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As temperatures remain colder than normal through midweek, there's now an increasing possibility for a can ventolin be purchased over the counter brief round of light accumulating snowfall.The quick-moving system will sweep through the region on Wednesday morning, Dec. 9.The time frame for snowfall is currently from about 8 a.m. To 11 a.m can ventolin be purchased over the counter. During that time, a trace to a half-inch or inch of accumulation is possible, which could cause slippery road conditions.After that window for snowfall, temperatures will gradually climb to a high temperature of around 40 degrees on Wednesday, which will be mostly cloudy throughout the day.There's also a chance of some scattered snow flurries overnight Monday, Dec.

7 into Tuesday, Dec. 8. No accumulation is expected.Tuesday will be mostly sunny on another cold day with a high temperature in the upper 30s and wind-chill values between 15 and 25 degrees.Check back to Daily Voice for updates. Click here to sign up for Daily Voice's free daily emails and news alerts.The number of active asthma treatment cases have caused some alarm for Westchester County Executive George Latimer, who compared the most recent data to the early spring when the ventolin was peaking in the area.Over the weekend, Westchester had 1,662 newly confirmed asthma treatment cases, bringing the year-to-date total up to 54,671, Latimer said during a asthma treatment briefing on Monday, Dec.

7. Of those cases, there are 7,830 active cases, which represents people who have tested positive within the past two weeks and have not passed the incubation period.The number of active cases is up from 5,764 a week ago, 4,662 two weeks ago, and approximately 3,400 three weeks ago."We've more than doubled the number of active cases in the past three weeks," Latimer said. "That takes us back to the end of April in terms of active cases, and that's a striking note. On or about April 28, we had a similar number at 8,000 cases." More than 300 people have been hospitalized with asthma treatment in Westchester, up from approximately 250 late last week.

There were 15 new ventolin-related deaths, bringing the death toll to 1,529 since early March."With the winter weather, we have less outdoor dining options, less outdoor activities, and functions, and things are going indoors, where the ventolin can spread more quickly," Latimer added. "We also have societal holidays, and in those kinds of gatherings, people come together in a social and family setting, it's nota. Community setting." A breakdown of the total, active, and new asthma treatment cases in Westchester on Monday, Dec. 7, according to the Department of Health:Yonkers.

10,673 (1,176 active, 296 new);New Rochelle. 5,015 (600, 176 new);Mount Vernon. 3,756 (335, 65 new);White Plains. 2,888 (437, 119 new);Port Chester.

2,150 (267, 59 new);Greenburgh. 1,831 (227, 56 new);Ossining Village. 1,779 (266, 54 new);Peekskill. 1,670 (220, 59 new);Cortlandt.

1,392 (157, 41 new);Yorktown. 1,396 (230, 83 new);Mount Pleasant. 969 (149, 51 new);Mamaroneck Village. 889 (172, 50 new);Harrison.

882 (173, 48 new);Eastchester. 787 (162, 32 new);Sleepy Hollow. 737 (89, 20 new);Somers. 717 (106, 29 new);Mount Kisco.

618 (153, 45 new);Bedford. 607 (149, 48 new);Scarsdale. 526 (67, 21 new);Dobbs Ferry. 496 (59, 22 new);Tarrytown.

487 (82, 24 new);Rye City. 463 (103, 23 new);New Castle. 417 (55, 14 new);North Castle. 414 (74, 24 new);Rye Brook.

365 (53, 15 new);Elmsford. 319 (46, 12 new);Mamaroneck Town. 306 (44, 14 new);Croton-on-Hudson. 304 (41, 13 new);Lewisboro.

306 (85, 18 new);North Salem. 272 (43, 6 new);Pelham. 287 (60, 20 new);Pleasantville. 259 (43, 7 new);Ossining Town.

235 (24, 14 new);Tuckahoe. 219 (23, 8 new);Hastings-on-Hudson. 202 (18, 3 new);Briarcliff Manor. 231 (49, 10 new);Pelham Manor.

205 (30, 9 new);Ardsley. 169 (34, 7 new);Bronxville. 172 (44, 14 new);Irvington. 159 (36, 9 new);Larchmont.

152 (29, 11 new);Buchanan. 85 (15, 1 new);Pound Ridge. 82 (22, 7 new).Latimer said last week that Westchester officials are also working with state health officials to link their asthma treatment reporting systems to provide new data for local residents and municipalities."This would allow us to bring additional statistics and additional information that can be shared with local officials, who have worked off what information we could give them based on the information we've been receiving."But if we can grow that framework, then they can share that information with (residents) so you can have an idea what's going on in your backyard, not just by municipality but down to your own zip code."On Sunday, Dec. 6, a total of 152,287 New Yorkers were tested for asthma treatment, with 4.79 percent testing positive for the ventolin.

There were 160 new asthma treatment patients hospitalized, bringing the total to 4,602. There are 872 ICU patients being treated for the ventolin, and 477 are intubated after testing positive.In the state's asthma treatment "micro-cluster" hotspots, the rate is at 6.57 percent, and the state's positivity rate not including those focus zones is at 4.27 percent.Statewide since the ventolin began, 705,827 positive asthma treatment cases have been confirmed out of 20.6 million who have been tested. There has been a total of 27,149 asthma treatment fatalities since the ventolin began. Click here to sign up for Daily Voice's free daily emails and news alerts.New York may be on the brink of a new economic shutdown as the number of new asthma treatment cases continues to climb during the ventolin’ “second wave” and threatens to potentially overwhelm the state’s hospital system.There are now more than 4,600 asthma treatment patients hospitalized in New York, setting off alarm bells in Cuomo’s head as his Department of Health issued a new order to hospitals across the state to increase their capacity by 25 percent as a precaution.By increasing hospital bed capacity, Cuomo estimated that the state could reach upwards of 58,000 asthma treatment-specific beds.

€œWe have 215 hospitals in this state, so it wasn’t a matter of the hospital system getting overwhelmed in the spring, it was individual hospitals that got overwhelmed because they didn’t balance their patients,” Cuomo said during a asthma treatment briefing on Monday, Dec. 7. €œOnce we figured it out in the spring, it went fine enough and now we have more experience in dealing with it.” If hospital capacity becomes “critical,” which has been defined as 90 percent of capacity, or is in danger of becoming critical, Cuomo said he would be forced to shut down that region in an attempt to reset the asthma treatment numbers.The number of asthma treatment patients being treated in New York hospitals peaked at approximately 19,000 in the spring when the state was “sucker-punched” by the ventolin coming from Europe.“If your seven-day rolling average shows that within three weeks you will hit crucial hospital capacity, we will close you down,” he said. €œIf our hospital capacity becomes critical, we're going to close down that region." During his briefing, Cuomo also called on retired nurses and doctors to return to service, noting that New York State will automatically renew registrations without cost.The governor estimated that upwards of 20,000 retired nurses and doctors could potentially be added to the roster of frontline workers combating the ventolin.“We’re well aware of staff resources, and these are staffs that are coming in stressed” he said.

€œTalk about a long year, they’ve had the longest year out of anyone. So we’re going to ask retired doctors and nurses to sign back up, and we’ll automatically renew registrations without cost.” Cuomo said that he expects cases to continue surging through at least the middle of January, and that hospitals are in danger of being overwhelmed until a treatment is approved and disseminated to the general population.“No state is better than we are at managing our hospital system, but you cannot overwhelm them,” he stated. €œYou can’t overwhelm the hospital system - that means people are dying on gurneys in hallways, and the life you could have saved you can’t save because you don’t have the staff, and people die unnecessarily.“The shut down could be as early as Monday if the hospitalization rate doesn’t stabilize,” Cuomo continued. €œIf you are at a rate that is going to overwhelm your hospitals, you must shut down … 'Oh we don’t want to do that again,' then change your behavior, but if you don’t want to change your behavior.

That is the reality of the situation.” Click here to sign up for Daily Voice's free daily emails and news alerts.The Putnam County SPCA is seeking information regarding the abandonment of an adult female beagle. On Tuesday, Dec. 1, around 1 p.m., a delivery driver observed an individual push the dog out of an older model, Black Jeep Wrangler onto the side of Route 301, in the Town of Carmel, said the SPCA.The vehicle then sped off as the dog attempted to follow it. The witness was able to catch the dog and brought it to the Putnam Humane shelter.

The Putnam County SPCA is asking for anyone that might have information on this incident to please contact the Putnam County SPCA Humane Law Enforcement Division at 845-520-6915.The dog pushed out of the vehicle.Putnam County SPCA“Abandonment of any animal is a crime in New York State," said SPCA Chief Ken Ross. "Anyone who does this, especially at this time of year, is heartless.”Animal crimes can be reported to the Putnam County SPCA 24 Hour Hotline at 845-520-6915. Click here to sign up for Daily Voice's free daily emails and news alerts.New restrictions on indoor dining in New York will be put in place if the asthma treatment hospitalization rates continue to climb as they have been in recent weeks, Gov. Andrew Cuomo cautioned.Cuomo said that if hospitalization rates don’t begin to stabilize, restaurants and bars in New York City will completely close for indoor seating, while the rest of the state will see the indoor dining capacity drop from a max of 50 percent to 25 percent.The changes will take effect within the next week, Cuomo said, and he will give restauranteurs a few days to “reorient.” Indoor dining in designated “red” and “orange” micro-clusters is already banned under the state’s asthma treatment strategy.According to Cuomo, each of the state’s 10 regions’ hospital rates will be reviewed independently and won’t have a bearing on shuttering indoor dining elsewhere.

The move comes following the Centers for Disease Control and Prevention releasing new guidance on indoor dining on Friday, Dec. 4. €œI believe that as the facts change, your opinions change. And as the facts change, your strategy should change,” Cuomo said during a asthma treatment briefing in Manhattan on Monday, Dec.

7. €œIf after five days we haven’t seen a stabilization in a region’s hospital rate, we’re going to clamp down on indoor dining.”There were 160 new asthma treatment patients admitted into New York hospitals overnight, bringing the total to 4,602 statewide as of Dec. 7, its highest total since May 22 but down from the peak, when approximately 19,000 were hospitalized. There are 872 (22 new) asthma treatment patients in ICU beds, and 477 (13 new) have been intubated.“The Thanksgiving wave is just starting to break, then you’ve got the Christmas, Hannakuh, Kwanza wave, then the New Year’s Eve, New Year’s Day wave, so it’s all a matter of function and New Yorkers can change that,” he said.

€œIt’s not just about indoor dining, you have to look at the big picture, and that hospitalization capacity.“If we don’t get the (hospitalization) rate under control, you’re going to overwhelm the hospital systems, and we’re going to have to go back to shutting down,” Cuomo continued. €œThere are certain absolutes, and what’s absolute here is that we cannot overwhelm the hospital systems, because if you do, you have to shut down (everything).” Click here to sign up for Daily Voice's free daily emails and news alerts..

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John Rawls begins a Theory of Justice buy ventolin no prescription with the observation that 'Justice is the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a whole cannot bronchodilator ventolin override'1 (p.3). The asthma treatment ventolin has resulted in lock-downs, the restriction of liberties, debate about the right to refuse medical treatment bronchodilator ventolin and many other changes to the everyday behaviour of persons. The justice issues it raises are diverse, profound and will demand our attention for some time.

How we can respect the Rawlsian commitment to the inviolability of each person, when bronchodilator ventolin the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and asthma treatment is quite well developed and this journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to asthma treatment triage situations. Their argument seems to highlight instances of what is called the McNamara fallacy. US Secretary of bronchodilator ventolin Defense Robert McNamara used enemy body counts as a measure of military success during the Vietnam war.

So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so bronchodilator ventolin they draw a distinction between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew between the different forms of procedural fairness. While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p.

85) there bronchodilator ventolin is little prospect of that. As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for asthma treatment is no exception. Instead, we should work toward a transparent bronchodilator ventolin and fair process, what Rawls would describe as imperfect procedural justice (p.

85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85).

Their proposal is to triage patients into three broad categories. High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about asthma treatment triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for asthma treatment can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for asthma treatment.

They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for asthma treatment that means looking beyond access to ICU. Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for asthma treatment in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to asthma treatment should broadened to include all the services a system might provide.Brown et al argue in favour of asthma treatment immunity passports and the following summarises one of the key arguments in their article.7asthma treatment immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from asthma treatment should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues.

Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to asthma treatment, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding.

Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the ventolin. Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the ventolin.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles.

They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about asthma treatment. These include that information about asthma treatment is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests.

They observe that asthma treatment has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for asthma treatment and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means. They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other.

These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The asthma treatment ventolin is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs asthma treatment spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly. In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access.

However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with asthma treatment who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020.

Central to these disucssions were two assumptions. First, that ICU admission was a valuable but scarce resource in the ventolin context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU.

In this paper we explain how scarcity and value were conflated in the early ICU asthma treatment triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question. Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a ventolin, such as masks or treatments.

ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient.

People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe asthma treatment ventolin generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission. The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups.

The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups. This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the ventolin with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have high rates of underlying comorbidities, some of which are prognostically relevant in asthma treatment .

Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears. Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it. Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases.

Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with asthma treatment are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the ventolin, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate.

This has the potential to compromise important decisions with regard to care for patients with asthma treatment.The emerging reality of ICUIn general, the majority of patients who are ventilated for asthma treatment in ICU will die. Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation. Emerging data show case fatality rates of 50%–88% for ventilated patients with asthma treatment.

In China11 and Italy about half of those with asthma treatment who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in asthma treatment needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired s such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage. Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-ventolin) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of asthma treatment, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with asthma treatment begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with asthma treatment admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds.

First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits. For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups.

In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with asthma treatment, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with asthma treatment in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the ventolin should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care.

This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas. Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the asthma treatment ventolin response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the asthma treatment ventolin, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to asthma treatment in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate preventon and control training when dealing with patients with asthma treatment or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation.

Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from asthma treatment. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with asthma treatment (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people). There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat asthma treatment with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist asthma treatment communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the ventolin.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team.

Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources.

These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the ventolin context. See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during asthma treatmentDespite the sometimes overwhelming pressure of the ventolin, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for asthma are quarantined in health facilities until they receive two consecutive negative tests.

Patients may be isolated in hospital for several weeks. To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity.

However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During asthma treatment the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers. Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear.

An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of asthma treatment, given the unprecedented nature and scale of the ventolin and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis. This suggests the need for asthma treatment-specific ACPs.

Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with asthma treatment is challenging and complex.

Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients. But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients.

And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature. Equity can be addressed more robustly if ventolin responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with asthma treatment.

Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the ventolin will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in s but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the asthma treatment Chronicles strip..

John Rawls begins a Theory of Justice with the observation can ventolin be purchased over the counter that 'Justice is the first virtue of social institutions, as truth is of systems of thought… Each person possesses an inviolability founded on justice that even the welfare of society as a http://www.ec-rene-schickele-mutzig.ac-strasbourg.fr/2021/03/21/fabrication-de-totems-ce1-ce2/ whole cannot override'1 (p.3). The asthma treatment ventolin has resulted in lock-downs, can ventolin be purchased over the counter the restriction of liberties, debate about the right to refuse medical treatment and many other changes to the everyday behaviour of persons. The justice issues it raises are diverse, profound and will demand our attention for some time. How we can respect the Rawlsian commitment to the inviolability of each person, when the welfare of societies as a whole is under threat goes to the heart of some of the difficult ethical issues we face and are discussed in this issue of the Journal of Medical Ethics.The debate about ICU triage and asthma treatment is quite well developed and this can ventolin be purchased over the counter journal has published several articles that explore aspects of this issue and how different places approach it.2–5 Newdick et al add to the legal analysis of triage decisions and criticise the calls for respecting a narrow conception of a legal right to treatment and more detailed national guidelines for how triage decisions should be made.6They consider scoring systems for clinical frailty, organ failure assessment, and raise some doubts about the fairness of their application to asthma treatment triage situations. Their argument seems to highlight instances of what is called the McNamara fallacy.

US Secretary of Defense Robert McNamara used enemy body can ventolin be purchased over the counter counts as a measure of military success during the Vietnam war. So, the fallacy occurs when we rely solely on considerations that appear to be quantifiable, to the neglect of vital qualitative, difficult to measure or contestable features.6 Newdick et al point to variation in assessment, subtlety in condition and other factors as reasons why it is misleading to present scoring systems as ‘objective’ tests for triage. In doing so they draw a distinction can ventolin be purchased over the counter between procedural and outcome consistency, which is important, and hints at distinctions Rawls drew between the different forms of procedural fairness. While we might hope to come up with a triage protocol that is procedurally fair and arrives at a fair outcome (what Rawls calls perfect procedural justice, p. 85) there is little prospect of can ventolin be purchased over the counter that.

As they observe, reasonable people can disagree about the outcomes we should aim for in allocating health resources and ICU triage for asthma treatment is no exception. Instead, we should work toward a transparent and fair process, what Rawls would describe as imperfect procedural justice (p can ventolin be purchased over the counter. 85). His example of this is a criminal trial where we adopt processes that we have reason to believe are our best chance of determining guilt, but which do not guarantee the truth of a verdict, and this is a reason why they must be transparent and consistent (p. 85).

Their proposal is to triage patients into three broad categories. High, medium and low priority, with the thought that a range of considerations could feed into that evaluation by an appropriately constituted clinical group.Ballantyne et al question another issue that is central to the debate about asthma treatment triage.4 They describe how utility measures such as QALYs, lives saved seem to be in tension with equity. Their central point is that ICU for asthma treatment can be futile, and that is a reason for questioning how much weight should be given to equality of access to ICU for asthma treatment. They claim that there is little point admitting someone to ICU when ICU is not in their best interests. Instead, the scope of equity should encompass preventing 'remediable differences among social, economic demographic or geographic groups' and for asthma treatment that means looking beyond access to ICU.

Their central argument can be summarised as follows.Maximising utility can entrench existing health inequalities.The majority of those ventilated for asthma treatment in ICU will die.Admitting frailer or comorbid patients to ICU is likely to do more harm than good to these groups.Therefore, better access to ICU is unlikely to promote health equity for these groups.Equity for those with health inequalities related to asthma treatment should broadened to include all the services a system might provide.Brown et al argue in favour of asthma treatment immunity passports and the following summarises one of the key arguments in their article.7asthma treatment immunity passports are a way of demonstrating low personal and social risk.Those who are at low personal risk and low social risk from asthma treatment should be permitted more freedoms.Permitting those with immunity passports greater freedoms discriminates against those who do not have passports.Low personal and social risk and preserving health system capacity are relevant reasons to discriminate between those who have immunity and those who do not.Brown et al then consider a number of potential problems with immunity passports, many of which are justice issues. Resentment by those who do not hold an immunity passport along with a loss of social cohesion, which is vital for responding to asthma treatment, are possible downsides. There is also the potential to advantage those who are immune, economically, and it could perpetuate existing inequalities. A significant objection, which is a problem for the justice of many policies, is free riding. Some might create fraudulent immunity passports and it might even incentivise intentional exposure to the ventolin.

Brown et al suggest that disincentives and punishment are potential solutions and they are in good company as the Rawlsian solution to free riding is for 'law and government to correct the necessary corrections.' (p. 268)Elves and Herring focus on a set of ethical principles intended to guide those making policy and individual level decisions about adult social care delivery impacted by the ventolin.8 They criticize the British government’s framework for being silent about what to do in the face of conflict between principles. They suggest the dominant values in the framework are based on autonomy and individualism and argue that there are good reasons for not making autonomy paramount in policy about asthma treatment. These include that information about asthma treatment is incomplete, so no one can be that informed on decisions about their health. The second is one that highlights the importance of viewing our present ethical challenges via the lens of justice or other ethical concepts such as community or solidarity that enable us to frame collective obligations and interests.

They observe that asthma treatment has demonstrated how health and how we live our lives are linked. That what an individual does can have profound impact on the health of many others.Their view is that appeals to self-determination ring hollow for asthma treatment and their proposed remedy is one that pushes us to reflect on what the liberal commitment to the inviolability of each person means. They explain Dworkin’s account of 'associative obligations' which occur within a group when they acknowledge special rights and responsibilities to each other. These obligations are a way of giving weight to community considerations, without collapsing into full-blown utilitarianism and while still respecting the inviolability of persons.The asthma treatment ventolin is pushing ethical deliberation in new directions and many of them turn on approaching medical ethics with a greater emphasis on justice and related ethical concepts.IntroductionAs asthma treatment spread internationally, healthcare services in many countries became overwhelmed. One of the main manifestations of this was a shortage of intensive care beds, leading to urgent discussion about how to allocate these fairly.

In the initial debates about allocation of scarce intensive care unit (ICU) resources, there was optimism about the ‘good’ of ICU access. However, rather than being a life-saving intervention, data began to emerge in mid-April showing that most critical patients with asthma treatment who receive access to a ventilator do not survive to discharge. The minority who survive leave the ICU with significant morbidity and a long and uncertain road to recovery. This reality was under-recognised in bioethics debates about ICU triage throughout March and April 2020. Central to these disucssions were two assumptions.

First, that ICU admission was a valuable but scarce resource in the ventolin context. And second, that both equity and utility considerations were important in determining which patients should have access to ICU. In this paper we explain how scarcity and value were conflated in the early ICU asthma treatment triage literature, leading to undue optimism about the ‘good’ of ICU access, which in turned fuelled equity-based arguments for ICU access. In the process, ethical issues regarding equitable access to end-of-life care more broadly were neglected.Equity requires the prevention of avoidable or remediable differences among social, economic, demographic, or geographic groups.1 How best to apply an equity lens to questions of distribution will depend on the nature of the resource in question. Equitable distribution of ICU beds is significantly more complex than equitable distribution of other goods that might be scarce in a ventolin, such as masks or treatments.

ICU (especially that which involves intubation and ventilation i.e. Mechanical ventilation) is a burdensome treatment option that can lead to significant suffering—both short and long term. The degree to which these burdens are justified depends on the probability of benefit, and this depends on the clinical status of the patient. People are rightly concerned about the equity implications of excluding patients from ICU on the grounds of pre-existing comorbidities that directly affect prognosis, especially when these align with and reflect social disadvantage. But this does not mean that aged, frail or comorbid patients should be admitted to ICU on the grounds of equity, when this may not be in their best interests.ICU triage debateThe asthma treatment ventolin generated extraordinary demand for critical care and required hard choices about who will receive presumed life-saving interventions such as ICU admission.

The debate has focused on whether or not a utilitarian approach aimed at maximising the number of lives (or life-years) saved should be supplemented by equity considerations that attempt to protect the rights and interests of members of marginalised groups. The utilitarian approach uses criteria for access to ICU that focus on capacity to benefit, understood as survival.2 Supplementary equity considerations have been invoked to relax the criteria in order to give a more diverse group of people a chance of entering ICU.3 4Equity-based critiques are grounded in the concern that a utilitarian approach aimed at maximising the number (or length) of lives saved may well exacerbate inequity in survival rates between groups. This potential for discrimination is heightened if triage tools use age as a proxy for capacity to benefit or are heavily reliant on Quality-Adjusted Life-Years (QALYs) which will deprioritise people with disabilities.5 6 Even if these pitfalls are avoided, policies based on maximising lives saved entrench existing heath inequalities because those most likely to benefit from treatment will be people of privilege who come into the ventolin with better health status than less advantaged people. Those from lower socioeconomic groups, and/or some ethnic minorities have http://www.physio-hanko.at/comming-soon/ high rates of underlying comorbidities, some of which are prognostically relevant in asthma treatment . Public health ethics requires that we acknowledge how apparently neutral triage tools reflect and reinforce these disparities, especially where the impact can be lethal.7But the utility versus equity debate is more complex than it first appears.

Both the utility and equity approach to ICU triage start from the assumption that ICU is a valuable good—the dispute is about how best to allocate it. Casting ICU admission as a scarce good subject to rationing has the (presumably unintended) effect of making access to critical care look highly appealing, triggering cognitive biases. Psychologists and marketers know that scarcity sells.8 People value a commodity more when it is difficult or impossible to obtain.9 When there is competition for scarce resources, people focus less on whether they really need or want the resource. The priority becomes securing access to the resource.Clinicians are not immune to scarcity-related cognitive bias. Clinicians treating patients with asthma treatment are working under conditions of significant information overload but without the high quality clinical research (generated from large data sets and rigorous methodology) usually available for decision-making.

