Where to buy amoxil pills

The buy antibiotics amoxil has solidified the role of comprehensive, affordable mental health benefits as a retention strategy where to buy amoxil pills for employers, a pair of surveys released Monday found. New surveys from the National Alliance of Healthcare Purchaser Coalitions and Mercer make the business case for packing quality mental health coverage into employee benefit plans. The findings, which cover hundreds of thousands of employees, include that mental health is a top area of focus for both where to buy amoxil pills employers as they craft benefits and for employees as they survey career options. Employees' mental health has a direct impact on their productivity, or their ability to perform their best at work, said Michael Thompson, CEO of the National Alliance, the umbrella organization for employer coalitions nationwide. His group's members represent public and private employers that spend more than $300 billion annually on healthcare for more than 45 million Americans.National Alliance conducted where to buy amoxil pills an online poll in August of 142 employers with at least 1,000 employees.

Mental health and substance use access and quality tied as the top area of focus for healthcare strategies in the next one to two years. "Employers have seen the impact of the deterioration of mental health during where to buy amoxil pills the amoxil and have actually seen it manifest in their workforce," Thompson said. "With that in mind, I think they are anxious to provide necessary support and access for employees who do have concerns, issues with their mental health." Mercer found that more than half of U.S. Employees reported some level of stress in the past year, and almost one-quarter said they experienced mental health issues such as depression or anxiety. One fifth where to buy amoxil pills said they're financially worse off than before the amoxil, and almost the same share feels less physically healthy.

Mercer fielded its survey of 14,000 employees in 13 countries—2,000 of them in the U.S.—between March and April. Half of employees Mercer surveyed where to buy amoxil pills said programs that reduce the cost of mental health treatment are highly or extremely valuable. That finding wasn't surprising, but it does validate the work employers have been doing over the past 18 months, said Kate Brown, who leads Mercer's Center for Health Innovation. Mercer also found that 45% of employees where to buy amoxil pills who felt they received good support from their employer during the amoxil also said they are less likely to leave their job as a result. Mercer's findings show that while mental and physical health benefits are important to employees, even more highly ranked was having flexible working arrangements, Brown said.

"It's creating a more supportive culture for where to buy amoxil pills your people," he added. "That's what proved to be so important."The National Alliance survey found employers have become somewhat more open to buy antibiotics treatment mandates for their employees amid the rise in cases fueled by the delta variant. In a March survey, just 8% of employers said they would mandate buy antibiotics treatments for all workers. That grew to 37% where to buy amoxil pills in August. The reason it's not higher is because employers are struggling economically with finding workers.

Anything that could potentially cause people to leave is a concern, Thompson said.President Joe Biden's expansive new rule mandating employers with more than 100 workers require them to where to buy amoxil pills be vaccinated or test for the amoxil weekly changes the dynamic and, frankly, makes it easier for employers to move in the direction they were already headed, Thompson said. Many employers wanted to roll out treatment mandates but wanted to avoid alienating workers, he added. Biden's mandate allows them where to buy amoxil pills to avoid that perception. "There are definitely employers that will view this new regulation as providing cover for a strategy that was harder to implement independently, particularly independent of their competitors," he said. "This will create a level playing field of all employees over 100 having some form of a mandate.

It will make it more viable for many employers to do it."The percentage of employers anticipating a return where to buy amoxil pills to a stabilized business environment by the end of 2021 declined from 65% to 57% over the past six months, the National Alliance found. Employers also cited affordability concerns with respect to their benefit plans as a big issue going forward, with 80% citing drug prices as a significant threat and 73% citing hospital prices as a significant threat. Centers of excellence tied as a leading area of focus for companies' healthcare strategies in the coming years, with 92% of where to buy amoxil pills respondents selecting it. That's where health plans steer members to a specific provider for specific big-ticket procedures, like joint replacements.Thompson said that aligns with the recent movement from a hands-off approach to employer healthcare delivery to one that's more "selective and directive for employees."Employees who took Mercer's survey also noted that their employers are their third most trusted source of health information, higher than private medical insurers, online retailers and even the government. "That's interesting finding if I'm in an HR seat," Brown where to buy amoxil pills said.

"I really have a high level of trust from my employees. I think that makes some of the choices employers have to make a little bit easier.".

Low price amoxil

	Amoxil	Neggram	Seromycin	Ciplox	Bactrim
Take with alcohol	Order online	Pharmacy	Nearby pharmacy	At walgreens	Order online
How long does stay in your system	Yes	Yes	No	Yes	No
Buy with mastercard	Register first	No	No	Yes	No
Buy with echeck	Canadian Pharmacy	No	Pharmacy	Online Pharmacy	Indian Pharmacy

How to cite low price amoxil this article:Singh OP buy cheap amoxil online. Mental health in diverse India. Need for low price amoxil 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 low price amoxil 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 infrastructure, child low price amoxil mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] low price amoxil have described in their model of gene environment interaction how public policies and social norms act on the 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 low price amoxil come to the 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 disorders low price amoxil.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression and anxiety were found in females low price amoxil. 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 the presentation of psychiatric disorders are apparent low price amoxil. 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 low price amoxil (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 stigma and discriminations low price amoxil. 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 low price amoxil out the problem, cost-effective 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 low price amoxil in this regard 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 low price amoxil 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 of marginalized population low price amoxil 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 low price amoxil enemy is economic inequality, our weapon is research highlighting the role of these factors on mental health. References 1.Compton MT, Shim RS. The social low price amoxil 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 low price amoxil of India, 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. Sathyanarayana Rao TS, Tandon A, editors.

Psychiatry in India. Training and Training Centres. 2nd ed. Mysuru, India. Ramya Creations.

2015. P. 753-76. 4.Prakash O. Lessons for postgraduate trainees about Dhat syndrome.

Indian J Psychiatry 2007;49:208-10. [PUBMED] [Full text] 5.Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting. Indian J Psychiatry 2016;58:129-41. [PUBMED] [Full text] 6.Jadhav S.

Dhāt syndrome. A re-evaluation. Psychiatry 2004;3:14-16. 7.Wen JK, Wang CL. Shen-Kui syndrome.

A culture-specific sexual neurosis in Taiwan. In. Kleinman A, Lin TY, editors. Normal and Abnormal Behaviour in Chinese Culture. Dordrecht, Holland.

D Reidel Publishing Co. 1980. P. 357-69. 8.De Silva P, Dissanayake SA.

The use of semen syndrome in Sri Lanka. A clinical study. Sex Marital Ther 1989;4:195-204. 9.Chadda RK, Ahuja N. Dhat syndrome.

A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9. 10.Rao TS, Rao VS, Rajendra PN, Mohammed A. A retrospective comparative study of teaching hospital and private clinic clients with sexual problems. Indian J Behav Sci 1995;5:58-63.

11.Mumford DB. The 'Dhat syndrome'. A culturally determined symptom of depression?. Acta Psychiatr Scand 1996;94:163-7. 12.Sumathipala A, Siribaddana SH, Bhugra D.

Culture-bound syndromes. The story of Dhat syndrome. Br J Psychiatry 2004;184:200-9. 13.Khan N. Dhat syndrome in relation to demographic characteristics.

Indian J Psychiatry 2005;47:54-57. [Full text] 14.Prakash O, Kar SK, Sathyanarayana Rao TS. Indian story on semen loss and related Dhat syndrome. Indian J Psychiatry 2014;56:377-82. [PUBMED] [Full text] 15.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.

Phenomenology and beliefs of patients with Dhat syndrome. A nationwide multicentric study. Int J Soc Psychiatry 2016;62:57-66. 16.MacFarland AS, Al-Maashani M, Al Busaidi Q, Al-Naamani A, El-Bouri M, Al-Adawi S. Culture-specific pathogenicity of Dhat (semen loss) Syndrome in an Arab/Islamic Society, Oman.

Oman Med J 2017;32:251-5. 17.Rao TS. Comprehensive Study of Prevalence Rates, Symptom Profile, Comorbidity and Management of Dhat Syndrome in Rural and Urban Communities. PhD Thesis. Department of Psychiatry, Jagadguru Sri Shivarathreeshwara Medical College, JSS University, Shivarathreeshwara Nagar Mysore, Karnataka, India.

2017. 18.Kar SK. Treatment - emergent Dhat syndrome in a young male with obsessive-compulsive disorder. An alarm for medication nonadherence. Acta Med Int 2019;6:44-45.

[Full text] 19.Kuchhal AK, Kumar S, Pardal PK, Aggarwal G. Effect of Dhat syndrome on body and mind. Int J Contemp Med Res 2019;6:H7-10. 20.Shakya DR. Dhat syndrome.

Study of clinical presentations in a teaching institute of eastern Nepal. J Psychosexual Health 2019;1:143-8. 21.Leff JP. Culture and the differentiation of emotional states. Br J Psychiatry 1973;123:299-306.

22.Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview. 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. J Clin Diagn Res 2015;9:C01-3. 24.Chadda RK. Dhat syndrome.

Is it a distinct clinical entity?. A study of illness behaviour characteristics. Acta Psychiatr Scand 1995;91:136-9. 25.Bhatia MS, Bohra N, Malik SC. 'Dhat' syndrome – A useful clinical entity.

Indian J Dermatol 1989;34:32-41. 26.Dewaraja R, Sasaki Y. Semen-loss syndrome. A comparison between Sri Lanka and Japan. American J Psychotherapy 1991;45:14-20.

27.Balhara YP. Culture-bound syndrome. Has it found its right niche?. Indian J Psychol Med 2011;33:210-5. [PUBMED] [Full text] 28.Prakash, S, Mandal P.

Is Dhat syndrome indeed a culturally determined form of depression?. Indian J Psychol Med 2015;37:107-9. 29.Prakash O, Kar SK. Dhat syndrome. A review and update.

J Psychosexual Health 2019;1:241-5. 30.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al. Comorbidity in patients with Dhat syndrome. A nationwide multicentric study. J Sex Med 2015;12:1398-401.

31.Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4. 32.Paris A. Dhat syndrome.

A review. Transcult Psychiatry Rev 1992;29:109-18. 33.Deb KS, Balhara YP. Dhat syndrome. A review of the world literature.

Indian J Psychol Med 2013;35:326-31. [PUBMED] [Full text] 34.Udina M, Foulon H, Valdés M, Bhattacharyya S, Martín-Santos R. Dhat syndrome. A systematic review. Psychosomatics 2013;54:212-8.

35.Kar SK, Sarkar S. Dhat syndrome. Evolution of concept, current understanding, and need of an integrated approach. J Hum Reprod Sci 2015;8:130-4. [PUBMED] [Full text] 36.World Health Organisation.

The ICD-10, Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva. World Health Organisation. 1992.

37.Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome. A functional somatic syndrome of the Indian subcontinent?. Gen Hosp Psychiatry 2005;27:215-7. 38.Wig NN.

Problem of mental health in India. J Clin Soc Psychiatry 1960;17:48-53. 39.Clyne MB. Indian patients. Practitioner 1964;193:195-9.

40.Yap PM. The culture bound reactive syndrome. In. Caudil W, Lin T, editors. Mental Health Research in Asia and the Pacific.

