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Heads Up - Changes Coming April 2021 Once again, NYS is changing the way http://amidism.com/how-to-get-ventolin-prescription/ people without Medicare access prescription drugs where can i buy ventolin nebules online. Since October 2011, most people who do not have Medicare obtained their drugs throug their Medicaid managed care plan. At that time, this drug benefit was "carved into" the Medicaid managed care benefit package.

Before that date, people enrolled where can i buy ventolin nebules online in a Medicaid managed care plan obtained all of their health care through the plan, but used their regular Medicaid card to access any drug available on the state formulary on a "fee for service" basis without needing to utilize a restricted pharmacy network or comply with managed care plan rules. COMING IN April 2021 - In the NYS Budget enacted in April 2020, the pharmacy benefit was "carved out" of "mainstream" Medicaid managed care plans. That means that members of managed care plans will access their drugs outside their plan, unlike the rest of their medical care, which is accessed from in-network providers.

How Prescription Drugs are Obtained through Managed Care plans No - Until April 2020 HOW DO MANAGED CARE where can i buy ventolin nebules online PLANS DEFINE THE PHARMACY BENEFIT FOR CONSUMERS?. The Medicaid pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies. Under Medicaid managed care.

Plan where can i buy ventolin nebules online formularies will be comparable to but not the same as the Medicaid formulary. Managed care plans are required to have drug formularies that are “comparable” to the Medicaid fee for service formulary. Plan formularies do not have to include all drugs covered listed on the fee for service formulary, but they must include generic or therapeutic equivalents of all Medicaid covered drugs.

The Pharmacy where can i buy ventolin nebules online Benefit will vary by plan. Each plan will have its own formulary and drug coverage policies like prior authorization and step therapy. Pharmacy networks can also differ from plan to plan.

Prescriber Prevails where can i buy ventolin nebules online applies in certain drug classes. Prescriber prevails applys to medically necessary precription drugs in the following classes. atypical antipsychotics, anti-depressants, anti-retrovirals, anti-rejection, seizure, epilepsy, endocrine, hemotologic and immunologic therapeutics.

Prescribers will need to demonstrate reasonable profession judgment where can i buy ventolin nebules online and supply plans witht requested information and/or clinical documentation. Pharmacy Benefit Information Website -- http://mmcdruginformation.nysdoh.suny.edu/-- This website provides very helpful information on a plan by plan basis regarding pharmacy networks and drug formularies. The Department of Health plans to build capacity for interactive searches allowing for comparison of coverage across plans in the near future.

Standardized Prior Autorization (PA) Form -- The Department of Health worked with managed care plans, provider organizations and other state agencies to develop a standard prior authorization form for the where can i buy ventolin nebules online pharmacy benefit in Medicaid managed care. The form will be posted on the Pharmacy Information Website in July of 2013. Mail Order Drugs -- Medicaid managed care members can obtain mail order/specialty drugs at any retail network pharmacy, as long as that retail network pharmacy agrees to a price that is comparable to the mail order/specialty pharmacy price.

CAN CONSUMERS SWITCH PLANS IN ORDER TO GAIN ACCESS where can i buy ventolin nebules online TO DRUGS?. Changing plans is often an effective strategy for consumers eligible for both Medicaid and Medicare (dual eligibles) who receive their pharmacy service through Medicare Part D, because dual eligibles are allowed to switch plans at any time. Medicaid consumers will have this option only in the limited circumstances during the first year of enrollment in managed care.

Medicaid managed care enrollees can only leave and join where can i buy ventolin nebules online another plan within the first 90 days of joining a health plan. After the 90 days has expired, enrollees are “locked in” to the plan for the rest of the year. Consumers can switch plans during the “lock in” period only for good cause.

The pharmacy where can i buy ventolin nebules online benefit changes are not considered good cause. After the first 12 months of enrollment, Medicaid managed care enrollees can switch plans at any time. STEPS CONSUMERS CAN TAKE WHEN A MANAGED CARE PLAM DENIES ACCESS TO A NECESSARY DRUG As a first step, consumers should try to work with their providers to satisfy plan requirements for prior authorization or step therapy or any other utilization control requirements.

If the plan still denies access, consumers can pursue review processes specific to managed care while at the same time pursuing a where can i buy ventolin nebules online fair hearing. All plans are required to maintain an internal and external review process for complaints and appeals of service denials. Some plans may develop special procedures for drug denials.

Information on these procedures should be provided in member where can i buy ventolin nebules online handbooks. Beginning April 1, 2018, Medicaid managed care enrollees whose plan denies prior approval of a prescription drug, or discontinues a drug that had been approved, will receive an Initial Adverse Determination notice from the plan - See Model Denial IAD Notice and IAD Notice to Reduce, Suspend or Stop Services The enrollee must first request an internal Plan Appeal and wait for the Plan's decision. An adverse decision is called a 'FInal Adverse Determination" or FAD.

See model Denial FAD Notice where can i buy ventolin nebules online and FAD Notice to Reduce, Suspend or Stop Services. The enroll has the right to request a fair hearing to appeal an FAD. The enrollee may only request a fair hearing BEFORE receiving the FAD if the plan fails to send the FAD in the required time limit, which is 30 calendar days in standard appeals, and 72 hours in expedited appeals.

The plan may extend the where can i buy ventolin nebules online time to decide both standard and expedited appeals by up to 14 days if more information is needed and it is in the enrollee's interest. AID CONTINUING -- If an enrollee requests a Plan Appeal and then a fair hearing because access to a drug has been reduced or terminated, the enrollee has the right to aid continuing (continued access to the drug in question) while waiting for the Plan Appeal and then the fair hearing. The enrollee must request the Plan Appeal and then the Fair Hearing before the effective date of the IAD and FAD notices, which is a very short time - only 10 days including mailing time.

See more about where can i buy ventolin nebules online the changes in Managed Care appeals here. Even though that article is focused on Managed Long Term Care, the new appeals requirements also apply to Mainstream Medicaid managed care. Enrollees who are in the first 90 days of enrollment, or past the first 12 months of enrollment also have the option of switching plans to improve access to their medications.

Consumers who experience problems with access to prescription drugs should always file where can i buy ventolin nebules online a complaint with the State Department of Health’s Managed Care Hotline, number listed below. ACCESSING MEDICAID'S PHARMACY BENEFIT IN FEE FOR SERVICE MEDICAID For those Medicaid recipients who are not yet in a Medicaid Managed Care program, and who do not have Medicare Part D, the Medicaid Pharmacy program covers most of their prescription drugs and select non-prescription drugs and medical supplies for Family Health Plus enrollees. Certain drugs/drug categories require the prescribers to obtain prior authorization.

These include brand name drugs that have a generic where can i buy ventolin nebules online alternative under New York's mandatory generic drug program or prescribed drugs that are not on New York's preferred drug list. The full Medicaid formulary can be searched on the eMedNY website. Even in fee for service Medicaid, prescribers must obtain prior authorization before prescribing non-preferred drugs unless otherwise indicated.

Prior authorization is required for original prescriptions, not refills where can i buy ventolin nebules online. A prior authorization is effective for the original dispensing and up to five refills of that prescription within the next six months. Click here for more information on NY's prior authorization process.

The New York State where can i buy ventolin nebules online Board of Pharmacy publishes an annual list of the 150 most frequently prescribed drugs, in the most common quantities. The State Department of Health collects retail price information on these drugs from pharmacies that participate in the Medicaid program. Click here to search for a specific drug from the most frequently prescribed drug list and this site can also provide you with the locations of pharmacies that provide this drug as well as their costs.

Click here to view New where can i buy ventolin nebules online York State Medicaid’s Pharmacy Provider Manual. WHO YOU CAN CALL FOR HELP Community Health Advocates Hotline. 1-888-614-5400 NY State Department of Health's Managed Care Hotline.

1-800-206-8125 where can i buy ventolin nebules online (Mon. - Fri. 8:30 am - 4:30 pm) NY State Department of Insurance.

1-800-400-8882 NY State Attorney General's Health where can i buy ventolin nebules online Care Bureau. 1-800-771-7755Haitian individuals and immigrants from some other countries who have applied for Temporary Protected Status (TPS) may be eligible for public health insurance in New York State. 2019 updates - The Trump administration has taken steps to end TPS status.

Two courts have temporarily enjoined the where can i buy ventolin nebules online termination of TPS, one in New York State in April 2019 and one in California in October 2018. The California case was argued in an appeals court on August 14, 2019, which the LA Times reported looked likely to uphold the federal action ending TPS. See US Immigration Website on TPS - General TPS website with links to status in all countries, including HAITI.

See also Pew where can i buy ventolin nebules online Research March 2019 article. Courts Block Changes in Public charge rule- See updates on the Public Charge rule here, blocked by federal court injunctions in October 2019. Read more about this change in public charge rules here.

What is Temporary Protected where can i buy ventolin nebules online Status?. TPS is a temporary immigration status granted to eligible individuals of a certain country designated by the Department of Homeland Security because serious temporary conditions in that country, such as armed conflict or environmental disaster, prevents people from that country to return safely. On January 21, 2010 the United States determined that individuals from Haiti warranted TPS because of the devastating earthquake that occurred there on January 12.

TPS gives undocumented Haitian residents, who were living in where can i buy ventolin nebules online the U.S. On January 12, 2010, protection from forcible deportation and allows them to work legally. It is important to note that the U.S.

Grants TPS to individuals from other countries, as well, including individuals from El Salvador, Honduras, Nicaragua, Somalia where can i buy ventolin nebules online and Sudan. TPS and Public Health Insurance TPS applicants residing in New York are eligible for Medicaid and Family Health Plus as long as they also meet the income requirements for these programs. In New York, applicants for TPS are considered PRUCOL immigrants (Permanently Residing Under Color of Law) for purposes of medical assistance eligibility and thus meet the immigration status requirements for Medicaid, Family Health Plus, and the Family Planning Benefit Program.

Nearly all children in New York remain eligible for Child where can i buy ventolin nebules online Health Plus including TPS applicants and children who lack immigration status. For more information on immigrant eligibility for public health insurance in New York see 08 GIS MA/009 and the attached chart. Where to Apply What to BringIndividuals who have applied for TPS will need to bring several documents to prove their eligibility for public health insurance.

Individuals will where can i buy ventolin nebules online need to bring. 1) Proof of identity. 2) Proof of residence in New York.

3) Proof of income where can i buy ventolin nebules online. 4) Proof of application for TPS. 5) Proof that U.S.

Citizenship and Immigration where can i buy ventolin nebules online Services (USCIS) has received the application for TPS. Free Communication Assistance All applicants for public health insurance, including Haitian Creole speakers, have a right to get help in a language they can understand. All Medicaid offices and enrollers are required to offer free translation and interpretation services to anyone who cannot communicate effectively in English.

A bilingual worker or an interpreter, whether in-person or over the telephone, must be provided in all where can i buy ventolin nebules online interactions with the office. Important documents, such as Medicaid applications, should be translated either orally or in writing. Interpreter services must be offered free of charge, and applicants requiring interpreter services must not be made to wait unreasonably longer than English speaking applicants.