The combination of overwhelming numbers of patients, high acuity and uncertainty regarding best practice is deeply anxiety provoking. In this context it is unsurprising that, at least in the early stages of the ventolin, they may not have the psychological bandwidth to challenge assumptions about the benefits of ICU admission for patients with severe disease. Zagury-Orly and Schwartzstein have recently argued that the health sector must accept that doctors’ reasoning and decision-making are susceptible to human anxieties and in the “…effort to ‘do good’ for our patients, we may fall prey to cognitive biases and therapeutic errors”.10We suggest the global publicity and panic regarding ICU triage distorted assessments of best interests and decision-making about admittance to ICU and slanted ethical debate. This has the potential to compromise important decisions with regard to care for patients with asthma treatment.The emerging reality of ICUIn general, the majority of patients who are ventilated for asthma treatment in ICU will die. Although comparing data from different health systems is challenging due to variation in admission criteria for ICU, clear trends are emerging with regard to those critically unwell and requiring mechanical ventilation.

Emerging data show case fatality rates of 50%–88% for ventilated patients with asthma treatment. In China11 and Italy about half of those with asthma treatment who receive ventilator support have not survived.12 In one small study in Wuhan the ICU mortality rate among those who received invasive mechanical ventilation was 86% (19/22).13 Interestingly, the rate among those who received less intensive non-invasive ventilation (NIV)1 was still 79% (23/29).13 Analysis of 5700 patients in the New York City area showed that the mortality for those receiving mechanical ventilation was 88%.14 In the UK, only 20% of those who have received mechanical ventilation have been discharged alive.15 Hence, the very real possibility of medical futility with regard to ventilation in asthma treatment needs to be considered.It is also important to consider the complications and side effects that occur in an ICU context. These patients are vulnerable to hospital acquired s such as ventilator associated pneumonias with high mortality rates in their own right,16 neuropathies, myopathies17 and skin damage. Significant long term morbidity (physical, mental and emotional challenges) can also be experienced by people who survive prolonged ventilation in ICU.12 18 Under normal (non-ventolin) circumstances, many ICU patients experience significant muscle atrophy and deconditioning, sleep disorders, severe fatigue,19 post-traumatic stress disorder,20 cognitive deficits,21 depression, anxiety, difficulty with daily activities and loss of employment.22 Although it is too soon to have data on the long term outcomes of ICU survivors in the specific context of asthma treatment, the UK Chartered Society of Physiotherapy predicts a ‘tsunami of rehabilitation needs’ as patients with asthma treatment begin to be discharged.23 The indirect effects of carer-burden should also not be underestimated, as research shows that caring for patients who have survived critical illness results in high levels of depressive symptoms for the majority of caregivers.24The emerging mortality data for patients with asthma treatment admitted to ICU—in conjunction with what is already known about the morbidity of ICU survivors—has significant implications for the utility–equity debates about allocating the scarce resource of ICU beds. First, they undermine the utility argument as there seems to be little evidence that ICU admission leads to better outcomes for patients, especially when the long term morbidity of extended ICU admission is included in the balance of burdens and benefits.

For some patients, perhaps many, the burdens of ICU will not outweigh the limited potential benefits. Second, the poor survival rates challenge the equity-based claim for preferential access to treatment for members of disadvantaged groups. In particular, admitting frailer or comorbid patients to ICU to fulfil equity goals is unlikely to achieve greater survival for these population groups, but will increase their risk of complications and may ultimately exacerbate or prolong their suffering.The high proportions of people who die despite ICU admission make it particularly important to consider what might constitute better or worse experiences of dying with asthma treatment, and how ICU admission affects the likelihood of a ‘good’ death. Critical care may compromise the ability of patients to communicate and engage with their families during the terminal phase of their lives—in the context of an intubated, ventilated patient this is unequivocal.Given the high rates of medical futility with patients with asthma treatment in ICU, the very significant risks for further suffering in the short and long term and the compromise of important psychosocial needs—such as communicating with our families—in the terminal phase of life, our ethical scope must be wider than ICU triage. Ho and Tsai argue that, “In considering effective and efficient allocation of healthcare resources as well as physical and psychological harm that can be incurred in prolonging the dying process, there is a critical need to reframe end-of-life care planning in the ICU.”25 We propose that the focus on equity concerns during the ventolin should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care.

This requires attention to minimising barriers to accessing culturally safe care in the following interlinked areas. Palliative care, and communication and decision support and advanced care planning.Palliative careScaling up palliative and hospice care is an essential component of the asthma treatment ventolin response. Avoiding non-beneficial or unwanted high-intensity care is critical when the capacity of the health system is stressed.26 Palliative care focuses on symptom management, quality of life and death, and holistic care of physical, psychological, social and spiritual health.27 Evidence from Italy has prompted recommendations that, “Governments must urgently recognise the essential contribution of hospice and palliative care to the asthma treatment ventolin, and ensure these services are integrated into the healthcare system response.”28 Rapid palliative care policy changes were implemented in response to asthma treatment in Italy, including more support in community settings, change in admission criteria and daily telephone support for families.28 To meet this increased demand, hospice and palliative care staff should be included in personal protective equipment (PPE) allocation and provided with appropriate preventon and control training when dealing with patients with asthma treatment or high risk areas.Attention must also be directed to maintaining supply lines for essential medications for pain, distress and sedation. Patients may experience pain due to existing comorbidities, but may also develop pain as a result of excessive coughing or immobility from asthma treatment. Such symptoms should be addressed using existing approaches to pain management.27 Supply lines for essential medications for distress and pain management, including fentanyl and midazolam are under threat in the USA and propofol—used in terminal sedation—may also be in short supply.29 The challenges are exacerbated when people who for various reasons eschew or are unable to secure hospital admission decline rapidly at home with asthma treatment (the time frame of recognition that someone is dying may be shorter than that through which hospice at home services usually support people).

There is growing debate about the fair allocation of novel drugs—sometimes available as part of ongoing clinical trials—to treat asthma treatment with curative intent.2 30 But we must also pay attention to the fair allocation of drugs needed to ease suffering and dying.Communication and end-of-life decision-making supportEnd-of-life planning can be especially challenging because patients, family members and healthcare providers often differ in what they consider most important near the end of life.31 Less than half of ICU physicians—40.6% in high income countries and 46.3% in low–middle income countries—feel comfortable holding end-of-life discussions with patients’ families.25 With ICUs bursting and health providers under extraordinary pressure, their capacity to effectively support end-of-life decisions and to ease dying will be reduced.This suggests a need for specialist asthma treatment communication support teams, analogous to the idea of specialist ICU triage teams to ensure consistency of decision making about ICU admissions/discharges, and to reduce the moral and psychological distress of health providers during the ventolin.32 These support teams could provide up to date information templates for patients and families, support decision-making, the development of advance care plans (ACPs) and act as a liaison between families (prevented from being in the hospital), the patient and the clinical team. Some people with disabilities may require additional communication support to ensure the patients’ needs are communicated to all health providers.33 This will be especially important if carers and visitors are not able to be present.To provide effective and appropriate support in an equitable way, communication teams will need to include those with the appropriate skills for caring for diverse populations including. Interpreters, specialist social workers, disability advocates and cultural support liaison officers for ethnic and religious minorities. Patient groups that already have comparatively poor health outcomes require dedicated resources. These support resources are essential if we wish to truly mitigate equity concerns that arisingduring the ventolin context.

See Box 1 for examples of specific communication and care strategies to support patients.Box 1 Supporting communication and compassionate care during asthma treatmentDespite the sometimes overwhelming pressure of the ventolin, health providers continue to invest in communication, compassionate care and end-of-life support. In some places, doctors have taken photos of their faces and taped these to the front of their PPE so that patients can ‘see’ their face.37 In Singapore, patients who test positive for asthma are quarantined in health facilities until they receive two consecutive negative tests. Patients may be isolated in hospital for several weeks. To help ease this burden on patients, health providers have dubbed themselves the ‘second family’ and gone out of their way to provide care as well as treatment. Elsewhere, medical, nursing and multi-disciplinary teams are utilising internet based devices to enable ‘virtual’ visits and contact between patients and their loved ones.38 Some centres are providing staff with masks with a see-through window panel that shows the wearer’s mouth, to support effective communication with patient with hearing loss who rely on lip reading.39Advance care planningACPs aim to honour decisions made by autonomous patients if and when they lose capacity.

However, talking to patients and their loved ones about clinical prognosis, ceilings of treatment and potential end-of-life care is challenging even in normal times. During asthma treatment the challenges are exacerbated by uncertainty and urgency, the absence of family support (due to visitor restrictions) and the wearing of PPE by clinicians and carers. Protective equipment can create a formidable barrier between the patient and the provider, often adding to the patient’s sense of isolation and fear. An Australian palliative care researcher with experience working in disaster zones, argues that the “PPE may disguise countenance, restrict normal human touch and create an unfamiliar gulf between you and your patient.”34 The physical and psychological barriers of PPE coupled with the pressure of high clinical loads do not seem conducive to compassionate discussions about patients’ end-of-life preferences. Indeed, a study in Singapore during the 2004 SARS epidemic demonstrated the barrier posed by PPE to compassionate end-of-life care.35Clinicians may struggle to interpret existing ACPs in the context of asthma treatment, given the unprecedented nature and scale of the ventolin and emerging clinical knowledge about the aetiology of the disease and (perhaps especially) about prognosis.

This suggests the need for asthma treatment-specific ACPs. Where possible, proactive planning should occur with high-risk patients, the frail, those in residential care and those with significant underlying morbidities. Ideally, ACP conversations should take place prior to illness, involve known health providers and carers, not be hampered by PPE or subject to time constraints imposed by acute care contexts. Of note here, a systematic review found that patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.36ConclusionHow best to address equity concerns in relation to ICU and end-of-life care for patients with asthma treatment is challenging and complex. Attempts to broaden clinical criteria to give patients with poorer prognoses access to ICU on equity grounds may result in fewer lives saved overall—this may well be justified if access to ICU confers benefit to these ‘equity’ patients.

But we must avoid tokenistic gestures to equity—admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. ICU admission may exacerbate and prolong suffering rather than ameliorate it, especially for frailer patients. And prolonging life at all costs may ultimately lead to a worse death. The capacity for harm not just the capacity for benefit should be emphasised in any triage tools and related literature. Equity can be addressed more robustly if ventolin responses scale up investment in palliative care services, communication and decision-support services and advanced care planning to meet the needs of all patients with asthma treatment.

Ultimately, however, equity considerations will require us to move even further from a critical care framework as the social and economic impact of the ventolin will disproportionately impact those most vulnerable. Globally, we will need an approach that does not just stop an exponential rise in s but an exponential rise in inequality.AcknowledgmentsWe would like to thank Tracy Anne Dunbrook and David Tripp for their helpful comments, and NUS Medicine for permission to reproduce the asthma treatment Chronicles strip..

What may interact with Ventolin?

• anti-infectives like chloroquine and pentamidine
• caffeine
• cisapride
• diuretics
• medicines for colds
• medicines for depression or for emotional or psychotic conditions
• medicines for weight loss including some herbal products
• methadone
• some antibiotics like clarithromycin, erythromycin, levofloxacin, and linezolid
• some heart medicines
• steroid hormones like dexamethasone, cortisone, hydrocortisone
• theophylline
• thyroid hormones

This list may not describe all possible interactions. Give your health care providers a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

Can you buy over the counter ventolin

AbstractBrazil is can you buy over the counter ventolin currently home to the largest Japanese population outside of Japan. In Brazil today, Japanese-Brazilians are considered to be successful members of Brazilian society. This was not always the case, however, and Japanese immigrants to Brazil endured can you buy over the counter ventolin much hardship to attain their current level of prestige. This essay explores this community’s trajectory towards the formation of the Japanese-Brazilian identity and the issues of mental health that arise in this immigrant community.

Through the analysis of Japanese-Brazilian novels, TV shows, film and public health studies, I seek to disentangle the themes of gender and modernisation, and how these themes concurrently grapple with Japanese-Brazilian mental health issues. These fictional narratives provide a lens into the experience of the Japanese-Brazilian community that is unavailable in traditional medical studies about their mental health.filmliterature and medicinemental health caregender studiesmedical humanitiesData availability statementData are available in a public, open access repository.Introduction and philosophical backgroundWork in the medical humanities has noted the importance of the ‘medical gaze’ and how it may ‘see’ the patient in ways which are specific, while possessing broad significance, in relation to developing medical can you buy over the counter ventolin knowledge. To diagnosis. And to the social position of the medical profession.1 Some authors have emphasised that vision is a distinctive modality of perception which merits its own consideration, and which may have a particular can you buy over the counter ventolin role to play in medical education and understanding.2 3 The clothing we wear has a strong impact on how we are perceived.

For example, commentary in this journal on the ‘white coat’ observes that while it may rob the medical doctor of individuality, it nonetheless grants an elevated status4. In contrast, the patient hospital gown may rob patients of individuality in a way that stigmatises them,5 reducing their status in the ward, and ultimately dehumanises them, in conflict with the humanistic approaches seen as central to the best practice in the care of older patients, and particularly those living with dementia.6The broad context of our concern is the visibility of patients and their needs. We draw on observations made during an ethnographic study of the can you buy over the counter ventolin everyday care of people living with dementia within acute hospital wards, to consider how patients’ clothing may impact on the way they were perceived by themselves and by others. Hence, we draw on this ethnography to contribute to discussion of the ‘medical gaze’ in a specific and informative context.The acute setting illustrates a situation in which there are great many biomedical, technical, recording, and timetabled routine task-oriented demands, organised and delivered by different staff members, together with demands for care and attention to particular individuals and an awareness of their needs.

Within this ward setting, we focus on patients who are living with dementia, since this group may be particularly vulnerable to a dehumanising gaze.6 We frame our discussion within the broader context of the general philosophical question of how we acquire knowledge of different types, and the moral consequences of this, particularly knowledge through visual perception.Debates throughout the history of philosophy raise questions about the nature and sources of our knowledge. Contrasts are often drawn can you buy over the counter ventolin between more reliable or less reliable knowledge. And between knowledge that is more technical or ‘objective’, and knowledge that is more emotionally based or more ‘subjective’. A frequent point of discussion is the reliability and characteristics of perception as a can you buy over the counter ventolin source of knowledge.

This epistemological discussion is mostly focused on vision, indicating its particular importance as a mode of perception to humans.7Likewise, in ethics, there is discussion of the origin of our moral knowledge and the particular role of perception.8 There is frequent recognition that the observer has some significant role in acquiring moral knowledge. Attention to qualities of the moral observer is not in itself a denial of moral reality. Indeed, it is the can you buy over the counter ventolin very essence of an ethical response to the world to recognise the deep reality of others as separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways.

The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine. Work that examines different ways of processing information, and of interacting with and being in the world, can be found in Iain McGilchrist’s The Master and His Emissary,10 where he draws on neurological can you buy over the counter ventolin discoveries and applies his ideas to the development of human culture. McGilchrist has recently expanded on the relevance of understanding two different approaches to knowledge for the practice of medicine.11 He argues that task-oriented perception, and a wider, more emotionally attuned awareness of the environment are necessary partners, but may in some circumstances compete, with the competitive edge often being given to the narrower, task-based attention.There has been critique of McGilchrist’s arguments as well as much support. We find his work can you buy over the counter ventolin a useful framework for understanding important debates in the ethics of medicine and of nursing about relationships of staff to patients.

In particular, it helps to illuminate the consequences of patients’ dress and personal appearance for how they are seen and treated.Dementia and personal appearanceOur work focuses on patients living with dementia admitted to acute hospital wards. Here, they are a large group, present alongside older patients unaffected by dementia, as well as younger patients. This mixed population provides a useful setting to consider can you buy over the counter ventolin the impact of personal appearance on different patient groups.The role of appearance in the presentation of the self has been explored extensively by Tseëlon,12 13 drawing on Goffman’s work on stigma5 and the presentation of the self14 using interactionist approaches. Drawing on the experiences on women in the UK, Tseëlon argues Goffman’s interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it.

Tseëlon suggests that understandings in this area, in the role appearance and clothing have in the presentation of the self, have been restricted by the perceived trivialities of the topic and limited to the field of fashion studies.15The personal appearance of older patients, and patients living with dementia in particular, has, more recently, been shown to be worthy of attention and of particular significance. Older people are often assumed to be left out of fashion, yet a concern with appearance remains.16 17 Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or dementia, and so conversely, attention to appearance can you buy over the counter ventolin is one way of combatting the stigma associated with dementia. Families and carers may also feel the importance of personal appearance. The significant body of work by Twigg and Buse in this field in particular draws attention to the role clothing has on preserving the identity and dignity or people living with dementia, while also constraining and enabling elements of care within long-term community settings.16–19 Within this paper, we examine the ways can you buy over the counter ventolin in which these phenomena can be even more acutely felt within the impersonal setting of the acute hospital.Work has also shown how people living with dementia strongly retain a felt, bodily appreciation for the importance of personal appearance.

The comfort and sensuous feel of familiar clothing may remain, even after cognitive capacities such as the ability to recognise oneself in a mirror, or verbal fluency, are lost.18 More strongly still, Kontos,20–22 drawing on the work of Merleau-Ponty and of Bourdieu, has convincingly argued that this attention to clothing and personal appearance is an important aspect of the maintenance of a bodily sense of self, which is also socially mediated, in part via such attention to appearance. Our observations lend support to Kontos’ hypothesis.Much of this previous work has considered clothing in the everyday life of people living with dementia in the context of community or long-term residential care.18 Here, we look at the visual impact of clothing and appearance in the different setting of the hospital ward and consider the consequent implications for patient care. This setting enables us to consider how the short-term and unfamiliar environments of the acute ward, together with the contrast between personal and institutional attire, impact on the perception of the patient by self and by others.There is a body of literature that examines the work of restoring the appearance of residents within long-term community care settings, for instance Ward et al’s work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-Tähkävuori25 examines the usage of garments designed for long-term care settings, exploring the conflict between clothing used to prevent undressing or facilitate the delivery of care, and the can you buy over the counter ventolin distress such clothing can cause, being powerfully symbolic of lower social status and associated with reduced autonomy.26 27Within this literature, there has also been a significant focus on the role of clothing, appearance and the tasks of personal care surrounding it, on the older female body. A corpus of feminist literature has examined the ageing process and the use of clothing to conceal ageing, the presentation of a younger self, or a ‘certain’ age28 It argues that once the ability to conceal the ageing process through clothing and grooming has been lost, the aged person must instead conceal themselves, dressing to hide themselves and becoming invisible in the process.29 This paper will explore how institutional clothing within hospital wards affects both the male and female body, the presentation of the ageing body and its role in reinforcing the invisibility of older people, at a time when they are paradoxically most visible, unclothed and undressed, or wearing institutional clothing within the hospital ward.Institutional clothing is designed and used to fulfil a practical function.

Its use may therefore perhaps incline us towards a ‘task-based’ mode of attention, which as McGilchrist argues,10 while having a vital place in our understanding of the world, may on occasion interfere with the forms of attention that may be needed to deliver good person-oriented care responsive to individual needs.MethodsEthnography involves the in-depth study of people’s actions and accounts within their natural everyday setting, collecting relatively unstructured data from a range of sources.30 Importantly, it can take into account the perspectives of patients, carers and hospital staff.31 Our approach to ethnography is informed by the symbolic interactionist research tradition, which aims to provide an interpretive understanding of the social world, with an emphasis on interaction, focusing on understanding how action and meaning are constructed within a setting.32 The value of this approach is the depth of understanding and theory generation it can provide.33The goal of ethnography is to identify social processes within the data. There are can you buy over the counter ventolin multiple complex and nuanced interactions within these clinical settings that are capable of ‘communicating many messages at once, even of subverting on one level what it appears to be “saying” on another’.34 Thus, it is important to observe interaction and performance. How everyday care work is organised and delivered. By obtaining observational data from within each institution on the everyday work of hospital wards, their family carers and the nursing can you buy over the counter ventolin and healthcare assistants (HCAs) who carry out this work, we can explore the ways in which hospital organisation, procedures and everyday care impact on care during a hospital admission.

It remedies a common weakness in many qualitative studies, that what people say in interviews may differ from what they do or their private justifications to others.35Data collection (observations and interviews) and analysis were informed by the analytic tradition of grounded theory.36 There was no prior hypothesis testing and we used the constant comparative method and theoretical sampling whereby data collection (observation and interview data) and analysis are inter-related,36 37 and are carried out concurrently.38 39 The flexible nature of this approach is important, because it can allow us to increase the ‘analytic incisiveness’35 of the study. Preliminary analysis of data collected from individual sites informed the focus of later stages of sampling, data collection and analysis in other sites.Thus, sampling requires a flexible, pragmatic approach and purposive and maximum variation sampling (theoretical sampling) was used. This included five hospitals selected to represent a range of hospitals types, geographies and socioeconomic catchments can you buy over the counter ventolin. Five hospitals were purposefully selected to represent a range of hospitals types.

Two large university teaching hospitals, two medium-sized general hospitals and one smaller general hospital. This included one urban, two inner city and two hospitals covering a mix can you buy over the counter ventolin of rural and suburban catchment areas, all situated within England and Wales.These sites represented a range of expertise and interventions in caring for people with dementia, from no formal expertise to the deployment of specialist dementia workers. Fractures, nutritional disorders, urinary tract and pneumonia40 41 are among the principal causes of admission to acute hospital settings among people with dementia. Thus, we focused observation within trauma and orthopaedic wards can you buy over the counter ventolin (80 days) and medical assessment units (MAU.

75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types. Observations were carried out by two researchers, can you buy over the counter ventolin each working in clusters of 2–4 days over a 6-week period at each site. A single day of observation could last a minimum of 2 hours and a maximum of 12 hours.

A total of 684 hours of observation were conducted for this study. This produced approximately 600 000 words of observational fieldnotes that can you buy over the counter ventolin were transcribed, cleaned and anonymised (by KF and AN). We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group. This allowed us to question what they are doing and why, can you buy over the counter ventolin and what are the caring practices of ward staff when interacting with people living with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient records and board data with the assistance of ward staff.

Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data. When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was this advisory group that informed us of the need of a better understanding of the can you buy over the counter ventolin impacts of the everyday care received by people living with dementia in acute hospital settings. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study.

The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data analysis was can you buy over the counter ventolin complete, the advisory group commented on our initial findings and recommendations. During and on completion of the analysis, a series of public consultation events were held with people living with dementia and family carers to ensure their involvement in discussing, informing and refining our analysis.FindingsWithin this paper, we focus on exploring the medical gaze through the embedded institutional cultures of patient clothing, and the implications this have for patients living with dementia within acute hospital wards. These findings emerged from can you buy over the counter ventolin our wider analysis of our ethnographic study examining ward cultures of care and the experiences of people living with dementia.

Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress. We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress. Within many wards, it was typical for all older patients to be dressed in hospital-issued institutional gowns and pyjamas (typically in pastel blue, pink, green or peach), paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip can you buy over the counter ventolin grip soles, while in other wards, it was standard practice for people to be supported to dress in their own clothes. Across all these wards, we observed that younger patients (middle aged/working age) were more likely to be able to wear their own clothes while admitted to a ward, than older patients and those with a dementia diagnosis.Among key signifiers of social status and individuality are the material things around the person, which in these hospital wards included the accoutrements around the bedside.

