How to get a viagra prescription from your doctor

How to cite this article:Singh how to get a viagra prescription from your doctor OP. Mental health in diverse India. Need for how to get a viagra prescription from your doctor advocacy.

Indian J Psychiatry 2021;63:315-6âUnity in diversityâ - That is the theme of India which we are quite proud of. We have how to get a viagra prescription from your doctor diversity in terms of geography â 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 how to get a viagra prescription from your doctor between the 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 how to get a viagra prescription from your doctor Shim[1] 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 how to get a viagra prescription from your doctor early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different 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 how to get a viagra prescription from your doctor onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of how to get a viagra prescription from your doctor depression and anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms.

Marriage was found to how to get a viagra prescription from your doctor be a negative prognostic indicator contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

Apart from culture bound syndromes, the role of cultural idioms of how to get a viagra prescription from your doctor distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1â5 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 how to get a viagra prescription from your doctor reducing stigma and discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the how to get a viagra prescription from your doctor 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 the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden how to get a viagra prescription from your doctor of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, the Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017 how to get a viagra prescription from your doctor. Another case filed by the IPS lead to change of name of the film from âMental Hai Kyaâ to âJudgemental Hai Kya.â 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 how to get a viagra prescription from your doctor Journal of Psychiatry has also come out with editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy how to get a viagra prescription from your doctor is economic inequality, our weapon is research highlighting the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social how to get a viagra prescription from your doctor 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 how to get a viagra prescription from your doctor Health Survey 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 1990â2017. 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 âa culturally determined idiom of distress.â 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 â 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 âDhatâ was taken from the Sanskrit language, which is an important word âDhatuâ and has known several meanings such as âmetal,â a âmedicinal constituent,â which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for âloss of semenâ, and the DS is a well-known âculture-bound syndrome (CBS).â[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 âwaste of bodily humorsâ being linked to the âloss of Dhatus.â[5] Semen has even been mentioned by Aristotle as a âsoul substanceâ and weakness associated with its loss.[6] This has led to a plethora of beliefs about âfood-blood-semenâ 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 âanxiety for loss of semenâ 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 âculture is closely associated with mental disorders through social and psychological activities.â 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 âCultural Variantâ 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 âcause-effectâ dilemma can never be fully resolved. Whether âloss of semenâ 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 âemotional distress and cultural contextsâ 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 âmood disordersâ 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 âcultural phenotypeâ 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 âsemen loss syndromeâ 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 âsemen loss anxietyâ suffer from a myriad of psychosexual symptoms, which have been attributed to âloss of vital essence through semenâ (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 â¥1. This study reported several parameters such as the âsense of being unhealthyâ (99%), worry (99%), feeling âno improvement despite treatmentâ (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 âDhatâ 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 âdhatâ 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 âDhatâ 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 âDhatâ multiple times a week. Among them, nearly 60% passed almost a spoonful of âDhatâ each time during a loss. This work on sexual disorders reported that the passage of âDhatâ 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 ânight fallsâ (60.1%) and âwhile passing stoolsâ (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the âloss of Dhat.â 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 âprecious,â 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 ânocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.â The assessment was done based on several indices, namely âSomatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.â 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 15â50 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 (16â23 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 âloss of something preciousâ, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and âDhatâ 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%â66.7%) were from rural areas, belonged to âconservative families and posed rigid views about sexâ (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 16â20 years (34%) followed by 21â25 years (28%), greater than 30 years (26%), 26â30 years (10%), and 11â15 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 18â25 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 âsupplements,â 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 Â± 3.5 years and concluded that the âpureâ 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 âplaceâ 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 âother nonpsychotic mental disordersâ (F48), DSM-V mentions it only in appendix section as âcultural concepts of distressâ 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 âtrue syndrome.â[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural âidiomâ 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 ânicheâ of DS in the near future.

It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader ânarrativeâ 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 âconstructâ 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 âseparateâ 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 âbird's eyeâ 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.

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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.

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OAC, oral where to buy women viagra anticoagulants. SE, systemic embolism. TIA, transient ischaemic attack.

VKA, vitamin K antagonists.In the accompanying where to buy women viagra editorial, Choi and Lee5 point out the strengths of this study including a clinically diverse international patient cohort with regular audits and a low rate of loss to follow-up, a sophisticated matching method, and results consistent with previous RCTs. However, limitations include the possibility of residual confounders. Possible discontinuation or switching of medications during this study period.