An applicant must never where can i buy ventolin nebules online be asked to bring their own interpreter. Related Resources on TPS and Public Health Insurance o The New York Immigration Coalition (NYIC) has compiled a list of agencies, law firms, and law schools responding to the tragedy in Haiti and the designation of Haiti for Temporary Protected Status. A copy of the list is posted at the NYIC’s website at http://www.thenyic.org.

o USCIS TPS website with links to status in all countries, including HAITI. O For information on eligibility for public health insurance programs call The Legal Aid Society’s Benefits Hotline 1-888-663-6880 Tuesdays, Wednesdays and Thursdays. 9:30 am - 12:30 pm FOR IMMIGRATION HELP.

CONTACT THE New York State New Americans Hotline for a referral to an organization to advise you. 212-419-3737 Monday-Friday, from 9:00 a.m. To 8:00 p.m.Saturday-Sunday, from 9:00 a.m.

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Welcome to the December edition of Emergency Medicine Journal, the liquid ventolin for toddlers https://www.novainstitute.net.au/cialis-with-viagra-together final one for 2020. This has been an ‘interesting’ year for Emergency Physicians and their departments, with many changes to working practices. We hope you are keeping well liquid ventolin for toddlers in these uncertain times.Vascular accessThe Editor’s choice this month is a randomised controlled trial (Chauvin et al) wherein patients requiring blood gas measurement were randomised to arterial or venous sampling.

While the findings of less pain and increased ease for venous sampling might not be surprising, it is surprising that the clinical utility of the biochemical data (as assessed by treating physician) is equivalent. This provides further evidence to support the move to venous blood gases for most patients.Vascular access liquid ventolin for toddlers in paediatric patients is the focus of Girotto et als’ paper, which validates predictive rules (DIVA and DIVA3) for difficult venous access. Of interest are the additional factors (nurse assessment of difficulty, and dehydration status of moderate severity or more) which identified difficult access when the rule had not predicted difficulty in siting a venous cannula.Targets.

Achievement and effectsThere liquid ventolin for toddlers has long been intense debate regarding the use of quality metrics to assess performance of Emergency Departments (cf the ‘Goodhart principle’). A number of papers in this month’s EMJ look at ‘targets’- the effect the presence of targets can have, and the ramifications of attempts to achieve targets.Sethi et al have used a ‘before and after’ study design to retrospectively assess the effect on Emergency Department Clinical Quality Indicators of hospital-wide interventions to improve patient flow through the hospital (the ‘Reader’s choice’ for this month). An improvement in the Emergency Department quality indicators liquid ventolin for toddlers was demonstrated when a programme designed to improve patient flow through the hospital was undertaken.

The authors suggest that this programme may have resulted in a hospital-wide focus on the issue of ‘exit block’ and this may have had a significant effect, by changing the ‘culture’ of the hospital.This is complemented neatly by two further papers in this month’s EMJ. First, Paling et al, looks at liquid ventolin for toddlers waiting times in Emergency Departments, using routinely collected hospital data. This paper suggests that higher bed occupancy, and higher numbers of long stay patients, increases the number of patients who remain in the Emergency Department beyond the ‘4 hour target (for England)’.

Second, Man et al studied the long waiting times for Emergency Medical Services (EMS), due to delayed handover from ambulance to the Emergency Department (referred to as ‘ambulance ramping’). The interventions within the Emergency Department designed to improve achievement of the ‘4 hour target (for Australia)’ also reduced EMS liquid ventolin for toddlers wait times. As with the Sethi paper, improving patient flow has a wider reaching impact.Another paper related to this topic is a validation of the NEDOCS overcrowding score, by Hargreaves et al.

This paper assesses this tool against clinician perception of crowding and patient liquid ventolin for toddlers safety. The relationship between changes in overcrowding score and clinician’s perception was assessed, and refinements to the score suggested. The differences between physician and nurse perceptions of crowding and safety are intriguing, however the ‘bottom line’ may be that the search continues for the perfect scoring system for liquid ventolin for toddlers crowding.Mental health in the emergency departmentA cross-sectional study of Emergency Department attendances across England (Baracaia et al) is discussed in Catherine Hayhurst’s commentary.

This reminds us of the high prevalence of patients presenting with mental health symptoms to our departments, and stimulates thought about how we can better meet their needs. This is further illustrated by the papers looking at care pathways for patients with self-harm who liquid ventolin for toddlers use ambulance services (Zayed at al), and the mental health triage tool derived using a Delphi study by Mackway-Jones.Emergency departments and asthma treatmentThis month sees three papers related to asthma treatment. Walton et al describe some of the key themes from an operational perspective, faced by UK Emergency Departments.

These themes will be familiar to many readers, as will some of the suggested solutions to the challenges.Choudhary and colleagues have looked at changes in liquid ventolin for toddlers clinical presentation of cardiovascular emergencies (acute coronary syndromes, rhythm disturbances and acute heart failure) and their management during the ventolin. While the changes in patient behaviour (eg, reduced attendance) are well known, the changes in clinician behaviour (eg, increased use of thrombolysis) are not.The third paper describes changing patterns of Paediatric attendances to Emergency Departments in Canada during the ventolin (Goldman et al). The findings here will chime with us all.A simple communication toolA personal favourite of mine (notwithstanding a conflict liquid ventolin for toddlers of interest!.

), is a report on a quality improvement initiative by Taher and colleagues. This project looked at reducing patient anxiety and improving patient satisfaction in the ‘rapid assessment’ area of a busy Emergency Department. This paper has much to commend it liquid ventolin for toddlers.

Involvement of patients in the analysis of the issue, patient-centred metrics, and a neat description of control charts and their use. Moreover, the simple ‘AEI’ communication tool described is one that I find elegant, liquid ventolin for toddlers effective and have adopted into my practice.Emergency mental health is part of our core business, although emergency department (ED) staff may have varying levels of comfort with this. We need to be as competent with the initial management of a patient with a mental health crisis as we are with trauma, sepsis or any other emergency.

To do this, we need compassion and empathy underpinned by systems and liquid ventolin for toddlers training for all our staff. Our attitudes to patients in crisis are often the key to improvements in care. If we are honest, some ED liquid ventolin for toddlers staff are fearful and worry that what they say may make a patient feel worse.

Others may resent patients who come repeatedly in crisis. It helps to consider these patients just as we would patients with asthma or liquid ventolin for toddlers diabetes who may also come ‘in crisis’. Our role is to help get them through that crisis, with kindness and competence.A detailed look at Hospital Episode Statistics (HES) for England 2013/2014 by Baracaia et al in EMJ show that 4.9% of all ED attendances were coded as having a primary mental health diagnosis.1 Cumulative HES data have shown an average increase in mental health attendances of 11% per year since 20132 (figure 1) far in excess of total ED attendance increase (figure 2).

National data from the USA show a 40.8% increase in ED visits for adult with a mental health presentation from 2009 to 2015.3 US paediatric visits for the same period rose by 56.5%3 and a worrying 2.5-fold increase over 3 years in the USA is reported for adolescents ED ….

Welcome to the December edition of https://www.novainstitute.net.au/cialis-with-viagra-together Emergency Medicine Journal, the final one for where can i buy ventolin nebules online 2020. This has been an ‘interesting’ year for Emergency Physicians and their departments, with many changes to working practices. We hope you are keeping well in these uncertain times.Vascular accessThe Editor’s choice this month is a randomised controlled trial (Chauvin et al) wherein patients requiring blood gas measurement were randomised to where can i buy ventolin nebules online arterial or venous sampling. While the findings of less pain and increased ease for venous sampling might not be surprising, it is surprising that the clinical utility of the biochemical data (as assessed by treating physician) is equivalent. This provides further evidence to support the move to venous blood gases for most patients.Vascular access in paediatric patients is the focus of Girotto et als’ paper, which validates predictive rules (DIVA and DIVA3) where can i buy ventolin nebules online for difficult venous access.

Of interest are the additional factors (nurse assessment of difficulty, and dehydration status of moderate severity or more) which identified difficult access when the rule had not predicted difficulty in siting a venous cannula.Targets. Achievement and effectsThere has long been intense debate regarding the use of quality metrics to where can i buy ventolin nebules online assess performance of Emergency Departments (cf the ‘Goodhart principle’). A number of papers in this month’s EMJ look at ‘targets’- the effect the presence of targets can have, and the ramifications of attempts to achieve targets.Sethi et al have used a ‘before and after’ study design to retrospectively assess the effect on Emergency Department Clinical Quality Indicators of hospital-wide interventions to improve patient flow through the hospital (the ‘Reader’s choice’ for this month). An improvement in the Emergency Department quality indicators where can i buy ventolin nebules online was demonstrated when a programme designed to improve patient flow through the hospital was undertaken. The authors suggest that this programme may have resulted in a hospital-wide focus on the issue of ‘exit block’ and this may have had a significant effect, by changing the ‘culture’ of the hospital.This is complemented neatly by two further papers in this month’s EMJ.

First, Paling et where can i buy ventolin nebules online al, looks at waiting times in Emergency Departments, using routinely collected hospital data. This paper suggests that higher bed occupancy, and higher numbers of long stay patients, increases the number of patients who remain in the Emergency Department beyond the ‘4 hour target (for England)’. Second, Man et al studied the long waiting times for Emergency Medical Services (EMS), due to delayed handover from ambulance to the Emergency Department (referred to as ‘ambulance ramping’). The interventions within the Emergency Department designed to improve achievement of the ‘4 hour target (for Australia)’ also reduced EMS wait where can i buy ventolin nebules online times. As with the Sethi paper, improving patient flow has a wider reaching impact.Another paper related to this topic is a validation of the NEDOCS overcrowding score, by Hargreaves et al.

This paper assesses this tool against clinician perception where can i buy ventolin nebules online of crowding and patient safety. The relationship between changes in overcrowding score and clinician’s perception was assessed, and refinements to the score suggested. The differences between physician and nurse perceptions of crowding and safety are intriguing, however the ‘bottom line’ may be that the search continues for the perfect scoring system for crowding.Mental health in the emergency departmentA cross-sectional study of Emergency Department where can i buy ventolin nebules online attendances across England (Baracaia et al) is discussed in Catherine Hayhurst’s commentary. This reminds us of the high prevalence of patients presenting with mental health symptoms to our departments, and stimulates thought about how we can better meet their needs. This is further illustrated by the papers looking at care pathways for patients with self-harm who use ambulance services (Zayed at al), and the mental health triage tool where can i buy ventolin nebules online derived using a Delphi study by Mackway-Jones.Emergency departments and asthma treatmentThis month sees three papers related to asthma treatment.

Walton et al describe some of the key themes from an operational perspective, faced by UK Emergency Departments. These themes will be familiar to many readers, as will some where can i buy ventolin nebules online of the suggested solutions to the challenges.Choudhary and colleagues have looked at changes in clinical presentation of cardiovascular emergencies (acute coronary syndromes, rhythm disturbances and acute heart failure) and their management during the ventolin. While the changes in patient behaviour (eg, reduced attendance) are well known, the changes in clinician behaviour (eg, increased use of thrombolysis) are not.The third paper describes changing patterns of Paediatric attendances to Emergency Departments in Canada during the ventolin (Goldman et al). The findings here will chime with where can i buy ventolin nebules online us all.A simple communication toolA personal favourite of mine (notwithstanding a conflict of interest!. ), is a report on a quality improvement initiative by Taher and colleagues.

This project looked at reducing patient anxiety and improving patient satisfaction in the ‘rapid assessment’ area of a busy Emergency Department. This paper where can i buy ventolin nebules online has much to commend it. Involvement of patients in the analysis of the issue, patient-centred metrics, and a neat description of control charts and their use. Moreover, the where can i buy ventolin nebules online simple ‘AEI’ communication tool described is one that I find elegant, effective and have adopted into my practice.Emergency mental health is part of our core business, although emergency department (ED) staff may have varying levels of comfort with this. We need to be as competent with the initial management of a patient with a mental health crisis as we are with trauma, sepsis or any other emergency.