Significantly, it was observed that people living with dementia were more likely to be wearing an institutional hospital gown or institutional pyjamas, and to have little to individuate the person at the bedside, on either their cabinet or the mobile tray table at their bedside. The wearing of institutional clothing was typically connected to can you buy over the counter ventolin fewer personal items on display or within reach of the patient, with any items tidied away out of sight. In contrast, younger working age patients often had many personal belongings, cards, gadgets, books, media players, with young adults also often having a range of ‘get well soon’ gifts, balloons and so on from the hospital gift shop) on display. This both afforded some elements of familiarity, but also marked the person out as someone with individuality and a certain social standing and place.Visibility of patients on a wardThe significance of the obscurity or invisibility of the patient in artworks depicting doctors has been commented on.4 Likewise, we can you buy over the counter ventolin observed that some patients within these wards were much more ‘visible’ to staff than others.

It was often apparent how the wearing of personal clothing could make the patient and their needs more readily visible to others as a person. This may be especially so given the contrast in appearance clothing may produce in this particular setting. On occasion, this may be remarked on by staff, can you buy over the counter ventolin and the resulting attention received favourably by the patient.A member of the bay team returned to a patient and found her freshly dressed in a white tee shirt, navy slacks and black velvet slippers and exclaimed aloud and appreciatively, ‘Wow, look at you!. €™ The patient looked pleased as she sat and combed her hair [site 3 day 1].Such a simple act of recognition as someone with a socially approved appearance takes on a special significance in the context of an acute hospital ward, and for patients living with dementia whose personhood may be overlooked in various ways.46This question of visibility of patients may also be particularly important when people living with dementia may be less able to make their needs and presence known.

In this example, a whole bay of patients was seemingly ‘invisible’. Here, the can you buy over the counter ventolin ethnographer is observing a four-bed bay occupied by male patients living with dementia.The man in bed 17 is sitting in his bedside chair. He is dressed in green hospital issue pyjamas and yellow grip socks. At 10 a.m., can you buy over the counter ventolin the physiotherapy team come and see him.

The physiotherapist crouches down in front of him and asks him how he is. He says he is unhappy, and the physiotherapist explains that she’ll be back later to see him again. The nurse checks on him, asks him if he wants a pillow, and puts it behind his head explaining to can you buy over the counter ventolin him, ‘You need to sit in the chair for a bit’. She pulls his bedside trolley near to him.

With the help of a Healthcare Assistant they make the bed. The Healthcare Assistant chats to him, puts cake out for can you buy over the counter ventolin him, and puts a blanket over his legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, ‘The problem is this is a really unstimulating environment’, then says to the patient, ‘All done, let’s have a bit of a tidy up,’ before wheeling the equipment out.The neighbouring patient in bed 18, is now sitting in his bedside chair, wearing (his own) striped pyjamas. His eyes are can you buy over the counter ventolin open, and he is looking around.

After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains. He says he doesn’t want to sit, and they say that is fine unless the doctors tell them otherwise.The nurse puts music on an old radio with a CD player which is at the doorway near the ward can you buy over the counter ventolin entrance. It sounds like music from a musical and the ward it is quite noisy suddenly.

She turns down the volume a bit, but it is very jaunty and upbeat. The man can you buy over the counter ventolin in bed 19 quietly sings along to the songs. €˜I am going to see my baby when I go home on victory day…’At ten thirty, the nurse goes off on her break. The rest of the team are spread around the can you buy over the counter ventolin other bays and side rooms.

There are long distances between bays within this ward. After all the earlier activity it is now very calm and peaceful in the bay. Patient 20 is sitting in the can you buy over the counter ventolin chair tapping his feet to the music. He has taken out a large hessian shopping bag out of his cabinet and is sorting through the contents.

There is can you buy over the counter ventolin a lot of paperwork in it which he is reading through closely and sorting.Opposite, patient 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down the chair. His head is in his hands and he suddenly looks in pain. He hasn’t can you buy over the counter ventolin touched his tea, and is talking to himself.

The junior medic was aware that 17 was not comfortable, and it had looked like she was going to get some advice, but she hasn’t come back. 18 drinks his tea and looks at a wool twiddle mitt sleeve, puts it down, and dozes. 19 has finished all his coffee and manages to put the cup down on the trolley.Everyone is tapping their feet or wiggling their toes to the music, or singing quietly to it, can you buy over the counter ventolin when a student nurse, who is working at the computer station in the corridor outside the room, comes in. She has a strong purposeful stride and looks irritated as she switches the music off.

It feels can you buy over the counter ventolin like a jolt to the room. She turns and looks at me and says, ‘Sorry were you listening to it?. €™ I tell her that I think these gentlemen were listening to it.She suddenly looks very startled and surprised and looks at the men in the room for the first time. They have all stopped can you buy over the counter ventolin tapping their toes and stopped singing along.

She turns it back on but asks me if she can turn it down. She leaves and goes back to her paperwork outside. Once it can you buy over the counter ventolin is turned back on everyone starts tapping their toes again. The music plays on.

€˜There’ll be bluebirds over the white cliffs of Dover, just you wait and see…’[Site 3 day 3]The music can you buy over the counter ventolin was played by staff to help combat the drab and unstimulating environment of this hospital ward for the patients, the very people the ward is meant to serve. Yet for this member of ward staff the music was perceived as a nuisance, the men for whom the music was playing seemingly did not register to her awareness. Only an individual of ‘higher’ status, the researcher, sitting at the end of this room was visible to her. This example illustrates can you buy over the counter ventolin the general question of the visibility or otherwise of patients.

Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the can you buy over the counter ventolin example below, a mother and two adult daughters visit the father of the family, who is not visible to them as the person they were so familiar with. His is not wearing his glasses, which are missing, and his daughters find this very difficult.

Even though he looks very different following his admission—he has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hue—it is his glasses which are a key concern for the family in can you buy over the counter ventolin their recognition of their father:As I enter the corridor to go back to the ward, I meet the wife and daughter of the patient in bed 2 in the hall and walk with them back to the ward. Their father looks very frail, his head is back, and his face is immobile, his eyes are closed, and his mouth is open. His skin looks darker than before, and his cheekbones and eye sockets are extremely prominent from weight loss. €˜I am like a bird I want to fly away…’ plays softly can you buy over the counter ventolin in the radio in the bay.

I sit with them for a bit and we chat—his wife holds his hand as we talk. His wife has to take two busses to get to the hospital and we talk about the potential care home they expect her husband will be discharged to. They hope it will be close because can you buy over the counter ventolin she does not drive. He isn’t wearing his glasses and his daughter tells me that they can’t find them.

We look can you buy over the counter ventolin in the bedside cabinet. She has never seen her dad without his glasses. €˜He doesn’t look like my dad without his glasses’ [Site 2 day 15].It was often these small aspects of personal clothing and grooming that prompted powerful responses from visiting family members. Missing glasses and missing teeth were notable in this regard (and with the follow-up visits from the relatives of discharged patients trying to retrieve these now lost can you buy over the counter ventolin objects).

The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a patient’s identity, such as wallets or keys, and particularly, for female patients, handbags, could be a prominent source of distress for individuals. These accessories to personal clothing were notable on these wards by their everyday absence, hidden away in bedside cupboards or simply not brought in with the patient at admission, and by the frequency with which patients requested and called out for them or tried to look for them, often in repetitive cycles that indicated their underlying anxiety about these belongings, but which would become invisible to staff, becoming an everyday background intrusion to the work of the wards.When considering the visibility and recognition of individual persons, missing glasses, especially glasses for distance vision, have a particular significance, for without them, a person may be less able to recognise and interact visually with others. Their presence facilitates the subject can you buy over the counter ventolin of the gaze, in gazing back, and hence helps to ground meaningful and reciprocal relationships of recognition. This may be one factor behind the distress of relatives in finding their loved ones’ glasses to be absent.Clothing as a source of distressAcross all sites, we observed patients living with dementia who exhibited obvious distress at aspects of their institutional apparel and at the absence of their own personal clothing.

Some older patients were clearly able to can you buy over the counter ventolin verbalise their understandings of the impacts of wearing institutional clothing. One patient remarked to a nurse of her hospital blue tracksuit. €˜I look like an Olympian or Wentworth prison in this outfit!. The latter I expect…’ The staff laughed as they walked her out of the bay (site 3 day 1).Institutional clothing may be a source of distress can you buy over the counter ventolin to patients, although they may be unable to express this verbally.

Kontos has shown how people living with dementia may retain an awareness at a bodily level of the demands of etiquette.20 Likewise, in our study, a man living with dementia, wearing a very large institutional pyjama top, which had no collar and a very low V neck, continually tried to pull it up to cover his chest. The neckline was particularly low, because the pyjamas were far too large for him. He continued to fiddle with can you buy over the counter ventolin his very low-necked top even when his lunch tray was placed in front of him. He clearly felt very uncomfortable with such clothing.

He continued using his hands to try to pull it up to cover his exposed chest, during and after the meal can you buy over the counter ventolin was finished (site 3 day 5).For some patients, the communication of this distress in relation to clothing may be liable to misinterpretation and may have further impacts on how they are viewed within the ward. Here, a patient living with dementia recently admitted to this ward became tearful and upset after having a shower. She had no fresh clothes, and so the team had provided her with a pink hospital gown to wear.‘I want my trousers, where is my bra, I’ve got no bra on.’ It is clear she doesn’t feel right without her own clothes on. The one-to-one healthcare assistant assigned to this patient tells her, ‘Your bra is dirty, do you want to can you buy over the counter ventolin wear that?.

€™ She replies, ‘No I want a clean one. Where are my trousers?. I want them, I’ve lost them.’ can you buy over the counter ventolin The healthcare assistant repeats the explaination that her clothes are dirty, and asks her, ‘Do you want your dirty ones?. €™ She is very teary ‘No, I want my clean ones.’ The carer again explains that they are dirty.The cleaner who always works in the ward arrives to clean the floor and sweeps around the patient as she sits in her chair, and as he does this, he says ‘Hello’ to her.

She is very teary and explains that can you buy over the counter ventolin she has lost her clothes. The cleaner listens sympathetically as she continues ‘I am all confused. I have lost my clothes. I am can you buy over the counter ventolin all confused.

How am I going to go to the shops with no clothes on!. €™ (site 5 day 5).This person experienced significant distress because of her absent clothes, but this would often be simply attributed to confusion, seen as a feature of her dementia. This then may solidify staff can you buy over the counter ventolin perceptions of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse.

The absence of can you buy over the counter ventolin her own familiar clothing contributes significantly to her distress and disorientation. Others have argued that people with limited verbal capacity and limited cognitive comprehension will have a direct appreciation of the grounding familiarity of wearing their own clothes, which give a bodily felt notion of comfort and familiarity.18 47 Familiar clothing may then be an essential prop to anchor the wearer within a recognisable social and meaningful space. To simply see clothing from a task-oriented point of view, as fulfilling a simply mechanical function, and that all clothing, whether personal or institutional have the same value and role, might be to interpret the desire to wear familiar clothing as an ‘optional extra’. However, for those patients most at risk of disorientation and distress within an unfamiliar environment, it could be a valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed other aspects of the role of can you buy over the counter ventolin personal grooming.

Personal grooming was notable by its absence beyond the necessary cleaning required for reasons of immediate hygiene and clinical need (such as the prevention of pressure ulcers). Older patients, and particular those living with dementia who were unable to carry out ‘self-care’ independently and were not able to request support with personal grooming, could, over their admission, become visibly unkempt and scruffy, hair could be left unwashed, uncombed and unstyled, while men could become hirsute through a lack of shaving. The simple act of a visitor dressing and grooming a patient as they prepared for discharge could transform their appearance and leave that patient looking more alert, appear to having increased capacity, than when sitting ungroomed in their bed or bedside chair.It is important to consider the can you buy over the counter ventolin impact of appearance and of personal care in the context of an acute ward. Kontos’ work examining life in a care home, referred to earlier, noted that people living with dementia may be acutely aware of transgressions in grooming and appearance, and noted many acts of self-care with personal appearance, such as stopping to apply lipstick, and conformity with high standards of table manners.

Clothing, etiquette and personal can you buy over the counter ventolin grooming are important indicators of social class and hence an aspect of belonging and identity, and of how an individual relates to a wider group. In Kontos’ findings, these rituals and standards of appearance were also observed in negative reactions, such as expressions of disgust, towards those residents who breached these standards. Hence, even in cases where an individual may be assessed as having considerable cognitive impairment, the importance of personal appearance must not be overlooked.For some patients within these wards, routine practices of everyday care at the bedside can increase the potential to influence whether they feel and appear socially acceptable. The delivery can you buy over the counter ventolin of routine timetabled care at the bedside can impact on people’s appearance in ways that may mark them out as failing to achieve accepted standards of embodied personhood.

The task-oriented timetabling of mealtimes may have significance. It was a typical observed feature of this routine, when a mealtime has ended, that people living with dementia were left with visible signs and features of the mealtime through spillages on faces, clothes, bed sheets and bedsides, that leave them at risk of being assessed as less socially acceptable and marked as having reduced independence. For example, a volunteer attempts to ‘feed’ a person living with dementia, when she gives up can you buy over the counter ventolin and leave the bedside (this woman living with dementia has resisted her attempts and explicitly says ‘no’), remnants of the food is left spread around her mouth (site E). In a different ward, the mealtime has ended, yet a large white plastic bib to prevent food spillages remains attached around the neck of a person living with dementia who is unable to remove it (site X).Of note, an adult would not normally wear a white plastic bib at home or in a restaurant.

It signifies a task-based apparel that is can you buy over the counter ventolin demeaning to an individual’s social status. This example also contrasts poignantly with examples from Kontos’ work,20 such as that of a female who had little or no ability to verbalise, but who nonetheless would routinely take her pearl necklace out from under her bib at mealtimes, showing she retained an acute awareness of her own appearance and the ‘right’ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes ‘placed her hand on her chest, to prevent her blouse from touching the food as she leaned over her plate’.20Patients who are less robust, who have cognitive impairments, who may be liable to disorientation and whose agency and personhood are most vulnerable are thus those for whom appropriate and familiar clothing may be most advantageous. However, we can you buy over the counter ventolin found the ‘Matthew effect’ to be frequently in operation.

To those who have the least, even that which they have will be taken away.48 Although there may be institutional and organisational rationales for putting a plastic cover over a patient, leaving it on for an extended period following a meal may act as a marker of dehumanising loss of social status. By being able to maintain familiar clothing and adornment to visually display social standing and identity, a person living with dementia may maintain a continuity of selfhood.However, it is also possible that dressing and grooming an older person may itself be a task-oriented institutional activity in certain contexts, as discussed by Lee-Treweek49 in the context of a nursing home preparing residents for ‘lounge view’ where visitors would see them, using residents to ‘create a visual product for others’ sometimes to the detriment of residents’ needs. Our observations regarding the importance of patient appearance must therefore be considered as part of the care of the whole person and a significant can you buy over the counter ventolin feature of the institutional culture.Patient status and appearanceWithin these wards, a new grouping of class could become imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs.

Those in the lowest classes can you buy over the counter ventolin may have limited opportunities to participate in society, and we observed the ways in which this applied to the people living with dementia within these acute wards. The differential impact of clothing as signifiers of social status has also been observed in a comparison of the white coat and the patient gown.4 It has been argued that while these both may help to mask individuality, they have quite different effects on social status on a ward. One might say that the white coat increases visibility as a person of standing and the attribution of agency, the patient gown diminishes both of these. (Within these wards, although white can you buy over the counter ventolin coats were not to be found, the dress code of medical staff did make them stand out.

For male doctors, for example, the uniform rarely strayed beyond chinos paired with a blue oxford button down shirt, sleeves rolled up, while women wore a wider range of smart casual office wear.) Likewise, we observed that the same arrangement of attire could be attributed to entirely different meanings for older patients with or without dementia.Removal of clothes and exposureWithin these wards, we observed high levels of behaviour perceived by ward staff as people living with dementia displaying ‘resistance’ to care.50 This included ‘resistance’ towards institutional clothing. This could include pulling up or removing hospital gowns, removing institutional pyjama trousers or pulling up gowns, and standing with gowns untied and exposed at the back (although this last example is an unavoidable design feature of the clothing itself). Importantly, the removal of clothing was limited to institutional gowns and pyjamas and we did not see any patients can you buy over the counter ventolin removing their own clothing. This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed.

These acts could and was can you buy over the counter ventolin often interpreted by ward staff as a patient’s ‘resistance’ to care. There was some variation in this interpretation. However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within these wards such as shouting or crying out, the removal of bedsheets and the can you buy over the counter ventolin subsequent bodily exposure would always be immediately corrected, the sheet replaced and the patient covered by either the nurse or HCA.

The act of removal was typically interpreted by ward staff as representing a feature of the person’s dementia and staff responses were framed as an issue of patient dignity, or the dignity and embarrassment of other patients and visitors to the ward. However, such responses to removal could lead to further cycles of removal and replacement, leading to an escalation of distress in the person can you buy over the counter ventolin. This was important, because the recording of ‘refusal of care’, or presumed ‘confusion’ associated with this, could have significant impacts on the care and discharge pathways available and prescribed for the individual patient.Consider the case of a woman living with dementia who is 90 years old (patient 1), in the example below. Despite having no immediate medical needs, she has been admitted to the MAU from a care home (following her husband’s stroke, he could no longer care for her).

Across the previous evening and morning shift, can you buy over the counter ventolin she was shouting, refusing all food and care and has received assistance from the specialist dementia care worker. However, during this shift, she has become calmer following a visit from her husband earlier in the day, has since eaten and requested drinks. Her care home would not readmit her, which meant she was not able to be discharged from the unit (an overflow unit due to a high number of admissions to the emergency department during a patch of exceptionally hot weather) until alternative arrangements could be made by social services.During our observations, she remains calm for the first 2 hours. When she can you buy over the counter ventolin does talk, she is very loud and high pitched, but this is normal for her and not a sign of distress.

For staff working on this bay, their attention is elsewhere, because of the other six patients on the unit, one is ‘on suicide watch’ and another is ‘refusing their medication’ (but does not have a diagnosis of dementia). At 15:10 patient 1 begins to can you buy over the counter ventolin remove her sheets:15:10. The unit seems chaotic today. Patient 1 has begun to loudly drum her fingers on the tray table.

She still has not been brought more milk, which she requested from the HCA an can you buy over the counter ventolin hour earlier. The bay that patient 1 is admitted to is a temporary overflow unit and as a result staff do not know where things are. 1 has moved her sheets off her legs, her bare knees peeking out over the top of piled sheets.15:15. The nurse in can you buy over the counter ventolin charge says, ‘Hello,’ when she walks past 1’s bed.

1 looks across and smiles back at her. The nurse in charge explains to her that she can you buy over the counter ventolin needs to shuffle up the bed. 1 asks the nurse about her husband. The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow.

1 says can you buy over the counter ventolin that he hasn’t been and she does not believe the nurse.15:25. I overhear the nurse in charge question, under her breath to herself, ‘Why 1 has been left on the unit?. €™ 1 has started asking for somebody to come and see her. The nurse in charge tells 1 that she needs to do some jobs first and can you buy over the counter ventolin then will come and talk to her.15:30.

1 has once again kicked her sheets off of her legs. A social can you buy over the counter ventolin worker comes onto the unit. 1 shouts, ‘Excuse me’ to her. The social worker replies, ‘Sorry I’m not staff, I don’t work here’ and leaves the bay.15:40.

1 keeps kicking sheets can you buy over the counter ventolin off her bed, otherwise the unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unit’s door. 1 is the only elderly patient on the unit. Again, the can you buy over the counter ventolin nurse in charge is heard sympathizing that this is not the right place for her.16:30.

A doctor approaches 1, tells her that she is on her list of people to say hello to, she is quite friendly. 1 tells her can you buy over the counter ventolin that she has been here for 3 days, (the rest is inaudible because of pitch). The doctor tries to cover 1 up, raising her bed sheet back over the bed, but 1 loudly refuses this. The doctor responds by ending the interaction, ‘See you later’, and leaves the unit.16:40.

1 attempts to talk to the new can you buy over the counter ventolin nurse assigned to the unit. She goes over to 1 and says, ‘What’s up my darling?. €™ It’s hard to follow 1 now as she sounds very upset. The RN’s first instinct, like with the doctor and the nurse in charge, can you buy over the counter ventolin is to cover up 1 s legs with her bed sheet.

When 1 reacts to this she talks to her and they agree to cover up her knees. 1 is talking about how her husband won’t come and visit can you buy over the counter ventolin her, and still sounds really upset about this. [Site 3, Day 13]Of note is that between days 6 and 15 at this site, observed over a particularly warm summer, this unit was uncomfortably hot and stuffy. The need to be uncovered could be viewed as a reasonable response, and in fact was considered acceptable for patients without a classification of dementia, provided they were otherwise clothed, such as the hospital gown patient 1 was wearing.

This is an example of an aspect can you buy over the counter ventolin of care where the choice and autonomy granted to patients assessed as having (or assumed to have) cognitive capacity is not available to people who are considered to have impaired cognitive capacity (a diagnosis of dementia) and carries the additional moral judgements of the appropriateness of behaviour and bodily exposure. In the example given above, the actions were linked to the patient’s resistance to their admission to the hospital, driven by her desire to return home and to be with her husband. Throughout observations over this 10-day period, patients perceived by staff as rational agents were allowed to strip down their bedding for comfort, whereas patients living with dementia who responded in this way were often viewed by staff as ‘undressing’, which would be interpreted as a feature of their condition, to be challenged and corrected by staff.Note how the same visual data triggered opposing interpretations of personal autonomy. Just as in the example above where distress over loss of familiar clothing may be interpreted as an aspect of can you buy over the counter ventolin confusion, yet lead to, or exacerbate, distress and disorientation.

So ‘deviant’ bedding may be interpreted, for some patients only, in ways that solidify notions of lack of agency and confusion, is another example of the Matthew effect48 at work through the organisational expectations of the clothed appearance of patients.Within wards, it is not unusual to see patients, especially those with a diagnosis of dementia or cognitive impairment, walking in the corridor inadvertently in some state of undress, typically exposed from behind by their hospital gowns. This exposure in itself is of course, an intrinsic functional feature of the can you buy over the counter ventolin design of the flimsy back-opening institutional clothing the patient has been placed in. This task-based clothing does not even fulfil this basic function very adequately. However, this inadvertent exposure could often be interpreted as an overt act of resistance to the ward and towards staff, especially when it led to exposed genitalia or continence products (pads or nappies).We speculate that the interpretation of resistance may be triggered by the visual prompt of disarrayed clothing and the meanings assumed to follow, where lack of decorum in attire is interpreted as indicating more general behavioural incompetence, cognitive impairment and/or standing outside the social order.DiscussionPrevious studies examining the significance of the visual, particularly Twigg and Buse’s work16–19 exploring the materialities of appearance, emphasise its key role in self-presentation, visibility, dignity and autonomy for older people and especially those living with dementia in care home settings.

Similarly, care home studies have demonstrated that institutional clothing, designed to facilitate task-based care, can be potentially dehumanising or and distressing.25 26 Our findings resonate with this work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of can you buy over the counter ventolin task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from McGilchrist’s work.10 The institutional culture of the wards produces an organisational task-based technical attention, which we found appeared to compete with and reduce the opportunity for ward staff to seek a finer emotional attunement to the person they are caring for and their needs. Focus on efficiency, pace and record keeping that measures individual task completion within a timetable of care may can you buy over the counter ventolin worsen all these effects.

Indeed, other work has shown that in some contexts, attention to visual appearance may itself be little more than a ‘task’ to achieve.49 McGilchrist makes clear, and we agree, that both forms of attention are vital, but more needs to be done to enable staff to find a balance.Previous work has shown how important appearance is to older people, and to people living with dementia in particular, both in terms of how they are perceived by others, but also how for this group, people living with dementia, clothing and personal grooming may act as a particularly important anchor into a familiar social world. These twin aspects of clothing and appearance—self-perception and perception by others—may be especially important in the fast-paced context of an acute ward environment, where patients living with dementia may be struggling with the impacts of an additional acute can you buy over the counter ventolin medical condition within in a highly timetabled and regimented and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways. We have seen above, for instance, how behaviour in relation to appearance may be seen as ‘resisting care’ in one group of patients, but as the natural expression of personal preference in patients viewed as being without cognitive impairments. Likewise, personal grooming might impact favourably on a patient’s alertness, visibility and status within the ward.Prior work has demonstrated the importance of the medical gaze for the perceptions of the patient.