Honolulu. East West Center Press. 1969. 41.Rao TS, Rao VS, Arif M, Rajendra PN, Murthy KA, Gangadhar TK, et al. Problems in medical practice.

A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S. Koro in Dhat syndrome. Indian J Soc Psychiatry 1992;8:74-5.

43.Priyadarshi S, Verma A. Dhat syndrome and its social impact. Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK. A study of male potency disorders.

Indian J Psychiatry 1977;19:13-8. [Full text] 45.Behere PB, Natraj GS. Dhat syndrome. The phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry 1984;26:76-8.

[PUBMED] [Full text] 46.Singh G. Dhat syndrome revisited. Indian J Psychiatry 1985;27:119-22. [PUBMED] [Full text] 47.Bhatia MS, Malik SC. 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?. J Ment Health Hum Behav1997;2:17-22. 49.Bhatia MS.

An analysis of 60 cases of culture bound syndromes. Indian J Med Sci 1999;53:149-52. [PUBMED] [Full text] 50.Morrone A, Nosotti L, Tumiati Mc, Cianconi P, Casadei F, Franco G. Dhat Syndrome. An Analysis of 18 Cases.

Paper Presented in 11th Congress of the European Academy of Dermatology &. Venerology. Prague. Czech. 2002.

51.Carstairs GM. Hinjra and jiryan. Two derivatives of Hindu attitudes to sexuality. Br J Med Psychol 1956;29:128-38. 52.Carstairs GM.

The Twice Born. Bloomington. Indiana University Press. 1961. 53.Carstairs GM.

Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972. Br J Psychiatry 1973;123:271-7. 54.Sathyanarayana Rao TS. Some thoughts on sexualities and research in India.

Indian J Psychiatry 2004;46:3-4. [PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update. Indian J Psychiatry 2010;52:S260-3.

56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction. Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V. 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. DSM-5. Washington.

DC. American Psychological Association. 2013. 59.Yasir Arafat SM. Dhat syndrome.

Culture bound, separate entity, or removed. J Behav Health 2017;6:147-50. 60.Prakash S, Sharan P, Sood M. A qualitative study on psychopathology of dhat syndrome in men. Implications for classification of disorders.

Asian J Psychiatr 2018;35:79-88. 61.Lewis-Fernández R, Aggarwal NK. Culture and psychiatric diagnosis. Adv Psychosom Med 2013;33:15-30. 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 where to buy amoxil pills article:Singh OP. Mental health in diverse India. Need for where to buy amoxil pills 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 – From the Himalayas to the deserts where to buy amoxil pills 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 where to buy amoxil pills states in terms of development, attitude toward 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 where to buy amoxil pills act on the 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 where to buy amoxil pills poor mental health, disease, and morbidity.When we come to the 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, where to buy amoxil pills 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 to buy amoxil pills. 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 the where to buy amoxil pills 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 where to buy amoxil pills 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 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 where to buy amoxil pills promoting rights of mentally ill persons and 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 where to buy amoxil pills out the problem, cost-effective 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 where to buy amoxil pills 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 where to buy amoxil pills 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 of marginalized where to buy amoxil pills 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 where to buy amoxil pills research highlighting the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social determinants of where to buy amoxil pills 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 where to buy amoxil pills of India, 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. Sathyanarayana Rao TS, Tandon A, editors. Psychiatry in India.

Training and Training Centres. 2nd ed. Mysuru, India.

753-76. 4.Prakash O. Lessons for postgraduate trainees about Dhat syndrome.

Indian J Psychiatry 2007;49:208-10. [PUBMED] [Full text] 5.Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting.

Indian J Psychiatry 2016;58:129-41. [PUBMED] [Full text] 6.Jadhav S. Dhāt syndrome.

A re-evaluation. Psychiatry 2004;3:14-16. 7.Wen JK, Wang CL.

Shen-Kui syndrome. A culture-specific sexual neurosis in Taiwan. In.

Kleinman A, Lin TY, editors. Normal and Abnormal Behaviour in Chinese Culture. Dordrecht, Holland.

357-69. 8.De Silva P, Dissanayake SA. The use of semen syndrome in Sri Lanka.

A clinical study. Sex Marital Ther 1989;4:195-204. 9.Chadda RK, Ahuja N.

Dhat syndrome. A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9.

10.Rao TS, Rao VS, Rajendra PN, Mohammed A. A retrospective comparative study of teaching hospital and private clinic clients with sexual problems. Indian J Behav Sci 1995;5:58-63.

11.Mumford DB. The 'Dhat syndrome'. A culturally determined symptom of depression?.

Acta Psychiatr Scand 1996;94:163-7. 12.Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes.

The story of Dhat syndrome. Br J Psychiatry 2004;184:200-9. 13.Khan N.

Dhat syndrome in relation to demographic characteristics. Indian J Psychiatry 2005;47:54-57. [Full text] 14.Prakash O, Kar SK, Sathyanarayana Rao TS.

Indian story on semen loss and related Dhat syndrome. Indian J Psychiatry 2014;56:377-82. [PUBMED] [Full text] 15.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.

Phenomenology and beliefs of patients with Dhat syndrome. A nationwide multicentric study. Int J Soc Psychiatry 2016;62:57-66.

16.MacFarland AS, Al-Maashani M, Al Busaidi Q, Al-Naamani A, El-Bouri M, Al-Adawi S. Culture-specific pathogenicity of Dhat (semen loss) Syndrome in an Arab/Islamic Society, Oman. Oman Med J 2017;32:251-5.

17.Rao TS. Comprehensive Study of Prevalence Rates, Symptom Profile, Comorbidity and Management of Dhat Syndrome in Rural and Urban Communities. PhD Thesis.

Department of Psychiatry, Jagadguru Sri Shivarathreeshwara Medical College, JSS University, Shivarathreeshwara Nagar Mysore, Karnataka, India. 2017. 18.Kar SK.

Treatment - emergent Dhat syndrome in a young male with obsessive-compulsive disorder. An alarm for medication nonadherence. Acta Med Int 2019;6:44-45.

[Full text] 19.Kuchhal AK, Kumar S, Pardal PK, Aggarwal G. Effect of Dhat syndrome on body and mind. Int J Contemp Med Res 2019;6:H7-10.

20.Shakya DR. Dhat syndrome. Study of clinical presentations in a teaching institute of eastern Nepal.

J Psychosexual Health 2019;1:143-8. 21.Leff JP. Culture and the differentiation of emotional states.

Br J Psychiatry 1973;123:299-306. 22.Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders.

An overview. 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. J Clin Diagn Res 2015;9:C01-3.

24.Chadda RK. Dhat syndrome. Is it a distinct clinical entity?.

A study of illness behaviour characteristics. Acta Psychiatr Scand 1995;91:136-9. 25.Bhatia MS, Bohra N, Malik SC.

'Dhat' syndrome – A useful clinical entity. Indian J Dermatol 1989;34:32-41. 26.Dewaraja R, Sasaki Y.

Semen-loss syndrome. A comparison between Sri Lanka and Japan. American J Psychotherapy 1991;45:14-20.

27.Balhara YP. Culture-bound syndrome. Has it found its right niche?.

Indian J Psychol Med 2011;33:210-5. [PUBMED] [Full text] 28.Prakash, S, Mandal P. Is Dhat syndrome indeed a culturally determined form of depression?.

Indian J Psychol Med 2015;37:107-9. 29.Prakash O, Kar SK. Dhat syndrome.

A review and update. J Psychosexual Health 2019;1:241-5. 30.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.

Comorbidity in patients with Dhat syndrome. A nationwide multicentric study. J Sex Med 2015;12:1398-401.

31.Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4.

Transcult Psychiatry Rev 1992;29:109-18. 33.Deb KS, Balhara YP. Dhat syndrome.

A review of the world literature. Indian J Psychol Med 2013;35:326-31. [PUBMED] [Full text] 34.Udina M, Foulon H, Valdés M, Bhattacharyya S, Martín-Santos R.

Dhat syndrome. A systematic review. Psychosomatics 2013;54:212-8.

35.Kar SK, Sarkar S. Dhat syndrome. Evolution of concept, current understanding, and need of an integrated approach.

J Hum Reprod Sci 2015;8:130-4. [PUBMED] [Full text] 36.World Health Organisation. The ICD-10, Classification of Mental and Behavioural Disorders.

Diagnostic Criteria for Research. Geneva. World Health Organisation.

1992. 37.Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome.

A functional somatic syndrome of the Indian subcontinent?. Gen Hosp Psychiatry 2005;27:215-7. 38.Wig NN.

Problem of mental health in India. J Clin Soc Psychiatry 1960;17:48-53. 39.Clyne MB.

Indian patients. Practitioner 1964;193:195-9. 40.Yap PM.

The culture bound reactive syndrome. In. Caudil W, Lin T, editors.

Mental Health Research in Asia and the Pacific. Honolulu. East West Center Press.

1969. 41.Rao TS, Rao VS, Arif M, Rajendra PN, Murthy KA, Gangadhar TK, et al. Problems in medical practice.

A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S.

Koro in Dhat syndrome. Indian J Soc Psychiatry 1992;8:74-5. 43.Priyadarshi S, Verma A.

Dhat syndrome and its social impact. Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK.

A study of male potency disorders. Indian J Psychiatry 1977;19:13-8. [Full text] 45.Behere PB, Natraj GS.

Dhat syndrome. The phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry 1984;26:76-8.

[PUBMED] [Full text] 46.Singh G. Dhat syndrome revisited. Indian J Psychiatry 1985;27:119-22.

[PUBMED] [Full text] 47.Bhatia MS, Malik SC. 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?. J Ment Health Hum Behav1997;2:17-22.

49.Bhatia MS. An analysis of 60 cases of culture bound syndromes. Indian J Med Sci 1999;53:149-52.

[PUBMED] [Full text] 50.Morrone A, Nosotti L, Tumiati Mc, Cianconi P, Casadei F, Franco G. Dhat Syndrome. An Analysis of 18 Cases.

Paper Presented in 11th Congress of the European Academy of Dermatology &. Venerology. Prague.

Hinjra and jiryan. Two derivatives of Hindu attitudes to sexuality. Br J Med Psychol 1956;29:128-38.

52.Carstairs GM. The Twice Born. Bloomington.

Indiana University Press. 1961. 53.Carstairs GM.

Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972. Br J Psychiatry 1973;123:271-7.

54.Sathyanarayana Rao TS. Some thoughts on sexualities and research in India. Indian J Psychiatry 2004;46:3-4.

[PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update.

Indian J Psychiatry 2010;52:S260-3. 56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction.

Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V. 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.

American Psychological Association. 2013. 59.Yasir Arafat SM.

Dhat syndrome. Culture bound, separate entity, or removed. J Behav Health 2017;6:147-50.

60.Prakash S, Sharan P, Sood M. A qualitative study on psychopathology of dhat syndrome in men. Implications for classification of disorders.

Asian J Psychiatr 2018;35:79-88. 61.Lewis-Fernández R, Aggarwal NK. Culture and psychiatric diagnosis.