Lack of detailed data on types of major bleeding, and regional or ethnic differences in outcomes where to buy women viagra. And any effects due to lack of adherence to therapy. As they conclude âThe GARFIELD-AF registry has reported valuable clinical practice patterns in AF worldwide, but it will also play a role as a pragmatic study for real-world practice-based RCTs.âThe prevalence and outcomes of adults over age 65 years with more than mild mitral regurgitation (MR) or tricuspid regurgitation (TR) was studied in 4755 subjects who had undergone echocardiography in the Oxford Valvular Heart Disease Population Study (OxVALVE).6 Overall, the prevalence of moderate or greater MR was 3.5% and TR was 2.6% with only about half these patients having previously diagnosed valve disease.

Subjects with regurgitation identified by screening were less likely to be symptomatic where to buy women viagra than those with known valve disease. The aetiology of MR was most often primary although 22% had secondary MR due to left ventricular systolic dysfunction (figure 3). Surgical intervention was rarely undertaken (2.4%) during the 64-month median follow-up.Mechanism of mitral regurgitation (MR).

The mechanisms of valve dysfunction in patients with moderate or greater MR are shown, where to buy women viagra according to Carpentier classification. Type 1, normal leaflet motion and position. Type 2, excess leaflet motion.

Type 3a, where to buy women viagra restricted leaflet motion in systole and diastole. Type 3b, restricted leaflet motion in systole." data-icon-position data-hide-link-title="0">Figure 3 Mechanism of mitral regurgitation (MR). The mechanisms of valve dysfunction in patients with moderate or greater MR are shown, according to Carpentier classification.

Type 1, normal where to buy women viagra leaflet motion and position. Type 2, excess leaflet motion. Type 3a, restricted leaflet motion in systole and diastole.

Newer nuclear imaging approaches include 18F-fluorodeoxyglucose positron emission tomography scans for diagnosis of infective endocarditis, particularly in patients with prosthetic valves, and the use of nuclear approaches as adjuncts for the where to buy women viagra diagnoses of sarcoidosis and amyloidosis.Our Cardiology in Focus series continues with an article10 on pregnancy during cardiology training which will be helpful for women considering pregnancy during cardiology training (or as a consultant cardiologist) for those providing training and support to those women (figure 4).Concerns of the pregnant cardiologist." data-icon-position data-hide-link-title="0">Figure 4 Concerns of the pregnant cardiologist.Clinical guidelines play an increasingly important role in care of patients with cardiovascular disease. Approaches to guideline development reflect the need to integrate a complex and ever-expanding evidence base with new treatment options and clinical expertise to formulate recommendations that then can be implemented both by individual healthcare providers and across healthcare systems. All guidelines for a specific disease condition start with the same evidence base, yet guidelines are developed in many different ways, by many different organisations, often addressing the same or overlapping types of cardiovascular disease, typically leading to at least subtle (and sometimes major) divergences in the resultant recommendations.Professional society recommendations, such as those generated by the European Society of Cardiology (ESC) and by the American Heart Association/American College of Cardiology (AHA/ACC), predominate, but many geographic regions have their own guidelines, tailoring recommendations to specific regional requirements.1 Government agencies and insurance providers also generate guidelines either directly in published documents or indirectly by restricting reimbursement.

Online medical textbooks, such as Up-to-Date, attempt to integrate and reconcile recommendations from multiple guideline sources, filling any gaps in clinical management where to buy women viagra with recommendations based on clinical expertise alone. Another approach is to convene an independent group of experts to address new practice changing evidence rapidly, focusing on a specific question, such as the BMJ Rapid Recs or Magic Evidence Ecosystem Foundation.2 3Why are there so many guidelines?. What are the limitations of our current approach?.

How can we optimise guideline development to improve care of patients with cardiovascular disease?.

A rigorous how to get a viagra prescription from your doctor transparent process based Cialis price canada on established standards. A more diverse group of stakeholders. Minimising conflicts of interest. Support by information specialists, medical writers and other how to get a viagra prescription from your doctor relevant experts.

Regular updates. Adaptation for regional considerations. And improved how to get a viagra prescription from your doctor methods for dissemination and access. As they conclude.