Other work has also shown how older people, and can you buy over the counter ventolin in particular people living with dementia, may be thought to be beyond concern for appearance, yet this does not accurately reflect the importance of appearance we found for this patient group. Indeed, we argue that our work, along with the work of others such as Kontos,20 21 shows that if anything, visual appearance is especially important for people living with dementia particularly within clinical settings. In considering the task of washing the patient, Pols53 considered ‘dignitas’ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to dignitas in the form of appearance may be a can you buy over the counter ventolin way of facilitating the treatment by others of a person with humanitas, and helping to realise dignity of patients.Data availability statementNo data are available.

Data are unavailable to protect anonymity.Ethics statementsPatient consent for publicationNot required.Ethics approvalEthics committee approval for the study was granted by the NHS Research Ethics Service (15/WA/0191).AcknowledgmentsThe authors acknowledge funding support from the NIHR.Notes1. Devan Stahl can you buy over the counter ventolin (2013). €œLiving into the imagined body. How the diagnostic image confronts the lived body.” Medical Humanities.

Medhum-2012–010286.2. Joyce Zazulak et al. (2017). "The art of medicine.

Arts-based training in observation and mindfulness for fostering the empathic response in medical residents.” Medical Humanities. Medhum-2016-011180.3. E Forde (2018). "Using photography to enhance GP trainees’ reflective practice and professional development." Medical Humanities.

Medhum-2017-011203.4. Caroline Wellbery and Melissa Chan (2014) “White coat, patient gown.” Medical Humanities. Medhum-2013–0 10 463.5. E Goffman (1990a).

Stigma. Notes on the management of spoiled identity, Penguin.6. J Bridges and C Wilkinson (2011). €œAchieving dignity for older people with dementia in hospital.” Nursing Standard 5 (29).7.

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Blackwell.9. S Weil (1953). Gravity and Grace. U of Nebraska Press.10.

I McGilchrist (2009). The Master and his Emissary. The divided brain and the making of the western world. New Haven and London, Yale University Press.11.

Iain McGilchrist (2011). €œPaying attention to the bipartite brain.” The Lancet 377 (9771). 1068–1069.12. Efrat Tseëlon (1992).

€œSelf presentation through appearance. A manipulative vs a dramaturgical approach”. Symbolic Interaction, 15(4). 501–514.13.

E Tseëlon (1995). The masque of femininity. The presentation of woman in everyday life. London.

Sage.14. E Goffman (1990b). The Presentation of Self in Everyday Life Penguin15. Efrat Tseëlon (2001).

€œFashion research and its discontents”. Fashion Theory, 5 (4). 435–451.16. Julia Twigg (2010a).

€œClothing and dementia. A neglected dimension?. € Journal of Ageing Studies 24(4). 223–230.17.

Julia Twigg and Christina E Buse (2013). €œDress, dementia and the embodiment of identity.” Dementia 12(3). 326–336.18. C.

E Buse and J. Twigg (2015). €œClothing, embodied identity and dementia. Maintaining the self through dress.” Age, Culture, Humanities (2).19.

Christina Buse and Julia Twigg (2018). €œDressing disrupted. Negotiating care through the materiality of dress in the context of dementia.” Sociology of Health &. Illness, 40(2).

340-352.20. PIA C Kontos (2004). Ethnographic reflections on selfhood, embodiment and Alzheimer's disease. Ageing &.

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

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

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

549–569.23. Richard Ward et al. (2016a). €œâ€˜Gonna make yer gorgeous’.

Everyday transformation, resistance and belonging in the care-based hair salon.” Dementia, 15(3). 395–413.24. Richard Ward, Sarah Campbell, and John Keady (2016b). €œAssembling the salon.

Learning from alternative forms of body work in dementia care.” Sociology of Health &. Illness, 38(8). 1287–1302.25. Sonja Iltanen-Tähkävuori, Minttu Wikberg, and Päivi Topo (2012).

Design and dementia. A case of garments designed to prevent undressing. Dementia, 11(1). 49–59.26.

Päivi Topo and Sonja Iltanen-Tähkävuori (2010). €œScripting patienthood with patient clothing.” Social Science &. Medicine, 70(11). 1682–1689.27.

Julia Twigg (2010b). €œWelfare embodied. The materiality of hospital dress. A commentary on Topo and Iltanen-Tähkävuori”.

Social Science and Medicine, 70(11), 1690–1692.28. Kathleen Woodward (2006). €œPerforming age, performing gender” National Women’s Studies Association (NWSA) Journal 18(1). 162–89.29.

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

Women, Bodies and Generations (pp. Ix-xxix). Bloomington. Indiana University Press.30.

M Hammersley and P Atkinson (1989). Ethnography. Principles in practice. London.

Routledge.31. V. J Caracelli (2006). Enhancing the policy process through the use of ethnography and other study frameworks.

A mixed-method strategy. Research in the Schools, 13(1). 84–92.32. W Housley and P Atkinson (2003).

Interactionism, Sage33. M Hammersley (1987) What's Wrong with Ethnography?. Methodological Explorations. London.

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

2435. K Charmaz and RG Mitchell (2001). €˜Grounded theory in ethnography’ in Atkinson P. (Ed) Handbook of Ethnography, 2001.

160-174. Sage. London36. B Glaser and A Strauss (1967).

The Discovery of Grounded Theory. London. Weidenfeld and Nicholson, 24(25). 288–30437.

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

J Green (1998). Commentary. Grounded theory and the constant comparative method. BMJ (Clinical research ed.), 316 (7137),:1064.39.

Roy Suddaby (2006). €œFrom the editors. What grounded theory is not.” Academy of management journal, 49(4). 633–642.40.

Elizabeth L Sampson et al. (2009). €œDementia in the acute hospital. Prospective cohort study of prevalence and mortality”.

British Journal of Psychiatry,195(1). 61–66. Doi:10.1192/bjp.bp.108.05533541. C Pinkert and B Holle (2012).

€œPeople with dementia in acute hospitals. Literature review of prevalence and reasons for hospital admission”. Z. Gerontol.

Geriatr. 45. 728–734.42. Robert E Herriott and William A.

Firestone (1983) “Multisite qualitative policy research. Optimising description and generalizability”. Education Research 12:14–1943. F Vogt (2002).

€œNo ethnography without comparison. The methodological significance of comparison in ethnographic research” Studies in Education Ethnography 6:23–4244. Benjamin Saunders et al. (2018).

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Making sense of qualitative data. Complementary research strategies. Sage Publications, Inc.46. Paula Boddington and Katie Featherstone (2018).

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

Christina Buse et al. (2014). €œLooking “out of place”. Analysing the spatial and symbolic meanings of dementia care settings through dress.” International Journal of Ageing and Later Life 9 (1).

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An ethnographic study of nursing auxiliary work” Work, Employment and Society, 11(1). 47–6350. Katie Featherstone et al. (2019b).

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An ethnography of the care of people living with dementia in acute hospital wards and its consequences.” International Journal of Nursing Studies.52. K Featherstone, A Northcott, and P Boddington (2020). €œUsing signs and symbols to identify hospital patients with a dementia diagnosis. Help or hindrance to recognition and care?.

€ Narrative Inquiry in Bioethics53. Jeannette Pols (2013). €œWashing the patient. Dignity and aesthetic values in nursing care” Nursing Philosophy, 14(3).

AbstractBrazil is http://emukconsultancy.co.uk/order-propecia-online/ currently home to the largest Japanese population can ventolin be purchased over the counter outside of Japan. In Brazil today, Japanese-Brazilians are considered to be successful members of Brazilian society. This was not can ventolin be purchased over the counter always the case, however, and Japanese immigrants to Brazil endured much hardship to attain their current level of prestige.

This essay explores this community’s trajectory towards the formation of the Japanese-Brazilian identity and the issues of mental health that arise in this immigrant community. Through the analysis of Japanese-Brazilian novels, TV shows, film and public health studies, I seek to disentangle the themes of gender and modernisation, and how these themes concurrently grapple with Japanese-Brazilian mental health issues. These fictional narratives provide a lens into the experience of the Japanese-Brazilian community that is unavailable in traditional medical studies about their mental health.filmliterature and medicinemental health caregender studiesmedical humanitiesData availability statementData are available in a public, open access repository.Introduction and philosophical backgroundWork in the medical humanities has noted the importance of the ‘medical gaze’ and how it may ‘see’ the patient in ways which are specific, can ventolin be purchased over the counter while possessing broad significance, in relation to developing medical knowledge.

To diagnosis. And to the social position of the medical profession.1 Some authors have emphasised that can ventolin be purchased over the counter vision is a distinctive modality of perception which merits its own consideration, and which may have a particular role to play in medical education and understanding.2 3 The clothing we wear has a strong impact on how we are perceived. For example, commentary in this journal on the ‘white coat’ observes that while it may rob the medical doctor of individuality, it nonetheless grants an elevated status4.

In contrast, the patient hospital gown may rob patients of individuality in a way that stigmatises them,5 reducing their status in the ward, and ultimately dehumanises them, in conflict with the humanistic approaches seen as central to the best practice in the care of older patients, and particularly those living with dementia.6The broad context of our concern is the visibility of patients and their needs. We draw on observations made during an ethnographic study of the everyday care of people living with dementia within acute hospital wards, to consider how patients’ clothing may impact on the way they were perceived by themselves can ventolin be purchased over the counter and by others. Hence, we draw on this ethnography to contribute to discussion of the ‘medical gaze’ in a specific and informative context.The acute setting illustrates a situation in which there are great many biomedical, technical, recording, and timetabled routine task-oriented demands, organised and delivered by different staff members, together with demands for care and attention to particular individuals and an awareness of their needs.

Within this ward setting, we focus on patients who are living with dementia, since this group may be particularly vulnerable to a dehumanising gaze.6 We frame our discussion within the broader context of the general philosophical question of how we acquire knowledge of different types, and the moral consequences of this, particularly knowledge through visual perception.Debates throughout the history of philosophy raise questions about the nature and sources of our knowledge. Contrasts are often can ventolin be purchased over the counter drawn between more reliable or less reliable knowledge. And between knowledge that is more technical or ‘objective’, and knowledge that is more emotionally based or more ‘subjective’.

A frequent point can ventolin be purchased over the counter of discussion is the reliability and characteristics of perception as a source of knowledge. This epistemological discussion is mostly focused on vision, indicating its particular importance as a mode of perception to humans.7Likewise, in ethics, there is discussion of the origin of our moral knowledge and the particular role of perception.8 There is frequent recognition that the observer has some significant role in acquiring moral knowledge. Attention to qualities of the moral observer is not in itself a denial of moral reality.

Indeed, it is the very essence of an ethical response to the world to recognise the deep reality can ventolin be purchased over the counter of others as separate persons. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways. The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine.

Work that examines different ways of processing can ventolin be purchased over the counter information, and of interacting with and being in the world, can be found in Iain McGilchrist’s The Master and His Emissary,10 where he draws on neurological discoveries and applies his ideas to the development of human culture. McGilchrist has recently expanded on the relevance of understanding two different approaches to knowledge for the practice of medicine.11 He argues that task-oriented perception, and a wider, more emotionally attuned awareness of the environment are necessary partners, but may in some circumstances compete, with the competitive edge often being given to the narrower, task-based attention.There has been critique of McGilchrist’s arguments as well as much support. We find his work a useful framework for understanding important debates in the ethics of medicine and of nursing about relationships of can ventolin be purchased over the counter staff to patients.

In particular, it helps to illuminate the consequences of patients’ dress and personal appearance for how they are seen and treated.Dementia and personal appearanceOur work focuses on patients living with dementia admitted to acute hospital wards. Here, they are a large group, present alongside older patients unaffected by dementia, as well as younger patients. This mixed population provides a useful setting to consider the impact of personal appearance on different patient groups.The role of appearance in the presentation of the self has been explored extensively by Tseëlon,12 13 drawing on Goffman’s work on can ventolin be purchased over the counter stigma5 and the presentation of the self14 using interactionist approaches.

Drawing on the experiences on women in the UK, Tseëlon argues Goffman’s interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it. Tseëlon suggests that understandings in this area, in the role appearance and clothing have in the presentation of the self, have been restricted by the perceived trivialities of the topic and limited to the field of fashion studies.15The personal appearance of older patients, and patients living with dementia in particular, has, more recently, been shown to be worthy of attention and of particular significance. Older people are often assumed to be left out of fashion, can ventolin be purchased over the counter yet a concern with appearance remains.16 17 Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or dementia, and so conversely, attention to appearance is one way of combatting the stigma associated with dementia.

Families and carers may also feel the importance of personal appearance. The significant body of work by Twigg and Buse in this field in particular draws attention to the role clothing has on preserving the identity and dignity or people living with dementia, while also constraining and enabling elements of care within long-term community settings.16–19 Within this paper, we examine the ways in which these phenomena can be even more acutely felt within the impersonal setting of the acute hospital.Work has also shown how people living with dementia strongly retain a felt, bodily appreciation can ventolin be purchased over the counter for the importance of personal appearance. The comfort and sensuous feel of familiar clothing may remain, even after cognitive capacities such as the ability to recognise oneself in a mirror, or verbal fluency, are lost.18 More strongly still, Kontos,20–22 drawing on the work of Merleau-Ponty and of Bourdieu, has convincingly argued that this attention to clothing and personal appearance is an important aspect of the maintenance of a bodily sense of self, which is also socially mediated, in part via such attention to appearance.

Our observations lend support to Kontos’ hypothesis.Much of this previous work has considered clothing in the everyday life of people living with dementia in the context of community or long-term residential care.18 Here, we look at the visual impact of clothing and appearance in the different setting of the hospital ward and consider the consequent implications for patient care. This setting enables us to consider how the short-term and unfamiliar environments of the acute ward, together with the contrast between personal and institutional attire, impact on the perception of the patient by self and by others.There is a body of literature that examines the work of restoring the appearance of residents within long-term community care settings, for instance Ward et al’s work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-Tähkävuori25 examines the usage of garments designed for long-term care settings, exploring the conflict between clothing used to prevent undressing or facilitate the delivery of care, and the distress such clothing can cause, being powerfully symbolic of lower social status and associated with reduced autonomy.26 27Within this literature, there has also been a significant focus on the role of can ventolin be purchased over the counter clothing, appearance and the tasks of personal care surrounding it, on the older female body. A corpus of feminist literature has examined the ageing process and the use of clothing to conceal ageing, the presentation of a younger self, or a ‘certain’ age28 It argues that once the ability to conceal the ageing process through clothing and grooming has been lost, the aged person must instead conceal themselves, dressing to hide themselves and becoming invisible in the process.29 This paper will explore how institutional clothing within hospital wards affects both the male and female body, the presentation of the ageing body and its role in reinforcing the invisibility of older people, at a time when they are paradoxically most visible, unclothed and undressed, or wearing institutional clothing within the hospital ward.Institutional clothing is designed and used to fulfil a practical function.

Its use may therefore perhaps incline us towards a ‘task-based’ mode of attention, which as McGilchrist argues,10 while having a vital place in our understanding of the world, may on occasion interfere with the forms of attention that may be needed to deliver good person-oriented care responsive to individual needs.MethodsEthnography involves the in-depth study of people’s actions and accounts within their natural everyday setting, collecting relatively unstructured data from a range of sources.30 Importantly, it can take into account the perspectives of patients, carers and hospital staff.31 Our approach to ethnography is informed by the symbolic interactionist research tradition, which aims to provide an interpretive understanding of the social world, with an emphasis on interaction, focusing on understanding how action and meaning are constructed within a setting.32 The value of this approach is the depth of understanding and theory generation it can provide.33The goal of ethnography is to identify social processes within the data. There are multiple complex and nuanced interactions within these clinical settings that are capable of ‘communicating many messages at once, even of subverting on one level what it appears can ventolin be purchased over the counter to be “saying” on another’.34 Thus, it is important to observe interaction and performance. How everyday care work is organised and delivered.

By obtaining observational data from within each institution on the everyday work of hospital can ventolin be purchased over the counter wards, their family carers and the nursing and healthcare assistants (HCAs) who carry out this work, we can explore the ways in which hospital organisation, procedures and everyday care impact on care during a hospital admission. It remedies a common weakness in many qualitative studies, that what people say in interviews may differ from what they do or their private justifications to others.35Data collection (observations and interviews) and analysis were informed by the analytic tradition of grounded theory.36 There was no prior hypothesis testing and we used the constant comparative method and theoretical sampling whereby data collection (observation and interview data) and analysis are inter-related,36 37 and are carried out concurrently.38 39 The flexible nature of this approach is important, because it can allow us to increase the ‘analytic incisiveness’35 of the study. Preliminary analysis of data collected from individual sites informed the focus of later stages of sampling, data collection and analysis in other sites.Thus, sampling requires a flexible, pragmatic approach and purposive and maximum variation sampling (theoretical sampling) was used.

This included five hospitals can ventolin be purchased over the counter selected to represent a range of hospitals types, geographies and socioeconomic catchments. Five hospitals were purposefully selected to represent a range of hospitals types. Two large university teaching hospitals, two medium-sized general hospitals and one smaller general hospital.

This included one urban, two inner city and two hospitals covering a mix of rural and suburban catchment areas, all situated within England and Wales.These sites represented a range of expertise and interventions in caring for people with dementia, from no formal expertise to the deployment can ventolin be purchased over the counter of specialist dementia workers. Fractures, nutritional disorders, urinary tract and pneumonia40 41 are among the principal causes of admission to acute hospital settings among people with dementia. Thus, we focused observation within can ventolin be purchased over the counter trauma and orthopaedic wards (80 days) and medical assessment units (MAU.

75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types. Observations were carried out can ventolin be purchased over the counter by two researchers, each working in clusters of 2–4 days over a 6-week period at each site.

A single day of observation could last a minimum of 2 hours and a maximum of 12 hours. A total of 684 hours of observation were conducted for this study. This produced approximately 600 000 words can ventolin be purchased over the counter of observational fieldnotes that were transcribed, cleaned and anonymised (by KF and AN).

We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group. This allowed us to question what they are doing and why, and what are the can ventolin be purchased over the counter caring practices of ward staff when interacting with people living with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient records and board data with the assistance of ward staff. Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data.

When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was can ventolin be purchased over the counter this advisory group that informed us of the need of a better understanding of the impacts of the everyday care received by people living with dementia in acute hospital settings. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study.

The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data analysis was complete, the advisory can ventolin be purchased over the counter group commented on our initial findings and recommendations. During and on completion of the analysis, a series of public consultation events were held with people living with dementia and family carers to ensure their involvement in discussing, informing and refining our analysis.FindingsWithin this paper, we focus on exploring the medical gaze through the embedded institutional cultures of patient clothing, and the implications this have for patients living with dementia within acute hospital wards.

These findings emerged from our wider analysis of can ventolin be purchased over the counter our ethnographic study examining ward cultures of care and the experiences of people living with dementia. Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress. We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress.

Within many wards, it was typical for all older patients to can ventolin be purchased over the counter be dressed in hospital-issued institutional gowns and pyjamas (typically in pastel blue, pink, green or peach), paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip grip soles, while in other wards, it was standard practice for people to be supported to dress in their own clothes. Across all these wards, we observed that younger patients (middle aged/working age) were more likely to be able to wear their own clothes while admitted to a ward, than older patients and those with a dementia diagnosis.Among key signifiers of social status and individuality are the material things around the person, which in these hospital wards included the accoutrements around the bedside. Significantly, it was observed that people living with dementia were more likely to be wearing an institutional hospital gown or institutional pyjamas, and to have little to individuate the person at the bedside, on either their cabinet or the mobile tray table at their bedside.

The wearing of institutional clothing was typically connected to fewer can ventolin be purchased over the counter personal items on display or within reach of the patient, with any items tidied away out of sight. In contrast, younger working age patients often had many personal belongings, cards, gadgets, books, media players, with young adults also often having a range of ‘get well soon’ gifts, balloons and so on from the hospital gift shop) on display. This both afforded some elements of familiarity, but also marked the person out as someone with individuality and a certain social standing and place.Visibility of can ventolin be purchased over the counter patients on a wardThe significance of the obscurity or invisibility of the patient in artworks depicting doctors has been commented on.4 Likewise, we observed that some patients within these wards were much more ‘visible’ to staff than others.

It was often apparent how the wearing of personal clothing could make the patient and their needs more readily visible to others as a person. This may be especially so given the contrast in appearance clothing may produce in this particular setting. On occasion, this may be remarked on by staff, and the resulting attention received favourably can ventolin be purchased over the counter by the patient.A member of the bay team returned to a patient and found her freshly dressed in a white tee shirt, navy slacks and black velvet slippers and exclaimed aloud and appreciatively, ‘Wow, look at you!.

€™ The patient looked pleased as she sat and combed her hair [site 3 day 1].Such a simple act of recognition as someone with a socially approved appearance takes on a special significance in the context of an acute hospital ward, and for patients living with dementia whose personhood may be overlooked in various ways.46This question of visibility of patients may also be particularly important when people living with dementia may be less able to make their needs and presence known. In this example, a whole bay of patients was seemingly ‘invisible’. Here, the ethnographer is observing a four-bed bay occupied by male patients can ventolin be purchased over the counter living with dementia.The man in bed 17 is sitting in his bedside chair.

He is dressed in green hospital issue pyjamas and yellow grip socks. At 10 a.m., the physiotherapy team come can ventolin be purchased over the counter and see him. The physiotherapist crouches down in front of him and asks him how he is.

He says he is unhappy, and the physiotherapist explains that she’ll be back later to see him again. The nurse checks on him, asks him if he wants a pillow, and can ventolin be purchased over the counter puts it behind his head explaining to him, ‘You need to sit in the chair for a bit’. She pulls his bedside trolley near to him.

With the help of a Healthcare Assistant they make the bed. The Healthcare can ventolin be purchased over the counter Assistant chats to him, puts cake out for him, and puts a blanket over his legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, ‘The problem is this is a really unstimulating environment’, then says to the patient, ‘All done, let’s have a bit of a tidy up,’ before wheeling the equipment out.The neighbouring patient in bed 18, is now sitting in his bedside chair, wearing (his own) striped pyjamas.

His eyes are can ventolin be purchased over the counter open, and he is looking around. After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains.

He says he doesn’t want to sit, and they say that is fine unless the doctors tell them otherwise.The nurse puts music on an old radio with a CD player which is can ventolin be purchased over the counter at the doorway near the ward entrance. It sounds like music from a musical and the ward it is quite noisy suddenly. She turns down the volume a bit, but it is very jaunty and upbeat.

The man can ventolin be purchased over the counter in bed 19 quietly sings along to the songs. €˜I am going to see my baby when I go home on victory day…’At ten thirty, the nurse goes off on her break. The rest of the can ventolin be purchased over the counter team are spread around the other bays and side rooms.

There are long distances between bays within this ward. After all the earlier activity it is now very calm and peaceful in the bay. Patient 20 is sitting in the chair tapping his can ventolin be purchased over the counter feet to the music.

He has taken out a large hessian shopping bag out of his cabinet and is sorting through the contents. There is a lot of paperwork in it which he is reading through closely and sorting.Opposite, patient can ventolin be purchased over the counter 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down the chair.

His head is in his hands and he suddenly looks in pain. He hasn’t can ventolin be purchased over the counter touched his tea, and is talking to himself. The junior medic was aware that 17 was not comfortable, and it had looked like she was going to get some advice, but she hasn’t come back.

18 drinks his tea and looks at a wool twiddle mitt sleeve, puts it down, and dozes. 19 has finished all his coffee and manages to put the cup down on the trolley.Everyone is tapping their feet or wiggling their toes to the music, or singing quietly to it, when a student nurse, who is working at the computer can ventolin be purchased over the counter station in the corridor outside the room, comes in. She has a strong purposeful stride and looks irritated as she switches the music off.

It feels can ventolin be purchased over the counter like a jolt to the room. She turns and looks at me and says, ‘Sorry were you listening to it?. €™ I tell her that I think these gentlemen were listening to it.She suddenly looks very startled and surprised and looks at the men in the room for the first time.