Adv Psychosom Med 2013;33:15-30. 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.

What is Amoxil?

AMOXICILLIN is a penicillin antibiotic. It kills or stops the growth of some bacteria. Amoxil is used to treat many kinds of s. It will not work for colds, flu, or other viral s.

Where to buy amoxil

End of term where to buy amoxil report‘Brown. You may discuss your report with the head now. You should know, there are some issues.’ where to buy amoxil Many of you will have similar recollections of mid-July during their schooldays. The annual feedback lurking, snake-like in the reeds, freedom never granted until the teachers’ handwritten, often indecipherable words had been parentally decodified at home, my own Achilles’ heels art and English literature perennial causes of teachers’ deep sighs.

I acknowledge that the stick men figures of my primary school art failed to evolve into anything more than uncannily similar stick men figures over the course of my pre-teenage years, the point at which my metaphorical knotted sheets and I furnished an escape. Are we where to buy amoxil also, collectively, guilty of leaving our socks proverbially at ankle length in places?. Asthma. What are where to buy amoxil the priorities?.

We kick off with a blistering pair of editorials which eviscerate a common practice from opposite, but not necessarily, mutually exclusive angles. The first is by Ian Sinha and argues the case for the replacement of prednisolone with dexamethasone in acute asthma attacks. The ubiquitous prednisolone is, its where to buy amoxil detractors assert, known for its (gustatory, olfactory and visual) unpalatability. Once sampled, no child ever trusts pink medicine again – its emetogenic capacity and potential for non-compliance given the 3 day rather than 1 day course often cited as additional drawbacks.

Mark Levy and colleagues challenge the need for the abandonment of prednisolone largely based on the lack of hard where to buy amoxil evidence. This is where interpretation has to be disentangled from personal biases. Not easy and the reality is that even the most robust meta-analyses can’t always furnish us with ‘the answers’. I could, but won’t take sides on this (just now) as it would spoil your fun, but perhaps this is too close to call and, as long as the right children (school age) get some steroids (of one hue or another) early on and the wrong children (most preschoolers) where to buy amoxil don’t that might be a reasonable compromise.

There are other high-profile priorities like the use of high protracted courses of beta agonists and after discharge underuse of inhaled steroid-LABA combinations. I’m already looking forward where to buy amoxil to the next round of discussions. The UK (and we can shoegaze all we like) is a perennial ‘could do better’/end of year report C-performer. Not as bad as my F grade art, of course, but, how hard can it be to score at least a B grade?.

See where to buy amoxil pages 729 and 730Neonatal sepsis. New dataThough a great deal of credit is due for progress during the Millennium and early Sustainable Development goal eras, the data can’t disguise the areas where little changed. Until recently at least, perinatal mortality was one. A rule of thumb where to buy amoxil reminder.

In most low and middle income countries infant mortality accounts for about two thirds of all under 5 mortality. Of infant mortality, about two thirds is where to buy amoxil neonatal (first month) and, of neonatal, two thirds perinatal, deaths in the first week. Causes are consistent. Prematurity, asphyxia and sepsis, the dysregulated host immune response to to which neonates are exquisitely sensitive.

We like to think we have a ballpark idea of the burden of peri and neonatal death globally, but this ballpark is a very where to buy amoxil elastic one. Carolin Fleischmann and colleagues’ meticulous systematic review and meta-analysis brings some clarity, not only in overall sepsis load, but (and this is particularly useful in antibiotic selection) the early and late onset phenotypes. Of the total screened 26 studies published between 1979 and 2019 met the criteria where to buy amoxil (including a tight sepsis definition) were included accounting for 2.8 million live births and close to 30,000 sepsis. Random-effects MA estimated an incidence rate of 2,824/100,000 births with a case fatality of 17.6%.

Between 2009 and 2018, the incidence was markedly worse at 3,390. This isn’t a finding we can dismiss simply under where to buy amoxil the smokescreen of ascertainment bias and improvement of criteria. Take a look at the beta lactam, fourth generation cephalosporin, carbapenem and linezolid resistance patterns in other studies and one can only conclude this is not good news. See page 745Non-accidental where to buy amoxil injury.

More science. New dataThe TEN4 Bruise Clinical Decision Rule (BCDR) was first reported by Pierce in 2010. It was estimated that ‘bruising on the torso, ear, or neck for a child <48 months of age and bruising in any where to buy amoxil region for an infant <4 months of age, in the absence of a publicly witnessed injury' had a sensitivity of 97% and a specificity of 84% for predicting abuse. Using data from previous studies on patterns in day to day bruising, NAI and inherited bleeding disorders, Alison Kemp and colleagues refine the tool to test its ability to differentiate between bruise distribution phenotypes.

Applying TEN4 to to children under 4 years of age, with at least one bruise had an estimated sensitivity of 69% and where to buy amoxil specificity for abuse of 74%, figures that will ultimately inform how we report and a court interprets findings in an area where uncertainty is the rule. See page 774Can one afford to simply wait?. Other than the surgical approach having changed from scalpel to laparoscope, the individual and family experience of appendicitis as a package in terms of inpatient time, discomfort and cost has changed little in the recent past. For such a common entity, exploring new alternatives was always going to be necessary and the surgery vs antibiotic/expectant where to buy amoxil hypothesis is one such avenue.

The CONTRACT study, one of a series of randomised controlled trials tests the effectiveness of treating children with uncomplicated (for example, unperforated) appendicitis with parenteral antibiotics rather than surgery. Bold, but not unreasonable, given the objective equipoise and long experience of this approach in some countries. It is where to buy amoxil likely that the results of these RCTs will determine the route children take for years if not decades. The trial feasibility study undertaken by Nigel Hall and colleagues lent weight to.

Parents’ enthusiasm where to buy amoxil (50% enrolled after being approached). Acceptability of randomisation and patient and surgeon adherence to trial procedures. See page 764Ethics statementsPatient consent for publicationNot required.The buy antibiotics amoxil has posed challenges for the delivery of healthcare for infants with disruption to 6-week health checks and health visitor services.1 An area of particular concern is late presentation to the hospital.2 However, current data do not offer an objective picture of how significant a problem this may be, with other reports showing low rates of delays in presentation.3 Infantile hypertrophic pyloric stenosis (IHPS) is a common, non-infective infantile condition with a predictable clinical course and therefore a good indicator condition to assess for delays in presentation. We aimed to assess whether infants with IHPS presented later where to buy amoxil during ‘lockdown’ compared with the same period the preceding year.Ten centres within the UK (England, Scotland and Northern Ireland) contributed data from babies with IHPS via a website (buy antibioticsinchildren.co.uk) between 23 March 2020 and 31 May 2020 (the buy antibiotics lockdown period) and between 23 March and 31 May 2019 (controls).

A total of 87 eligible infants were included, comprising 40 controls (46%) and 47 cases (54%). The demographic and baseline characteristics of the two groups were similar (table 1 and figure 1).View this table:Table 1 Characteristics of control (2019 patients) and lockdown (2020) patientsComparison between the age at presentation (A) and admission where to buy amoxil weight (B) of infants with IHPS in the control period (2019) and the lockdown period. No significant difference is seen between the two groups (age at admission p=0.64, admission weight p=0.84). IHPS, Infantile hypertrophic pyloric stenosis." data-icon-position data-hide-link-title="0">Figure 1 Comparison between the age at presentation (A) and admission weight (B) of infants with IHPS in the control period (2019) and the lockdown period.

No significant difference is where to buy amoxil seen between the two groups (age at admission p=0.64, admission weight p=0.84). IHPS, Infantile hypertrophic pyloric stenosis.Median age and weight at presentation in the control group were 31 days (24–41) and 3600 g (3190–4081), and those in the lockdown group were 34 days (26–41) and 3580 g (3120–4085). These differences were where to buy amoxil not statistically significant (p=0.64, p=0.84) (figure 1). The change in standardised weight loss was also comparable.

(table 2). Patients requirement for preoperative intensive care and serum biochemistry was also similar except the lockdown group had a statistically but not clinically significant where to buy amoxil higher serum potassium (4.16 vs 4.5 mmol/L, p=0.04) (table 2).View this table:Table 2 Comparison of the primary and secondary outcome measures for infants presenting during the lockdown and control periodsAs an indicator condition, we have some reassurance that infants with IHPS have not had a significantly delayed presentation due to the buy antibiotics lockdown. A recent objective study looking at paediatric presentations to emergency departments found very low numbers of delayed presentations to the hospital, with minimal associated morbidity.3 4 Prompt, proactive changes to National Health Service 111 algorithms, guidance for parents by the Royal College of Paediatrics and Child Health5 and the rapid uptake of virtual general practice and health visitor consultations may have avoided morbidity. Further work, focusing on different types of conditions, or different subsections of society will help provide useful information relating to the impact of societal lockdown on healthcare-seeking behaviour in the UK and will enable more effective delivery of healthcare provision and public messaging in the event of further lockdowns.Ethics statementsPatient consent for publicationNot required..

End of where to buy amoxil pills term report‘Brown. You may discuss your report with the head now. You should know, there are some issues.’ Many of you will have similar where to buy amoxil pills recollections of mid-July during their schooldays.

The annual feedback lurking, snake-like in the reeds, freedom never granted until the teachers’ handwritten, often indecipherable words had been parentally decodified at home, my own Achilles’ heels art and English literature perennial causes of teachers’ deep sighs. I acknowledge that the stick men figures of my primary school art failed to evolve into anything more than uncannily similar stick men figures over the course of my pre-teenage years, the point at which my metaphorical knotted sheets and I furnished an escape. Are we also, collectively, guilty of leaving our socks proverbially where to buy amoxil pills at ankle length in places?.

Asthma. What are where to buy amoxil pills the priorities?. We kick off with a blistering pair of editorials which eviscerate a common practice from opposite, but not necessarily, mutually exclusive angles.

The first is by Ian Sinha and argues the case for the replacement of prednisolone with dexamethasone in acute asthma attacks. The ubiquitous prednisolone is, its detractors assert, known for its where to buy amoxil pills (gustatory, olfactory and visual) unpalatability. Once sampled, no child ever trusts pink medicine again – its emetogenic capacity and potential for non-compliance given the 3 day rather than 1 day course often cited as additional drawbacks.

Mark Levy and colleagues challenge the need for where to buy amoxil pills the abandonment of prednisolone largely based on the lack of hard evidence. This is where interpretation has to be disentangled from personal biases. Not easy and the reality is that even the most robust meta-analyses can’t always furnish us with ‘the answers’.

I could, but won’t take sides on this (just now) as it would spoil your fun, but perhaps this is too close to call and, as long as the where to buy amoxil pills right children (school age) get some steroids (of one hue or another) early on and the wrong children (most preschoolers) don’t that might be a reasonable compromise. There are other high-profile priorities like the use of high protracted courses of beta agonists and after discharge underuse of inhaled steroid-LABA combinations. I’m already looking where to buy amoxil pills forward to the next round of discussions.

The UK (and we can shoegaze all we like) is a perennial ‘could do better’/end of year report C-performer. Not as bad as my F grade art, of course, but, how hard can it be to score at least a B grade?. See pages 729 where to buy amoxil pills and 730Neonatal sepsis.

