altogether, our studies demonstrated a potential bidirectional relationship between daytime napping and Alzheimer's dementia."Study participants had an average baseline age of about 80, and how napping at younger ages relates to late-life cognitive performance, decline, or dementia warrants further study, he added. Judy George covers neurology and neuroscience news for MedPage Today, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, where to buy kamagra epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more. Follow Disclosures This work was supported by the NIH.The 24-hour news cycle is just as important to medicine as it is to politics, finance, or sports where to buy kamagra.

    At MedPage Today, new information is posted daily, but keeping up can be a challenge. As an aid for our readers and for a little amusement, here is a 10-question quiz based on the news of the where to buy kamagra week. Topics include where to buy kamagra COVID reinfections, Trump's healthcare agenda, and a hospital CEO's resignation. After taking the quiz, scroll down in your browser window to find the correct answers and explanations, as well as links to the original articles..

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    Masks slow the spread of SARS-CoV-2 by reducing how much infected people spray the virus into the environment around them when they cough kamagra tabletten kaufen or talk. Evidence from laboratory experiments, hospitals and whole countries show that masks work, and the Centers for Disease Control and Prevention recommends face coverings for the kamagra tabletten kaufen U.S. Public. With all this evidence, mask wearing has become the norm in many places.I am an infectious disease doctor and a professor of kamagra tabletten kaufen medicine at the University of California, San Francisco. As governments and workplaces began to recommend or mandate mask wearing, my colleagues and I noticed an interesting trend.

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    Both recent experiments in animal models using coronavirus and nearly a hundred years of viral research show that lower viral doses usually means less severe disease.No mask is perfect, and wearing one might not prevent you from getting infected. But it might be the difference between a case of COVID-19 that sends you to the hospital and a case so mild you don’t even realize you’re infected.Exposure Dose Determines Severity of DiseaseWhen you breathe in a respiratory virus, it immediately begins hijacking any cells it lands near to turn where to buy kamagra them into virus production machines. The immune system tries to stop this process to halt the spread of the virus.The amount of virus that you’re exposed to – called the viral inoculum, or dose – has a lot to do with how sick you get.

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    Many animal studies have shown that the higher the dose of a virus you give an animal, the more sick it becomes. In 2015, researchers tested this concept in human volunteers using a where to buy kamagra nonlethal flu virus and found the same result. The higher the flu virus dose given to the volunteers, the sicker they became.In July, researchers published a paper showing that viral dose was related to disease severity in hamsters exposed to the coronavirus.

    Hamsters who were given a where to buy kamagra higher viral dose got more sick than hamsters given a lower dose.Based on this body of research, it seems very likely that if you are exposed to SARS-CoV-2, the lower the dose, the less sick you will get.So what can a person do to lower the exposure dose?. Masks Reduce Viral DoseMost infectious where to buy kamagra disease researchers and epidemiologists believe that the coronavirus is mostly spread by airborne droplets and, to a lesser extent, tiny aerosols. Research shows that both cloth and surgical masks can block the majority of particles that could contain SARS-CoV-2.

    While no mask is perfect, the goal is not to block all of the virus, but where to buy kamagra simply reduce the amount that you might inhale. Almost any mask will successfully block some amount.Laboratory experiments have shown that good cloth masks and surgical masks could block at least 80% of viral particles from entering your nose and mouth. Those particles and other contaminants will get trapped in where to buy kamagra the fibers of the mask, so the CDC recommends washing your cloth mask after each use if possible.The final piece of experimental evidence showing that masks reduce viral dose comes from another hamster experiment.

    Hamsters were divided into an unmasked group and a masked group by placing surgical mask material over the pipes that brought air into the cages of the masked group. Hamsters infected with the coronavirus were placed in cages next where to buy kamagra to the masked and unmasked hamsters, and air was pumped from the infected cages into the cages with uninfected hamsters.As expected, the masked hamsters were less likely to get infected with COVID-19. But when some of the masked hamsters did get infected, they had more mild disease than the unmasked hamsters.Masks Increase Rate of Asymptomatic CasesIn July, the CDC estimated that around 40% of people infected with SARS-CoV-2 are asymptomatic, and a number of other studies have confirmed this number.However, in places where everyone wears masks, the rate of asymptomatic infection seems to be much higher.

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    In the outbreaks from both plants, nearly 95% of infected people were asymptomatic.There is no doubt that universal mask wearing slows the spread of the coronavirus. My colleagues where to buy kamagra and I believe that evidence from laboratory experiments, case studies like the cruise ship and food processing plant outbreaks and long-known biological principles make a strong case that masks protect the wearer too.The goal of any tool to fight this pandemic is to slow the spread of the virus and save lives. Universal masking will do both.Monica Gandhi is a Professor of Medicine with the Division of HIV, Infectious Diseases and Global Medicine at the University of California, San Francisco.

    This article originally appeared on The Conversation and is republished under a Creative Commons where to buy kamagra license. Read the original here..

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    Abstract The COVID-19 pandemic has emerged as a major stressor of a global scale, kamagra tablets side effects affecting all aspects of our lives, and is likely to contribute to a surge kamagra 365 pharmacy 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 kamagra tablets side effects 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 kamagra tablets side effects.

    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 kamagra tablets side effects 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, kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects 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 kamagra tablets side effects the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8.

    2.Arango kamagra tablets side effects 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 kamagra tablets side effects 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.

    Abstract 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 when to take kamagra oral jelly to where to buy kamagra 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 where to buy kamagra “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 where to buy kamagra 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 where to buy kamagra 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, where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra.

    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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra. 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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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, where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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 where to buy kamagra 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), where to buy kamagra 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, where to buy kamagra 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 where to buy kamagra. Am J Psychiatry 2014;171:827-8.

    2.Arango where to buy kamagra 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 where to buy kamagra 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.

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