They have all stopped tapping their toes can ventolin be purchased over the counter and stopped singing along. She turns it back on but asks me if she can turn it down. She leaves and goes back to her paperwork outside.

Once it is turned back on everyone starts tapping can ventolin be purchased over the counter their toes again. The music plays on. €˜There’ll be bluebirds over the white can ventolin be purchased over the counter cliffs of Dover, just you wait and see…’[Site 3 day 3]The music was played by staff to help combat the drab and unstimulating environment of this hospital ward for the patients, the very people the ward is meant to serve.

Yet for this member of ward staff the music was perceived as a nuisance, the men for whom the music was playing seemingly did not register to her awareness. Only an individual of ‘higher’ status, the researcher, sitting at the end of this room was visible to her. This example illustrates the general question can ventolin be purchased over the counter of the visibility or otherwise of patients.

Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the example below, a mother and two adult daughters visit the father of the family, who is not visible to them as the person can ventolin be purchased over the counter they were so familiar with.

His is not wearing his glasses, which are missing, and his daughters find this very difficult. Even though he looks very different following his admission—he has lost a large amount of weight and has sunken cheekbones, and his skin has taken on a darker hue—it is his glasses which are a key concern for the family in their recognition of their father:As I enter the corridor to go back to the ward, I meet the wife and daughter of the patient in bed 2 in the hall and walk with them back to the can ventolin be purchased over the counter ward. Their father looks very frail, his head is back, and his face is immobile, his eyes are closed, and his mouth is open.

His skin looks darker than before, and his cheekbones and eye sockets are extremely prominent from weight loss. €˜I am can ventolin be purchased over the counter like a bird I want to fly away…’ plays softly in the radio in the bay. I sit with them for a bit and we chat—his wife holds his hand as we talk.

His wife has to take two busses to get to the hospital and we talk about the potential care home they expect her husband will be discharged to. They hope it will can ventolin be purchased over the counter be close because she does not drive. He isn’t wearing his glasses and his daughter tells me that they can’t find them.

We look in the bedside cabinet can ventolin be purchased over the counter. She has never seen her dad without his glasses. €˜He doesn’t look like my dad without his glasses’ [Site 2 day 15].It was often these small aspects of personal clothing and grooming that prompted powerful responses from visiting family members.

Missing glasses and missing teeth can ventolin be purchased over the counter were notable in this regard (and with the follow-up visits from the relatives of discharged patients trying to retrieve these now lost objects). The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a patient’s identity, such as wallets or keys, and particularly, for female patients, handbags, could be a prominent source of distress for individuals. These accessories to personal clothing were notable on these wards by their everyday absence, hidden away in bedside cupboards or simply not brought in with the patient at admission, and by the frequency with which patients requested and called out for them or tried to look for them, often in repetitive cycles that indicated their underlying anxiety about these belongings, but which would become invisible to staff, becoming an everyday background intrusion to the work of the wards.When considering the visibility and recognition of individual persons, missing glasses, especially glasses for distance vision, have a particular significance, for without them, a person may be less able to recognise and interact visually with others.

Their presence facilitates the subject of the gaze, in gazing back, and hence can ventolin be purchased over the counter helps to ground meaningful and reciprocal relationships of recognition. This may be one factor behind the distress of relatives in finding their loved ones’ glasses to be absent.Clothing as a source of distressAcross all sites, we observed patients living with dementia who exhibited obvious distress at aspects of their institutional apparel and at the absence of their own personal clothing. Some older patients were clearly able to verbalise their understandings can ventolin be purchased over the counter of the impacts of wearing institutional clothing.

One patient remarked to a nurse of her hospital blue tracksuit. €˜I look like an Olympian or Wentworth prison in this outfit!. The latter I expect…’ The staff laughed as they walked her out can ventolin be purchased over the counter of the bay (site 3 day 1).Institutional clothing may be a source of distress to patients, although they may be unable to express this verbally.

Kontos has shown how people living with dementia may retain an awareness at a bodily level of the demands of etiquette.20 Likewise, in our study, a man living with dementia, wearing a very large institutional pyjama top, which had no collar and a very low V neck, continually tried to pull it up to cover his chest. The neckline was particularly low, because the pyjamas were far too large for him. He continued to fiddle with his very low-necked top even can ventolin be purchased over the counter when his lunch tray was placed in front of him.

He clearly felt very uncomfortable with such clothing. He continued using his hands to try to pull it up can ventolin be purchased over the counter to cover his exposed chest, during and after the meal was finished (site 3 day 5).For some patients, the communication of this distress in relation to clothing may be liable to misinterpretation and may have further impacts on how they are viewed within the ward. Here, a patient living with dementia recently admitted to this ward became tearful and upset after having a shower.

She had no fresh clothes, and so the team had provided her with a pink hospital gown to wear.‘I want my trousers, where is my bra, I’ve got no bra on.’ It is clear she doesn’t feel right without her own clothes on. The one-to-one healthcare assistant assigned to this can ventolin be purchased over the counter patient tells her, ‘Your bra is dirty, do you want to wear that?. €™ She replies, ‘No I want a clean one.

Where are my trousers?. I want them, I’ve lost them.’ The healthcare assistant can ventolin be purchased over the counter repeats the explaination that her clothes are dirty, and asks her, ‘Do you want your dirty ones?. €™ She is very teary ‘No, I want my clean ones.’ The carer again explains that they are dirty.The cleaner who always works in the ward arrives to clean the floor and sweeps around the patient as she sits in her chair, and as he does this, he says ‘Hello’ to her.

She is very teary and explains that can ventolin be purchased over the counter she has lost her clothes. The cleaner listens sympathetically as she continues ‘I am all confused. I have lost my clothes.

I am can ventolin be purchased over the counter all confused. How am I going to go to the shops with no clothes on!. €™ (site 5 day 5).This person experienced significant distress because of her absent clothes, but this would often be simply attributed to confusion, seen as a feature of her dementia.

This then may solidify staff perceptions can ventolin be purchased over the counter of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse. The absence of can ventolin be purchased over the counter her own familiar clothing contributes significantly to her distress and disorientation.

Others have argued that people with limited verbal capacity and limited cognitive comprehension will have a direct appreciation of the grounding familiarity of wearing their own clothes, which give a bodily felt notion of comfort and familiarity.18 47 Familiar clothing may then be an essential prop to anchor the wearer within a recognisable social and meaningful space. To simply see clothing from a task-oriented point of view, as fulfilling a simply mechanical function, and that all clothing, whether personal or institutional have the same value and role, might be to interpret the desire to wear familiar clothing as an ‘optional extra’. However, for can ventolin be purchased over the counter those patients most at risk of disorientation and distress within an unfamiliar environment, it could be a valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed other aspects of the role of personal grooming.

Personal grooming was notable by its absence beyond the necessary cleaning required for reasons of immediate hygiene and clinical need (such as the prevention of pressure ulcers). Older patients, and particular those living with dementia who were unable to carry out ‘self-care’ independently and were not able to request support with personal grooming, could, over their admission, become visibly unkempt and scruffy, hair could be left unwashed, uncombed and unstyled, while men could become hirsute through a lack of shaving. The simple act of a visitor dressing and grooming a patient as they prepared for discharge could transform their appearance and leave that patient looking more alert, appear to having increased capacity, than when sitting ungroomed in their bed or bedside chair.It is important to consider the impact of can ventolin be purchased over the counter appearance and of personal care in the context of an acute ward.

Kontos’ work examining life in a care home, referred to earlier, noted that people living with dementia may be acutely aware of transgressions in grooming and appearance, and noted many acts of self-care with personal appearance, such as stopping to apply lipstick, and conformity with high standards of table manners. Clothing, etiquette and personal grooming are important indicators of social class and hence an aspect of belonging and identity, and of how an individual relates to a can ventolin be purchased over the counter wider group. In Kontos’ findings, these rituals and standards of appearance were also observed in negative reactions, such as expressions of disgust, towards those residents who breached these standards.

Hence, even in cases where an individual may be assessed as having considerable cognitive impairment, the importance of personal appearance must not be overlooked.For some patients within these wards, routine practices of everyday care at the bedside can increase the potential to influence whether they feel and appear socially acceptable. The delivery of routine timetabled care at the bedside can can ventolin be purchased over the counter impact on people’s appearance in ways that may mark them out as failing to achieve accepted standards of embodied personhood. The task-oriented timetabling of mealtimes may have significance.

It was a typical observed feature of this routine, when a mealtime has ended, that people living with dementia were left with visible signs and features of the mealtime through spillages on faces, clothes, bed sheets and bedsides, that leave them at risk of being assessed as less socially acceptable and marked as having reduced independence. For example, a volunteer attempts to ‘feed’ a person living with dementia, when she gives up and leave the bedside (this woman can ventolin be purchased over the counter living with dementia has resisted her attempts and explicitly says ‘no’), remnants of the food is left spread around her mouth (site E). In a different ward, the mealtime has ended, yet a large white plastic bib to prevent food spillages remains attached around the neck of a person living with dementia who is unable to remove it (site X).Of note, an adult would not normally wear a white plastic bib at home or in a restaurant.

It signifies a task-based apparel that is demeaning to an individual’s social status can ventolin be purchased over the counter. This example also contrasts poignantly with examples from Kontos’ work,20 such as that of a female who had little or no ability to verbalise, but who nonetheless would routinely take her pearl necklace out from under her bib at mealtimes, showing she retained an acute awareness of her own appearance and the ‘right’ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes ‘placed her hand on her chest, to prevent her blouse from touching the food as she leaned over her plate’.20Patients who are less robust, who have cognitive impairments, who may be liable to disorientation and whose agency and personhood are most vulnerable are thus those for whom appropriate and familiar clothing may be most advantageous.

However, we can ventolin be purchased over the counter found the ‘Matthew effect’ to be frequently in operation. To those who have the least, even that which they have will be taken away.48 Although there may be institutional and organisational rationales for putting a plastic cover over a patient, leaving it on for an extended period following a meal may act as a marker of dehumanising loss of social status. By being able to maintain familiar clothing and adornment to visually display social standing and identity, a person living with dementia may maintain a continuity of selfhood.However, it is also possible that dressing and grooming an older person may itself be a task-oriented institutional activity in certain contexts, as discussed by Lee-Treweek49 in the context of a nursing home preparing residents for ‘lounge view’ where visitors would see them, using residents to ‘create a visual product for others’ sometimes to the detriment of residents’ needs.

Our observations regarding the importance of patient appearance must therefore be considered as part of the care of the whole person and can ventolin be purchased over the counter a significant feature of the institutional culture.Patient status and appearanceWithin these wards, a new grouping of class could become imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs. Those in the lowest classes may have limited opportunities to participate in society, and we observed the ways in which this applied to the people living with can ventolin be purchased over the counter dementia within these acute wards.

The differential impact of clothing as signifiers of social status has also been observed in a comparison of the white coat and the patient gown.4 It has been argued that while these both may help to mask individuality, they have quite different effects on social status on a ward. One might say that the white coat increases visibility as a person of standing and the attribution of agency, the patient gown diminishes both of these. (Within these wards, although white coats were not can ventolin be purchased over the counter to be found, the dress code of medical staff did make them stand out.

For male doctors, for example, the uniform rarely strayed beyond chinos paired with a blue oxford button down shirt, sleeves rolled up, while women wore a wider range of smart casual office wear.) Likewise, we observed that the same arrangement of attire could be attributed to entirely different meanings for older patients with or without dementia.Removal of clothes and exposureWithin these wards, we observed high levels of behaviour perceived by ward staff as people living with dementia displaying ‘resistance’ to care.50 This included ‘resistance’ towards institutional clothing. This could include pulling up or removing hospital gowns, removing institutional pyjama trousers or pulling up gowns, and standing with gowns untied and exposed at the back (although this last example is an unavoidable design feature of the clothing itself). Importantly, the removal of clothing was limited to institutional gowns and pyjamas and we did not see any patients removing can ventolin be purchased over the counter their own clothing.

This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed. These acts could and was often interpreted can ventolin be purchased over the counter by ward staff as a patient’s ‘resistance’ to care. There was some variation in this interpretation.

However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within these wards such as shouting or crying out, the removal of bedsheets and the can ventolin be purchased over the counter subsequent bodily exposure would always be immediately corrected, the sheet replaced and the patient covered by either the nurse or HCA. The act of removal was typically interpreted by ward staff as representing a feature of the person’s dementia and staff responses were framed as an issue of patient dignity, or the dignity and embarrassment of other patients and visitors to the ward.

However, such responses to removal could lead to further cycles of removal and replacement, can ventolin be purchased over the counter leading to an escalation of distress in the person. This was important, because the recording of ‘refusal of care’, or presumed ‘confusion’ associated with this, could have significant impacts on the care and discharge pathways available and prescribed for the individual patient.Consider the case of a woman living with dementia who is 90 years old (patient 1), in the example below. Despite having no immediate medical needs, she has been admitted to the MAU from a care home (following her husband’s stroke, he could no longer care for her).

Across the previous evening and morning shift, she can ventolin be purchased over the counter was shouting, refusing all food and care and has received assistance from the specialist dementia care worker. However, during this shift, she has become calmer following a visit from her husband earlier in the day, has since eaten and requested drinks. Her care home would not readmit her, which meant she was not able to be discharged from the unit (an overflow unit due to a high number of admissions to the emergency department during a patch of exceptionally hot weather) until alternative arrangements could be made by social services.During our observations, she remains calm for the first 2 hours.

When she does can ventolin be purchased over the counter talk, she is very loud and high pitched, but this is normal for her and not a sign of distress. For staff working on this bay, their attention is elsewhere, because of the other six patients on the unit, one is ‘on suicide watch’ and another is ‘refusing their medication’ (but does not have a diagnosis of dementia). At 15:10 patient 1 can ventolin be purchased over the counter begins to remove her sheets:15:10.

The unit seems chaotic today. Patient 1 has begun to loudly drum her fingers on the tray table. She still has not been can ventolin be purchased over the counter brought more milk, which she requested from the HCA an hour earlier.

The bay that patient 1 is admitted to is a temporary overflow unit and as a result staff do not know where things are. 1 has moved her sheets off her legs, her bare knees peeking out over the top of piled sheets.15:15. The nurse in charge can ventolin be purchased over the counter says, ‘Hello,’ when she walks past 1’s bed.

1 looks across and smiles back at her. The nurse can ventolin be purchased over the counter in charge explains to her that she needs to shuffle up the bed. 1 asks the nurse about her husband.

The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow. 1 says that he hasn’t been and she can ventolin be purchased over the counter does not believe the nurse.15:25. I overhear the nurse in charge question, under her breath to herself, ‘Why 1 has been left on the unit?.

€™ 1 has started asking for somebody to come and see her. The nurse in charge tells 1 that she needs to do some jobs first and then will can ventolin be purchased over the counter come and talk to her.15:30. 1 has once again kicked her sheets off of her legs.

A social worker comes onto can ventolin be purchased over the counter the unit. 1 shouts, ‘Excuse me’ to her. The social worker replies, ‘Sorry I’m not staff, I don’t work here’ and leaves the bay.15:40.

1 keeps kicking sheets can ventolin be purchased over the counter off her bed, otherwise the unit is quiet. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unit’s door. 1 is the only elderly patient on the unit.

Again, the nurse in charge is heard sympathizing that this is not can ventolin be purchased over the counter the right place for her.16:30. A doctor approaches 1, tells her that she is on her list of people to say hello to, she is quite friendly. 1 tells her that she has been here for 3 days, (the can ventolin be purchased over the counter rest is inaudible because of pitch).

The doctor tries to cover 1 up, raising her bed sheet back over the bed, but 1 loudly refuses this. The doctor responds by ending the interaction, ‘See you later’, and leaves the unit.16:40. 1 attempts can ventolin be purchased over the counter to talk to the new nurse assigned to the unit.

She goes over to 1 and says, ‘What’s up my darling?. €™ It’s hard to follow 1 now as she sounds very upset. The RN’s first instinct, like with the doctor and the nurse in charge, is to cover up 1 s legs can ventolin be purchased over the counter with her bed sheet.

When 1 reacts to this she talks to her and they agree to cover up her knees. 1 is talking can ventolin be purchased over the counter about how her husband won’t come and visit her, and still sounds really upset about this. [Site 3, Day 13]Of note is that between days 6 and 15 at this site, observed over a particularly warm summer, this unit was uncomfortably hot and stuffy.

The need to be uncovered could be viewed as a reasonable response, and in fact was considered acceptable for patients without a classification of dementia, provided they were otherwise clothed, such as the hospital gown patient 1 was wearing. This is an example of an can ventolin be purchased over the counter aspect of care where the choice and autonomy granted to patients assessed as having (or assumed to have) cognitive capacity is not available to people who are considered to have impaired cognitive capacity (a diagnosis of dementia) and carries the additional moral judgements of the appropriateness of behaviour and bodily exposure. In the example given above, the actions were linked to the patient’s resistance to their admission to the hospital, driven by her desire to return home and to be with her husband.

Throughout observations over this 10-day period, patients perceived by staff as rational agents were allowed to strip down their bedding for comfort, whereas patients living with dementia who responded in this way were often viewed by staff as ‘undressing’, which would be interpreted as a feature of their condition, to be challenged and corrected by staff.Note how the same visual data triggered opposing interpretations of personal autonomy. Just as in the example above where distress can ventolin be purchased over the counter over loss of familiar clothing may be interpreted as an aspect of confusion, yet lead to, or exacerbate, distress and disorientation. So ‘deviant’ bedding may be interpreted, for some patients only, in ways that solidify notions of lack of agency and confusion, is another example of the Matthew effect48 at work through the organisational expectations of the clothed appearance of patients.Within wards, it is not unusual to see patients, especially those with a diagnosis of dementia or cognitive impairment, walking in the corridor inadvertently in some state of undress, typically exposed from behind by their hospital gowns.

This exposure in itself is of course, an intrinsic functional feature of the design of the flimsy back-opening institutional clothing the patient has been placed can ventolin be purchased over the counter in. This task-based clothing does not even fulfil this basic function very adequately. However, this inadvertent exposure could often be interpreted as an overt act of resistance to the ward and towards staff, especially when it led to exposed genitalia or continence products (pads or nappies).We speculate that the interpretation of resistance may be triggered by the visual prompt of disarrayed clothing and the meanings assumed to follow, where lack of decorum in attire is interpreted as indicating more general behavioural incompetence, cognitive impairment and/or standing outside the social order.DiscussionPrevious studies examining the significance of the visual, particularly Twigg and Buse’s work16–19 exploring the materialities of appearance, emphasise its key role in self-presentation, visibility, dignity and autonomy for older people and especially those living with dementia in care home settings.

Similarly, care home studies have demonstrated that institutional clothing, designed to facilitate task-based care, can be potentially dehumanising or and distressing.25 26 Our findings resonate with this work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, but is significant for the quality and humanity of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside can ventolin be purchased over the counter care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from McGilchrist’s work.10 The institutional culture of the wards produces an organisational task-based technical attention, which we found appeared to compete with and reduce the opportunity for ward staff to seek a finer emotional attunement to the person they are caring for and their needs.

Focus on efficiency, pace and record keeping that measures individual task can ventolin be purchased over the counter completion within a timetable of care may worsen all these effects. Indeed, other work has shown that in some contexts, attention to visual appearance may itself be little more than a ‘task’ to achieve.49 McGilchrist makes clear, and we agree, that both forms of attention are vital, but more needs to be done to enable staff to find a balance.Previous work has shown how important appearance is to older people, and to people living with dementia in particular, both in terms of how they are perceived by others, but also how for this group, people living with dementia, clothing and personal grooming may act as a particularly important anchor into a familiar social world. These twin aspects of clothing and appearance—self-perception and perception by others—may be especially important in the fast-paced context of an acute can ventolin be purchased over the counter ward environment, where patients living with dementia may be struggling with the impacts of an additional acute medical condition within in a highly timetabled and regimented and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways.

We have seen above, for instance, how behaviour in relation to appearance may be seen as ‘resisting care’ in one group of patients, but as the natural expression of personal preference in patients viewed as being without cognitive impairments. Likewise, personal grooming might impact favourably on a patient’s alertness, visibility and status within the ward.Prior work has demonstrated the importance of the medical gaze for the perceptions of the patient. Other work has also shown how older people, and in particular people living with dementia, may be thought to be beyond concern for appearance, yet this can ventolin be purchased over the counter does not accurately reflect the importance of appearance we found for this patient group.

Indeed, we argue that our work, along with the work of others such as Kontos,20 21 shows that if anything, visual appearance is especially important for people living with dementia particularly within clinical settings. In considering the task of washing the patient, Pols53 considered ‘dignitas’ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to dignitas in the form of can ventolin be purchased over the counter appearance may be a way of facilitating the treatment by others of a person with humanitas, and helping to realise dignity of patients.Data availability statementNo data are available.

Data are unavailable to protect anonymity.Ethics statementsPatient consent for publicationNot required.Ethics approvalEthics committee approval for the study was granted by the NHS Research Ethics Service (15/WA/0191).AcknowledgmentsThe authors acknowledge funding support from the NIHR.Notes1. Devan Stahl can ventolin be purchased over the counter (2013). €œLiving into the imagined body.

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

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

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

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

E Goffman (1990a). Stigma. Notes on the management of spoiled identity, Penguin.6.

J Bridges and C Wilkinson (2011). €œAchieving dignity for older people with dementia in hospital.” Nursing Standard 5 (29).7. J Dancy (1985).

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

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

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

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

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

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

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

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

E Goffman (1990b). The Presentation of Self in Everyday Life Penguin15. Efrat Tseëlon (2001).

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

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

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

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

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

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

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

PIA C Kontos (2004). Ethnographic reflections on selfhood, embodiment and Alzheimer's disease. Ageing &.

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

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

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

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

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

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

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

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

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

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

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

162–89.29. K.M Woodward (1999). Introduction.

In K.M. Woodward (ed.), Figuring Age. Women, Bodies and Generations (pp.

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

M Hammersley and P Atkinson (1989). Ethnography. Principles in practice.

J Caracelli (2006). Enhancing the policy process through the use of ethnography and other study frameworks. A mixed-method strategy.

Research in the Schools, 13(1). 84–92.32. W Housley and P Atkinson (2003).

Interactionism, Sage33. M Hammersley (1987) What's Wrong with Ethnography?. Methodological Explorations.

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

The Anthropology of Experience New York. PAJ Publications. 2435.

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

B Glaser and A Strauss (1967). The Discovery of Grounded Theory. London.

Weidenfeld and Nicholson, 24(25). 288–30437. Juliet M.

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

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

€œFrom the editors. What grounded theory is not.” Academy of management journal, 49(4). 633–642.40.

Elizabeth L Sampson et al. (2009). €œDementia in the acute hospital.

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

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

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

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

Education Research 12:14–1943. F Vogt (2002). €œNo ethnography without comparison.

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

€œSaturation in qualitative research. Exploring its conceptualization and operationalization.” Quality and Quantity 52 (4). 1893–1907.45.

A Coffey and P Atkinson (1996). Making sense of qualitative data. Complementary research strategies.

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

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

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

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

K. Merton (1968). €œThe Matthew effect in science.

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

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

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

Katie Featherstone, Andy Northcott, and Jackie Bridges (2019a). €œRoutines of resistance. An ethnography of the care of people living with dementia in acute hospital wards and its consequences.” International Journal of Nursing Studies.52.

K Featherstone, A Northcott, and P Boddington (2020). €œUsing signs and symbols to identify hospital patients with a dementia diagnosis. Help or hindrance to recognition and care?.

€ Narrative Inquiry in Bioethics53. Jeannette Pols (2013). €œWashing the patient.

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

Aerolin ventolin

Face coverings are aerolin ventolin not classified as medical devices unless there are medical claims or representations. Some mask and face covering medical devices may incorporate or be coated with materials that claim to be anti-microbial. Anti-microbial substances may kill or inhibit the growth of microorganisms. Some examples of anti-microbial substances include, but are not aerolin ventolin limited to. Silver copper Nanoform Graphene fabric coatings saltTo date, Health Canada has not received any data that support the safety and effectiveness of these substances when used with masks or face coverings.