New dataThough a great deal of credit is due for progress during the Millennium and early Sustainable Development goal eras, the data can’t disguise the areas where little changed. Until recently at least, perinatal mortality was one. A rule of thumb reminder where to buy amoxil pills.

In most low and middle income countries infant mortality accounts for about two thirds of all under 5 mortality. Of infant mortality, about two thirds is neonatal (first month) and, of neonatal, two thirds perinatal, deaths in the first week where to buy amoxil pills. Causes are consistent.

Prematurity, asphyxia and sepsis, the dysregulated host immune response to to which neonates are exquisitely sensitive. We like to think we have a ballpark idea of the burden of where to buy amoxil pills peri and neonatal death globally, but this ballpark is a very elastic one. Carolin Fleischmann and colleagues’ meticulous systematic review and meta-analysis brings some clarity, not only in overall sepsis load, but (and this is particularly useful in antibiotic selection) the early and late onset phenotypes.

Of the total screened 26 studies published between 1979 and 2019 met the where to buy amoxil pills criteria (including a tight sepsis definition) were included accounting for 2.8 million live births and close to 30,000 sepsis. Random-effects MA estimated an incidence rate of 2,824/100,000 births with a case fatality of 17.6%. Between 2009 and 2018, the incidence was markedly worse at 3,390.

This isn’t a finding we can dismiss simply under the where to buy amoxil pills smokescreen of ascertainment bias and improvement of criteria. Take a look at the beta lactam, fourth generation cephalosporin, carbapenem and linezolid resistance patterns in other studies and one can only conclude this is not good news. See page 745Non-accidental where to buy amoxil pills injury.

More science. New dataThe TEN4 Bruise Clinical Decision Rule (BCDR) was first reported by Pierce in 2010. It was estimated that ‘bruising on the torso, ear, or neck for a child <48 months of age and bruising in any region for an infant <4 months of age, in the absence of a publicly witnessed injury' had a sensitivity of 97% and where to buy amoxil pills a specificity of 84% for predicting abuse.

Using data from previous studies on patterns in day to day bruising, NAI and inherited bleeding disorders, Alison Kemp and colleagues refine the tool to test its ability to differentiate between bruise distribution phenotypes. Applying TEN4 to to children under 4 years of age, with at least one bruise had an estimated sensitivity of 69% and specificity for abuse of 74%, figures that will ultimately inform how we report and a court interprets findings in an area where uncertainty is the rule where to buy amoxil pills. See page 774Can one afford to simply wait?.

Other than the surgical approach having changed from scalpel to laparoscope, the individual and family experience of appendicitis as a package in terms of inpatient time, discomfort and cost has changed little in the recent past. For such a common entity, exploring new alternatives was always going to be necessary and the surgery vs where to buy amoxil pills antibiotic/expectant hypothesis is one such avenue. The CONTRACT study, one of a series of randomised controlled trials tests the effectiveness of treating children with uncomplicated (for example, unperforated) appendicitis with parenteral antibiotics rather than surgery.

Bold, but not unreasonable, given the objective equipoise and long experience of this approach in some countries. It is likely that the results of these RCTs will determine the route children take where to buy amoxil pills for years if not decades. The trial feasibility study undertaken by Nigel Hall and colleagues lent weight to.

Parents’ enthusiasm where to buy amoxil pills (50% enrolled after being approached). Acceptability of randomisation and patient and surgeon adherence to trial procedures. See page 764Ethics statementsPatient consent for publicationNot required.The buy antibiotics amoxil has posed challenges for the delivery of healthcare for infants with disruption to 6-week health checks and health visitor services.1 An area of particular concern is late presentation to the hospital.2 However, current data do not offer an objective picture of how significant a problem this may be, with other reports showing low rates of delays in presentation.3 Infantile hypertrophic pyloric stenosis (IHPS) is a common, non-infective infantile condition with a predictable clinical course and therefore a good indicator condition to assess for delays in presentation.

We aimed to assess whether infants with IHPS where to buy amoxil pills presented later during ‘lockdown’ compared with the same period the preceding year.Ten centres within the UK (England, Scotland and Northern Ireland) contributed data from babies with IHPS via a website (buy antibioticsinchildren.co.uk) between 23 March 2020 and 31 May 2020 (the buy antibiotics lockdown period) and between 23 March and 31 May 2019 (controls). A total of 87 eligible infants were included, comprising 40 controls (46%) and 47 cases (54%). The demographic and baseline characteristics of the two groups were similar (table 1 and figure 1).View this table:Table 1 Characteristics of control (2019 patients) and lockdown (2020) patientsComparison between the age at presentation (A) and admission weight (B) of where to buy amoxil pills infants with IHPS in the control period (2019) and the lockdown period.

No significant difference is seen between the two groups (age at admission p=0.64, admission weight p=0.84). IHPS, Infantile hypertrophic pyloric stenosis." data-icon-position data-hide-link-title="0">Figure 1 Comparison between the age at presentation (A) and admission weight (B) of infants with IHPS in the control period (2019) and the lockdown period. No significant difference is seen between the two where to buy amoxil pills groups (age at admission p=0.64, admission weight p=0.84).

IHPS, Infantile hypertrophic pyloric stenosis.Median age and weight at presentation in the control group were 31 days (24–41) and 3600 g (3190–4081), and those in the lockdown group were 34 days (26–41) and 3580 g (3120–4085). These differences were where to buy amoxil pills not statistically significant (p=0.64, p=0.84) (figure 1). The change in standardised weight loss was also comparable.

(table 2). Patients requirement for preoperative intensive care and serum biochemistry was also similar except the lockdown group had a statistically but not clinically significant higher serum potassium (4.16 vs 4.5 mmol/L, p=0.04) where to buy amoxil pills (table 2).View this table:Table 2 Comparison of the primary and secondary outcome measures for infants presenting during the lockdown and control periodsAs an indicator condition, we have some reassurance that infants with IHPS have not had a significantly delayed presentation due to the buy antibiotics lockdown. A recent objective study looking at paediatric presentations to emergency departments found very low numbers of delayed presentations to the hospital, with minimal associated morbidity.3 4 Prompt, proactive changes to National Health Service 111 algorithms, guidance for parents by the Royal College of Paediatrics and Child Health5 and the rapid uptake of virtual general practice and health visitor consultations may have avoided morbidity.

Further work, focusing on different types of conditions, or different subsections of society will help provide useful information relating to the impact of societal lockdown on healthcare-seeking behaviour in the UK and will enable more effective delivery of healthcare provision and public messaging in the event of further lockdowns.Ethics statementsPatient consent for publicationNot required..

Amoxil for strep throat

Under the Paperwork Reduction Act of 1995 (the PRA), federal agencies are required to publish notice in the Federal http://www.ec-prot-printzheim.ac-strasbourg.fr/?page_id=39 Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action amoxil for strep throat. Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden. Comments must be received by July 20, 2021. When commenting, amoxil for strep throat please reference the document identifier or OMB control number.

To be assured consideration, comments and recommendations must be submitted in any one of the following ways. 1. Electronically. You may send your comments electronically to http://www.regulations.gov.

Follow the instructions for “Comment or Submission” or “More Search Options” to find the information collection document(s) that are accepting comments. 2. By regular mail. You may mail written comments to the following address.

CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention. Document Identifier/OMB Control Number. ____, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following.

1. Access CMS' website address at website address at https://www.cms.gov/​Regulations-and-Guidance/​Legislation/​PaperworkReductionActof1995/​PRA-Listing.html. Start Further Info William N. Parham at (410) 786-4669.

End Further Info End Preamble Start Supplemental Information Contents This notice sets out a summary of the use and burden associated with the following information collections. More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES). CMS-10241 Survey of Retail Prices CMS-10545 Outcome and Assessment Information Set (OASIS) OASIS-D Under the PRA (44 U.S.C. 3501-3520), federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor.

The term “collection of information” is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA requires federal agencies to publish a 60-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for approval. To comply with this requirement, CMS is publishing this notice.

Information Collection 1. Type of Information Collection Request. Revision of a currently approved collection. Title of Information Collection.

Survey of Retail Prices. Use. This information collection request provides for a survey of the average acquisition costs of all covered outpatient drugs purchased by retail community pharmacies. CMS may best place to buy amoxil contract with a vendor to conduct monthly surveys of retail prices for covered outpatient drugs.

Such prices represent a nationwide average of consumer purchase prices, net of discounts and rebates. The contractor shall provide notification when a drug product becomes generally available and that the contract include such terms and conditions as the Secretary shall specify, including a requirement that the vendor monitor the marketplace. CMS has developed a National Average Drug Acquisition Cost (NADAC) for states to consider when developing reimbursement methodology. The NADAC is a pricing benchmark that is based on the national average costs that pharmacies pay to acquire Medicaid covered outpatient drugs.

This pricing benchmark is based on drug acquisition costs collected directly from pharmacies through a nationwide survey process. This survey is conducted on a monthly basis to ensure that the NADAC reference file remains current and up-to-date. Form Number. CMS-10241 (OMB control number 0938-1041).

Frequency. Monthly. Affected Public. Private sector (Business or other for-profits).

Number of Respondents. 72,000. Total Annual Responses. 72,000.

Total Annual Hours. 36,000. (For policy questions regarding this collection contact. Lisa Shochet at 410-786-5445.) 2.

Type of Information Collection Request. Revision of a currently approved collection. Title of Information Collection. Outcome and Assessment Information Set (OASIS) OASIS-D.

Use. Due to the buy antibiotics related Public Health Emergency, the next version of the Outcome and Assessment Information Set (OASIS), version E planned for implementation January 1, 2021, was delayed. This request is for the Office of Management and Budget (OMB) approval to extend the current OASIS-D expiration date in order for home health agencies to continue data collection required for participation in the Medicare program. The current version of the OASIS-D, data item set was approved by OMB on December 6, 2018 and implemented on January 1, 2019.

This request includes updated calculations using 2020 data for wages, number of home health agencies and number of OASIS assessments at each time point. Form Number. CMS-10545 (OMB control number. 0938-1279).

Notice generic amoxil online for sale where to buy amoxil pills. The Centers for Medicare &. Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of where to buy amoxil pills 1995 (the PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action. Interested persons are invited to send comments regarding our burden estimates or any other aspect of this collection of information, including the necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

Comments must be received by July 20, 2021. When commenting, please reference the document identifier or OMB where to buy amoxil pills control number. To be assured consideration, comments and recommendations must be submitted in any one of the following ways. 1. Electronically.

You may send your comments electronically to http://www.regulations.gov. Follow the instructions for “Comment or Submission” or “More Search Options” to find the information collection document(s) that are accepting comments. 2. By regular mail. You may mail written comments to the following address.

CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention. Document Identifier/OMB Control Number. ____, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. To obtain copies of a supporting statement and any related forms for the proposed collection(s) summarized in this notice, you may make your request using one of following. 1.