ÂCurrent cardiovascular society guidelines fall short of best practice. We can and must do better.âVisual summary of reporting criteria for clinical practice guidelines as detailed in the Appraisal of Guidelines, Research and Evaluation (AGREE) checklist." data-icon-position data-hide-link-title="0">Figure 1 Visual summary of reporting criteria for clinical practice guidelines as detailed in the Appraisal of Guidelines, Research and Evaluation (AGREE) how to get a viagra prescription from your doctor checklist.In patients with atrial fibrillation (AF) at moderate or high risk of stroke, randomised controlled trials (RCTs) have shown superiority or non-inferiority of non-vitamin K oral anticoagulants (NOACs) over vitamin K anticoagulants (VKA) for prevention of stroke or systemic embolism along with reduced rates of intracranial haemorrhage. However, patients in RCTs may not be representative of the full range of patients seen in clinical practice. In order to address this issue, Camm and colleagues4 used a method called overlap propensity matching to compare the effectiveness of VKA and different NOACs for mortality, stroke/systemic embolism and major bleeding in patients with newly diagnosed AF and an indication for oral anticoagulation.

Based on 25 551 patients in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) study, they confirmed that âImportant benefits in terms of mortality and major bleeding were observed with NOAC versus VKA with no difference among NOAC subtypesâ (figure how to get a viagra prescription from your doctor 2).Adjusted* HRs and corresponding 95% CIs for selected outcomes at 2 years of follow-up by OAC treatment at baseline. The reference considered is the treatment reported as second. *Obtained using an overlap-weighted Cox model. Variables included how to get a viagra prescription from your doctor in the weighting scheme are.

Country and cohort enrolment, sex, age, ethnicity, type of AF, care setting specialty and location, congestive heart failure, acute coronary syndromes, vascular disease, carotid occlusive disease, prior stroke/TIA/SE, prior bleeding, venous thromboembolism, hypertension, hypercholesterolaemia, diabetes, cirrhosis, moderate to severe chronic kidney disease, dementia, hyperthyroidism, hypothyroidism, current smoking, heavy alcohol consumption, body mass index (BMI) heart rate, systolic and diastolic blood pressure at diagnosis and baseline antiplatelet use. DTI, direct thrombin inhibitor. FXaI, factor how to get a viagra prescription from your doctor Xa inhibitors. NOAC, non-vitamin K oral anticoagulants.

OAC, oral anticoagulants. SE, systemic embolism how to get a viagra prescription from your doctor. TIA, transient ischaemic attack. VKA, vitamin K antagonists." data-icon-position data-hide-link-title="0">Figure 2 Adjusted* HRs and corresponding 95% CIs for selected outcomes at 2 years of follow-up by OAC treatment at baseline.

The reference how to get a viagra prescription from your doctor considered is the treatment reported as second. *Obtained using an overlap-weighted Cox model. Variables included in the weighting scheme are. Country and cohort enrolment, sex, age, ethnicity, type of AF, care setting how to get a viagra prescription from your doctor specialty and location, congestive heart failure, acute coronary syndromes, vascular disease, carotid occlusive disease, prior stroke/TIA/SE, prior bleeding, venous thromboembolism, hypertension, hypercholesterolaemia, diabetes, cirrhosis, moderate to severe chronic kidney disease, dementia, hyperthyroidism, hypothyroidism, current smoking, heavy alcohol consumption, body mass index (BMI) heart rate, systolic and diastolic blood pressure at diagnosis and baseline antiplatelet use.

DTI, direct thrombin inhibitor. FXaI, factor Xa inhibitors. NOAC, non-vitamin K oral anticoagulants how to get a viagra prescription from your doctor. OAC, oral anticoagulants.

SE, systemic embolism. TIA, transient how to get a viagra prescription from your doctor ischaemic attack. VKA, vitamin K antagonists.In the accompanying editorial, Choi and Lee5 point out the strengths of this study including a clinically diverse international patient cohort with regular audits and a low rate of loss to follow-up, a sophisticated matching method, and results consistent with previous RCTs. However, limitations include the possibility of residual confounders.

Possible discontinuation or switching how to get a viagra prescription from your doctor of medications during this study period. Lack of detailed data on types of major bleeding, and regional or ethnic differences in outcomes. And any effects due to lack of adherence to therapy. As they conclude âThe GARFIELD-AF registry has reported valuable clinical practice patterns in AF worldwide, but it will also play a role as a how to get a viagra prescription from your doctor pragmatic study for real-world practice-based RCTs.âThe prevalence and outcomes of adults over age 65 years with more than mild mitral regurgitation (MR) or tricuspid regurgitation (TR) was studied in 4755 subjects who had undergone echocardiography in the Oxford Valvular Heart Disease Population Study (OxVALVE).6 Overall, the prevalence of moderate or greater MR was 3.5% and TR was 2.6% with only about half these patients having previously diagnosed valve disease.