To do where can i buy ventolin nebules online this, we need compassion and empathy underpinned by systems and training for all our staff. Our attitudes to patients in crisis are often the key to improvements in care. If we are where can i buy ventolin nebules online honest, some ED staff are fearful and worry that what they say may make a patient feel worse. Others may resent patients who come repeatedly in crisis. It helps to consider these patients just as where can i buy ventolin nebules online we would patients with asthma or diabetes who may also come ‘in crisis’.

Our role is to help get them through that crisis, with kindness and competence.A detailed look at Hospital Episode Statistics (HES) for England 2013/2014 by Baracaia et al in EMJ show that 4.9% of all ED attendances were coded as having a primary mental health diagnosis.1 Cumulative HES data have shown an average increase in mental health attendances of 11% per year since 20132 (figure 1) far in excess of total ED attendance increase (figure 2). National data from the USA show a 40.8% increase in ED visits for adult with a mental health presentation from 2009 to 2015.3 US paediatric visits for the same period rose by 56.5%3 and a worrying 2.5-fold increase over 3 years in the USA is reported for adolescents ED ….

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.

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No need to wear headphones on top of your ears, or visit this page take out your can you buy ventolin over the counter hearing aids out to wear earbuds. You can stream sound from your phone, laptop, TV or other device. This is a very handy way to listen to music or podcasts.

Noise-cancelling headphones also may can you buy ventolin over the counter be worn over your hearing aids, so you don’t need to turn the music as high. Also, keep in mind using Bluetooth a lot may drain your batteries faster than usual. ITE hearing aids can often be worn with on-ear or over-the-ear headphones.

If your hearing aids don't have Bluetooth With all of the different headphones on the market today, which ones can you buy ventolin over the counter work best with hearing aids?. That all depends upon what type of hearing aids you wear. Here are a few things to consider, and keep in mind your hearing care specialist can provide guidance, as well.

We especially recommend seeking professional help if you need to can you buy ventolin over the counter wear a headset for work. A 'trial-and-error process' First and foremost, we can't stress enough that this may take a little bit of legwork on your part to find the right fit. If you're ordering headphones for home delivery, read the return policy closely.

Better yet, go to a store can you buy ventolin over the counter and try on several headphones, if you can. "It’s a long trial-and-error process and I definitely recommend trying on some headphones whenever you see them at a store to get a good feel for how it’ll work with your specific hearing aids," explained one Reddit commenter on this post about hearing aids and headphones. In-the-ear (ITE) hearing aids Finding good fitting headphones when you wear devices that fit inside the ear canal is a lot less problematic than it is with other models.

Invisible-in-the-canal (IIC) hearing aids and completely-in-the-canal (CIC) can you buy ventolin over the counter hearing aids are the tiniest hearing aids on the market. Their ability to fit inside the ear canal make them more discreet than other models. These devices are usually prescribed for those with mild or moderate hearing loss.

In-the-canal (ITC) hearing aids can you buy ventolin over the counter sit in the lower portion of the outer ear bowl, which makes them comfortable and easy to use. Because they are slightly larger than IIC and CIC hearing aids, they have a longer battery life and able to address a wider range of hearing losses. Low-profile hearing aids sit inside the ear, although range in size from half shell designs to those which fill almost the entire ear bowl.

Because they are larger and can you buy ventolin over the counter easier to handle, they may be more desirable for those with dexterity issues. Since all components of the above devices fit completely inside the ear canal, they are usually compatible with on-ear or over-the-ear headphones. Those who wear IIC hearing aids may even be able to use earbuds.

Behind-the-ear (BTE) hearing aids Those who wear BTE or receiver-in-the-canal (RIC) devices may find over-the-ear can you buy ventolin over the counter headphones the best option. Or, as we mention above, turn on your Bluetooth streamingg so you can ditch the headphones altogether. BTE hearing aids range in size from mini BTEs with ua-thin tubing to those which work with earmolds to address severe to profound hearing loss.

RIC and receiver-in-the-ear can you buy ventolin over the counter (RITE) hearing aids have the speaker built into the ear tip instead of the main body of the hearing aid. When using headphones with these hearing devices, choose a model which fits completely over the hearing aids’ microphone, which is located outside the ear canal and behind the ear. If it doesn’t fit completely over, the hearing aid will pick up external sound instead of what is coming from the headphone.

You may have to try a can you buy ventolin over the counter few models to find the right fit. The key is to make sure the headphone speakers are located far enough away from the hearing aid microphones to prevent problems with audio feedback. Bone-conduction headphones Bone-conduction headphones don't actually rest on the ear, but directly in front.

People who wear in-the-ear hearing aids may especially like this option, as they don't block incoming sound, which is a nice safety can you buy ventolin over the counter feature. "While conventional earbuds and headphones may interfere with or jostle hearing aids, bone conduction headphones bypass this," explains Lily Katz of website SoundGuys. However, if you have behind-the-ear headphones, you may still experience some discomfort as the headset may rub against the hearing aids (look for a pair of returnable hearing aids so you can test this out!.

). Headphones for single-sided deafness When you have hearing loss in one ear, you lose out on the sensation of "surround sound" otherwise known as listening in stereo. Bone-conduction headphones can be a good option to get around this.

Also, this eBay seller makes these "Two ears in one" stereo headphones that may be helpful for people with single-sided deafness. What if you don't want to wear hearing aids?. Want to ditch the hearing aids altogether while you wear headphones?.

That's an option, too. Depending on how severe your hearing loss is, you may want to get special headphones known as amplified headphones, which can deliver signals more loudly than standard headphones. A separate headphone “equalizer” allows you to boost low, mid and high frequencies to suit yourself and your unique pattern of hearing loss.

Ask your hearing healthcare professional If you’re still having trouble finding headphones which work with your hearing aids, make sure you’re using the hearing aid program for the listening environment you're in. If you’re in doubt about which program to use—or how to switch between programs on your hearing devices—ask your hearing healthcare professional for assistance. Ask for a "music" setting A program which emphasizes speech may not be the best one to use when you’re listening to music or audiobooks, learn more about optimizing your hearing aids for music.

You can still damage your hearing To prevent additional noise-induced hearing loss, make sure you follow the 80-90 rule when using headphones or earbuds, regardless of whether or not you wear hearing aids. Listen at 80 percent or less of your device’s volume for no more than 90 minutes a day. More.

How to prevent hearing loss from headphones or earbuds As always, if you find you’re not hearing your best, schedule an appointment with a hearing healthcare professional for a thorough evaluation.The late actor Edward Albert once said, “The simple act of caregiving is heroic.” All across the U.S., family members and loved ones have dedicated themselves to helping those who can’t help themselves.According to the 2020 AARP Caregivers Report, approximately 41.8 million Americans have provided unpaid care to an adult age 50 or older in the past year. One in five Americans takes care of either a child or adult (or both). Many care recipients have complicated medical situations—with frailty, dementia, and mobility issues being common reasons older adults need care.

If you're taking care of someone with hearing loss, be mindful of the communicationchallenges you might face. So, how often does hearing loss factor into the daily lives of caregivers?. The AARP report didn't include that information, but the NIDCD reports that more than 50 percent of those over the age of 75 have hearing loss.

Hearing loss, whether treated or untreated, comes with a host of other implications that caregivers need to be aware of. First, seniors with hearing loss will have challenges communicating, and you may need to learn key communication tools to help them interact with you and others. They're also more at risk for health problems, both physical and emotional.

These health risks include feelings of depression and isolation as well as cognitive decline. Other physical risks include the risk of falls, which are three times more likely to occur even with mild hearing loss, and the inability to hear warnings and alarms. And since most general practitioners do not routinely screen for hearing loss, it often falls to the caregiver to make sure matters of hearing health are tended to.

This means either requesting a hearing screening during a regular check-up or making an appointment with a hearing health professional. Signs of hearing loss Those providing care to a person with hearing loss can face other challenges as well. Everything from attending doctor’s appointments and to simply watching a television program requires factoring hearing loss into the equation.

Caregivers may find themselves compensating for their loved one's hearing loss. It is helpful for caretakers to learn about hearing loss so they can help the person they are caring for live a happy and fulfilled life—which reduces the burden on you, as well. “The simple act of caregiving is heroic.” - Edward Albert There are numerous early warning signs that can indicate that the person you are caring for might have hearing loss.

Make an appointment to see a hearing healthcare professional if the person you are caring for. Frequently asks you or others to repeat themselves Has to increase the volume on the TV to uncomfortable levels Reports that sounds are muffled Seems more withdrawn or easily fatigued by listening to conversation Seems to have trouble hearing amid background noise Has difficulty distinguishing consonant sounds, such as “K” and “T," and hearing children's and women's voices Hearing aid treatment can ease many stressors If you suspect there is hearing loss, take action. Hearing aids have health benefits, such as delaying the onset of dementia.

Not to mention they make communication much easier!. To get started, first make an appointment with a hearing care care professional, preferably one that specializes in senior care. Next, since hearing aids are a considerable expense, when helping the person in your care shop for hearing aids, knowing a few things going in can help you make the right decision.

Educate yourself about the costs involved prior to shopping for hearing aids. Hearing aids typically cost anywhere from $1,000 to $3,500 per device, but Medicare, AARP and the VA all have programs that can offset the cost. There are many different types and styles of hearing aids available, so provide as much information as possible to the hearing care professional about the capabilities, lifestyle and needs of the person in your care.

Request a demonstration of any device that is chosen to make sure it meets the needs of the person in your care. Remember, hearing aids should never cause pain or discomfort to the person wearing them. If there is pain, they are not fitted correctly.

In some cases, cochlear implants may be recommended. Hearing aid maintenance 101 After the person in your care has received his hearing aids, depending on his cognitive and fine motor skills, it might fall to you as the caregiver to perform basic cleaning and maintenance tasks on hearing aids. Some things to keep in mind.

Hearing aids need regular cleaning to remove dust and earwax in order to perform properly. The soft brush or cloth that comes with them can be used for this purpose. Never insert anything into the receiver, as it can be easily damaged.

Filters need to be changed on a regular basis to prevent wax and dirt buildup. Make sure the person in your care removes hearing aids overnight. Storing them in a dry-kit is helpful to remove any moisture that has built up during the course of the day and to keep the devices safe overnight.

Change batteries on a regular basis, or set them on their recharger if they are rechargeable. See your hearing care professional on a regular basis for more thorough cleaning, adjustments and any other necessary maintenance. Caregiving and hearing loss As a caregiver to a person with hearing loss, there is much to be considered to make sure the person in your care can hear the world around him and enjoy as much independence as possible.

Some general caregiver guidelines to keep in mind are. Be patient. Learning as much as you can about the difficulties hearing loss presents to those who have it and the emotional/psychological implications will help you in being empathetic to the feelings and emotions of the person in your care.

Find out about the resources in your area that can help assist the person in your care, from looped public spaces to hearing care professionals to organizations that can assist with the cost of hearing aids. Educate yourself about hearing loss so you can distinguish fact from fiction. Your loved one's hearing care provider can be a big help in this area.

Watch out for environmental factors that could worsen the hearing loss. These include harmful noise levels and medications that have hearing loss as a side effect. Making small changes in the home environment can reduce frustration and allow the person in your care to feel more independent.