Access CMS' website address at website address at https://www.cms.gov/​Regulations-and-Guidance/​Legislation/​PaperworkReductionActof1995/​PRA-Listing.html. Start Further Info William N. Parham at (410) 786-4669. End Further Info End Preamble Start Supplemental Information Contents This notice sets out a summary of the use and burden associated with the following information collections. More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES).

CMS-10241 Survey of Retail Prices CMS-10545 Outcome and Assessment Information Set (OASIS) OASIS-D Under the PRA (44 U.S.C. 3501-3520), federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. The term “collection of information” is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. Section 3506(c)(2)(A) of the PRA requires federal agencies to publish a 60-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension or reinstatement of an existing collection of information, before submitting the collection to OMB for approval.

To comply with this requirement, CMS is publishing this notice. Information Collection 1. Type of Information Collection Request. Revision of a currently approved collection. Title of Information Collection.

Survey of Retail Prices. Use. This information collection request provides for a survey of the average acquisition costs of all covered outpatient drugs purchased by retail community pharmacies. CMS may contract with a vendor to conduct monthly surveys of retail prices for covered outpatient drugs. Such prices represent a nationwide average of consumer purchase prices, net of discounts and rebates.

The contractor shall provide notification when a drug product becomes generally available and that the contract include such terms and conditions as the Secretary shall specify, including a requirement that the vendor monitor the marketplace. CMS has developed a National Average Drug Acquisition Cost (NADAC) for states to consider when developing reimbursement methodology. The NADAC is a pricing benchmark that is based on the national average costs that pharmacies pay to acquire Medicaid covered outpatient drugs. This pricing benchmark is based on drug acquisition costs collected directly from pharmacies through a nationwide survey process. This survey is conducted on a monthly basis to ensure that the NADAC reference file remains current and up-to-date.

Form Number. CMS-10241 (OMB control number 0938-1041). Frequency. Monthly. Affected Public.

Private sector (Business or other for-profits). Number of Respondents. 72,000. Total Annual Responses. 72,000.

Total Annual Hours. 36,000. (For policy questions regarding this collection contact. Lisa Shochet at 410-786-5445.) 2. Type of Information Collection Request.

Revision of a currently approved collection. Title of Information Collection. Outcome and Assessment Information Set (OASIS) OASIS-D. Use. Due to the buy antibiotics related Public Health Emergency, the next version of the Outcome and Assessment Information Set (OASIS), version E planned for implementation January 1, 2021, was delayed.

This request is for the Office of Management and Budget (OMB) approval to extend the current OASIS-D expiration date in order for home health agencies to continue data collection required for participation in the Medicare program. The current version of the OASIS-D, data item set was approved by OMB on December 6, 2018 and implemented on January 1, 2019. This request includes updated calculations using 2020 data for wages, number of home health agencies and number of OASIS assessments at each time point. Form Number. CMS-10545 (OMB control number.

How to buy cheap amoxil

Here's some information on how cold weather and moisture can damage hearing aids, how to buy cheap amoxil what to be aware of and how you can prevent weather damage. Also, find out about tinnitus and winter weather, and why clogged ears are more common in cold weather.Hearing aids, cold weather and moisture Moisture and condensation can quicklydamage hearing aids. Temperature extremes can be damaging to a hearing aid and its batteries. The cold itself is not necessarily damaging, but the condensation that occurs how to buy cheap amoxil due to temperature change can damage internal components. Even when it isn't snowing or raining, moisture is present because extreme temperature changes are common in the winter.

For example, if you are walking outside and the temperature is 20 degrees Fahrenheit, you will almost certainly be bundled up from head to toe with a hat over your ears. But when how to buy cheap amoxil you head indoors, it could be nearly 50 degrees warmer because the heat is on. Even if you take off your coat and other winter gear right away, the temperature change can form condensation on your hearing aids. And maybe you were walking quickly and your head began to sweat, which could also damage your hearing aids and batteries. Signs of moisture damage Moisture can ruin the microphone and receiver of your how to buy cheap amoxil hearing aids, as well as clog the earmold tubing and sound and cause corrosion.

Here are some tell-tale signs that your hearing aids have been damaged. Your hearing aid cuts out during loud noises. The sound fades or how to buy cheap amoxil comes and goes. Everything you hear is punctuated by static. Sounds are unclear or seem distorted.

Your hearing aid completely stops working and then how to buy cheap amoxil starts again. This might happen a few times. Hearing aid fixes If you think your hearing aids have been exposed to moisture, there are other things to check first. Such as how to buy cheap amoxil. Your hearing aid is turned on and (if you have one) the T-switch is in the right position.

If you have disposable batteries, make sure they have been inserted correctly. Also, sometimes when batteries are dying, you will see some of the same signs how to buy cheap amoxil as above. Check to make sure the battery is not corroded. If it is, it will have a white powdery substance and should be thrown out immediately. The battery contacts, which are the points where the batteries touch the how to buy cheap amoxil hearing aids.

Clean them or remove moisture with a dry cotton swab. The earmold, to be sure it or the sound outlet are not clogged with wax. Or, if you wear domes (a tiny cone that's inserted deep in the ear), make sure they are how to buy cheap amoxil not damaged. More. How to troubleshoot common hearing aid problems If none of these things seem to be the issue, you may have moisture in your hearing aid.

If you wear how to buy cheap amoxil behind-the-ear (BTE) hearing aids, look in the tubing for moisture droplets. If you wear earmolds, you can purchase an earmold puffer, which blows out any moisture, and consider having your earmolds fitted with a moisture dispersing tube. For in-the-ear (ITE) hearing aids, it's a little trickier to remove the moisture. If you don't already have one, purchase a hearing aid drying device and place your hearing aids in how to buy cheap amoxil it immediately to hopefully dry them out and avoid damage. Not sure what kind of hearing aid you have?.

Check out our primer on hearing aid types and styles. Precautions for cold weather and hearing aids While moisture how to buy cheap amoxil is hard to avoid in extreme cold, there are some precautions you can take in an attempt to keep your hearing aids dry and safe. Protect with earmuffs Earmuffs aren't only for keeping your ears warm while you're skating on the neighborhood pond or ice fishing with your favorite nephew. Specialized earmuffs are available specifically for protecting your ears from damaging noise. Even if you how to buy cheap amoxil already have hearing loss, further damage from noise is almost completely preventable by simply limiting your exposure.

Noise-reduction earmuffs are not just for winter. In fact, they will come in handy many times throughout the year. Whether you're using your noisy lawnmower in the spring, enjoying a fireworks show in the summer and taking how to buy cheap amoxil in a football game in a noisy arena, earmuffs will keep the noise level safe. Depending upon the style you choose, expect to pay anywhere from $10 on up for earmuffs that reduce noise by as much as 30 dB. Buy a pair of sweatbands Some active hearing aid wearers continue to work up a sweat outdoors while enjoying winter sports.

You may also get caught outside during periods how to buy cheap amoxil of heavy snow or freezing rain. To minimize the amount of moisture your behind-the-ear hearing aids are exposed to as a result of perspiration—or precipitation—during the winter months, invest in hearing aid sweatbands. These accessories are available in a variety of colors and sizes, with an average price of $20 per pair. Most of how to buy cheap amoxil them are washable and slip on easily, acting as a moisture repellant and providing a windscreen for your microphone. If your hearing healthcare provider doesn't sell them, you can find them easily online.

Other wise ideas. Purchase a hearing aid how to buy cheap amoxil drying kit or dehumidifier. Remove your hearing aid batteries and store your devices in this device every night. Some even sanitize hearing aids during storage. Dehumidifiers range in price from $5 to $100 and can be purchased online, through how to buy cheap amoxil your hearing care provider or in many drug stores.

Use an umbrella in the rain and wear a raincoat with a hood. If you think your hearing aid has gotten wet, remove the battery immediately. Ear protection for winter Ears hurt from cold how to buy cheap amoxil weather?. Don't risk exostosis!. It turns out earmuffs, hats, and scarves are not just fashion accessories.

Always keep your ears covered in very cold weather to reduce discomfort and how to buy cheap amoxil the risk of frostbite. In fact, excessive exposure to extreme cold and wet conditions can lead to a rare condition known as exostosis. Also known as “surfer’s ear” due to the condition being especially prevalent in those who spend time in or around cold water, exostosis results when exposure to the cold causes abnormal bone growths to appear on the bone surrounding the ear canal. As a result, the ear canal can become blocked, how to buy cheap amoxil which increases the risk of due to trapped fluid. While the condition can be corrected surgically, avid skiers, snowmobilers or snowshoers should make sure to keep their ears warm, dry and covered to reduce their risk.

Also known as “surfer’s ear” due to the condition being prevalent in those who spend time in or around cold water, exostosis results when exposure to the cold causes knobs of bony growth to appear on the bone surrounding the ear canal. Can cold weather how to buy cheap amoxil cause ringing in the ears?. Tinnitus and winter For some people, cold, wintry weather triggers their tinnitus, or ringing in the ears. Research shows that internet search terms for tinnitus go up in the winter!. Exactly why tinnitus how to buy cheap amoxil is more common in winter, though, isn't well understood.

It's thought to be less about the frosty temperatures affecting our ears, and more about seasonal trends, such as more cold and flu s (which can increase pressure in the ear), unhealthy activities that can lead to high blood pressure (such as eating lots of salty foods), and increased rates of depression and stress. All of these things are known risk factors for tinnitus. Cold weather and clogged ears Changes in barometric pressure can how to buy cheap amoxil leave your ears feeling clogged any time of year. Add in a seasonal respiratory swelling up your sinuses and you can feel downright miserable. Read more about the causes of clogged ears.

Why ear s are more common in winter During the winter, your ears are often colder, which means reduced circulation how to buy cheap amoxil to provide a healthy blood supply. Meanwhile, amoxiles and bacterial s are a lot more common in the winter. Put these together, and you have a heightened risk sinus s and a painful condition known as otitis media. Otitis media, or an ear , causes painful swelling and inflammation of the how to buy cheap amoxil middle ear. The swelling and can build up and increase the pressure behind the ear drum and block drainage from the Eustachian tube.

Antibiotics can treat most ear s, but until the fluid is cleared, temporary hearing loss can result. Be sure to treat colds and flu immediately with rest, medication and plenty of fluids, and if how to buy cheap amoxil you suspect an ear see a doctor immediately to prevent hearing damage. Your doctor may prescribe medication and/or nasal sprays to help you get some relief. You can reduce your risk of ear s by keeping your ears warm and dry when you are outside in winter weather. Maintaining a healthy diet and exercising to improve blood circulation can also be helpful, especially in the how to buy cheap amoxil colder months when resistance to is lower.

Whatever you do, don't put a cotton swab in your ear, as it can push hardened earwax further back into the ear. Winter travel If you are planning on flying to your holiday travel destination, be careful not to fly if you are ears are persistently clogged. A ruptured eardrum or severe can how to buy cheap amoxil result, leading to temporary hearing loss and other problems. It is better to reschedule your flight if possible to prevent further problems. More.