Subjects with regurgitation identified by screening were less likely to be symptomatic than those with known valve disease. The aetiology of MR was most often primary although 22% had secondary MR due to left ventricular systolic dysfunction (figure 3). Surgical intervention was rarely undertaken (2.4%) during the 64-month median follow-up.Mechanism of mitral regurgitation how to get a viagra prescription from your doctor (MR). The mechanisms of valve dysfunction in patients with moderate or greater MR are shown, according to Carpentier classification.

Type 1, normal leaflet motion and position. Type 2, how to get a viagra prescription from your doctor excess leaflet motion. Type 3a, restricted leaflet motion in systole and diastole. Type 3b, restricted leaflet motion in systole." data-icon-position data-hide-link-title="0">Figure 3 Mechanism of mitral regurgitation (MR).

The mechanisms of valve dysfunction in patients with moderate or greater MR are shown, according to how to get a viagra prescription from your doctor Carpentier classification. Type 1, normal leaflet motion and position. Type 2, excess leaflet motion. Type 3a, restricted leaflet how to get a viagra prescription from your doctor motion in systole and diastole.

Type 3b, restricted leaflet motion in systole.In an editorial, Bouleti and Iung7 point out that the prevalence of MR and TR increases even further in those over age 75 years and that the number of patients with secondary MR and a low left ventricular ejection fraction is of concern given the association with impaired long-term survival. They conclude. ÂThese findings highlight the need for educational programmes to increase the awareness on heart valve disease, how to get a viagra prescription from your doctor for evaluation of the adherence to guidelines and for the continuous development and evaluation of less invasive interventions targeting elderly patients.âThe Education in Heart article in this issue summarises the recommended approach to screening for cardiovascular disease in healthy individuals.8 A state-of-the-art review article on nuclear cardiology9 provides an overview of myocardial perfusion imaging techniques and clinical applications for ischaemic heart disease, heart failure, and myocardial disease and . Newer nuclear imaging approaches include 18F-fluorodeoxyglucose positron emission tomography scans for diagnosis of infective endocarditis, particularly in patients with prosthetic valves, and the use of nuclear approaches as adjuncts for the diagnoses of sarcoidosis and amyloidosis.Our Cardiology in Focus series continues with an article10 on pregnancy during cardiology training which will be helpful for women considering pregnancy during cardiology training (or as a consultant cardiologist) for those providing training and support to those women (figure 4).Concerns of the pregnant cardiologist." data-icon-position data-hide-link-title="0">Figure 4 Concerns of the pregnant cardiologist.Clinical guidelines play an increasingly important role in care of patients with cardiovascular disease.

Approaches to guideline development reflect the need to integrate a complex and ever-expanding evidence base with new treatment options and clinical expertise to formulate recommendations that then can be implemented both by individual healthcare providers and across healthcare systems. All guidelines for a specific disease condition start with the same evidence base, yet guidelines are developed in many different ways, by many different organisations, often addressing the same or overlapping types of cardiovascular disease, typically leading to at least subtle (and sometimes major) divergences in the resultant recommendations.Professional society recommendations, such as those generated by the European Society of Cardiology (ESC) and by the American Heart Association/American College of Cardiology (AHA/ACC), predominate, but many geographic regions have their own guidelines, tailoring recommendations to specific regional requirements.1 Government agencies and insurance providers also generate guidelines how to get a viagra prescription from your doctor either directly in published documents or indirectly by restricting reimbursement. Online medical textbooks, such as Up-to-Date, attempt to integrate and reconcile recommendations from multiple guideline sources, filling any gaps in clinical management with recommendations based on clinical expertise alone. Another approach is to convene an independent group of experts to address new practice changing evidence rapidly, focusing on a specific question, such as the BMJ Rapid Recs or Magic Evidence Ecosystem Foundation.2 3Why are there so many guidelines?.

What are the limitations of our current approach?.