These include amplified phones, flashing or vibrating alarms and television-specific assistive listening devices (ALDs). Talk to the person you are caring for to find out what works best for them in terms of communication. Do they prefer you to speak near one ear versus the other, for example, or is it easier for them if they can see your lips move?.

Need help?. Consult our directory Caregivers face many challenges, and in particular caregivers to those with hearing loss have much to learn.

You can where can i buy ventolin nebules online http://www.hr-upshot.com/pfizer-viagra-online/ stream sound from your phone, laptop, TV or other device. This is a very handy way to listen to music or podcasts. Noise-cancelling headphones also may be worn over your hearing aids, so you don’t need to turn the music as high. Also, keep in mind using Bluetooth a lot may drain your batteries faster than where can i buy ventolin nebules online usual. ITE hearing aids can often be worn with on-ear or over-the-ear headphones.

If your hearing aids don't have Bluetooth With all of the different headphones on the market today, which ones work best with hearing aids?. That all where can i buy ventolin nebules online depends upon what type of hearing aids you wear. Here are a few things to consider, and keep in mind your hearing care specialist can provide guidance, as well. We especially recommend seeking professional help if you need to wear a headset for work. A 'trial-and-error process' First and foremost, we can't stress enough that this may take a little bit of legwork on your part where can i buy ventolin nebules online to find the right fit.

If you're ordering headphones for home delivery, read the return policy closely. Better yet, go to a store and try on several headphones, if you can. "It’s a long trial-and-error process and I definitely recommend trying on some headphones whenever you see them at a store to get a good feel for how it’ll work with your specific hearing aids," explained one Reddit where can i buy ventolin nebules online commenter on this post about hearing aids and headphones. In-the-ear (ITE) hearing aids Finding good fitting headphones when you wear devices that fit inside the ear canal is a lot less problematic than it is with other models. Invisible-in-the-canal (IIC) hearing aids and completely-in-the-canal (CIC) hearing aids are the tiniest hearing aids on the market.

Their ability to fit inside the ear canal make where can i buy ventolin nebules online them more discreet than other models. These devices are usually prescribed for those with mild or moderate hearing loss. In-the-canal (ITC) hearing aids sit in the lower portion of the outer ear bowl, which makes them comfortable and easy to use. Because they are slightly larger than IIC and CIC hearing aids, they have where can i buy ventolin nebules online a longer battery life and able to address a wider range of hearing losses. Low-profile hearing aids sit inside the ear, although range in size from half shell designs to those which fill almost the entire ear bowl.

Because they are larger and easier to handle, they may be more desirable for those with dexterity issues. Since all components of the above devices fit completely inside where can i buy ventolin nebules online the ear canal, they are usually compatible with on-ear or over-the-ear headphones. Those who wear IIC hearing aids may even be able to use earbuds. Behind-the-ear (BTE) hearing aids Those who wear BTE or receiver-in-the-canal (RIC) devices may find over-the-ear headphones the best option. Or, as we mention above, turn on your Bluetooth streamingg so you can ditch the headphones altogether where can i buy ventolin nebules online.

BTE hearing aids range in size from mini BTEs with ua-thin tubing to those which work with earmolds to address severe to profound hearing loss. RIC and receiver-in-the-ear (RITE) hearing aids have the speaker built into the ear tip instead of the main body of the hearing aid. When using headphones with these hearing where can i buy ventolin nebules online devices, choose a model which fits completely over the hearing aids’ microphone, which is located outside the ear canal and behind the ear. If it doesn’t fit completely over, the hearing aid will pick up external sound instead of what is coming from the headphone. You may have to try a few models to find the right fit.

The key is to make where can i buy ventolin nebules online sure the headphone speakers are located far enough away from the hearing aid microphones to prevent problems with audio feedback. Bone-conduction headphones Bone-conduction headphones don't actually rest on the ear, but directly in front. People who wear in-the-ear hearing aids may especially like this option, as they don't block incoming sound, which is a nice safety feature. "While conventional earbuds and headphones may interfere with or jostle hearing aids, bone conduction headphones bypass this," explains Lily Katz of website where can i buy ventolin nebules online SoundGuys. However, if you have behind-the-ear headphones, you may still experience some discomfort as the headset may rub against the hearing aids (look for a pair of returnable hearing aids so you can test this out!.

). Headphones for single-sided deafness where can i buy ventolin nebules online When you have hearing loss in one ear, you lose out on the sensation of "surround sound" otherwise known as listening in stereo. Bone-conduction headphones can be a good option to get around this. Also, this eBay seller makes these "Two ears in one" stereo headphones that may be helpful for people with single-sided deafness. What if you don't want to where can i buy ventolin nebules online wear hearing aids?.

Want to ditch the hearing aids altogether while you wear headphones?. That's an option, too. Depending on how severe your hearing loss is, you where can i buy ventolin nebules online may want to get special headphones known as amplified headphones, which can deliver signals more loudly than standard headphones. A separate headphone “equalizer” allows you to boost low, mid and high frequencies to suit yourself and your unique pattern of hearing loss. Ask your hearing healthcare professional If you’re still having trouble finding headphones which work with your hearing aids, make sure you’re using the hearing aid program for the listening environment you're in.

If you’re in doubt about which program to use—or how to switch between programs on your hearing devices—ask your hearing healthcare where can i buy ventolin nebules online professional for assistance. Ask for a "music" setting A program which emphasizes speech may not be the best one to use when you’re listening to music or audiobooks, learn more about optimizing your hearing aids for music. You can still damage your hearing To prevent additional noise-induced hearing loss, make sure you follow the 80-90 rule when using headphones or earbuds, regardless of whether or not you wear hearing aids. Listen at 80 percent or less of your device’s volume for no more where can i buy ventolin nebules online than 90 minutes a day. More.

How to prevent hearing loss from headphones or earbuds As always, if you find you’re not hearing your best, schedule an appointment with a hearing healthcare professional for a thorough evaluation.The late actor Edward Albert once said, “The simple act of caregiving is heroic.” All across the U.S., family members and loved ones have dedicated themselves to helping those who can’t help themselves.According to the 2020 AARP Caregivers Report, approximately 41.8 million Americans have provided unpaid care to an adult age 50 or older in the past year. One in five Americans where can i buy ventolin nebules online takes care of either a child or adult (or both). Many care recipients have complicated medical situations—with frailty, dementia, and mobility issues being common reasons older adults need care. If you're taking care of someone with hearing loss, be mindful of the communicationchallenges you might face. So, how often does hearing loss factor into the daily lives of caregivers?.

The AARP report didn't include that information, but the NIDCD reports that more than 50 percent of those over the age of 75 have where can i buy ventolin nebules online hearing loss. Hearing loss, whether treated or untreated, comes with a host of other implications that caregivers need to be aware of. First, seniors with hearing loss will have challenges communicating, and you may need to learn key communication tools to help them interact with you and others. They're also more where can i buy ventolin nebules online at risk for health problems, both physical and emotional. These health risks include feelings of depression and isolation as well as cognitive decline.

Other physical risks include the risk of falls, which are three times more likely to occur even with mild hearing loss, and the inability to hear warnings and alarms. And since most general practitioners do not routinely screen for hearing loss, it often falls to the caregiver to make sure matters of hearing where can i buy ventolin nebules online health are tended to. This means either requesting a hearing screening during a regular check-up or making an appointment with a hearing health professional. Signs of hearing loss Those providing care to a person with hearing loss can face other challenges as well. Everything from attending doctor’s appointments and to simply watching a television program requires factoring hearing loss into where can i buy ventolin nebules online the equation.

Caregivers may find themselves compensating for their loved one's hearing loss. It is helpful for caretakers to learn about hearing loss so they can help the person they are caring for live a happy and fulfilled life—which reduces the burden on you, as well. “The simple act of caregiving is heroic.” where can i buy ventolin nebules online - Edward Albert There are numerous early warning signs that can indicate that the person you are caring for might have hearing loss. Make an appointment to see a hearing healthcare professional if the person you are caring for. Frequently asks you or others to repeat themselves Has to increase the volume on the TV to uncomfortable levels Reports that sounds are muffled Seems more withdrawn or easily fatigued by listening to conversation Seems to have trouble hearing amid background noise Has difficulty distinguishing consonant sounds, such as “K” and “T," and hearing children's and women's voices Hearing aid treatment can ease many stressors If you suspect there is hearing loss, take action.

Hearing aids have health benefits, such as delaying the onset of dementia where can i buy ventolin nebules online. Not to mention they make communication much easier!. To get started, first make an appointment with a hearing care care professional, preferably one that specializes in senior care. Next, since hearing aids are a considerable expense, when helping the person in your care shop for hearing aids, knowing a few things going in can where can i buy ventolin nebules online help you make the right decision. Educate yourself about the costs involved prior to shopping for hearing aids.

Hearing aids typically cost anywhere from $1,000 to $3,500 per device, but Medicare, AARP and the VA all have programs that can offset the cost. There are many different types and styles of hearing aids available, so provide as much information as possible where can i buy ventolin nebules online to the hearing care professional about the capabilities, lifestyle and needs of the person in your care. Request a demonstration of any device that is chosen to make sure it meets the needs of the person in your care. Remember, hearing aids should never cause pain or discomfort to the person wearing them. If there is pain, they are not fitted where can i buy ventolin nebules online correctly.

In some cases, cochlear implants may be recommended. Hearing aid maintenance 101 After the person in your care has received his hearing aids, depending on his cognitive and fine motor skills, it might fall to you as the caregiver to perform basic cleaning and maintenance tasks on hearing aids. Some things to where can i buy ventolin nebules online keep in mind. Hearing aids need regular cleaning to remove dust and earwax in order to perform properly. The soft brush or cloth that comes with them can be used for this purpose.

Never insert anything into the receiver, as it where can i buy ventolin nebules online can be easily damaged. Filters need to be changed on a regular basis to prevent wax and dirt buildup. Make sure the person in your care removes hearing aids overnight. Storing them in where can i buy ventolin nebules online a dry-kit is helpful to remove any moisture that has built up during the course of the day and to keep the devices safe overnight. Change batteries on a regular basis, or set them on their recharger if they are rechargeable.

See your hearing care professional on a regular basis for more thorough cleaning, adjustments and any other necessary maintenance. Caregiving and hearing loss As a caregiver to a person with hearing loss, there is much to be considered to make sure where can i buy ventolin nebules online the person in your care can hear the world around him and enjoy as much independence as possible. Some general caregiver guidelines to keep in mind are. Be patient. Learning as much as you can about the difficulties hearing loss presents to those who have it and the emotional/psychological implications will help you where can i buy ventolin nebules online in being empathetic to the feelings and emotions of the person in your care.

Find out about the resources in your area that can help assist the person in your care, from looped public spaces to hearing care professionals to organizations that can assist with the cost of hearing aids. Educate yourself about hearing loss so you can distinguish fact from fiction. Your loved one's hearing care provider can be a big help in this where can i buy ventolin nebules online area. Watch out for environmental factors that could worsen the hearing loss. These include harmful noise levels and medications that have hearing loss as a side effect.

Making small changes in the home environment can where can i buy ventolin nebules online reduce frustration and allow the person in your care to feel more independent. These include amplified phones, flashing or vibrating alarms and television-specific assistive listening devices (ALDs). Talk to the person you are caring for to find out what works best for them in terms of communication. Do they prefer you to speak near one ear versus the other, for example, or is it easier for them if they can see your lips where can i buy ventolin nebules online move?. Need help?.