It is also not known whether these substances improve the performance of medical masks in a measurable way. Regulatory considerations and aerolin ventolin claims In Canada, face coverings that are used only to reduce droplets or aerosols passing between individuals are not regulated as medical devices. However, if the product label includes anti-microbial claims, these face coverings become Class I medical devices. Section 25 of the Medical Device Regulations allows for the request of supporting safety, effectiveness and quality information from Class I manufacturers. Limitations to the claims Bacterial Filtration Efficiency (BFE) aerolin ventolin is a measurement of a medical mask material's resistance to penetration of a specific kind of microbe.

A 3 µm (300 nm) in diameter bacteria. Results are reported as percent efficiency and correlate with the ability of the fabric to resist bacterial penetration. Higher BFE aerolin ventolin percentages in this test indicate better barrier efficiency. In general, a BFE rating could be interpreted as material filtration efficiency. This measurement is not to be taken in isolation and without a reference to a test method or international standard.

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If the anti-microbial substances are present in nanoform(s), a characterization of those substances (for example, derivitization, layers, platelets, thickness, lateral dimensions, charged sites), including a certificate of analysis showing impurities. Information describing potential inhalation exposure to anti-microbial substance particulates that includes at least. intended use pattern (such as frequency, number of uses) summarized test data that fully characterize the amount (mass) and sizes (particle size distribution and aerolin ventolin mass median aerodynamic diameter - MMAD) of particulates that are shed during the intended use pattern and human inhalation exposure range estimates in terms of mg/L/hr, and mg/kg-bw/day, based on the information in a) and b) Evidence in the form of test reports that support all anti-viral (anti-asthma treatment) and/or antimicrobial claims made on the product label. This may include the use of a scientifically justified surrogate ventolin(es). Study details such as specific component/materials that were tested in the test samples should be included, and the test samples should be identical to the product.

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International activity The U.S. Food and Drug Administration regulates face coverings aerolin ventolin with anti-microbial claims as medical devices. Self-sanitizing claims are detergent claims that are overseen by the Pest Management Regulatory Agency in Canada and the Environmental Protection Agency in the United States. Related links Glossary of terms Face coverings (also known as non-medical masks). Source control masks (to help control an infected wearer from transmitting the aerolin ventolin ventolin to others) that are made from a variety of woven fabrics.

Face coverings may be made of different combinations of fabrics, layering sequences and available in diverse shapes. They are a sewn mask secured with ties or straps around the head or behind the ears. They are factory-made or made from household items such as aerolin ventolin scarves or t-shirts. The fabrics and/or materials used in face coverings are not the same as the ones used in medical masks or respirators. Medical device:  A device within the meaning of the Food and Drugs Act, but does not include any device that is intended for use in relation to animals.  Medical masks.

Includes surgical, aerolin ventolin procedural, isolation and other control devices intended to offer protection to the wearer. They are designed with 3 layers of non-woven materials and meet labelled filtration levels (80% to 100%) using recognized standards. Personal protective equipment (PPE). Personal aerolin ventolin protective equipment consists of gowns, gloves, masks, facial protection (masks and eye protection, face shields or masks with visor attachment) or respirators. They can be used by health care workers to provide a barrier that will prevent potential exposure to infectious microorganisms.

Respirator. A device that is tested and certified by procedures established by testing and certification agencies recognized by the authority having jurisdiction and is used aerolin ventolin to protect the user from inhaling a hazardous atmosphere. The most common respirator used in health care is a N95 half-face piece filtering respirator. It's a personal protective device that fits tightly around the nose and mouth of the wearer. It's used to reduce the risk of inhaling aerolin ventolin hazardous airborne particles and aerosols, including dust particles and infectious agents.From.

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Along with asthma treatment screening self-assessments, such measures include. practising social distancing practising good respiratory etiquette and hand hygiene equipping inspectors with sanitation supplies, non-medical masks and other required PPE making adjustments for additional provincial, territorial, local and community specific public health guidance, where applicable Health Canada inspectors are governed by applicable acts and regulations and follow procedures referenced in A aerolin ventolin Guide to Health Canada Inspections. As such, inspectors continue to have the power to enter any place or premises at any reasonable time where. a regulated activity is being conducted or a regulated product, article, device or thing, or relevant document is located Anyone at the place of the inspection is legally required to give the inspector all reasonable assistance. To stay safe and help limit the spread of asthma treatment, Health Canada expects that public health guidance and mitigation measures will be followed while the inspector is onsite.

Silver copper can ventolin be purchased over the counter Nanoform Graphene fabric coatings saltTo date, Health Canada has not received any data that support the safety and effectiveness of these substances when used with masks or face coverings. It is also not known whether these substances improve the performance of medical masks in a measurable way. Regulatory considerations and claims In Canada, face coverings that are used only to reduce droplets or aerosols passing between individuals are not regulated as medical devices.

However, if the can ventolin be purchased over the counter product label includes anti-microbial claims, these face coverings become Class I medical devices. Section 25 of the Medical Device Regulations allows for the request of supporting safety, effectiveness and quality information from Class I manufacturers. Limitations to the claims Bacterial Filtration Efficiency (BFE) is a measurement of a medical mask material's resistance to penetration of a specific kind of microbe.

A 3 µm (300 nm) in diameter can ventolin be purchased over the counter bacteria. Results are reported as percent efficiency and correlate with the ability of the fabric to resist bacterial penetration. Higher BFE percentages in this test indicate better barrier efficiency.

In general, a BFE rating could be interpreted as can ventolin be purchased over the counter material filtration efficiency. This measurement is not to be taken in isolation and without a reference to a test method or international standard. To achieve a high level of filtration, anti-microbial non-medical masks should be manufactured from a non-woven polypropylene material.

All claims must be supported by evidence and available for review upon can ventolin be purchased over the counter request. Safety and effectiveness requirements Medical masks or other personal protective equipment claiming microbial protection should meet the safety and effectiveness requirements described below. This information must be available for review upon request in the case of MDEL holders.

It should be submitted by manufacturers filing an can ventolin be purchased over the counter interim order (IO) application or responding to regulatory requests for information. A clear intended use/indications statement for the product along with complete labelling. Labelling includes user manuals, instructions for use (IFU), directions for use (DFU), outer package labelling, promotional material and website links.

A detailed description of the list of materials (for example, chemical and popular/trade names) can ventolin be purchased over the counter and their technical specifications (for example, physical/chemical properties), used in the manufacture of the mask. This includes all material constituents added to the mask to impart anti-microbial or anti-viral properties. A full description of how the anti-microbial or anti-viral technology (for example, coatings) is produced and incorporated into, or bonded with, the mask materials, as well as a mechanistic description of the expected anti-microbial action.

If the anti-microbial substances are present in nanoform(s), can ventolin be purchased over the counter a characterization of those substances (for example, derivitization, layers, platelets, thickness, lateral dimensions, charged sites), including a certificate of analysis showing impurities. Information describing potential inhalation exposure to anti-microbial substance particulates that includes at least. intended use pattern (such as frequency, number of uses) summarized test data that fully characterize the amount (mass) and sizes (particle size distribution and mass median aerodynamic diameter - MMAD) of particulates that are shed during the intended use pattern and human inhalation exposure range estimates in terms of mg/L/hr, and mg/kg-bw/day, based on the information in a) and b) Evidence in the form of test reports that support all anti-viral (anti-asthma treatment) and/or antimicrobial claims made on the product label.

This may include the use of a scientifically justified surrogate can ventolin be purchased over the counter ventolin(es). Study details such as specific component/materials that were tested in the test samples should be included, and the test samples should be identical to the product. If there are differences in the materials, concentrations or other properties should be provided along with a justification for how they are representative of the final product in spite of these differences (for example, represent worst-case scenario testing).

Evidence of biocompatibility (such as non-cytotoxic, non-irritating and can ventolin be purchased over the counter non-sensitizing) of the patient contacting materials in their final manufactured product form. Performance data/reports demonstrating that the respirators/masks meet ASTM F2100, EN 14683, EN 149 and GB2626 (or any other standards claimed). If it is claimed that the mask can be washed, then instructions for washing should be provided.

In addition, evidence must be provided that the performance claims made (for example, in 8 can ventolin be purchased over the counter above) are maintained after a proposed maximum number of wash cycles as indicated in the device labelling. International activity The U.S. Food and Drug Administration regulates face coverings with anti-microbial claims as medical devices.

Self-sanitizing claims are detergent claims can ventolin be purchased over the counter that are overseen by the Pest Management Regulatory Agency in Canada and the Environmental Protection Agency in the United States. Related links Glossary of terms Face coverings (also known as non-medical masks). Source control masks (to help control an infected wearer from transmitting the ventolin to others) that are made from a variety of woven fabrics.

Face coverings may be made of can ventolin be purchased over the counter different combinations of fabrics, layering sequences and available in diverse shapes. They are a sewn mask secured with ties or straps around the head or behind the ears. They are factory-made or made from household items such as scarves or t-shirts.

The fabrics and/or materials used can ventolin be purchased over the counter in face coverings are not the same as the ones used in medical masks or respirators. Medical device:  A device within the meaning of the Food and Drugs Act, but does not include any device that is intended for use in relation to animals.  Medical masks. Includes surgical, procedural, isolation and other control devices intended to offer protection to the wearer.

They are designed with 3 layers of non-woven materials and meet labelled filtration can ventolin be purchased over the counter levels (80% to 100%) using recognized standards. Personal protective equipment (PPE). Personal protective equipment consists of gowns, gloves, masks, facial protection (masks and eye protection, face shields or masks with visor attachment) or respirators.

They can be used by health care workers to provide a barrier can ventolin be purchased over the counter that will prevent potential exposure to infectious microorganisms. Respirator. A device that is tested and certified by procedures established by testing and certification agencies recognized by the authority having jurisdiction and is used to protect the user from inhaling a hazardous atmosphere.

The most common respirator used in health can ventolin be purchased over the counter care is a N95 half-face piece filtering respirator. It's a personal protective device that fits tightly around the nose and mouth of the wearer. It's used to reduce the risk of inhaling hazardous airborne particles and aerosols, including dust particles and infectious agents.From.

Health CanadaDate can ventolin be purchased over the counter published. 2021-04-07 Health Canada regulates health products, such as drugs and medical devices. We also regulate consumer and commercial products and substances, such as cosmetics, pesticides, tobacco, cannabis and controlled substances.

As part of our regulatory activities, we conduct inspections to mitigate risks and protect the health and safety of can ventolin be purchased over the counter Canadians. Learn more about what Health Canada does as a regulator. During the asthma treatment ventolin, we continue to take a risk-based approach to inspections.

Onsite work can ventolin be purchased over the counter remains a key tool in helping us fulfill our mandate to deliver essential inspection activities. Health Canada uses remote or virtual tools to complement onsite inspection activities. We're using these tools, where appropriate and without compromising the ability to verify and assess compliance, for all of the products and substances that we regulate.

When onsite activities are conducted, Health Canada is implementing appropriate asthma treatment mitigation measures can ventolin be purchased over the counter in adherence with public health guidance. Along with asthma treatment screening self-assessments, such measures include. practising social distancing practising good respiratory etiquette and hand hygiene equipping inspectors with sanitation supplies, non-medical masks and other required PPE making adjustments for additional provincial, territorial, local and community specific public health guidance, where applicable Health Canada inspectors are governed by applicable acts and regulations and follow procedures referenced in A Guide to Health Canada Inspections.

As such, inspectors continue to have the power to enter can ventolin be purchased over the counter any place or premises at any reasonable time where. a regulated activity is being conducted or a regulated product, article, device or thing, or relevant document is located Anyone at the place of the inspection is legally required to give the inspector all reasonable assistance. To stay safe and help limit the spread of asthma treatment, Health Canada expects that public health guidance and mitigation measures will be followed while the inspector is onsite.

Consideration for the health and safety of inspectors and regulated parties is a joint can ventolin be purchased over the counter responsibility. Where it isn't possible to reduce the risks of asthma treatment, we may explore other options. Health Canada will continue to monitor developments regarding asthma treatment and adjust plans for onsite delivery, as needed.

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Send one self-addressed adhesive label to assist that office in processing your request or include a fax number to which the Authorization may be sent. See the SUPPLEMENTARY INFORMATION Start Printed Page 74347section for electronic access to the Authorization. Start Further Info are ventolin and salbutamol the same Jennifer J. Ross, Office of Counterterrorism and Emerging Threats, Food and Drug Administration, 10903 New Hampshire Ave., Bldg.

1, Rm. 4332, Silver are ventolin and salbutamol the same Spring, MD 20993-0002, 301-796-8510 (this is not a toll free number). End Further Info End Preamble Start Supplemental Information I. Background Section 564 of the FD&C Act (21 U.S.C.

360bbb-3) allows FDA to strengthen the public are ventolin and salbutamol the same health protections against biological, chemical, radiological, or nuclear agent or agents. Among other things, section 564 of the FD&C Act allows FDA to authorize the use of an unapproved medical product or an unapproved use of an approved medical product in certain situations. With this EUA authority, FDA can help ensure that medical countermeasures may be used in emergencies to diagnose, treat, or prevent serious or life-threatening diseases or conditions caused by a biological, chemical, radiological, or nuclear agent or agents when there are no adequate, approved, and available alternatives. Section 564(b)(1) of the FD&C Act provides that, before an EUA may be issued, the Secretary of HHS must declare that circumstances exist justifying the authorization based on one of are ventolin and salbutamol the same the following grounds.

(1) A determination by the Secretary of Homeland Security that there is a domestic emergency, or a significant potential for a domestic emergency, involving a heightened risk of attack with a biological, chemical, radiological, or nuclear agent or agents. (2) a determination by the Secretary of Defense that there is a military emergency, or a significant potential for a military emergency, involving a heightened risk to U.S. Military forces, including personnel operating under the authority are ventolin and salbutamol the same of title 10 or title 50 of the U.S. Code, of attack with (A) a biological, chemical, radiological, or nuclear agent or agents.

Or (B) an agent or agents that may cause, or are otherwise associated with, an imminently life-threatening and specific risk to U.S. Military forces; [] (3) a determination by the Secretary of HHS that there is a public health emergency, or a significant potential for a public health emergency, that affects, or are ventolin and salbutamol the same has a significant potential to affect, national security or the health and security of U.S. Citizens living abroad, and that involves a biological, chemical, radiological, or nuclear agent or agents, or a disease or condition that may be attributable to such agent or agents. Or (4) the identification of a material threat by the Secretary of Homeland Security pursuant to section 319F-2 of the Public Health Service (PHS) Act (42 U.S.C.

247d-6b) sufficient to affect national security are ventolin and salbutamol the same or the health and security of U.S. Citizens living abroad. Once the Secretary of HHS has declared that circumstances exist justifying an authorization under section 564 of the FD&C Act, FDA may authorize the emergency use of a drug, device, or biological product if the Agency concludes that the statutory criteria are satisfied. Under section 564(h)(1) of the FD&C Act, are ventolin and salbutamol the same FDA is required to publish in the Federal Register a notice of each authorization, and each termination or revocation of an authorization, and an explanation of the reasons for the action.

Section 564 of the FD&C Act permits FDA to authorize the introduction into interstate commerce of a drug, device, or biological product intended for use when the Secretary of HHS has declared that circumstances exist justifying the authorization of emergency use. Products appropriate for emergency use may include products and uses that are not approved, cleared, or licensed under section 505, 510(k), 512, or 515 of the FD&C Act (21 U.S.C. 355, 360(k), 360b, or 360e) or are ventolin and salbutamol the same section 351 of the PHS Act (42 U.S.C. 262), or conditionally approved under section 571 of the FD&C Act (21 U.S.C.

360ccc). FDA may issue an EUA only if, after consultation with the HHS Assistant Secretary for Preparedness and Response, the Director of the National Institutes of Health, and the Director of the Centers for Disease Control and Prevention (to the extent feasible and appropriate given the applicable are ventolin and salbutamol the same circumstances), FDA [] concludes. (1) That an agent referred to in a declaration of emergency or threat can cause a serious or life-threatening disease or condition. (2) that, based on the totality of scientific evidence available to FDA, including data from adequate and well-controlled clinical trials, if available, it is reasonable to believe that (A) the product may be effective in diagnosing, treating, or preventing (i) such disease or condition.

Or (ii) a serious or life-threatening disease or condition caused by a product authorized under section 564, approved or cleared under the FD&C Act, or licensed under section 351 of the PHS Act, for diagnosing, treating, or preventing such a disease or condition caused by such are ventolin and salbutamol the same an agent. And (B) the known and potential benefits of the product, when used to diagnose, prevent, or treat such disease or condition, outweigh the known and potential risks of the product, taking into consideration the material threat posed by the agent or agents identified in a declaration under section 564(b)(1)(D) of the FD&C Act, if applicable. (3) that there is no adequate, approved, and available alternative to the product for diagnosing, preventing, or treating such disease or condition. (4) in the case of a determination described in section 564(b)(1)(B)(ii), that the request for emergency use is made by the Secretary of Defense are ventolin and salbutamol the same.

And (5) that such other criteria as may be prescribed by regulation are satisfied. No other criteria for issuance have been prescribed by regulation under section 564(c)(4) of the FD&C Act. III. Electronic Access An electronic version of this document and the full text of the Authorizations are available on the internet at https://www.fda.gov/​emergency-preparedness-and-response/​mcm-legal-regulatory-and-policy-framework/​emergency-use-authorization.

IV. The Authorizations Having concluded that the criteria for the issuance and, in some cases reissuance, of the following Authorizations under section 564(c) of the FD&C Act are met, FDA has authorized the emergency use of the following products for diagnosing, treating, or preventing asthma treatment subject to the terms of each Authorization. The Authorizations in their entirety, including any authorized fact sheets and other written materials, are available on the internet from the FDA web page entitled “Emergency Use Authorization,” available at https://www.fda.gov/​emergency-preparedness-and-response/​mcm-legal-regulatory-and-policy-framework/​emergency-use-authorization. The lists that follow include Authorizations issued, in some cases reissued, from May 16, 2020, through September 14, 2020, and we have included explanations of the reasons for their issuance, as required by section 564(h)(1) of the FD&C Act.

FDA is hereby announcing the following Authorizations for molecular diagnostic Start Printed Page 74348and antigen tests for asthma treatment, excluding multianalyte tests: [] Color Genomics, Inc.'s Color asthma LAMP Diagnostic Assay, issued May 18, 2020, and reissued July 24, 2020. Quidel Corp.'s Lyra Direct asthma Assay, issued May 18, 2020. P23 Labs, LLC's P23 Labs TaqPath SARSd-CoV-2 Assay, issued May 21, 2020, and reissued July 10, 2020. SEASUN BIOMATERIALS, Inc.'s AQ-TOP asthma treatment Rapid Detection Kit, issued May 21, 2020.

SolGent Co., Ltd.'s DiaPlexQ Novel asthma (2019-nCoV) Detection Kit, issued May 21, 2020. BioCore Co., Ltd.'s BioCore 2019-nCoV Real Time PCR Kit, issued May 21, 2020. Exact Sciences Laboratories' SARSd-CoV-2 (N gene detection) Test, issued May 22, 2020, and reissued August 3, 2020. Dba SpectronRx's Hymon SARSd-CoV-2 Test Kit, issued May 22, 2020.

PrivaPath Diagnostics, Inc.'s LetsGetChecked asthma (asthma treatment) Test, issued May 28, 2020, and reissued August 14, 2020. Gravity Diagnostics, LLC's Gravity Diagnostics asthma treatment Assay, issued June 1, 2020. Phosphorus Diagnostics LLC's Phosphorus asthma treatment RT-qPCR Test, issued June 4, 2020. Genetron Health (Beijing) Co., Ltd.'s Genetron SARSd-CoV-2 RNA Test, issued June 5, 2020.

Euroimmun US Inc.'s EURORealTime SARSd-CoV-2, issued June 8, 2020. ChromaCode Inc.'s HDPCR SARSd-CoV-2 Assay, issued June 9, 2020. Illumina, Inc.'s Illumina asthma treatmentSeq Test, issued June 9, 2020. Tide Laboratories, LLC's DTPM asthma treatment RT-PCR Test, issued June 10, 2020.

TBG Biotechnology Corp.'s ExProbe SARSd-CoV-2 Testing Kit, issued June 10, 2020. Cue Health, Inc.'s Cue asthma treatment Test, issued June 10, 2020. RTA Laboratories Biological Products Pharmaceutical and Machinery Industry's Diagnovital SARSd-CoV-2 Real-Time PCR Kit, issued June 12, 2020. Kaiser Permanente Mid-Atlantic States's KPMAS asthma treatment Test, issued June 13, 2020, and reissued September 9, 2020.

Applied BioCode, Inc.'s BioCode SARSd-CoV-2 Assay, issued June 15, 2020. The Ohio State University Wexner Medical Center's OSUWMC asthma treatment RT-PCR test, issued June 17, 2020. Omnipathology Solutions Medical Corp.'s Omni asthma treatment Assay by RT-PCR, issued June 17, 2020. Jiangsu Bioperfectus Technologies Co., Ltd.'s asthma treatment asthma Real Time PCR Kit, issued June 18, 2020.

3B Blackbio Biotech India Ltd., a subsidiary of Kilpest India Ltd.'s TRUPCR SARSd-CoV-2 Kit, issued June 18, 2020. HealthQuest Esoterics's HealthQuest Esoterics TaqPath SARSd-CoV-2 Assay, issued June 23, 2020. University of Alabama at Birmingham Fungal Reference Lab's FRL SARS CoV-2 Test, issued June 23, 2020. Gencurix, Inc.'s GenePro SARSd-CoV-2 Test, issued June 23, 2020.

University of Texas MD Anderson Cancer Center, Molecular Diagnostics Laboratory's MD Anderson High-throughput SARSd-CoV-2 RT-PCR Assay, issued June 24, 2020. Diagnostic Solutions Laboratory, LLC's DSL asthma treatment Assay, issued June 25, 2020. PreciGenome LLC's FastPlex Triplex SARSd-CoV-2 detection kit (RT-Digital PCR), issued June 25, 2020. PlexBio Co., Ltd.'s IntelliPlex SARSd-CoV-2 Detection Kit, issued June 25, 2020.

Inform Diagnostics, Inc.'s Inform Diagnostics SARSd-CoV-2 RT-PCR Assay, issued June 26, 2020. Acupath Laboratories, Inc.'s Acupath asthma treatment Real-Time (RT-PCR) Assay, issued June 29, 2020. LifeHope Labs' LifeHope 2019-nCoV Real-Time RT-PCR Diagnostic Panel, issued June 29, 2020. Psomagen, Inc.'s Psoma asthma treatment RT Test, issued June 30, 2020.

TNS Co., Ltd.'s (Bio TNS) asthma treatment RT-PCR Peptide Nucleic Acid (PNA) kit, issued June 30, 2020. The Kroger Co.'s Kroger Health asthma treatment Test Home Collection Kit, issued June 30, 2020. CENTOGENE US, LLC's CentoFast-SARSd-CoV-2 RT-PCR Assay, issued July 1, 2020. Becton, Dickinson and Co.'s BD Veritor System for Rapid Detection of SARSd-CoV-2, issued July 2, 2020.

Laboratorio Clinico Toledo's Laboratorio Clinico Toledo SARSd-CoV-2 Assay, issued July 6, 2020. Gene By Gene's Gene By Gene SARSd-CoV-2 Detection Test, issued July 7, 2020. Access Bio, Inc.'s CareStart asthma treatment MDx RT-PCR, issued July 7, 2020. Enzo Life Sciences, Inc.'s AMPIPROBE SARSd-CoV-2 Test System, issued July 7, 2020.