Airplanes and how to buy cheap amoxil ear pain. Why it happens and what you can do.What would it be like if you could feel sounds like doorbells ringing, alarm clocks buzzing, and water faucets accidentally left dripping?. The Buzz wearable wristband uses haptic technology to translate sounds intovibrations. A new device how to buy cheap amoxil that turns sound into dynamic patterns of vibrations does just that, and it's helping those who are deaf or hard-of-hearing access vital information in a unique way. Neosensory Buzz, a wearable device resembling a wristwatch, mimics the ear’s cochlea by sending vibrations via the nervous system to the brain, effectively creating another sensory channel to the brain’s auditory processing center.

(It can be worn by people who don't have hearing loss, too.) Turning sound into unique vibrations Dr. David Eagleman, PhD, a Stanford University neuroscientist, and how to buy cheap amoxil co-founder of Neosensory Dr. Scott Novich, PhD, began researching sensory substitutions for the Deaf in 2013. The technology they build essentially focuses on sending data streams to the brain through the sense of touch, known as haptic feedback. €œThe brain is locked in a vault of silence and darkness inside your skull, yet it constructs this whole world how to buy cheap amoxil for us,” Eagleman explained, describing the eyes, ears and fingers as peripheral “plug and play” sensory devices.

€œYour brain doesn’t know and it doesn’t care where it gets the data from. It is fundamentally always trying to get information across the senses. Whatever information comes in, it just figures out what to do with it.” Adjustable settings via smartphone app Buzz can be programmed to user preference using how to buy cheap amoxil three different modes. Everyday mode adjusts to the user’s surroundings, canceling out unnecessary background noise. Sleep mode filters out sounds like snoring while still alerting the user to emergency sounds such as sirens or smoke alarms Music mode allows users to feel the pulse of the beat along with nuances of the melody.

The wearable also features an alarm setting, which users can customize how to buy cheap amoxil with their desired vibration pattern. How Buzz differs from current assistive technology Assistive listening devices such as hearing loops, FM systems, infrared systems, and hearing aid accessories rely on amplification to deliver sound. Assistive alerting devices, such as bed shakers and flashing strobe lights, use touch and sight to alert users to alarm situations. There are also new smartwatch apps how to buy cheap amoxil that identify sounds and display them as text on the watch face, such as the free SoundWatch for watches that use Google Android OS. Buzz uses sensory substitution to feed sound information directly to the brain through the skin.

It benefits those who were born Deaf as well as those who were born with hearing but currently use hearing aids or other assistive listening devices. Users describe wearing Buzz as how to buy cheap amoxil a tri-modal hearing experience. “They are seeing someone’s lips move, hearing something through their ears and they’re feeling vibration on their skin,” Eagleman said. €œWhen they put all three of those channels together they get a really rich sense of what’s going on.” Future models focus on high-frequency hearing loss Neosensory plans to launch a new device specifically designed for those with high-frequency hearing loss in 2021 using the same hardware programmed with different algorithms. The technology captures high-frequency phonemes and turns them into very how to buy cheap amoxil particular vibrations on a specific part of the wrist.

A phoneme is a unit of sound that distinguishes one word from another. For example, those with high-frequency hearing loss often have problems distinguishing between consonants f, h, and s. Eagleman calls the patented technology cross-sensory boosting how to buy cheap amoxil. €œFor people with age-related hearing loss, it’s just a few phonemes that start getting hard to hear,” Eagleman said. €œWith cross-sensory boosting, your ears still do most of the work but the wristband tells you which phoneme was just said.

It allows people to understand what’s happening with speech in particular.” Buzz debuted in March 2020 amid the buy antibiotics amoxil and is now sold worldwide.

Temperature extremes where to buy amoxil pills can be damaging to a hearing aid and its batteries. The cold itself is not necessarily damaging, but the condensation that occurs due to temperature change can damage internal components. Even when it isn't snowing or raining, moisture is present because extreme temperature changes are common in the winter. For example, if you are walking outside and the temperature is 20 degrees Fahrenheit, you will almost certainly be where to buy amoxil pills bundled up from head to toe with a hat over your ears.

But when you head indoors, it could be nearly 50 degrees warmer because the heat is on. Even if you take off your coat and other winter gear right away, the temperature change can form condensation on your hearing aids. And maybe where to buy amoxil pills you were walking quickly and your head began to sweat, which could also damage your hearing aids and batteries. Signs of moisture damage Moisture can ruin the microphone and receiver of your hearing aids, as well as clog the earmold tubing and sound and cause corrosion.

Here are some tell-tale signs that your hearing aids have been damaged. Your hearing aid cuts out where to buy amoxil pills during loud noises. The sound fades or comes and goes. Everything you hear is punctuated by static.

Sounds are unclear or seem distorted where to buy amoxil pills. Your hearing aid completely stops working and then starts again. This might happen a few times. Hearing aid where to buy amoxil pills fixes If you think your hearing aids have been exposed to moisture, there are other things to check first.

Such as. Your hearing aid is turned on and (if you have one) the T-switch is in the right position. If you have disposable batteries, make sure they have been where to buy amoxil pills inserted correctly. Also, sometimes when batteries are dying, you will see some of the same signs as above.

Check to make sure the battery is not corroded. If it is, it will have a where to buy amoxil pills white powdery substance and should be thrown out immediately. The battery contacts, which are the points where the batteries touch the hearing aids. Clean them or remove moisture with a dry cotton swab.

The earmold, to be sure it or the sound outlet are not clogged where to buy amoxil pills with wax. Or, if you wear domes (a tiny cone that's inserted deep in the ear), make sure they are not damaged. More. How to troubleshoot common hearing aid problems If none of these things seem where to buy amoxil pills to be the issue, you may have moisture in your hearing aid.

If you wear behind-the-ear (BTE) hearing aids, look in the tubing for moisture droplets. If you wear earmolds, you can purchase an earmold puffer, which blows out any moisture, and consider having your earmolds fitted with a moisture dispersing tube. For in-the-ear (ITE) hearing aids, it's a little trickier to remove the moisture where to buy amoxil pills. If you don't already have one, purchase a hearing aid drying device and place your hearing aids in it immediately to hopefully dry them out and avoid damage.

Not sure what kind of hearing aid you have?. Check out where to buy amoxil pills our primer on hearing aid types and styles. Precautions for cold weather and hearing aids While moisture is hard to avoid in extreme cold, there are some precautions you can take in an attempt to keep your hearing aids dry and safe. Protect with earmuffs Earmuffs aren't only for keeping your ears warm while you're skating on the neighborhood pond or ice fishing with your favorite nephew.

Specialized earmuffs are available where to buy amoxil pills specifically for protecting your ears from damaging noise. Even if you already have hearing loss, further damage from noise is almost completely preventable by simply limiting your exposure. Noise-reduction earmuffs are not just for winter. In fact, they will come in handy many times where to buy amoxil pills throughout the year.

Whether you're using your noisy lawnmower in the spring, enjoying a fireworks show in the summer and taking in a football game in a noisy arena, earmuffs will keep the noise level safe. Depending upon the style you choose, expect to pay anywhere from $10 on up for earmuffs that reduce noise by as much as 30 dB. Buy a pair of sweatbands Some active where to buy amoxil pills hearing aid wearers continue to work up a sweat outdoors while enjoying winter sports. You may also get caught outside during periods of heavy snow or freezing rain.

To minimize the amount of moisture your behind-the-ear hearing aids are exposed to as a result of perspiration—or precipitation—during the winter months, invest in hearing aid sweatbands. These accessories are available in a variety of colors where to buy amoxil pills and sizes, with an average price of $20 per pair. Most of them are washable and slip on easily, acting as a moisture repellant and providing a windscreen for your microphone. If your hearing healthcare provider doesn't sell them, you can find them easily online.

Other wise where to buy amoxil pills ideas. Purchase a hearing aid drying kit or dehumidifier. Remove your hearing aid batteries and store your devices in this device every night. Some even sanitize where to buy amoxil pills hearing aids during storage.

Dehumidifiers range in price from $5 to $100 and can be purchased online, through your hearing care provider or in many drug stores. Use an umbrella in the rain and wear a raincoat with a hood. If you think your hearing aid has where to buy amoxil pills gotten wet, remove the battery immediately. Ear protection for winter Ears hurt from cold weather?.

Don't risk exostosis!. It turns out earmuffs, hats, and scarves are not just where to buy amoxil pills fashion accessories. Always keep your ears covered in very cold weather to reduce discomfort and the risk of frostbite. In fact, excessive exposure to extreme cold and wet conditions can lead to a rare condition known as exostosis.

Also known where to buy amoxil pills as “surfer’s ear” due to the condition being especially prevalent in those who spend time in or around cold water, exostosis results when exposure to the cold causes abnormal bone growths to appear on the bone surrounding the ear canal. As a result, the ear canal can become blocked, which increases the risk of due to trapped fluid. While the condition can be corrected surgically, avid skiers, snowmobilers or snowshoers should make sure to keep their ears warm, dry and covered to reduce their risk. Also known as “surfer’s ear” due to the condition being prevalent in those who spend time in or around cold water, exostosis where to buy amoxil pills results when exposure to the cold causes knobs of bony growth to appear on the bone surrounding the ear canal.

Can cold weather cause ringing in the ears?. Tinnitus and winter For some people, cold, wintry weather triggers their tinnitus, or ringing in the ears. Research shows where to buy amoxil pills that internet search terms for tinnitus go up in the winter!. Exactly why tinnitus is more common in winter, though, isn't well understood.

It's thought to be less about the frosty temperatures affecting our ears, and more about seasonal trends, such as more cold and flu s (which can increase pressure in the ear), unhealthy activities that can lead to high blood pressure (such as eating lots of salty foods), and increased rates of depression and stress. All of these where to buy amoxil pills things are known risk factors for tinnitus. Cold weather and clogged ears Changes in barometric pressure can leave your ears feeling clogged any time of year. Add in a seasonal respiratory swelling up your sinuses and you can feel downright miserable.

Read more where to buy amoxil pills about the causes of clogged ears. Why ear s are more common in winter During the winter, your ears are often colder, which means reduced circulation to provide a healthy blood supply. Meanwhile, amoxiles and bacterial s are a lot more common in the winter. Put these together, and you have a heightened risk sinus s and a painful condition known as otitis where to buy amoxil pills media.

Otitis media, or an ear , causes painful swelling and inflammation of the middle ear. The swelling and can build up and increase the pressure behind the ear drum and block drainage from the Eustachian tube. Antibiotics can treat most ear where to buy amoxil pills s, but until the fluid is cleared, temporary hearing loss can result. Be sure to treat colds and flu immediately with rest, medication and plenty of fluids, and if you suspect an ear see a doctor immediately to prevent hearing damage.

Your doctor may prescribe medication and/or nasal sprays to help you get some relief. You can reduce your risk of ear s by keeping your ears warm and dry when you are outside in winter where to buy amoxil pills weather. Maintaining a healthy diet and exercising to improve blood circulation can also be helpful, especially in the colder months when resistance to is lower. Whatever you do, don't put a cotton swab in your ear, as it can push hardened earwax further back into the ear.

Winter travel If you are planning on flying to your holiday travel destination, be careful not to fly if you are ears are persistently clogged where to buy amoxil pills. A ruptured eardrum or severe can result, leading to temporary hearing loss and other problems. It is better to reschedule your flight if possible to prevent further problems. More.