Consult our directory Caregivers face many challenges, and in particular caregivers to those with hearing loss have much to learn. But taking these few simple steps can help improve the day to day quality life for the person in your care and help them engage in life once again.

Ventolin not helping wheezing

Latest Arthritis ventolin not helping wheezing News By Steven Reinberg HealthDay ReporterTUESDAY, Dec. 29, 2020 (HealthDay News)Millions of Americans ventolin not helping wheezing suffer from the pain of arthritic knees. But an innovative exercise regimen may help relieve discomfort and improve knee function, a new study finds.The program is called STEP-KOA (short for stepped exercise program for patients with knee osteoarthritis). It starts with gentle exercises at home and, if needed, moves to phone consultation and in-person physical therapy."STEP-KOA could be an efficient way to deliver exercise and physical therapy services for people with knee osteoarthritis, since it reserves the ventolin not helping wheezing more resource-intensive steps for people who do not make improvements earlier," said lead author Kelli Allen.

She's a research health scientist at the Durham VA Medical Center in North Carolina."This could be important in health systems that are trying to maximize resources or when there is limited access to physical therapy," Allen said.For the study, researchers from the Veterans Affairs Health Care ventolin not helping wheezing System randomly assigned more than 300 patients with painful knee osteoarthritis to either STEP-KOA or arthritis education. Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative, "wear-and-tear" type of arthritis.STEP-KOA starts with ventolin not helping wheezing an internet-based exercise program. If it is not effective, the patient moves to step two, which included twice-monthly coaching phone calls for three months.If pain still does ventolin not helping wheezing not improve, the patient moves to step three, which included in-person physical therapy.Participants in the arthritis education group were mailed educational materials every two weeks.After nine months, 65% of patients in STEP-KOA progressed to step two, and 35% went on to step three.Compared to participants who received education only, the stepped-care group had greater improvement in pain and function, the researchers reported.This strategy could lower health care costs and tailor programs to patients' needs, the study authors said.However, a prominent orthopedic surgeon called this approach backwards.It should start instead with physical therapy and move on to patients doing exercises on their own, said Dr.

Jeffrey Schildhorn of Lenox Hill Hospital in New York City."It seemed like this study was designed for a style of medicine that I think very few of us would appreciate," Schildhorn said. "It was almost like you're preparing for a future where there are limited resources, and you try to do everything remotely, and you put the responsibility on the patient," he added.Schildhorn noted that 90 patients dropped out of the program, and only 10% remained at step one throughout the study.Because each patient's knee damage and perception of pain is unique, an effective program must be individually designed, he said."I think that it's imperative that people who have mild to moderate disease try to ventolin not helping wheezing do whatever they can on their own, with or without in-person physical therapy," Schildhorn said.The key is to keep the joint moving with gentle exercise. A multimodal approach that includes periodic check-ins with a therapist, being shown in person how to do the movements with follow-up by phone or video chat is a viable approach, he said.But patients need to do their exercises at home every day, Schildhorn emphasized."Someone who goes to physical therapy three times a week probably doesn't do as well as someone who goes three times a week and practices on their own. The majority of the ventolin not helping wheezing value comes with daily in-home, stretching exercises," Schildhorn said.

"If you go to physical therapy two times a week, then do nothing the other five days, there's ventolin not helping wheezing zero value there."The report was published online Dec. 29 in the Annals of Internal Medicine.More informationLearn more about knee osteoarthritis from the American Academy of Orthopaedic Surgeons.SOURCES. Kelli Allen, PhD, research health scientist, Durham VA Medical Center, Durham, N.C., and associate director, Durham Center of Innovation to Accelerate Discovery and Practice Transformation ventolin not helping wheezing. Jeffrey Schildhorn, ventolin not helping wheezing MD, orthopedic surgeon, Lenox Hill Hospital, New York City.

Annals of Internal Medicine, Dec. 29, 2020, ventolin not helping wheezing onlineCopyright © 2020 HealthDay. All rights ventolin not helping wheezing reserved. SLIDESHOW What Is Rheumatoid Arthritis (RA)?.

Symptoms, Treatment, ventolin not helping wheezing Diagnosis See SlideshowLatest Heart News TUESDAY, Dec. 29, 2020 (American Heart Association News)Deep in their hearts, everyone has to be looking forward to a fresh start in 2021.And who would know better about matters of the heart than a cardiologist?. We asked some of the nation's best about resolutions – what they're planning for themselves, and what they wish their patients would focus on for a healthy and happy new year.Their advice begins ventolin not helping wheezing with a reminder that the threat of asthma treatment will not vanish at the stroke of midnight on Dec. 31."You need to resolve to stay healthy and safe," ventolin not helping wheezing said Dr.

Ivor Benjamin, director of the Cardiovascular Center and professor of medicine at the Medical College of Wisconsin in Milwaukee. "It's an ever-present challenge for everyone, independent ventolin not helping wheezing of where they are."In California, Dr. Robert Harrington ventolin not helping wheezing is chair of the department of medicine at Stanford University. He's making its institutional motto a personal one as the fight against the asthma goes on.Stanford Medicine tells its health care workers, researchers, staff and students to be safe, be smart, be kind, said Harrington, a past president of the American Heart Association.

"So my personal resolution is that I will work ventolin not helping wheezing at staying safe through good public health measures of mask-wearing, frequent hand-washing and appropriate social distancing. At staying smart by keeping up to date with ventolin not helping wheezing the latest news and research on asthma treatment. And at staying kind by focusing on our extended community needs."Here's hoping that my patients can do the same."Even as the ventolin is a top health concern, there's room for thinking beyond it."The new year is always a good time for patients to reprioritize their health," said Dr. Fatima Rodriguez, an assistant professor of cardiovascular medicine ventolin not helping wheezing at Stanford.

She'd like patients to focus on healthy eating and scheduling physical activity every day. "There are ventolin not helping wheezing no quick fixes to optimal cardiovascular health. It takes consistency."Dr ventolin not helping wheezing. Rachel M.

Bond, system director of women's heart health at Dignity Health in Arizona, suggests resolving to learn the art of relaxation."Although stress and anxiety are common – and we've had more ventolin not helping wheezing than our fair share of both in 2020 – chronic stress and anxiety can be dangerous for our heart health." Anxiety can trigger the release of stress hormones such as cortisol and adrenaline, which can increase heart rate and blood pressure. Women are at higher risk for stress-related heart issues, Bond said."Finding healthy ventolin not helping wheezing ways to cope with this is a must," she said. She suggests meditation, exercise, listening to music, conversing with family or friends or even seeking professional help.Relaxation was on Rodriguez's mind with her personal resolutions. She's aiming to take time to disconnect from devices – "no email, no ventolin not helping wheezing cellphones, no social media.

I'd also love to prioritize time for reading non-medical literature and journaling."Bond said she isn't traditionally a resolution-maker. "I usually try to shy away from making yearly resolutions, as if I fail to stick to them, I feel an ventolin not helping wheezing extreme level of guilt."To that point – Benjamin, a past president of the AHA, said it's important to make resolutions that are realistic.For example, he'd like to lower his handicap in golf. "But it's kind of hard to do that when I live in Wisconsin and there's still snow on the ground for the next four to five months."For ventolin not helping wheezing patients looking to make healthy changes, Benjamin offers this simple advice year-round. "I am looking for progress, and not perfection."For example, instead of setting out to run a marathon, a good resolution for adults might be to follow the federal recommendation to get at least 150 minutes of brisk exercise every week.

"I tell my patients walk 30 minutes a day and take ventolin not helping wheezing a day or two off for good measure. Just do the math, and you're going to get there."He and Bond both looked inward with some of ventolin not helping wheezing their personal goals. Benjamin hopes he can spend more time in the present, "so that I can be a catalyst and, hopefully, a positive force for everything that's around me."And Bond said "with 2020 being a year for the history books – and a chapter I am eager to close," she's focused on gratitude."What 2020 has taught me is that life-altering triumphs, no matter how great or small, should be celebrated, as who knows what tomorrow may bring. ...

I choose to take an initiative to ensure I am thankful for all the small mercies I've experienced and will continue to experience in my life." QUESTION In the U.S., 1 in every 4 deaths is caused by heart disease. See Answer American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position of the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved.

If you have questions or comments about this story, please email [email protected]By Michael MerschelAmerican Heart Association NewsCopyright © 2020 HealthDay. All rights reserved. From Healthy Heart Resources Featured Centers Health Solutions From Our SponsorsLatest asthma News By Ernie Mundell HealthDay ReporterWEDNESDAY, Dec. 30, 2020The first recorded case of a faster-spreading variant of the new asthma has been detected in a 20-year-old man in Colorado, Gov.

Jared Polis said Tuesday.The young man carries a variant of the ventolin that is thought to be more contagious -- but not more lethal -- than variants previously circulating globally this year.The rapid spread of the new variant within Britain has caused a virtual shutdown there, with many countries banning or restricting flights from the United Kingdom. Many scientists in the United States have assumed that the novel variant is already circulating among Americans.The Colorado man has no history of recent travel, state health officials said, and is currently under isolation southeast of Denver in Elbert County, The New York Times reported.According to the Times, Colorado Politics said that the Elbert County director of public health has also reported a second suspected case of the new variant in the state.Both cases were found in people who worked in the county but did not live there -- raising the odds of statewide spread, the Times said.The detection of the more contagious form of asthma adds urgency to efforts already underway to vaccinate Americans. In a news release, Colorado health officials reiterated that treatments already in use should be just as effective against the new variant of the ventolin.However, "now I'm worried there will be another spring wave due to the variant," scientist Trevor Bedford, who studies the asthma at Fred Hutchinson Cancer Research Center in Seattle, told the Times. "It's a race with the treatment, but now the ventolin has just gotten a little bit faster."Another asthma treatment enters final trialsIn other news, treatment maker Novavax, along with federal health researchers, announced Monday that a phase 3 trial will begin on the safety and effectiveness of another asthma treatment -- the fifth shot to reach this final stage of development."We've come this far, this fast, but we need to get to the finish line," Dr.

Francis Collins, director of the U.S. National Institutes of Health (NIH), said in an NIH statement.Novavax will enroll 30,000 people from 115 testing sites across the United States and Mexico, and testing is already underway in Britain. The treatment -- which right now is known as NVX-CoV2373 -- comes in two doses and is designed to enhance the body's immune response to the asthma' distinctive spike protein.The Novavax shot is somewhat different from approved treatments from Pfizer and Moderna, in that it manufactures its own antigens that mimic the asthma' spike protein. However, these antigens "cannot replicate and cannot cause asthma treatment," the NIH said in the statement.If phase 3 trials prove the Novavax treatment to be safe and effective, the shot has one big advantage over the Moderna and Pfizer treatments.

It needs only standard refrigeration, not the freezing or ultra-cold temperature storage required by the first two treatments.According to CBS News, two other pharmaceutical companies, Johnson &. Johnson's Janssen and AstraZeneca, also have phase 3 asthma treatment trials underway in the United States.Uptick in treatment acceptanceWhen queried in polls conducted earlier this year, only about half of American adults said they planned to get any treatment against the new asthma. But after a largely successful rollout this month of two safe and effective shots, many of those initial doubters now say they'll line up to get their treatment doses when their turn comes.According to the Times, polls conducted by Gallup, the Kaiser Family Foundation and the Pew Research Center all show treatment acceptance rates rising from about 50% this summer to more than 60% and, in one poll, 73%.That last number approaches the threshold scientists have deemed necessary for herd immunity, where enough of a population is immune and the spread of the asthma begins to recede."As soon as it is my turn to get the treatment, I will be there front and center!. I am very excited and hopeful," Joanne Barnes, 68, a retired elementary school teacher from Fairbanks, Alaska, told the Times.Earlier this summer, Barnes had told the paper the opposite.