Clinical Research Sequencing Platform (CRSP), LLC at the Broad Institute of MIT and Harvard's CRSP SARSd-CoV-2 Real-time Reverse Transcriptase (RT)-PCR Diagnostic Assay, issued July 8, 2020. BioSewoom, Inc.'s Real-Q 2019-nCoV Detection Kit, issued July 9, 2020. UCSF Health Clinical Laboratories, UCSF Clinical Labs at China Basin's SARSd-CoV-2 RNA DETECTR Assay, issued July 9, 2020. Boston Medical Center's BMC-CReM asthma treatment Test, issued July 10, 2020.

KogeneBiotech Co., Ltd.'s PowerChek 2019-nCoV Real-time PCR Kit, issued July 13, 2020. Trax Management Services Inc.'s PhoenixDx SARSd-CoV-2 Multiplex, issued July 13, 2020. Compass Laboratory Services, LLC's Compass Laboratory Services SARSd-CoV2 Assay, issued July 13, 2020. Quest Diagnostics Infectious Disease, Inc.'s Quest Diagnostics PF SARSd-CoV-2 Assay, issued July 15, 2020, and reissued August 21, 2020.

Quest Diagnostics Infectious Disease, Inc.'s Quest Diagnostics RC SARSd-CoV-2 Assay, issued July 15, 2020, and reissued August 21, 2020. Quest Diagnostics Infectious Disease, Inc.'s Quest Diagnostics HA SARSd-CoV-2 Assay, issued July 15, 2020, and reissued August 21, 2020. Boston Heart Diagnostics' Boston Heart asthma treatment RT-PCR Test, issued July 16, 2020. Access Genetics, LLC's OraRisk asthma treatment RT-PCR, issued July 17, 2020.

DiaCarta, Inc.'s Quantiventolin SARSd-CoV-2 Multiplex Test Kit, issued July 21, 2020. Helix OpCo LLC's (dba Helix's) Helix asthma treatment Test, issued July 23, 2020. Jiangsu CoWin Biotech Co., Ltd.'s Novel asthma (SARSd-CoV-2) Fast Nucleic Acid Detection Kit (PCR-Fluorescence Probing), issued July 24, 2020. LabCorp's asthma treatment RT-PCR Test, reissued July 24, 2020 (original issuance March 16, 2020).

Eli Lilly and Co.'s Lilly SARSd-CoV-2 Assay, issued July 27, 2020;Start Printed Page 74349 Sandia National Laboratories' SNL-NM 2019 nCoV Real-Time RT-PCR Diagnostic Assay, issued July 27, 2020. Clinical Reference Laboratory, Inc.'s CRL Rapid Response, issued July 30, 2020. University of California San Diego Health's UCSD RC SARSd-CoV-2 Assay, issued July 31, 2020. Xiamen Zeesan Biotech Co., Ltd.'s SARSd-CoV-2 Test Kit (Real-time PCR), issued July 31, 2020.

ISPM Labs, LLC dba Capstone Healthcare's Genus SARSd-CoV-2 Assay, issued August 3, 2020. Poplar Healthcare's Poplar SARSd-CoV-2 TMA Pooling assay, issued August 3, 2020. Cleveland Clinic Robert J. Tomsich Pathology and Laboratory Medicine Institute's Cleveland Clinic SARSd-CoV-2 Assay, issued August 3, 2020.

Ethos Laboratories' Ethos Laboratories SARSd-CoV-2 MALDI-TOF Assay, issued August 3, 2020. Wren Laboratories LLC's Wren Laboratories asthma treatment PCR Test, issued August 3, 2020. Vela Operations Singapore Pte Ltd.'s ViroKey SARSd-CoV-2 RT-PCR Test, issued August 5, 2020. Helix OpCo LLC's (dba Helix) Helix asthma treatment NGS Test, issued August 6, 2020.

George Washington University Public Health Laboratory's GWU SARSd-CoV-2 RT-PCR Test, issued August 7, 2020. Quest Diagnostics Infectious Disease, Inc.'s SARSd-CoV-2 RNA, Qualitative Real-Time RT-PCR, reissued August 7, 2020 (original issuance March 17, 2020). Alpha Genomix Laboratories' Alpha Genomix TaqPath SARSd-CoV-2 Combo Assay, issued August 10, 2020. Solaris Diagnostics' Solaris Multiplex SARSd-CoV-2 Assay, issued August 10, 2020.

Biomeme, Inc.'s Biomeme SARSd-CoV-2 Real-Time RT-PCR Test, issued August 11, 2020. LumiraDx UK Ltd.'s LumiraDx asthma RNA STAR, issued August 11, 2020. Pro-Lab Diagnostics' Pro-AmpRT SARSd-CoV-2 Test, issued August 13, 2020. Yale School of Public Health, Department of Epidemiology of Microbial Diseases' SalivaDirect, issued August 15, 2020, and reissued August 28, 2020.

ZhuHai Sinochips Bioscience Co., Ltd.'s asthma treatment Nucleic Acid RT-PCR Test Kit, issued August 17, 2020. LumiraDx UK Ltd.'s LumiraDx SARSd-CoV-2 Ag Test, issued August 18, 2020. Assurance Scientific Laboratories' Assurance SARSd-CoV-2 Panel, reissued August 19, 2020 (original issuance May 15, 2020). Guardant Health, Inc.'s Guardant-19, issued August 21, 2020.

DxTerity Diagnostics, Inc.'s DxTerity SARSd-CoV-2 RT-PCR Test, issued August 21, 2020. Texas Department of State Health Services, Laboratory Services Section's Texas Department of State Health Services SARSd-CoV-2 Assay, issued August 21, 2020. Fluidigm Corp.'s Advanta Dx SARSd-CoV-2 RT-PCR Assay, issued August 25, 2020. QDx Pathology Services' QDX SARSd-CoV-2 Assay, issued August 25, 2020.

Cuur Diagnostics' Cuur Diagnostics SARSd-CoV-2 Molecular Assay, issued August 26, 2020. Abbott Diagnostics Scarborough, Inc.'s BinaxNOW asthma treatment Ag Card, issued August 26, 2020. Patients Choice Laboratories, LLC's PCL SARSd-CoV-2 Real-Time RT-PCR Assay, issued August 28, 2020. DxTerity Diagnostics, Inc.'s DxTerity SARSd-CoV-2 RT PCR CE Test, issued August 28, 2020.

T2 Biosystems, Inc.'s T2SARSd-CoV-2 Panel, issued August 31, 2020. MiraDx's MiraDx SARSd-CoV-2 RT-PCR assay, issued August 31, 2020. Mammoth Biosciences, Inc.'s SARSd-CoV-2 DETECTR Reagent Kit, issued August 31, 2020. BayCare Laboratories, LLC's BayCare SARSd-CoV-2 RT PCR Assay, issued August 31, 2020.

Detectachem Inc.'s MobileDetect Bio BCC19 (MD-Bio BCC19) Test Kit, issued September 1, 2020. OPTOLANE Technologies, Inc.'s Kaira 2019-nCoV Detection Kit, issued September 1, 2020. Bioeksen R&D Technologies Ltd.'s Bio-Speedy Direct RT-qPCR SARSd-CoV-2, issued September 2, 2020. BillionToOne, Inc.'s qSanger-asthma treatment Assay, issued September 4, 2020.

Verily Life Sciences' Verily asthma treatment RT-PCR Test, issued September 8, 2020. And Beijing Wantai Biological Pharmacy Enterprise Co., Ltd.'s Wantai SARSd-CoV-2 RT-PCR Kit, issued September 9, 2020. FDA is hereby announcing the following Authorizations for serology tests: [] Healgen Scientific LLC's asthma treatment IgG/IgM Rapid Test Cassette (Whole Blood/Serum/Plasma), issued May 29, 2020. Siemens Healthcare Diagnostics Inc.'s Atellica IM SARSd-CoV-2 Total (COV2T), issued May 29, 2020.

Siemens Healthcare Diagnostics Inc.'s ADVIA Centaur SARSd-CoV-2 Total (COV2T), issued May 29, 2020. Hangzhou Biotest Biotech Co., Ltd.'s RightSign asthma treatment IgG/IgM Rapid Test Cassette, issued June 4, 2020. Vibrant America Clinical Labs' Vibrant asthma treatment Ab Assay, issued June 4, 2020. Siemens Healthcare Diagnostics Inc.'s Dimension Vista SARSd-CoV-2 Total antibody assay (COV2T), issued June 8, 2020.

Siemens Healthcare Diagnostics Inc.'s Dimension EXL SARSd-CoV-2 Total antibody assay (CV2T), issued June 8, 2020. InBios International, Inc.'s SCoV-2 Detect IgG ELISA [enzyme-linked immunosorbent assay], issued June 10, 2020. Cellex Inc.'s qSARSd-CoV-2 IgG/IgM Rapid Test, reissued June 12, 2020 (original issuance April 1, 2020). Emory Medical Laboratories' SARSd-CoV-2 RBD IgG test, issued June 15, 2020.

Biohit Healthcare (Hefei) Co. Ltd.'s Biohit SARSd-CoV-2 IgM/IgG Antibody Test Kit, issued June 18, 2020. Hangzhou Laihe Biotech Co., Ltd.'s LYHER Novel asthma (2019-nCoV) IgM/IgG Antibody Combo Test Kit (Colloidal Gold), issued June 19, 2020. Babson Diagnostics, Inc.'s Babson Diagnostics aC19G1, issued June 23, 2020.

Beckman Coulter, Inc.'s Access SARSd-CoV-2 IgG, issued June 26, 2020. InBios International, Inc.'s SCoV-2 Detect IgM ELISA, issued June 30, 2020. Assure Tech.'s (Hangzhou Co., Ltd.) Assure asthma treatment IgG/IgM Rapid Test Device, issued July 6, 2020. Diazyme Laboratories, Inc.'s Diazyme DZ-Lite SARSd-CoV-2 IgG CLIA Kit, issued July 8, 2020.

Beijing Wantai Biological Pharmacy Enterprise Co., Ltd.'s WANTAI SARSd-CoV-2 Ab Rapid Test, July 10, 2020;Start Printed Page 74350 Salofa Oy's Sienna-Clarity COVIBLOCK asthma treatment IgG/IgM Rapid Test Cassette, issued July 13, 2020. Luminex Corp.'s xMAP SARSd-CoV-2 Multi-Antigen IgG Assay, issued July 16, 2020. Megna Health, Inc.'s Rapid asthma treatment IgM/IgG Combo Test Kit, issued July 17, 2020. Access Bio, Inc.'s CareStart asthma treatment IgM/IgG, issued July 24, 2020.

Xiamen Biotime Biotechnology Co., Ltd.'s BIOTIME SARSd-CoV-2 IgG/IgM Rapid Qualitative Test, issued July 24, 2020. Siemens Healthcare Diagnostics Inc.'s ADVIA Centaur SARSd-CoV-2 IgG (COV2G), issued July 31, 2020. Siemens Healthcare Diagnostics Inc.'s Atellica IM SARSd-CoV-2 IgG (COV2G), issued July 31, 2020. Beijing Wantai Biological Pharmacy Enterprise Co., Ltd.'s WANTAI SARSd-CoV-2 Ab ELISA, issued August 5, 2020.

BioMérieux SA's VIDAS SARSd-CoV-2 IgM, issued August 6, 2020. BioMérieux SA's VIDAS SARSd-CoV-2 IgG, issued August 6, 2020. Diazyme Laboratories, Inc.'s Diazyme DZ-Lite SARSd-CoV-2 IgM CLIA Kit, issued August 17, 2020. BioCheck, Inc.'s BioCheck SARSd-CoV-2 IgG and IgM Combo Test, issued August 17, 2020.

Biocan Diagnostics Inc.'s Tell Me Fast Novel asthma (asthma treatment) IgG/IgM Antibody Test, issued August 25, 2020. TBG Biotechnology Corp.'s TBG SARSd-CoV-2 IgG/IgM Rapid Test Kit, issued August 31, 2020. University of Arizona Genetics Core for Clinical Services' asthma treatment ELISA pan-Ig Antibody Test, issued August 31, 2020. Sugentech, Inc.'s SGTi-flex asthma treatment IgG, issued September 3, 2020.

BioCheck, Inc.'s BioCheck asthma IgG Antibody Test Kit, issued September 9, 2020. BioCheck, Inc.'s BioCheck asthma IgM Antibody Test Kit, issued September 9, 2020. And Shenzhen New Industries Biomedical Engineering Co., Ltd.'s MAGLUMI 2019-nCoV IgM/IgG, issued September 14, 2020. FDA is hereby announcing the following Authorizations for multianalyte in vitro diagnostics: [] Centers for Disease Control and Prevention's Influenza asthma (Flu SC2) Multiplex Assay, issued July 2, 2020.

Roche Molecular Systems, Inc.'s cobas asthma &. Influenza A/B, issued September 3, 2020. And Roche Molecular Systems, Inc.'s cobas asthma &. Influenza A/B Nucleic Acid Test for use on the cobas Liat System, issued September 14, 2020.

FDA is hereby announcing the following Authorizations for personal respiratory protective devices: [] FDA is hereby announcing the following Authorizations for other medical devices. Baxter Healthcare Corp.'s Prismaflex ST Set, issued May 20, 2020; [] STERIS Corp.'s AMSCO Medium Steam Sterilizers + the STERIS STEAM Decon Cycle, issued May 21, 2020; [] Certain Gowns and Other Apparel, issued May 22, 2020; [] CLEW Medical Ltd.'s CLEWICU System, issued May 26, 2020; [] Abiomed, Inc.'s Impella RP System, issued May 29, 2020; [] Start Printed Page 74351 Roche Diagnostics' Elecsys IL-6, issued on June 2, 2020; [] Battelle Memorial Institute's Battelle CCDS Critical Care Decontamination System (“Batelle Decontamination System”), reissued June 6, 2020 [] (original issuance March 29, 2020). STERIS Corp.'s STERIS Sterilization System, reissued June 6, 2020 [] (original issuance April 9, 2020). Stryker Instruments' STERIZONE VP4 N95 Respirator Decontamination Cycle, reissued June 6, 2020 [] (original issuance on April 14, 2020).

Advanced Sterilization Products, Inc.'s (ASP) STERRAD 100S, NX, and 100NX Sterilization Systems (“ASP STERRAD Sterilization Systems”), reissued June 6, 2020 [] (original issuance April 11, 2020). Stryker Sustainability Solutions' (SSS) SSS VHP N95 Respirator Decontamination System, issued May 27, 2020, reissued June 6, 2020; [] Sterilucent, Inc.'s Sterilucent HC 80TT Hydrogen Peroxide Sterilizer (“Sterilucent Sterilization System”), reissued June 6, 2020 [] (original issuance April 20, 2020). Duke University Health System's Duke Decontamination System for Decontamination and Reuse of N95 Respirators with Hydrogen Peroxide Vapor (“Duke Decontamination System”), reissued June 6, 2020 [] (original issuance May 7, 2020). Technical Safety Services LLC's 20-CS Decontamination System, issued June 13, 2020; [] Oceanetics, Inc.'s Negative-pressure Respiratory System with Advanced Ventilation Return (“NRSAVR-100”), issued June 13, 2020; [] US Army and MHS's asthma treatment Airway Management Isolation Chamber (CAMIC), issued May 19, 2020 and reissued to US Army Medical Research Development Command June 22, 2020; [] Start Printed Page 74352 electroCore, Inc.'s gammaCore Sapphire CV, issued July 10, 2020; [] Michigan State University Animal Care Program's MSU Decontamination System, issued July 24, 2020; [] IkonX, Inc.'s Airway Dome, issued July 24, 2020; [] Abiomed, Inc.'s Impella Left Ventricular (LV) Support Systems, issued August 3, 2020; [] Baxter Healthcare Corp.'s Prismaflex HF20 Set, issued August 10, 2020; [] NovaSterilis, Inc.'s Nova2200 using the NovaClean decontamination process for decontaminating compatible N95 respirators, issued August 20, 2020; [] and Color Genomics, Inc.'s Color asthma treatment Self-Swab Collection Kit, issued August 31, 2020.[] Start Signature Dated.

November 13, 2020. Lauren K. Roth, Acting Principal Associate Commissioner for Policy. End Signature End Supplemental Information [FR Doc.

2020-25603 Filed 11-19-20. 8:45 am]BILLING CODE 4164-01-PBy Kelsie George Rural residents across the U.S. May be at higher risk for severe illness from asthma treatment due to the aging population, higher rates of underlying chronic disease, and higher likelihood of having a disability. Combined with limited health care infrastructure and greater travel times to access in-person care, these challenges limit access to critical health care for the approximately 20% of Americans that live in rural communities.

Today, Nov. 19, is National Rural Health Day, an annual celebration of rural communities and their success in addressing their unique challenges in accessing and delivering health care services. This day is an opportunity to recognize the positive things that are taking place in rural health. For example, amid the asthma treatment ventolin, states are ensuring access to quality health care for rural residents through several policy strategies—such as bolstering telehealth services and supporting rural hospitals and health facilities.

Bolstering Telehealth Access and Coverage Patients and providers are seeking opportunities to access and deliver health care services during the asthma treatment public health crisis. Bolstering telehealth access and coverage is one way states are enhancing access to care, especially for large rural populations. On the payment front. Colorado required Medicaid reimbursement for telehealth services at the same rate as in-person services for Rural Health Clinics, federal Indian Health Service facilities, and Federally Qualified Health Centers.

Florida appropriated $4 million to implement a pilot project to provide behavioral telehealth services to children in public schools, with a focus on rural communities. Michigan expanded originating sites (the patient’s location during a telehealth visit) to include in-home and in-school settings. In part to ensure access to telehealth services, Mississippi authorized grant funding for the asthma treatment Broadband Provider Grant Program Fund to expand rural broadband capacity and facilitate telemedicine, remote work and distance learning. Supporting Rural Hospitals and Health Facilities Health care infrastructure presents a challenge for rural communities given the potentially long distances to health facilities, the large geographic areas health facilities serve, and the shortage of health professionals in rural regions.

The Food and Drug Administration (FDA) is announcing the issuance and reissuance of Emergency Use Authorizations (EUAs) (the Authorizations) for can ventolin be purchased over the counter certain medical devices related to the asthma Disease 2019 (asthma treatment) public health emergency. FDA has issued, and in some cases reissued, the Authorizations listed in this document under the Federal Food, Drug, and Cosmetic Act (FD&C Act). These Authorizations contain, among other things, conditions on the emergency use of the authorized products. The Authorizations follow the February 4, 2020, determination by Secretary of Health and Human Services (HHS) that can ventolin be purchased over the counter there is a public health emergency that has a significant potential to affect national security or the health and security of U.S. Citizens living abroad, and that involves the ventolin that causes asthma treatment, and the subsequent declarations on February 4, 2020, March 2, 2020, and March 24, 2020, that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the ventolin that causes asthma treatment, personal respiratory protective devices, and medical devices, including alternative products used as medical devices, respectively, subject to the terms of any authorization issued under the FD&C Act.

These Authorizations, which include an explanation of the reasons for issuance and reissuance, are listed in this document, and are available on FDA's website at the links indicated. These Authorizations are applicable can ventolin be purchased over the counter on their date of issuance/reissuance. Submit written requests for single copies of an EUA to the Office of Counterterrorism and Emerging Threats, Food and Drug Administration, 10903 New Hampshire Ave., Bldg. 1, Rm. 4338, Silver can ventolin be purchased over the counter Spring, MD 20993-0002.

Send one self-addressed adhesive label to assist that office in processing your request or include a fax number to which the Authorization may be sent. See the SUPPLEMENTARY INFORMATION Start Printed Page 74347section for electronic access to the Authorization. Start Further can ventolin be purchased over the counter Info Jennifer J. Ross, Office of Counterterrorism and Emerging Threats, Food and Drug Administration, 10903 New Hampshire Ave., Bldg. 1, Rm.

4332, Silver Spring, MD 20993-0002, 301-796-8510 (this can ventolin be purchased over the counter is not a toll free number). End Further Info End Preamble Start Supplemental Information I. Background Section 564 of the FD&C Act (21 U.S.C. 360bbb-3) allows FDA to strengthen the public health protections against biological, chemical, radiological, or nuclear agent or can ventolin be purchased over the counter agents. Among other things, section 564 of the FD&C Act allows FDA to authorize the use of an unapproved medical product or an unapproved use of an approved medical product in certain situations.

With this EUA authority, FDA can help ensure that medical countermeasures may be used in emergencies to diagnose, treat, or prevent serious or life-threatening diseases or conditions caused by a biological, chemical, radiological, or nuclear agent or agents when there are no adequate, approved, and available alternatives. Section 564(b)(1) of the FD&C Act provides that, before an EUA may be issued, the Secretary of HHS must declare that circumstances exist justifying can ventolin be purchased over the counter the authorization based on one of the following grounds. (1) A determination by the Secretary of Homeland Security that there is a domestic emergency, or a significant potential for a domestic emergency, involving a heightened risk of attack with a biological, chemical, radiological, or nuclear agent or agents. (2) a determination by the Secretary of Defense that there is a military emergency, or a significant potential for a military emergency, involving a heightened risk to U.S. Military forces, including personnel operating under the authority can ventolin be purchased over the counter of title 10 or title 50 of the U.S.

Code, of attack with (A) a biological, chemical, radiological, or nuclear agent or agents. Or (B) an agent or agents that may cause, or are otherwise associated with, an imminently life-threatening and specific risk to U.S. Military forces; [] (3) a determination by can ventolin be purchased over the counter the Secretary of HHS that there is a public health emergency, or a significant potential for a public health emergency, that affects, or has a significant potential to affect, national security or the health and security of U.S. Citizens living abroad, and that involves a biological, chemical, radiological, or nuclear agent or agents, or a disease or condition that may be attributable to such agent or agents. Or (4) the identification of a material threat by the Secretary of Homeland Security pursuant to section 319F-2 of the Public Health Service (PHS) Act (42 U.S.C.

247d-6b) sufficient to affect national security can ventolin be purchased over the counter or the health and security of U.S. Citizens living abroad. Once the Secretary of HHS has declared that circumstances exist justifying an authorization under section 564 of the FD&C Act, FDA may authorize the emergency use of a drug, device, or biological product if the Agency concludes that the statutory criteria are satisfied. Under section 564(h)(1) of the FD&C Act, FDA is required to publish in the Federal Register a notice of each authorization, and each termination or revocation of an authorization, and an explanation can ventolin be purchased over the counter of the reasons for the action. Section 564 of the FD&C Act permits FDA to authorize the introduction into interstate commerce of a drug, device, or biological product intended for use when the Secretary of HHS has declared that circumstances exist justifying the authorization of emergency use.

Products appropriate for emergency use may include products and uses that are not approved, cleared, or licensed under section 505, 510(k), 512, or 515 of the FD&C Act (21 U.S.C. 355, 360(k), 360b, or 360e) or can ventolin be purchased over the counter section 351 of the PHS Act (42 U.S.C. 262), or conditionally approved under section 571 of the FD&C Act (21 U.S.C. 360ccc). FDA may issue an EUA only if, after consultation with the HHS Assistant Secretary for Preparedness can ventolin be purchased over the counter and Response, the Director of the National Institutes of Health, and the Director of the Centers for Disease Control and Prevention (to the extent feasible and appropriate given the applicable circumstances), FDA [] concludes.

(1) That an agent referred to in a declaration of emergency or threat can cause a serious or life-threatening disease or condition. (2) that, based on the totality of scientific evidence available to FDA, including data from adequate and well-controlled clinical trials, if available, it is reasonable to believe that (A) the product may be effective in diagnosing, treating, or preventing (i) such disease or condition. Or (ii) a serious can ventolin be purchased over the counter or life-threatening disease or condition caused by a product authorized under section 564, approved or cleared under the FD&C Act, or licensed under section 351 of the PHS Act, for diagnosing, treating, or preventing such a disease or condition caused by such an agent. And (B) the known and potential benefits of the product, when used to diagnose, prevent, or treat such disease or condition, outweigh the known and potential risks of the product, taking into consideration the material threat posed by the agent or agents identified in a declaration under section 564(b)(1)(D) of the FD&C Act, if applicable. (3) that there is no adequate, approved, and available alternative to the product for diagnosing, preventing, or treating such disease or condition.