Airplanes and ear pain. Why it happens and what you can do.What would it be like if you could feel sounds like doorbells ringing, alarm clocks buzzing, and water faucets accidentally left dripping?. The Buzz wearable wristband uses haptic technology to translate sounds intovibrations. A new device that turns sound into dynamic patterns of vibrations does just that, and it's helping those who are deaf or hard-of-hearing access vital information in a unique way.

Neosensory Buzz, a wearable device resembling a wristwatch, mimics the ear’s cochlea by sending vibrations via the nervous system to the brain, effectively creating another sensory channel to the brain’s auditory processing center. (It can be worn by people who don't have hearing loss, too.) Turning sound into unique vibrations Dr. David Eagleman, PhD, a Stanford University neuroscientist, and co-founder of Neosensory Dr. Scott Novich, PhD, began researching sensory substitutions for the Deaf in 2013.

The technology they build essentially focuses on sending data streams to the brain through the sense of touch, known as haptic feedback. €œThe brain is locked in a vault of silence and darkness inside your skull, yet it constructs this whole world for us,” Eagleman explained, describing the eyes, ears and fingers as peripheral “plug and play” sensory devices. €œYour brain doesn’t know and it doesn’t care where it gets the data from. It is fundamentally always trying to get information across the senses.

Whatever information comes in, it just figures out what to do with it.” Adjustable settings via smartphone app Buzz can be programmed to user preference using three different modes. Everyday mode adjusts to the user’s surroundings, canceling out unnecessary background noise. Sleep mode filters out sounds like snoring while still alerting the user to emergency sounds such as sirens or smoke alarms Music mode allows users to feel the pulse of the beat along with nuances of the melody. The wearable also features an alarm setting, which users can customize with their desired vibration pattern.

How Buzz differs from current assistive technology Assistive listening devices such as hearing loops, FM systems, infrared systems, and hearing aid accessories rely on amplification to deliver sound. Assistive alerting devices, such as bed shakers and flashing strobe lights, use touch and sight to alert users to alarm situations. There are also new smartwatch apps that identify sounds and display them as text on the watch face, such as the free SoundWatch for watches that use Google Android OS. Buzz uses sensory substitution to feed sound information directly to the brain through the skin.

It benefits those who were born Deaf as well as those who were born with hearing but currently use hearing aids or other assistive listening devices. Users describe wearing Buzz as a tri-modal hearing experience. “They are seeing someone’s lips move, hearing something through their ears and they’re feeling vibration on their skin,” Eagleman said. €œWhen they put all three of those channels together they get a really rich sense of what’s going on.” Future models focus on high-frequency hearing loss Neosensory plans to launch a new device specifically designed for those with high-frequency hearing loss in 2021 using the same hardware programmed with different algorithms.

The technology captures high-frequency phonemes and turns them into very particular vibrations on a specific part of the wrist. A phoneme is a unit of sound that distinguishes one word from another. For example, those with high-frequency hearing loss often have problems distinguishing between consonants f, h, and s. Eagleman calls the patented technology cross-sensory boosting.

€œFor people with age-related hearing loss, it’s just a few phonemes that start getting hard to hear,” Eagleman said. €œWith cross-sensory boosting, your ears still do most of the work but the wristband tells you which phoneme was just said. It allows people to understand what’s happening with speech in particular.” Buzz debuted in March 2020 amid the buy antibiotics amoxil and is now sold worldwide. €œBuzz helps you hear through your skin,” Eagleman said.

€œIt’s essentially doing exactly what the brain is doing.

How to buy amoxil

Brain cells called astrocytes how to buy amoxil play a key http://reachoutla.com/renova-cost-per-tube// role in helping neurons develop and function properly, but there's still a lot scientists don't understand about how astrocytes perform these important jobs. Now, a team of scientists led by Associate Professor Nicola Allen has found one way that neurons and astrocytes work together to form healthy connections called synapses. This insight into how to buy amoxil normal astrocyte function could help scientists better understand disorders linked to problems with neuronal development, including autism spectrum disorders.

The study was published September 8, 2021, in the journal eLife."We know that astrocytes could play a role in neurodevelopmental disorders, so we wanted to ask. How are they playing a role how to buy amoxil in typical development?. " says Allen, a member of the Molecular Neurobiology Laboratory.

"In order how to buy amoxil to better understand the disorders, we first have to understand what happens normally."Synapses form critical connections between neurons, allowing neurons to send signals and information throughout the body. Astrocyte cells play a role in synapse development by giving neurons directions, such as telling them when to start growing a synapse, when to stop, when to prune it back, and when to stabilize the connection.Allen and her team took a closer look at how this process plays out in the visual cortex of the mouse brain. They sequenced the RNA of astrocytes at different stages of brain development to assess gene activity and compared it with neuronal synapse development.

They found that astrocyte signaling how to buy amoxil was directly related to each stage of neuronal development. The researchers then wanted to know how the astrocytes knew to make these signals at the right time.First, the researchers looked at what happened to the astrocytes when they changed the neurons' activity. To do this, they stopped how to buy amoxil neurons from releasing a neurotransmitter called glutamate that can signal to astrocytes, and this stopped the astrocytes from showing the typical developmental changes.

Next, the scientists stopped the astrocytes from responding to neurotransmitters, and found this stopped the astrocytes from expressing the right signals. With both these manipulations, the development of synapses was also disrupted, in line with the changes observed in the astrocytes.Collectively, the findings how to buy amoxil suggest that astrocytes are responding to neurotransmitters produced by neurons to control the timing of when astrocytes produce signals to instruct neuronal development, according to Allen."It makes sense that you have this constant feedback going on between the neuron and the astrocyte," says Allen. "They are sending signals to each other.

'Am I in the right place?. ' 'Yes, how to buy amoxil you are.' 'I've made a connection now -- do I keep it?. ' 'Yes, you do.' And they keep going back and forth."Next, Allen and her team are studying whether these signals can be manipulated -- for example, to stimulate neurons to repair synapses or form new ones in disorders of aging, such as Alzheimer's disease.Other authors included Isabella Farhy-Tselnicker, Matthew M.

Boisvert, Hanqing Liu, Cari Dowling, how to buy amoxil Galina A. Erickson, Elena Blanco-Suarez, Maxim N. Shokhirev and Joseph how to buy amoxil R.

Ecker from Salk. And Chen Farhy from Sanford Burnham Prebys.The research was supported by the National Institutes of Health, the Pew Charitable Trusts, the Chan Zuckerberg Initiative, the Howard Hughes Medical Institute and the Hearst Foundations. Story Source how to buy amoxil.

Materials provided by Salk Institute. Note. Content may be edited for style and length.It's hard to know what climate change will mean for Earth's interconnected and interdependent webs of life.

But one team of researchers at Duke University says we might begin to get a glimpse of the future from just a few ounces of microbial soup.Every drop of pond water and teaspoon of soil is teeming with tens of thousands of tiny unicellular creatures called protists. They're so abundant that they are estimated to weigh twice as much as all the animals on Earth combined.Neither animals nor plants nor fungi, the more than 200,000 known species of protists are often overlooked. But as temperatures warm, they could play a big role in buffering the effects of climate change, said Jean Philippe Gibert, an assistant professor of biology at Duke.That's because of what protists like to eat.

They gobble up bacteria, which release carbon dioxide into the air when they respire, just like we do when we breathe out. But because bacteria account for more of the planet's biomass than any other living thing besides plants, they are among the largest natural emitters of carbon dioxide -- the greenhouse gas most responsible for global warming.In a study published Oct. 19 in Proceedings of the National Academy of Sciences, Gibert, postdoctoral researcher Dan Wieczynski and colleagues tested the effects of warming on bacteria-eating protists by creating mini ecosystems -- glass flasks each containing 10 different species of protists going about the business of eating and competing and reproducing.The flasks were kept at five temperatures ranging from 60 degrees to 95 degrees Fahrenheit.

Two weeks later, the researchers looked to see which species had survived at each temperature and measured how much CO2 they gave off during respiration."To me, the question was a simple one in nature," Gibert said. "Is there something to be measured on living organisms, today, that may allow us to predict their response to increasing temperature, tomorrow?. "The answer was yes.

The researchers were surprised to find that each species' response to temperature could be predicted from just a few simple measurements of their size, shape and cell contents. And together, these factors in turn influenced respiration rates for the community as a whole.They also found that by taking measurements such as cell size and shape and plugging them into a mathematical model, they could get very close to how things played out in their mini ecosystems in reality."We can actually use what we know about the relationship between traits and temperature responses at the species level, and scale it all the way up to a whole ecosystem level," Wieczynski said.The work is important because it sheds light on "how climate change will alter microbial communities and how this will feed back to influence the pace of climate change," Wieczynski said.This research was supported by a grant from the U.S. Department of Energy (DE-SC0020362).

Story Source. Materials provided by Duke University. Original written by Robin A.

Smith. Note. Content may be edited for style and length.Contrary to widely held gender stereotypes, women are not more emotional than men, researchers say.Feelings such as enthusiasm, nervousness or strength are often interpreted differently between the two genders.

It's what being "emotional" means to men vs. Women that is part of a new University of Michigan study that dispels these biases.For instance, a man whose emotions fluctuate during a sporting event is described as "passionate." But a woman whose emotions change due to any event, even if provoked, is considered "irrational," says the study's senior author Adriene Beltz, U-M assistant professor of psychology.Beltz and colleagues Alexander Weigard, U-M assistant professor of psychiatry, and Amy Loviska, a graduate student at Purdue University, followed 142 men and women over 75 days to learn more about their daily emotions, both positive and negative. The women were divided into four groups.

One naturally cycling and three others using different forms of oral contraceptives.The researchers detected fluctuations in emotions three different ways, and then compared the sexes. They found little-to-no differences between the men and the various groups of women, suggesting that men's emotions fluctuate to the same extent as women's do (although likely for different reasons)."We also didn't find meaningful differences between the groups of women, making clear that emotional highs and lows are due to many influences -- not only hormones," she said.The findings have implications beyond everyday people, the researchers say. Women have historically been excluded from research participation in part due to the assumption that ovarian hormone fluctuations lead to variation, especially in emotion, that can't be experimentally controlled, they say."Our study uniquely provides psychological data to show that the justifications for excluding women in the first place (because fluctuating ovarian hormones, and consequently emotions, confounded experiments) were misguided," Beltz said.

Story Source. Materials provided by University of Michigan. Note.

Content may be edited for style and length.Songbirds share the human sense of rhythm, but it is a rare trait in non-human mammals. An international research team led by senior investigators Marco Gamba from the University of Turin and MPI’s Andrea Ravignani set out to look for musical abilities in primates. €œThere is longstanding interest in understanding how human musicality evolved, but musicality is not restricted to humans”, says Ravignani.

€œLooking for musical features in other species allows us to build an ‘evolutionary tree’ of musical traits, and understand how rhythm capacities originated and evolved in humans.”To find out whether non-human mammals have a sense of rhythm, the team decided to study one of the few ‘singing’ primates, the critically endangered lemur Indri indri. The researchers wanted to know whether indri songs have categorical rhythm, a ‘rhythmic universal’ found across human musical cultures. Rhythm is categorical when intervals between sounds have exactly the same duration (1:1 rhythm) or doubled duration (1:2 rhythm).