That she would not get the shot. The game-changers for her, Barnes said, were "the Biden administration, returning to listening to science and the fantastic stats associated with the treatments."With more than 19 million asthma treatment cases in the United States by Wednesday and more than 338,000 Americans now killed by the disease, more people than ever have now been personally affected by the new asthma. That harsh reality might also be driving some to reconsider getting the shot. "More people have either been affected or infected by asthma treatment," Rupali Limaye, an expert on treatment behavior at the Johns Hopkins Bloomberg School of Public Health in Baltimore, told the Times.

"They know someone who had a severe case or died. They are fatigued and want to get back to their normal lives."Media campaigns, including on-camera moments with politicians and scientists -- such as Vice President Mike Pence, President-Elect Joe Biden and Dr. Anthony Fauci -- all rolling up their sleeves for the shots may have also helped boost acceptance.Still, large pockets of skepticism and resistance to vaccination remain. According to the Times, mistrust of the treatment is higher among Blacks than whites, among Republicans compared to Democrats, and among people living in rural areas versus those in cities.Still, resistance is fading slowly among most groups, the Times said.One Black American, Mike Brown, runs a barbershop in Hyattsville, Md.

This summer he said he wouldn't get any asthma treatment, but has since changed his mind."The news that it was 95% effective sold me," Brown told the Times. "The side effects sound like what you get after a bad night of drinking and you hurt the next day. Well, I've had many of those and I can deal with that to get rid of the face masks."A global scourgeBy Wednesday, the U.S. asthma case count passed 19.5 million while the death toll neared 339,000, according to a Times tally.

On Wednesday, the top five states for asthma s were. California with more than 2.2 million cases. Texas with over 1.7 million cases. Florida with almost 1.3 million cases.

Illinois with over 950,000 cases. And New York with over 950,000 cases.Curbing the spread of the asthma in the rest of the world remains challenging.In India, the asthma case count was over 10.2 million on Wednesday, a Johns Hopkins University tally showed. Brazil had over 7.5 million cases and over 192,000 deaths as of Wednesday, the Hopkins tally showed.Worldwide, the number of reported s passed 82 million on Wednesday, with nearly 1.8 million deaths recorded, according to the Hopkins tally.More informationThe U.S. Centers for Disease Control and Prevention has more on the new asthma.SOURCES.

Washington Post. The New York TimesCopyright © 2020 HealthDay. All rights reserved.Latest Lungs News By Denise Mann HealthDay ReporterWEDNESDAY, Dec. 30, 2020 (HealthDay News)Nurses are known for being kind, caring and sympathetic, but Brianna Fogelman brings an uncommon empathy to her nursing job at Johns Hopkins Medicine in Baltimore.Fogelman, 27, underwent a double lung transplant last year to treat a rare lung disease and returned this fall to work in the same hospital where she received her life-changing surgery."I understand how it feels to have your ability to breathe taken away from you in just a couple of days," she said.Though she had always planned to become a nurse, it wasn't until after her transplant that it felt like more of a calling, Fogelman said."My interest and passion spiked tremendously after I became a patient," she said.The former high school track and field athlete was in her third year of nursing school when she was diagnosed in the spring of 2019 with hypersensitivity pneumonitis.

It's a rare disease that causes inflammation that can lead to irreversible lung scarring.The condition is caused by inhaling specific environmental allergens -- in Fogelman's case, feathers. As a child, she had parakeets as pets and eventually developed an allergy to all types of feathers, including those in pillows, blankets and jackets. As a result, her lung condition worsened.She and her doctors tried everything to improve her breathing, including immunosuppressants and steroids to reduce inflammation, and Fogelman said her lungs were "decent" for a while.Then, in 2018, she developed an that would be pivotal for her health. "I had six to eight lung collapses from 2018 to 2019," she recalled.Despite that, Fogelman managed to continue her nursing training at Wesley College in Dover, Del.But soon after graduation, she got pneumonia and lost all remaining lung function.

She was placed on the emergency transplant waiting list.On June 24, 2019, after a couple of disappointments, she received her new lungs.It was the 100th transplant surgery at Johns Hopkins for her surgeon Dr. Errol Bush, who is thrilled to have Fogelman back at Hopkins -- as a nurse."She is an amazing nurse because of what she has been through," said Bush, surgical director of Hopkins' advanced lung disease and lung transplant program.Fogelman's transplant surgery was a success, though it had an unexpected wrinkle. The lower lobe of her new right lung had to be removed during the operation so it could better fit in her small chest cavity.Though she is not directly treating patients with asthma treatment or other infectious lung diseases, the hope is that she will see more lung transplant patients once the ventolin is under control. The medications she takes to prevent organ rejection make her more susceptible to s like asthma treatment.Fogelman is one of the lucky ones, Bush said.

Many donor lungs are too damaged to transplant safely due to underlying disease or time spent on mechanical breathing machines, he said."She knows how it feels to be intubated and waiting for lungs," Bush said. "We went through multiple donors and letdowns when lungs weren't good."It all gives nurse Fogelman a special sensitivity to patients."She can answer questions like, 'Is it painful?. ' and help relieve anxiety and offer support in ways that the rest of our care members aren't able to do," Bush said.Waiting for new lungs was hard, Fogelman added."I empathize with patients who feel helpless and don't see the light at the end of tunnel," she said. "You are always getting bad news, and that's how I felt for so long."All the time in the hospital waiting for new lungs left her a bit out of shape, but Fogelman feels "really good," she said."I can do everything," she said.

"I can run and walk upstairs."She is vocal about the benefits and importance of organ donation."Overall, it's very important that people try to understand that organ donation is so important and should try to get to know people who have benefited," Fogelman said.More informationTo learn more about organ donation, visit the U.S. Government Information on Organ Donation and Transplantation.SOURCES. Brianna Fogelman, RN, Johns Hopkins Medicine, Baltimore. Errol Bush, MD, surgical director, Advanced Lung Disease and Lung Transplant Program, associate professor of surgery, Johns Hopkins University School of Medicine, BaltimoreCopyright © 2020 HealthDay.

All rights reserved. QUESTION COPD (chronic obstructive pulmonary disease) is the same as adult-onset asthma. See AnswerLatest asthma News WEDNESDAY, Dec. 30, 2020 (HealthDay News)A new study confirms what you likely already know from experience -- it can be hard to recognize people when they're wearing masks during the asthma treatment ventolin."For those of you who don't always recognize a friend or acquaintance wearing a mask, you are not alone," said researchers Tzvi Ganel and Erez Freud."Faces are among the most informative and significant visual stimuli in human perception and play a unique role in communicative, social daily interactions," they noted.

"The unprecedented effort to minimize asthma treatment transmission has created a new dimension in facial recognition due to mask wearing."Ganel is head of the Laboratory for Visual Perception and Action at Ben-Gurion University of the Negev in Beersheba, Israel. Freud is an assistant professor of psychology at York University in Toronto.For their online study, they assessed how well nearly 500 people could identify masked and unmasked faces.The participants were 15% less likely to identify someone wearing a mask, according to findings published Dec. 21 in the journal Scientific Reports.Researchers found that masks interfere with getting an overall impression of faces and force people to check out specific facial features, which takes longer and is a less accurate."Instead of looking at the entire face, we're now forced to look at eyes, nose, cheeks and other visible elements separately to construct an entire facial face percept -- which we used to do instantly," the researchers explained in a university news release.They said the challenge of identifying people wearing masks could have major effects on daily life, including social interactions and education."Given that mask wearing has rapidly become an important norm in countries around the globe, future research should explore the social and psychological implications of wearing masks on human behavior," Ganel said. "The magnitude of the effect of masks that we report in the current study is probably an underestimation of the actual degree in performance dropdown for masked faces."More informationThe U.S.

Food and Drug Administration has more on masks.SOURCE. Ben-Gurion University of the Negev, news release, Dec. 21, 2020Robert PreidtCopyright © 2020 HealthDay. All rights reserved..

Latest Arthritis News By Steven where can i buy ventolin nebules online Reinberg HealthDay ReporterTUESDAY, Dec. 29, 2020 (HealthDay News)Millions of Americans suffer from the pain of where can i buy ventolin nebules online arthritic knees. But an innovative exercise regimen may help relieve discomfort and improve knee function, a new study finds.The program is called STEP-KOA (short for stepped exercise program for patients with knee osteoarthritis).

It starts with gentle exercises at home and, if needed, moves to phone consultation and in-person physical therapy."STEP-KOA could be an efficient way to deliver exercise and physical therapy services for people where can i buy ventolin nebules online with knee osteoarthritis, since it reserves the more resource-intensive steps for people who do not make improvements earlier," said lead author Kelli Allen. She's a research health scientist at the Durham VA Medical Center where can i buy ventolin nebules online in North Carolina."This could be important in health systems that are trying to maximize resources or when there is limited access to physical therapy," Allen said.For the study, researchers from the Veterans Affairs Health Care System randomly assigned more than 300 patients with painful knee osteoarthritis to either STEP-KOA or arthritis education. Osteoarthritis is the most common form of arthritis in the knee.

It is a degenerative, "wear-and-tear" type of arthritis.STEP-KOA starts where can i buy ventolin nebules online with an internet-based exercise program. If it is not effective, the patient moves to step two, which included twice-monthly coaching phone calls for three months.If pain still does not improve, the patient moves to step three, which included in-person physical therapy.Participants in the arthritis education group were mailed educational materials every two weeks.After nine months, 65% of patients where can i buy ventolin nebules online in STEP-KOA progressed to step two, and 35% went on to step three.Compared to participants who received education only, the stepped-care group had greater improvement in pain and function, the researchers reported.This strategy could lower health care costs and tailor programs to patients' needs, the study authors said.However, a prominent orthopedic surgeon called this approach backwards.It should start instead with physical therapy and move on to patients doing exercises on their own, said Dr. Jeffrey Schildhorn of Lenox Hill Hospital in New York City."It seemed like this study was designed for a style of medicine that I think very few of us would appreciate," Schildhorn said.

"It was almost like you're preparing for a future where there are limited resources, and you try to do everything remotely, and you put the responsibility on the patient," he added.Schildhorn noted that 90 patients dropped out of the program, and only 10% remained at step one throughout the study.Because each patient's knee damage and perception where can i buy ventolin nebules online of pain is unique, an effective program must be individually designed, he said."I think that it's imperative that people who have mild to moderate disease try to do whatever they can on their own, with or without in-person physical therapy," Schildhorn said.The key is to keep the joint moving with gentle exercise. A multimodal approach that includes periodic check-ins with a therapist, being shown in person how to do the movements with follow-up by phone or video chat is a viable approach, he said.But patients need to do their exercises at home every day, Schildhorn emphasized."Someone who goes to physical therapy three times a week probably doesn't do as well as someone who goes three times a week and practices on their own. The majority of the value comes with where can i buy ventolin nebules online daily in-home, stretching exercises," Schildhorn said.