(4) in the case of a determination described in section 564(b)(1)(B)(ii), that the request can ventolin be purchased over the counter for emergency use is made by the Secretary of Defense. And (5) that such other criteria as may be prescribed by regulation are satisfied. No other criteria for issuance have been prescribed by regulation under section 564(c)(4) of the FD&C Act. III. Electronic Access An electronic version of this document and the full text of the Authorizations are available on the internet at https://www.fda.gov/​emergency-preparedness-and-response/​mcm-legal-regulatory-and-policy-framework/​emergency-use-authorization.

IV. The Authorizations Having concluded that the criteria for the issuance and, in some cases reissuance, of the following Authorizations under section 564(c) of the FD&C Act are met, FDA has authorized the emergency use of the following products for diagnosing, treating, or preventing asthma treatment subject to the terms of each Authorization. The Authorizations in their entirety, including any authorized fact sheets and other written materials, are available on the internet from the FDA web page entitled “Emergency Use Authorization,” available at https://www.fda.gov/​emergency-preparedness-and-response/​mcm-legal-regulatory-and-policy-framework/​emergency-use-authorization. The lists that follow include Authorizations issued, in some cases reissued, from May 16, 2020, through September 14, 2020, and we have included explanations of the reasons for their issuance, as required by section 564(h)(1) of the FD&C Act. FDA is hereby announcing the following Authorizations for molecular diagnostic Start Printed Page 74348and antigen tests for asthma treatment, excluding multianalyte tests: [] Color Genomics, Inc.'s Color asthma LAMP Diagnostic Assay, issued May 18, 2020, and reissued July 24, 2020.

Quidel Corp.'s Lyra Direct asthma Assay, issued May 18, 2020. P23 Labs, LLC's P23 Labs TaqPath SARSd-CoV-2 Assay, issued May 21, 2020, and reissued July 10, 2020. SEASUN BIOMATERIALS, Inc.'s AQ-TOP asthma treatment Rapid Detection Kit, issued May 21, 2020. SolGent Co., Ltd.'s DiaPlexQ Novel asthma (2019-nCoV) Detection Kit, issued May 21, 2020. BioCore Co., Ltd.'s BioCore 2019-nCoV Real Time PCR Kit, issued May 21, 2020.

Exact Sciences Laboratories' SARSd-CoV-2 (N gene detection) Test, issued May 22, 2020, and reissued August 3, 2020. Dba SpectronRx's Hymon SARSd-CoV-2 Test Kit, issued May 22, 2020. PrivaPath Diagnostics, Inc.'s LetsGetChecked asthma (asthma treatment) Test, issued May 28, 2020, and reissued August 14, 2020. Gravity Diagnostics, LLC's Gravity Diagnostics asthma treatment Assay, issued June 1, 2020. Phosphorus Diagnostics LLC's Phosphorus asthma treatment RT-qPCR Test, issued June 4, 2020.

Genetron Health (Beijing) Co., Ltd.'s Genetron SARSd-CoV-2 RNA Test, issued June 5, 2020. Euroimmun US Inc.'s EURORealTime SARSd-CoV-2, issued June 8, 2020. ChromaCode Inc.'s HDPCR SARSd-CoV-2 Assay, issued June 9, 2020. Illumina, Inc.'s Illumina asthma treatmentSeq Test, issued June 9, 2020. Tide Laboratories, LLC's DTPM asthma treatment RT-PCR Test, issued June 10, 2020.

TBG Biotechnology Corp.'s ExProbe SARSd-CoV-2 Testing Kit, issued June 10, 2020. Cue Health, Inc.'s Cue asthma treatment Test, issued June 10, 2020. RTA Laboratories Biological Products Pharmaceutical and Machinery Industry's Diagnovital SARSd-CoV-2 Real-Time PCR Kit, issued June 12, 2020. Kaiser Permanente Mid-Atlantic States's KPMAS asthma treatment Test, issued June 13, 2020, and reissued September 9, 2020. Applied BioCode, Inc.'s BioCode SARSd-CoV-2 Assay, issued June 15, 2020.

The Ohio State University Wexner Medical Center's OSUWMC asthma treatment RT-PCR test, issued June 17, 2020. Omnipathology Solutions Medical Corp.'s Omni asthma treatment Assay by RT-PCR, issued June 17, 2020. Jiangsu Bioperfectus Technologies Co., Ltd.'s asthma treatment asthma Real Time PCR Kit, issued June 18, 2020. 3B Blackbio Biotech India Ltd., a subsidiary of Kilpest India Ltd.'s TRUPCR SARSd-CoV-2 Kit, issued June 18, 2020. HealthQuest Esoterics's HealthQuest Esoterics TaqPath SARSd-CoV-2 Assay, issued June 23, 2020.

University of Alabama at Birmingham Fungal Reference Lab's FRL SARS CoV-2 Test, issued June 23, 2020. Gencurix, Inc.'s GenePro SARSd-CoV-2 Test, issued June 23, 2020. University of Texas MD Anderson Cancer Center, Molecular Diagnostics Laboratory's MD Anderson High-throughput SARSd-CoV-2 RT-PCR Assay, issued June 24, 2020. Diagnostic Solutions Laboratory, LLC's DSL asthma treatment Assay, issued June 25, 2020. PreciGenome LLC's FastPlex Triplex SARSd-CoV-2 detection kit (RT-Digital PCR), issued June 25, 2020.

PlexBio Co., Ltd.'s IntelliPlex SARSd-CoV-2 Detection Kit, issued June 25, 2020. Inform Diagnostics, Inc.'s Inform Diagnostics SARSd-CoV-2 RT-PCR Assay, issued June 26, 2020. Acupath Laboratories, Inc.'s Acupath asthma treatment Real-Time (RT-PCR) Assay, issued June 29, 2020. LifeHope Labs' LifeHope 2019-nCoV Real-Time RT-PCR Diagnostic Panel, issued June 29, 2020. Psomagen, Inc.'s Psoma asthma treatment RT Test, issued June 30, 2020.

TNS Co., Ltd.'s (Bio TNS) asthma treatment RT-PCR Peptide Nucleic Acid (PNA) kit, issued June 30, 2020. The Kroger Co.'s Kroger Health asthma treatment Test Home Collection Kit, issued June 30, 2020. CENTOGENE US, LLC's CentoFast-SARSd-CoV-2 RT-PCR Assay, issued July 1, 2020. Becton, Dickinson and Co.'s BD Veritor System for Rapid Detection of SARSd-CoV-2, issued July 2, 2020. Laboratorio Clinico Toledo's Laboratorio Clinico Toledo SARSd-CoV-2 Assay, issued July 6, 2020.

Gene By Gene's Gene By Gene SARSd-CoV-2 Detection Test, issued July 7, 2020. Access Bio, Inc.'s CareStart asthma treatment MDx RT-PCR, issued July 7, 2020. Enzo Life Sciences, Inc.'s AMPIPROBE SARSd-CoV-2 Test System, issued July 7, 2020. Clinical Research Sequencing Platform (CRSP), LLC at the Broad Institute of MIT and Harvard's CRSP SARSd-CoV-2 Real-time Reverse Transcriptase (RT)-PCR Diagnostic Assay, issued July 8, 2020. BioSewoom, Inc.'s Real-Q 2019-nCoV Detection Kit, issued July 9, 2020.

UCSF Health Clinical Laboratories, UCSF Clinical Labs at China Basin's SARSd-CoV-2 RNA DETECTR Assay, issued July 9, 2020. Boston Medical Center's BMC-CReM asthma treatment Test, issued July 10, 2020. KogeneBiotech Co., Ltd.'s PowerChek 2019-nCoV Real-time PCR Kit, issued July 13, 2020. Trax Management Services Inc.'s PhoenixDx SARSd-CoV-2 Multiplex, issued July 13, 2020. Compass Laboratory Services, LLC's Compass Laboratory Services SARSd-CoV2 Assay, issued July 13, 2020.

Quest Diagnostics Infectious Disease, Inc.'s Quest Diagnostics PF SARSd-CoV-2 Assay, issued July 15, 2020, and reissued August 21, 2020. Quest Diagnostics Infectious Disease, Inc.'s Quest Diagnostics RC SARSd-CoV-2 Assay, issued July 15, 2020, and reissued August 21, 2020. Quest Diagnostics Infectious Disease, Inc.'s Quest Diagnostics HA SARSd-CoV-2 Assay, issued July 15, 2020, and reissued August 21, 2020. Boston Heart Diagnostics' Boston Heart asthma treatment RT-PCR Test, issued July 16, 2020. Access Genetics, LLC's OraRisk asthma treatment RT-PCR, issued July 17, 2020.

DiaCarta, Inc.'s Quantiventolin SARSd-CoV-2 Multiplex Test Kit, issued July 21, 2020. Helix OpCo LLC's (dba Helix's) Helix asthma treatment Test, issued July 23, 2020. Jiangsu CoWin Biotech Co., Ltd.'s Novel asthma (SARSd-CoV-2) Fast Nucleic Acid Detection Kit (PCR-Fluorescence Probing), issued July 24, 2020. LabCorp's asthma treatment RT-PCR Test, reissued July 24, 2020 (original issuance March 16, 2020). Eli Lilly and Co.'s Lilly SARSd-CoV-2 Assay, issued July 27, 2020;Start Printed Page 74349 Sandia National Laboratories' SNL-NM 2019 nCoV Real-Time RT-PCR Diagnostic Assay, issued July 27, 2020.

Clinical Reference Laboratory, Inc.'s CRL Rapid Response, issued July 30, 2020. University of California San Diego Health's UCSD RC SARSd-CoV-2 Assay, issued July 31, 2020. Xiamen Zeesan Biotech Co., Ltd.'s SARSd-CoV-2 Test Kit (Real-time PCR), issued July 31, 2020. ISPM Labs, LLC dba Capstone Healthcare's Genus SARSd-CoV-2 Assay, issued August 3, 2020. Poplar Healthcare's Poplar SARSd-CoV-2 TMA Pooling assay, issued August 3, 2020.

Cleveland Clinic Robert J. Tomsich Pathology and Laboratory Medicine Institute's Cleveland Clinic SARSd-CoV-2 Assay, issued August 3, 2020. Ethos Laboratories' Ethos Laboratories SARSd-CoV-2 MALDI-TOF Assay, issued August 3, 2020. Wren Laboratories LLC's Wren Laboratories asthma treatment PCR Test, issued August 3, 2020. Vela Operations Singapore Pte Ltd.'s ViroKey SARSd-CoV-2 RT-PCR Test, issued August 5, 2020.

Helix OpCo LLC's (dba Helix) Helix asthma treatment NGS Test, issued August 6, 2020. George Washington University Public Health Laboratory's GWU SARSd-CoV-2 RT-PCR Test, issued August 7, 2020. Quest Diagnostics Infectious Disease, Inc.'s SARSd-CoV-2 RNA, Qualitative Real-Time RT-PCR, reissued August 7, 2020 (original issuance March 17, 2020). Alpha Genomix Laboratories' Alpha Genomix TaqPath SARSd-CoV-2 Combo Assay, issued August 10, 2020. Solaris Diagnostics' Solaris Multiplex SARSd-CoV-2 Assay, issued August 10, 2020.

Biomeme, Inc.'s Biomeme SARSd-CoV-2 Real-Time RT-PCR Test, issued August 11, 2020. LumiraDx UK Ltd.'s LumiraDx asthma RNA STAR, issued August 11, 2020. Pro-Lab Diagnostics' Pro-AmpRT SARSd-CoV-2 Test, issued August 13, 2020. Yale School of Public Health, Department of Epidemiology of Microbial Diseases' SalivaDirect, issued August 15, 2020, and reissued August 28, 2020. ZhuHai Sinochips Bioscience Co., Ltd.'s asthma treatment Nucleic Acid RT-PCR Test Kit, issued August 17, 2020.

LumiraDx UK Ltd.'s LumiraDx SARSd-CoV-2 Ag Test, issued August 18, 2020. Assurance Scientific Laboratories' Assurance SARSd-CoV-2 Panel, reissued August 19, 2020 (original issuance May 15, 2020). Guardant Health, Inc.'s Guardant-19, issued August 21, 2020. DxTerity Diagnostics, Inc.'s DxTerity SARSd-CoV-2 RT-PCR Test, issued August 21, 2020. Texas Department of State Health Services, Laboratory Services Section's Texas Department of State Health Services SARSd-CoV-2 Assay, issued August 21, 2020.

Fluidigm Corp.'s Advanta Dx SARSd-CoV-2 RT-PCR Assay, issued August 25, 2020. QDx Pathology Services' QDX SARSd-CoV-2 Assay, issued August 25, 2020. Cuur Diagnostics' Cuur Diagnostics SARSd-CoV-2 Molecular Assay, issued August 26, 2020. Abbott Diagnostics Scarborough, Inc.'s BinaxNOW asthma treatment Ag Card, issued August 26, 2020. Patients Choice Laboratories, LLC's PCL SARSd-CoV-2 Real-Time RT-PCR Assay, issued August 28, 2020.

DxTerity Diagnostics, Inc.'s DxTerity SARSd-CoV-2 RT PCR CE Test, issued August 28, 2020. T2 Biosystems, Inc.'s T2SARSd-CoV-2 Panel, issued August 31, 2020. MiraDx's MiraDx SARSd-CoV-2 RT-PCR assay, issued August 31, 2020. Mammoth Biosciences, Inc.'s SARSd-CoV-2 DETECTR Reagent Kit, issued August 31, 2020. BayCare Laboratories, LLC's BayCare SARSd-CoV-2 RT PCR Assay, issued August 31, 2020.

Detectachem Inc.'s MobileDetect Bio BCC19 (MD-Bio BCC19) Test Kit, issued September 1, 2020. OPTOLANE Technologies, Inc.'s Kaira 2019-nCoV Detection Kit, issued September 1, 2020. Bioeksen R&D Technologies Ltd.'s Bio-Speedy Direct RT-qPCR SARSd-CoV-2, issued September 2, 2020. BillionToOne, Inc.'s qSanger-asthma treatment Assay, issued September 4, 2020. Verily Life Sciences' Verily asthma treatment RT-PCR Test, issued September 8, 2020.

And Beijing Wantai Biological Pharmacy Enterprise Co., Ltd.'s Wantai SARSd-CoV-2 RT-PCR Kit, issued September 9, 2020. FDA is hereby announcing the following Authorizations for serology tests: [] Healgen Scientific LLC's asthma treatment IgG/IgM Rapid Test Cassette (Whole Blood/Serum/Plasma), issued May 29, 2020. Siemens Healthcare Diagnostics Inc.'s Atellica IM SARSd-CoV-2 Total (COV2T), issued May 29, 2020. Siemens Healthcare Diagnostics Inc.'s ADVIA Centaur SARSd-CoV-2 Total (COV2T), issued May 29, 2020. Hangzhou Biotest Biotech Co., Ltd.'s RightSign asthma treatment IgG/IgM Rapid Test Cassette, issued June 4, 2020.

Vibrant America Clinical Labs' Vibrant asthma treatment Ab Assay, issued June 4, 2020. Siemens Healthcare Diagnostics Inc.'s Dimension Vista SARSd-CoV-2 Total antibody assay (COV2T), issued June 8, 2020. Siemens Healthcare Diagnostics Inc.'s Dimension EXL SARSd-CoV-2 Total antibody assay (CV2T), issued June 8, 2020. InBios International, Inc.'s SCoV-2 Detect IgG ELISA [enzyme-linked immunosorbent assay], issued June 10, 2020. Cellex Inc.'s qSARSd-CoV-2 IgG/IgM Rapid Test, reissued June 12, 2020 (original issuance April 1, 2020).

Emory Medical Laboratories' SARSd-CoV-2 RBD IgG test, issued June 15, 2020. Biohit Healthcare (Hefei) Co. Ltd.'s Biohit SARSd-CoV-2 IgM/IgG Antibody Test Kit, issued June 18, 2020. Hangzhou Laihe Biotech Co., Ltd.'s LYHER Novel asthma (2019-nCoV) IgM/IgG Antibody Combo Test Kit (Colloidal Gold), issued June 19, 2020. Babson Diagnostics, Inc.'s Babson Diagnostics aC19G1, issued June 23, 2020.

Beckman Coulter, Inc.'s Access SARSd-CoV-2 IgG, issued June 26, 2020. InBios International, Inc.'s SCoV-2 Detect IgM ELISA, issued June 30, 2020. Assure Tech.'s (Hangzhou Co., Ltd.) Assure asthma treatment IgG/IgM Rapid Test Device, issued July 6, 2020. Diazyme Laboratories, Inc.'s Diazyme DZ-Lite SARSd-CoV-2 IgG CLIA Kit, issued July 8, 2020. Beijing Wantai Biological Pharmacy Enterprise Co., Ltd.'s WANTAI SARSd-CoV-2 Ab Rapid Test, July 10, 2020;Start Printed Page 74350 Salofa Oy's Sienna-Clarity COVIBLOCK asthma treatment IgG/IgM Rapid Test Cassette, issued July 13, 2020.

Luminex Corp.'s xMAP SARSd-CoV-2 Multi-Antigen IgG Assay, issued July 16, 2020. Megna Health, Inc.'s Rapid asthma treatment IgM/IgG Combo Test Kit, issued July 17, 2020. Access Bio, Inc.'s CareStart asthma treatment IgM/IgG, issued July 24, 2020. Xiamen Biotime Biotechnology Co., Ltd.'s BIOTIME SARSd-CoV-2 IgG/IgM Rapid Qualitative Test, issued July 24, 2020. Siemens Healthcare Diagnostics Inc.'s ADVIA Centaur SARSd-CoV-2 IgG (COV2G), issued July 31, 2020.

Siemens Healthcare Diagnostics Inc.'s Atellica IM SARSd-CoV-2 IgG (COV2G), issued July 31, 2020. Beijing Wantai Biological Pharmacy Enterprise Co., Ltd.'s WANTAI SARSd-CoV-2 Ab ELISA, issued August 5, 2020. BioMérieux SA's VIDAS SARSd-CoV-2 IgM, issued August 6, 2020. BioMérieux SA's VIDAS SARSd-CoV-2 IgG, issued August 6, 2020. Diazyme Laboratories, Inc.'s Diazyme DZ-Lite SARSd-CoV-2 IgM CLIA Kit, issued August 17, 2020.

BioCheck, Inc.'s BioCheck SARSd-CoV-2 IgG and IgM Combo Test, issued August 17, 2020. Biocan Diagnostics Inc.'s Tell Me Fast Novel asthma (asthma treatment) IgG/IgM Antibody Test, issued August 25, 2020. TBG Biotechnology Corp.'s TBG SARSd-CoV-2 IgG/IgM Rapid Test Kit, issued August 31, 2020. University of Arizona Genetics Core for Clinical Services' asthma treatment ELISA pan-Ig Antibody Test, issued August 31, 2020. Sugentech, Inc.'s SGTi-flex asthma treatment IgG, issued September 3, 2020.

BioCheck, Inc.'s BioCheck asthma IgG Antibody Test Kit, issued September 9, 2020. BioCheck, Inc.'s BioCheck asthma IgM Antibody Test Kit, issued September 9, 2020. And Shenzhen New Industries Biomedical Engineering Co., Ltd.'s MAGLUMI 2019-nCoV IgM/IgG, issued September 14, 2020. FDA is hereby announcing the following Authorizations for multianalyte in vitro diagnostics: [] Centers for Disease Control and Prevention's Influenza asthma (Flu SC2) Multiplex Assay, issued July 2, 2020. Roche Molecular Systems, Inc.'s cobas asthma &.

Influenza A/B, issued September 3, 2020. And Roche Molecular Systems, Inc.'s cobas asthma &. Influenza A/B Nucleic Acid Test for use on the cobas Liat System, issued September 14, 2020. FDA is hereby announcing the following Authorizations for personal respiratory protective devices: [] FDA is hereby announcing the following Authorizations for other medical devices. Baxter Healthcare Corp.'s Prismaflex ST Set, issued May 20, 2020; [] STERIS Corp.'s AMSCO Medium Steam Sterilizers + the STERIS STEAM Decon Cycle, issued May 21, 2020; [] Certain Gowns and Other Apparel, issued May 22, 2020; [] CLEW Medical Ltd.'s CLEWICU System, issued May 26, 2020; [] Abiomed, Inc.'s Impella RP System, issued May 29, 2020; [] Start Printed Page 74351 Roche Diagnostics' Elecsys IL-6, issued on June 2, 2020; [] Battelle Memorial Institute's Battelle CCDS Critical Care Decontamination System (“Batelle Decontamination System”), reissued June 6, 2020 [] (original issuance March 29, 2020).

STERIS Corp.'s STERIS Sterilization System, reissued June 6, 2020 [] (original issuance April 9, 2020). Stryker Instruments' STERIZONE VP4 N95 Respirator Decontamination Cycle, reissued June 6, 2020 [] (original issuance on April 14, 2020). Advanced Sterilization Products, Inc.'s (ASP) STERRAD 100S, NX, and 100NX Sterilization Systems (“ASP STERRAD Sterilization Systems”), reissued June 6, 2020 [] (original issuance April 11, 2020). Stryker Sustainability Solutions' (SSS) SSS VHP N95 Respirator Decontamination System, issued May 27, 2020, reissued June 6, 2020; [] Sterilucent, Inc.'s Sterilucent HC 80TT Hydrogen Peroxide Sterilizer (“Sterilucent Sterilization System”), reissued June 6, 2020 [] (original issuance April 20, 2020). Duke University Health System's Duke Decontamination System for Decontamination and Reuse of N95 Respirators with Hydrogen Peroxide Vapor (“Duke Decontamination System”), reissued June 6, 2020 [] (original issuance May 7, 2020).

Technical Safety Services LLC's 20-CS Decontamination System, issued June 13, 2020; [] Oceanetics, Inc.'s Negative-pressure Respiratory System with Advanced Ventilation Return (“NRSAVR-100”), issued June 13, 2020; [] US Army and MHS's asthma treatment Airway Management Isolation Chamber (CAMIC), issued May 19, 2020 and reissued to US Army Medical Research Development Command June 22, 2020; [] Start Printed Page 74352 electroCore, Inc.'s gammaCore Sapphire CV, issued July 10, 2020; [] Michigan State University Animal Care Program's MSU Decontamination System, issued July 24, 2020; [] IkonX, Inc.'s Airway Dome, issued July 24, 2020; [] Abiomed, Inc.'s Impella Left Ventricular (LV) Support Systems, issued August 3, 2020; [] Baxter Healthcare Corp.'s Prismaflex HF20 Set, issued August 10, 2020; [] NovaSterilis, Inc.'s Nova2200 using the NovaClean decontamination process for decontaminating compatible N95 respirators, issued August 20, 2020; [] and Color Genomics, Inc.'s Color asthma treatment Self-Swab Collection Kit, issued August 31, 2020.[] Start Signature Dated. November 13, 2020. Lauren K. Roth, Acting Principal Associate Commissioner for Policy. End Signature End Supplemental Information [FR Doc.

2020-25603 Filed 11-19-20. 8:45 am]BILLING CODE 4164-01-PBy Kelsie George Rural residents across the U.S. May be at higher risk for severe illness from asthma treatment due to the aging population, higher rates of underlying chronic disease, and higher likelihood of having a disability. Combined with limited health care infrastructure and greater travel times to access in-person care, these challenges limit access to critical health care for the approximately 20% of Americans that live in rural communities. Today, Nov.

19, is National Rural Health Day, an annual celebration of rural communities and their success in addressing their unique challenges in accessing and delivering health care services. This day is an opportunity to recognize the positive things that are taking place in rural health. For example, amid the asthma treatment ventolin, states are ensuring access to quality health care for rural residents through several policy strategies—such as bolstering telehealth services and supporting rural hospitals and health facilities. Bolstering Telehealth Access and Coverage Patients and providers are seeking opportunities to access and deliver health care services during the asthma treatment public health crisis. Bolstering telehealth access and coverage is one way states are enhancing access to care, especially for large rural populations.

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