This type of rhythm makes a song easily recognisable, even if it is sung at different speeds. Would indri songs show this “uniquely human” rhythm?. Ritardando in the rainforestOver a period of twelve years, the researchers from Turin visited the rainforest of Madagascar to collaborate with a local primate study group.

The investigators recorded songs from twenty indri groups (39 animals), living in their natural habitat. Members of an indri family group tend to sing together, in harmonised duets and choruses. The team found that indri songs had the classic rhythmic categories (both 1:1 and 1:2), as well as the typical ‘ritardando’ or slowing down found in several musical traditions.

Male and female songs had a different tempo but showed the same rhythm.According to first author Chiara de Gregorio and her colleagues, this is the first evidence of a ‘rhythmic universal’ in a non-human mammal. But why should another primate produce categorical ‘music-like’ rhythms?. The ability may have evolved independently among ‘singing’ species, as the last common ancestor between humans and indri lived 77.5 million years ago.

Rhythm may make it easier to produce and process songs, or even to learn them.Endangered species“Categorical rhythms are just one of the six universals that have been identified so far”, explains Ravignani. €œWe would like to look for evidence of others, including an underlying ‘repetitive’ beat and a hierarchical organisation of beats—in indri and other species.” The authors encourage other researchers to gather data on indri and other endangered species, “before it is too late to witness their breath-taking singing displays.” Story Source. Materials provided by Max Planck Institute for Psycholinguistics.

Note. Content may be edited for style and length..

Brain cells called where to buy amoxil pills astrocytes play a key role in helping neurons develop and function properly, but there's still a lot scientists don't http://reachoutla.com/renova-cost-per-tube// understand about how astrocytes perform these important jobs. Now, a team of scientists led by Associate Professor Nicola Allen has found one way that neurons and astrocytes work together to form healthy connections called synapses. This insight into normal astrocyte function could help scientists better understand disorders linked to problems with neuronal where to buy amoxil pills development, including autism spectrum disorders. The study was published September 8, 2021, in the journal eLife."We know that astrocytes could play a role in neurodevelopmental disorders, so we wanted to ask.

How are they playing a role in typical development? where to buy amoxil pills. " says Allen, a member of the Molecular Neurobiology Laboratory. "In order to better understand the disorders, we first have to understand where to buy amoxil pills what happens normally."Synapses form critical connections between neurons, allowing neurons to send signals and information throughout the body. Astrocyte cells play a role in synapse development by giving neurons directions, such as telling them when to start growing a synapse, when to stop, when to prune it back, and when to stabilize the connection.Allen and her team took a closer look at how this process plays out in the visual cortex of the mouse brain.

They sequenced the RNA of astrocytes at different stages of brain development to assess gene activity and compared it with neuronal synapse development. They found that astrocyte signaling was directly related to each stage of neuronal where to buy amoxil pills development. The researchers then wanted to know how the astrocytes knew to make these signals at the right time.First, the researchers looked at what happened to the astrocytes when they changed the neurons' activity. To do this, they stopped neurons where to buy amoxil pills from releasing a neurotransmitter called glutamate that can signal to astrocytes, and this stopped the astrocytes from showing the typical developmental changes.

Next, the scientists stopped the astrocytes from responding to neurotransmitters, and found this stopped the astrocytes from expressing the right signals. With both these manipulations, the development of synapses was also disrupted, in line with the changes observed in the astrocytes.Collectively, the findings suggest that astrocytes are responding to neurotransmitters produced by neurons to control the timing of when astrocytes produce signals to instruct neuronal development, according to Allen."It makes sense that you have this constant feedback where to buy amoxil pills going on between the neuron and the astrocyte," says Allen. "They are sending signals to each other. 'Am I in the right place?.

' 'Yes, you are.' 'I've made a connection now -- do I where to buy amoxil pills keep it?. ' 'Yes, you do.' And they keep going back and forth."Next, Allen and her team are studying whether these signals can be manipulated -- for example, to stimulate neurons to repair synapses or form new ones in disorders of aging, such as Alzheimer's disease.Other authors included Isabella Farhy-Tselnicker, Matthew M. Boisvert, Hanqing Liu, Cari Dowling, Galina A where to buy amoxil pills. Erickson, Elena Blanco-Suarez, Maxim N.

Shokhirev and where to buy amoxil pills Joseph R. Ecker from Salk. And Chen Farhy from Sanford Burnham Prebys.The research was supported by the National Institutes of Health, the Pew Charitable Trusts, the Chan Zuckerberg Initiative, the Howard Hughes Medical Institute and the Hearst Foundations. Story Source where to buy amoxil pills.

Materials provided by Salk Institute. Note. Content may be edited for style and length.It's hard to know what climate change will mean for Earth's interconnected and interdependent webs of life. But one team of researchers at Duke University says we might begin to get a glimpse of the future from just a few ounces of microbial soup.Every drop of pond water and teaspoon of soil is teeming with tens of thousands of tiny unicellular creatures called protists.

They're so abundant that they are estimated to weigh twice as much as all the animals on Earth combined.Neither animals nor plants nor fungi, the more than 200,000 known species of protists are often overlooked. But as temperatures warm, they could play a big role in buffering the effects of climate change, said Jean Philippe Gibert, an assistant professor of biology at Duke.That's because of what protists like to eat. They gobble up bacteria, which release carbon dioxide into the air when they respire, just like we do when we breathe out. But because bacteria account for more of the planet's biomass than any other living thing besides plants, they are among the largest natural emitters of carbon dioxide -- the greenhouse gas most responsible for global warming.In a study published Oct.

19 in Proceedings of the National Academy of Sciences, Gibert, postdoctoral researcher Dan Wieczynski and colleagues tested the effects of warming on bacteria-eating protists by creating mini ecosystems -- glass flasks each containing 10 different species of protists going about the business of eating and competing and reproducing.The flasks were kept at five temperatures ranging from 60 degrees to 95 degrees Fahrenheit. Two weeks later, the researchers looked to see which species had survived at each temperature and measured how much CO2 they gave off during respiration."To me, the question was a simple one in nature," Gibert said. "Is there something to be measured on living organisms, today, that may allow us to predict their response to increasing temperature, tomorrow?. "The answer was yes.

The researchers were surprised to find that each species' response to temperature could be predicted from just a few simple measurements of their size, shape and cell contents. And together, these factors in turn influenced respiration rates for the community as a whole.They also found that by taking measurements such as cell size and shape and plugging them into a mathematical model, they could get very close to how things played out in their mini ecosystems in reality."We can actually use what we know about the relationship between traits and temperature responses at the species level, and scale it all the way up to a whole ecosystem level," Wieczynski said.The work is important because it sheds light on "how climate change will alter microbial communities and how this will feed back to influence the pace of climate change," Wieczynski said.This research was supported by a grant from the U.S. Department of Energy (DE-SC0020362). Story Source.

Materials provided by Duke University. Original written by Robin A. Smith. Note.

Content may be edited for style and length.Contrary to widely held gender stereotypes, women are not more emotional than men, researchers say.Feelings such as enthusiasm, nervousness or strength are often interpreted differently between the two genders. It's what being "emotional" means to men vs. Women that is part of a new University of Michigan study that dispels these biases.For instance, a man whose emotions fluctuate during a sporting event is described as "passionate." But a woman whose emotions change due to any event, even if provoked, is considered "irrational," says the study's senior author Adriene Beltz, U-M assistant professor of psychology.Beltz and colleagues Alexander Weigard, U-M assistant professor of psychiatry, and Amy Loviska, a graduate student at Purdue University, followed 142 men and women over 75 days to learn more about their daily emotions, both positive and negative. The women were divided into four groups.

One naturally cycling and three others using different forms of oral contraceptives.The researchers detected fluctuations in emotions three different ways, and then compared the sexes. They found little-to-no differences between the men and the various groups of women, suggesting that men's emotions fluctuate to the same extent as women's do (although likely for different reasons)."We also didn't find meaningful differences between the groups of women, making clear that emotional highs and lows are due to many influences -- not only hormones," she said.The findings have implications beyond everyday people, the researchers say. Women have historically been excluded from research participation in part due to the assumption that ovarian hormone fluctuations lead to variation, especially in emotion, that can't be experimentally controlled, they say."Our study uniquely provides psychological data to show that the justifications for excluding women in the first place (because fluctuating ovarian hormones, and consequently emotions, confounded experiments) were misguided," Beltz said. Story Source.

Materials provided by University of Michigan. Note. Content may be edited for style and length.Songbirds share the human sense of rhythm, but it is a rare trait in non-human mammals. An international research team led by senior investigators Marco Gamba from the University of Turin and MPI’s Andrea Ravignani set out to look for musical abilities in primates.

€œThere is longstanding interest in understanding how human musicality evolved, but musicality is not restricted to humans”, says Ravignani. €œLooking for musical features in other species allows us to build an ‘evolutionary tree’ of musical traits, and understand how rhythm capacities originated and evolved in humans.”To find out whether non-human mammals have a sense of rhythm, the team decided to study one of the few ‘singing’ primates, the critically endangered lemur Indri indri. The researchers wanted to know whether indri songs have categorical rhythm, a ‘rhythmic universal’ found across human musical cultures. Rhythm is categorical when intervals between sounds have exactly the same duration (1:1 rhythm) or doubled duration (1:2 rhythm).

This type of rhythm makes a song easily recognisable, even if it is sung at different speeds. Would indri songs show this “uniquely human” rhythm?. Ritardando in the rainforestOver a period of twelve years, the researchers from Turin visited the rainforest of Madagascar to collaborate with a local primate study group. The investigators recorded songs from twenty indri groups (39 animals), living in their natural habitat.

Members of an indri family group tend to sing together, in harmonised duets and choruses. The team found that indri songs had the classic rhythmic categories (both 1:1 and 1:2), as well as the typical ‘ritardando’ or slowing down found in several musical traditions. Male and female songs had a different tempo but showed the same rhythm.According to first author Chiara de Gregorio and her colleagues, this is the first evidence of a ‘rhythmic universal’ in a non-human mammal. But why should another primate produce categorical ‘music-like’ rhythms?.

The ability may have evolved independently among ‘singing’ species, as the last common ancestor between humans and indri lived 77.5 million years ago. Rhythm may make it easier to produce and process songs, or even to learn them.Endangered species“Categorical rhythms are just one of the six universals that have been identified so far”, explains Ravignani. €œWe would like to look for evidence of others, including an underlying ‘repetitive’ beat and a hierarchical organisation of beats—in indri and other species.” The authors encourage other researchers to gather data on indri and other endangered species, “before it is too late to witness their breath-taking singing displays.” Story Source. Materials provided by Max Planck Institute for Psycholinguistics.

Note. Content may be edited for style and length..

• Lasix 100mg price
• How to get viagra over the counter
• Purchase viagra
• Cipro prices walmart
• How to get ventolin prescription