"If you go to physical therapy two times a week, then where can i buy ventolin nebules online do nothing the other five days, there's zero value there."The report was published online Dec. 29 in the Annals of Internal Medicine.More informationLearn more about knee osteoarthritis from the American Academy of Orthopaedic Surgeons.SOURCES. Kelli Allen, PhD, research health scientist, Durham VA Medical Center, Durham, N.C., and where can i buy ventolin nebules online associate director, Durham Center of Innovation to Accelerate Discovery and Practice Transformation.

Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, where can i buy ventolin nebules online New York City. Annals of Internal Medicine, Dec. 29, 2020, where can i buy ventolin nebules online onlineCopyright © 2020 HealthDay.

All rights where can i buy ventolin nebules online reserved. SLIDESHOW What Is Rheumatoid Arthritis (RA)?. Symptoms, Treatment, Diagnosis See SlideshowLatest Heart News where can i buy ventolin nebules online TUESDAY, Dec.

29, 2020 (American Heart Association News)Deep in their hearts, everyone has to be looking forward to a fresh start in 2021.And who would know better about matters of the heart than a cardiologist?. We asked some of where can i buy ventolin nebules online the nation's best about resolutions – what they're planning for themselves, and what they wish their patients would focus on for a healthy and happy new year.Their advice begins with a reminder that the threat of asthma treatment will not vanish at the stroke of midnight on Dec. 31."You need to resolve to stay healthy where can i buy ventolin nebules online and safe," said Dr.

Ivor Benjamin, director of the Cardiovascular Center and professor of medicine at the Medical College of Wisconsin in Milwaukee. "It's an where can i buy ventolin nebules online ever-present challenge for everyone, independent of where they are."In California, Dr. Robert Harrington is chair of the department where can i buy ventolin nebules online of medicine at Stanford University.

He's making its institutional motto a personal one as the fight against the asthma goes on.Stanford Medicine tells its health care workers, researchers, staff and students to be safe, be smart, be kind, said Harrington, a past president of the American Heart Association. "So my where can i buy ventolin nebules online personal resolution is that I will work at staying safe through good public health measures of mask-wearing, frequent hand-washing and appropriate social distancing. At staying smart by keeping up to date with the where can i buy ventolin nebules online latest news and research on asthma treatment.

And at staying kind by focusing on our extended community needs."Here's hoping that my patients can do the same."Even as the ventolin is a top health concern, there's room for thinking beyond it."The new year is always a good time for patients to reprioritize their health," said Dr. Fatima Rodriguez, where can i buy ventolin nebules online an assistant professor of cardiovascular medicine at Stanford. She'd like patients to focus on healthy eating and scheduling physical activity every day.

"There are no quick fixes to optimal where can i buy ventolin nebules online cardiovascular health. It takes consistency."Dr where can i buy ventolin nebules online. Rachel M.

Bond, system director of women's heart health at Dignity Health in Arizona, suggests resolving to learn the art of relaxation."Although stress and anxiety are common – and we've had more than our fair share of both in 2020 – chronic stress and anxiety can be dangerous for our heart health." Anxiety can where can i buy ventolin nebules online trigger the release of stress hormones such as cortisol and adrenaline, which can increase heart rate and blood pressure. Women are at higher risk for stress-related heart issues, Bond said."Finding healthy ways to cope with this is a must," she said where can i buy ventolin nebules online. She suggests meditation, exercise, listening to music, conversing with family or friends or even seeking professional help.Relaxation was on Rodriguez's mind with her personal resolutions.

She's aiming to take time to disconnect from devices – "no email, no where can i buy ventolin nebules online cellphones, no social media. I'd also love to prioritize time for reading non-medical literature and journaling."Bond said she isn't traditionally a resolution-maker. "I usually try to shy away from making yearly resolutions, as if I fail to stick to them, I feel an extreme level of guilt."To that point – Benjamin, a past president where can i buy ventolin nebules online of the AHA, said it's important to make resolutions that are realistic.For example, he'd like to lower his handicap in golf.

"But it's kind of hard to do that when I live in Wisconsin and where can i buy ventolin nebules online there's still snow on the ground for the next four to five months."For patients looking to make healthy changes, Benjamin offers this simple advice year-round. "I am looking for progress, and not perfection."For example, instead of setting out to run a marathon, a good resolution for adults might be to follow the federal recommendation to get at least 150 minutes of brisk exercise every week. "I tell my patients walk 30 minutes where can i buy ventolin nebules online a day and take a day or two off for good measure.

Just do the where can i buy ventolin nebules online math, and you're going to get there."He and Bond both looked inward with some of their personal goals. Benjamin hopes he can spend more time in the present, "so that I can be a catalyst and, hopefully, a positive force for everything that's around me."And Bond said "with 2020 being a year for the history books – and a chapter I am eager to close," she's focused on gratitude."What 2020 has taught me is that life-altering triumphs, no matter how great or small, should be celebrated, as who knows what tomorrow may bring. ...

I choose to take an initiative to ensure I am thankful for all the small mercies I've experienced and will continue to experience in my life." QUESTION In the U.S., 1 in every 4 deaths is caused by heart disease. See Answer American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position of the American Heart Association.

Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved. If you have questions or comments about this story, please email [email protected]By Michael MerschelAmerican Heart Association NewsCopyright © 2020 HealthDay. All rights reserved.

From Healthy Heart Resources Featured Centers Health Solutions From Our SponsorsLatest asthma News By Ernie Mundell HealthDay ReporterWEDNESDAY, Dec. 30, 2020The first recorded case of a faster-spreading variant of the new asthma has been detected in a 20-year-old man in Colorado, Gov. Jared Polis said Tuesday.The young man carries a variant of the ventolin that is thought to be more contagious -- but not more lethal -- than variants previously circulating globally this year.The rapid spread of the new variant within Britain has caused a virtual shutdown there, with many countries banning or restricting flights from the United Kingdom.

Many scientists in the United States have assumed that the novel variant is already circulating among Americans.The Colorado man has no history of recent travel, state health officials said, and is currently under isolation southeast of Denver in Elbert County, The New York Times reported.According to the Times, Colorado Politics said that the Elbert County director of public health has also reported a second suspected case of the new variant in the state.Both cases were found in people who worked in the county but did not live there -- raising the odds of statewide spread, the Times said.The detection of the more contagious form of asthma adds urgency to efforts already underway to vaccinate Americans. In a news release, Colorado health officials reiterated that treatments already in use should be just as effective against the new variant of the ventolin.However, "now I'm worried there will be another spring wave due to the variant," scientist Trevor Bedford, who studies the asthma at Fred Hutchinson Cancer Research Center in Seattle, told the Times. "It's a race with the treatment, but now the ventolin has just gotten a little bit faster."Another asthma treatment enters final trialsIn other news, treatment maker Novavax, along with federal health researchers, announced Monday that a phase 3 trial will begin on the safety and effectiveness of another asthma treatment -- the fifth shot to reach this final stage of development."We've come this far, this fast, but we need to get to the finish line," Dr.

Francis Collins, director of the U.S. National Institutes of Health (NIH), said in an NIH statement.Novavax will enroll 30,000 people from 115 testing sites across the United States and Mexico, and testing is already underway in Britain. The treatment -- which right now is known as NVX-CoV2373 -- comes in two doses and is designed to enhance the body's immune response to the asthma' distinctive spike protein.The Novavax shot is somewhat different from approved treatments from Pfizer and Moderna, in that it manufactures its own antigens that mimic the asthma' spike protein.

However, these antigens "cannot replicate and cannot cause asthma treatment," the NIH said in the statement.If phase 3 trials prove the Novavax treatment to be safe and effective, the shot has one big advantage over the Moderna and Pfizer treatments. It needs only standard refrigeration, not the freezing or ultra-cold temperature storage required by the first two treatments.According to CBS News, two other pharmaceutical companies, Johnson &. Johnson's Janssen and AstraZeneca, also have phase 3 asthma treatment trials underway in the United States.Uptick in treatment acceptanceWhen queried in polls conducted earlier this year, only about half of American adults said they planned to get any treatment against the new asthma.

But after a largely successful rollout this month of two safe and effective shots, many of those initial doubters now say they'll line up to get their treatment doses when their turn comes.According to the Times, polls conducted by Gallup, the Kaiser Family Foundation and the Pew Research Center all show treatment acceptance rates rising from about 50% this summer to more than 60% and, in one poll, 73%.That last number approaches the threshold scientists have deemed necessary for herd immunity, where enough of a population is immune and the spread of the asthma begins to recede."As soon as it is my turn to get the treatment, I will be there front and center!. I am very excited and hopeful," Joanne Barnes, 68, a retired elementary school teacher from Fairbanks, Alaska, told the Times.Earlier this summer, Barnes had told the paper the opposite. That she would not get the shot.

The game-changers for her, Barnes said, were "the Biden administration, returning to listening to science and the fantastic stats associated with the treatments."With more than 19 million asthma treatment cases in the United States by Wednesday and more than 338,000 Americans now killed by the disease, more people than ever have now been personally affected by the new asthma. That harsh reality might also be driving some to reconsider getting the shot. "More people have either been affected or infected by asthma treatment," Rupali Limaye, an expert on treatment behavior at the Johns Hopkins Bloomberg School of Public Health in Baltimore, told the Times.

"They know someone who had a severe case or died. They are fatigued and want to get back to their normal lives."Media campaigns, including on-camera moments with politicians and scientists -- such as Vice President Mike Pence, President-Elect Joe Biden and Dr. Anthony Fauci -- all rolling up their sleeves for the shots may have also helped boost acceptance.Still, large pockets of skepticism and resistance to vaccination remain.

According to the Times, mistrust of the treatment is higher among Blacks than whites, among Republicans compared to Democrats, and among people living in rural areas versus those in cities.Still, resistance is fading slowly among most groups, the Times said.One Black American, Mike Brown, runs a barbershop in Hyattsville, Md. This summer he said he wouldn't get any asthma treatment, but has since changed his mind."The news that it was 95% effective sold me," Brown told the Times. "The side effects sound like what you get after a bad night of drinking and you hurt the next day.

Well, I've had many of those and I can deal with that to get rid of the face masks."A global scourgeBy Wednesday, the U.S. asthma case count passed 19.5 million while the death toll neared 339,000, according to a Times tally. On Wednesday, the top five states for asthma s were.

California with more than 2.2 million cases. Texas with over 1.7 million cases. Florida with almost 1.3 million cases.

Illinois with over 950,000 cases. And New York with over 950,000 cases.Curbing the spread of the asthma in the rest of the world remains challenging.In India, the asthma case count was over 10.2 million on Wednesday, a Johns Hopkins University tally showed. Brazil had over 7.5 million cases and over 192,000 deaths as of Wednesday, the Hopkins tally showed.Worldwide, the number of reported s passed 82 million on Wednesday, with nearly 1.8 million deaths recorded, according to the Hopkins tally.More informationThe U.S.

Centers for Disease Control and Prevention has more on the new asthma.SOURCES. Washington Post. The New York TimesCopyright © 2020 HealthDay.

All rights reserved.Latest Lungs News By Denise Mann HealthDay ReporterWEDNESDAY, Dec. 30, 2020 (HealthDay News)Nurses are known for being kind, caring and sympathetic, but Brianna Fogelman brings an uncommon empathy to her nursing job at Johns Hopkins Medicine in Baltimore.Fogelman, 27, underwent a double lung transplant last year to treat a rare lung disease and returned this fall to work in the same hospital where she received her life-changing surgery."I understand how it feels to have your ability to breathe taken away from you in just a couple of days," she said.Though she had always planned to become a nurse, it wasn't until after her transplant that it felt like more of a calling, Fogelman said."My interest and passion spiked tremendously after I became a patient," she said.The former high school track and field athlete was in her third year of nursing school when she was diagnosed in the spring of 2019 with hypersensitivity pneumonitis. It's a rare disease that causes inflammation that can lead to irreversible lung scarring.The condition is caused by inhaling specific environmental allergens -- in Fogelman's case, feathers.

As a child, she had parakeets as pets and eventually developed an allergy to all types of feathers, including those in pillows, blankets and jackets. As a result, her lung condition worsened.She and her doctors tried everything to improve her breathing, including immunosuppressants and steroids to reduce inflammation, and Fogelman said her lungs were "decent" for a while.Then, in 2018, she developed an that would be pivotal for her health. "I had six to eight lung collapses from 2018 to 2019," she recalled.Despite that, Fogelman managed to continue her nursing training at Wesley College in Dover, Del.But soon after graduation, she got pneumonia and lost all remaining lung function.

She was placed on the emergency transplant waiting list.On June 24, 2019, after a couple of disappointments, she received her new lungs.It was the 100th transplant surgery at Johns Hopkins for her surgeon Dr. Errol Bush, who is thrilled to have Fogelman back at Hopkins -- as a nurse."She is an amazing nurse because of what she has been through," said Bush, surgical director of Hopkins' advanced lung disease and lung transplant program.Fogelman's transplant surgery was a success, though it had an unexpected wrinkle. The lower lobe of her new right lung had to be removed during the operation so it could better fit in her small chest cavity.Though she is not directly treating patients with asthma treatment or other infectious lung diseases, the hope is that she will see more lung transplant patients once the ventolin is under control.

The medications she takes to prevent organ rejection make her more susceptible to s like asthma treatment.Fogelman is one of the lucky ones, Bush said. Many donor lungs are too damaged to transplant safely due to underlying disease or time spent on mechanical breathing machines, he said."She knows how it feels to be intubated and waiting for lungs," Bush said. "We went through multiple donors and letdowns when lungs weren't good."It all gives nurse Fogelman a special sensitivity to patients."She can answer questions like, 'Is it painful?.

' and help relieve anxiety and offer support in ways that the rest of our care members aren't able to do," Bush said.Waiting for new lungs was hard, Fogelman added."I empathize with patients who feel helpless and don't see the light at the end of tunnel," she said. "You are always getting bad news, and that's how I felt for so long."All the time in the hospital waiting for new lungs left her a bit out of shape, but Fogelman feels "really good," she said."I can do everything," she said. "I can run and walk upstairs."She is vocal about the benefits and importance of organ donation."Overall, it's very important that people try to understand that organ donation is so important and should try to get to know people who have benefited," Fogelman said.More informationTo learn more about organ donation, visit the U.S.

Government Information on Organ Donation and Transplantation.SOURCES. Brianna Fogelman, RN, Johns Hopkins Medicine, Baltimore. Errol Bush, MD, surgical director, Advanced Lung Disease and Lung Transplant Program, associate professor of surgery, Johns Hopkins University School of Medicine, BaltimoreCopyright © 2020 HealthDay.

All rights reserved. QUESTION COPD (chronic obstructive pulmonary disease) is the same as adult-onset asthma. See AnswerLatest asthma News WEDNESDAY, Dec.

30, 2020 (HealthDay News)A new study confirms what you likely already know from experience -- it can be hard to recognize people when they're wearing masks during the asthma treatment ventolin."For those of you who don't always recognize a friend or acquaintance wearing a mask, you are not alone," said researchers Tzvi Ganel and Erez Freud."Faces are among the most informative and significant visual stimuli in human perception and play a unique role in communicative, social daily interactions," they noted. "The unprecedented effort to minimize asthma treatment transmission has created a new dimension in facial recognition due to mask wearing."Ganel is head of the Laboratory for Visual Perception and Action at Ben-Gurion University of the Negev in Beersheba, Israel. Freud is an assistant professor of psychology at York University in Toronto.For their online study, they assessed how well nearly 500 people could identify masked and unmasked faces.The participants were 15% less likely to identify someone wearing a mask, according to findings published Dec.

21 in the journal Scientific Reports.Researchers found that masks interfere with getting an overall impression of faces and force people to check out specific facial features, which takes longer and is a less accurate."Instead of looking at the entire face, we're now forced to look at eyes, nose, cheeks and other visible elements separately to construct an entire facial face percept -- which we used to do instantly," the researchers explained in a university news release.They said the challenge of identifying people wearing masks could have major effects on daily life, including social interactions and education."Given that mask wearing has rapidly become an important norm in countries around the globe, future research should explore the social and psychological implications of wearing masks on human behavior," Ganel said. "The magnitude of the effect of masks that we report in the current study is probably an underestimation of the actual degree in performance dropdown for masked faces."More informationThe U.S. Food and Drug Administration has more on masks.SOURCE.

Ben-Gurion University of the Negev, news release, Dec. 21, 2020Robert PreidtCopyright © 2020 HealthDay. All rights reserved..

Rinse mouth after ventolin

How to more information cite this rinse mouth after ventolin article:Singh OP. Mental health in diverse India. Need for rinse mouth after ventolin advocacy. Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of.

We have diversity in terms of geography rinse mouth after ventolin – From the Himalayas to the deserts to the seas. Every region has its own distinct culture and food. There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward rinse mouth after ventolin women, health infrastructure, child mortality, and other sociodemographic development indexes.

There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the rinse mouth after ventolin distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the rinse mouth after ventolin field of mental health, we find huge differences between different states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset rinse mouth after ventolin disorders. This may be due to lead toxicity, nutritional status, and perinatal issues.

Higher rates of depression and rinse mouth after ventolin anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was found to be a negative prognostic indicator contrary to the western norms.[3]Cultural influences on rinse mouth after ventolin the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.

The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, it was 41,197, and in rinse mouth after ventolin higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill persons and rinse mouth after ventolin reducing stigma and discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective rinse mouth after ventolin interventions, and their efficacy.Advocacy can be done at institutional level, organizational level, and individual level. There has been huge work done in this regard at institution level.

Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of rinse mouth after ventolin Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers. Similarly, at organizational level, the Indian Psychiatric rinse mouth after ventolin Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality.

The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also come out with editorials highlighting the need of care rinse mouth after ventolin of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research highlighting the role of these factors on rinse mouth after ventolin mental health.

References 1.Compton MT, Shim RS. The social rinse mouth after ventolin determinants of mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.

National Mental Health Survey of India, 2015-16 rinse mouth after ventolin. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No.

129. 2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.

The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India.

2019. Available from. Https://ncrb.gov.in. [Last accessed on 2021 Jun 24].

5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses.

Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr. N. N.

Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as “a culturally determined idiom of distress.” It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients.

The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature. It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords.

Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome. A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr.

President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020. I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.

His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr.

Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr. Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K.

Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals. I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.

Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions. Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area.

Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome. A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology.

Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS. The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively.

Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management.

He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent. The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners.

A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders.

The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.

The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms.

Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%). The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness.

Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic. Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.

Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it.

The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss. Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine.

They were assessed for a period of 6 months. More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex.

Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI). Men with DS reported greater symptoms on BSI than those without DS.

60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness.

This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire. Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).

Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders.

The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS.

The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice.

Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments.

About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.

Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia). Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India.

They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic. Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background.

Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years).

The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache.

More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia. About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders).

Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.

Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains. The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation.

Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class.

Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss. They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.

The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%).

About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation.

The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively.

Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%).

Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively. Two-third patients belonged to rural areas of residence.

Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata. The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset.

Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.

Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks.

As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help. The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals.

Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to ventolin pill cost the local terminology and beliefs.

Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual. Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same.

Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization.

Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity. The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.

While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression.

In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health.

It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time. In.

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J Soc Psychiatry 1986;2:403-25. 23.Sameer M, Menon V, Chandrasekaran R. Is 'Pure' Dhat syndrome a stable diagnostic entity?. A naturalistic long term follow up study from a tertiary care centre.

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Dhat syndrome – A useful diagnostic entity in Indian culture. Br J Psychiatry 1991;159:691-5. 48.Bhatia MS, Choudhry S, Shome S. Dhat syndrome - Is it a syndrome of Dhat only?.

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Current nosology of Dhat syndrome and state of evidence. Indian J Health Sex Cult 2018;4:8-14. 58.APA (American Psychological Association). Diagnostic and Statistical Manual of Mental Disorders.

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62.Sharan P, Keeley J. Cultural perspectives related to international classification of diseases-11. Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

How to cite this article:Singh where can i buy ventolin nebules online OP. Mental health in diverse India. Need for where can i buy ventolin nebules online advocacy. Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of.

We have where can i buy ventolin nebules online diversity in terms of geography – From the Himalayas to the deserts to the seas. Every region has its own distinct culture and food. There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, health where can i buy ventolin nebules online infrastructure, child mortality, and other sociodemographic development indexes.

There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading where can i buy ventolin nebules online to social inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different where can i buy ventolin nebules online states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of where can i buy ventolin nebules online adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders. This may be due to lead toxicity, nutritional status, and perinatal issues.

Higher rates of depression and anxiety were found in females where can i buy ventolin nebules online. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was found to be a where can i buy ventolin nebules online negative prognostic indicator contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.

The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic where can i buy ventolin nebules online strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill persons and reducing where can i buy ventolin nebules online stigma and discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, organizational level, and where can i buy ventolin nebules online individual level. There has been huge work done in this regard at institution level.

Important research work done in this regard where can i buy ventolin nebules online includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers. Similarly, at organizational level, the Indian Psychiatric Society (IPS) has filed a case for lacunae where can i buy ventolin nebules online in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality.

The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also come out with editorials highlighting the need of care of marginalized population such as where can i buy ventolin nebules online migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research highlighting where can i buy ventolin nebules online the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social determinants where can i buy ventolin nebules online of mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.

National Mental Health Survey of India, where can i buy ventolin nebules online 2015-16. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No.

129. 2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.

The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India.

2019. Available from. Https://ncrb.gov.in. [Last accessed on 2021 Jun 24].

5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses.

Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr. N. N.

Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as “a culturally determined idiom of distress.” It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients.

The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature. It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords.

Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome. A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr.

President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020. I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.

His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr.

Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr. Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K.

Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals. I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.

Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions. Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area.

Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome. A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology.

Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS. The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively.

Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management.

He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent. The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners.

A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders.

The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.

The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms.

Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%). The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness.

Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic. Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.

Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it.

The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss. Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine.

They were assessed for a period of 6 months. More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex.

Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI). Men with DS reported greater symptoms on BSI than those without DS.

60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness.

This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire. Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).

Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders.

The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS.

The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice.

Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments.

About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.

Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia). Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India.

They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic. Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background.

Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years).

The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache.

More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia. About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders).

Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.

Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains. The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation.

Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class.

Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss. They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.

The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%).

About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation.

The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively.

Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%).

Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively. Two-third patients belonged to rural areas of residence.

Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata. The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset.

Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.

Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks.

As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help. The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals.

Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs.

Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual. Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same.

Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization.

Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity. The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.

While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression.

In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health.

It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time. In.

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None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

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