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A man has been accused of keeping a sloth and a wallaby in unsafe and unsatisfactory conditions in his New York home.The United States Department of Agriculture cited Long Island resident Larry Wallach after searching his East Rockaway home and allegedly found a sloth living in an enclosure in his garage taking viagra during the June 2021 inspection."Hanging from the ceiling in the interior of the sloth enclosure, is a light fixture and on the floor of the interior is a portable electric humidifier with the cord exposed," the USDA complaint said. "The sloth has access to the exposed light and the humidifier, which could injure the animal by burning, broken glass, or electrical shock. "The slothâs enclosure is covered by a fabric tarp, taking viagra which is a potential fire hazard as the humidifier and the light fixture have exposed electrical wires."During the inspection, a wallaby was found housed in an outdoor enclosure with a 39-inch back fence, the USDA said. There is not a perimeter fence of sufficient height that functions as a secondary containment system to prevent the wallaby from escaping," the complaint said.In August 2020, Wallach "took a tiger cub, that according to records provided by the licensee was approximately 6 weeks old, to a park where the public had direct contact to handle and pet the cub," the USDA complaint said.

"The licensee did not restrict access to the unleashed cub and did taking viagra not maintain a barrier, allowing the cub to walk among the crowd."Wallach now risks the possibility of having his animal-handling licenses revoked by the USDA. Click here to sign up for Daily Voice's free daily emails and news alerts.Police said they have located a person who was in crisis following a domestic incident in Westchester County.The North Castle Police Department issued an alert on Wednesday, Oct. 13, saying officers had searched taking viagra the Windmill area for one of the people involved in a domestic incident who was in a personal crisis.Police said after searching the area, the person was found and taken for appropriate care.Authorities said there is no concern for the safety of area residents. North Castle Police did not provide further details about the incident.

Click here to sign up for Daily Voice's free daily emails and news taking viagra alerts.The White House erectile dysfunction treatment Summit recently convened world leaders, multilateral organizations, global health experts, and the private sector to address the viagra. We were privileged to be among the stakeholders as representatives of Seed Global Health, which partners with governments to strengthen health workforces in countries with critical shortages.The Summitâs main call was for collective action to heal from the erectile dysfunction treatment viagra and protect against future global health threats. To this end, we heard dialogue focused on taking viagra global treatment equity. On improving global manufacturing capacity for erectile dysfunction treatments, personal protective equipment, diagnostics, and treatments, including oxygen.

And on taking viagra financial commitments to ensure global health security and preparedness.What we didnât hear was much discussion about the one factor essential for the success of all of these initiatives. The worldâs âhealth care heroes.â This omission was surprising because health care workers are the foundation of health systems. They deliver every element of viagra response and manage associated crises.advertisement As erectile dysfunction treatment has pushed people into poverty, increased food taking viagra insecurity, reduced access to health care worldwide, reversed progress in maternal and child mortality, and worsened outcomes for infectious and chronic diseases, these increased disease burdens will only expand the need for health care workers.Despite these truths, and the global loss of more than 100,000 health workers during this viagra, the global community has not yet demonstrated that it will collectively change course. Without meaningful changes in priorities, the health workforce will continue to be underfunded, undervalued, and underprotected.

This failure is most stark taking viagra in low and middle-income countries (LMICs), feeding longstanding inequities in the global health workforce.advertisement Long before the emergence of erectile dysfunction treatment, health care workers in low- and middle-income countries faced profound occupational hazards. They are at least three times more likely to be diagnosed with tuberculosis and up to six times more likely to be hospitalized with drug-resistant tuberculosis than the general population in high disease-burden countries. Health workers in Guinea, Liberia, and Sierra Leone were at least 21 times more likely to contract Ebola than the populations taking viagra they served during the outbreak in 2014-2015. At least 513 health workers died of Ebola during this period, leading to a reduction in the health workforce by up to 8% in affected West African countries.The impact is enduring.

Post-Ebola investments for Guinea, Liberia, and Sierra Leone have fallen woefully short of the projected recovery needs. These countries now require up to a 10-fold increase in their health workforces to reach regional averages and minimum international benchmarks for health worker to population ratios.By 2030, there will be a global shortage of more than 18 million health care workers, disproportionately taking viagra in low- and middle-income countries. Inadequate staffing already worsens the physical and mental demands of providing health care in these countries, fueled by inadequate resources, immense workloads, and emotional exhaustion from the toll of watching people die preventable deaths. Though difficult to quantify, burnout rates among physicians taking viagra and nurses in African countries are high â upwards of 80% in some hospitals.

Burnout and work stressors, in turn, are key drivers of health care workers migration abroad, which further compounds health workforce shortages.According to estimates by the WHO, the average investment required to scale up the health workforce to meet whatâs needed over a 20-year period is about $488 million a year per country.The funds required to close these financing gaps actually exist. Itâs the international political taking viagra will thatâs lacking. Domestic governments, donors, philanthropy, and the private sector have the means to meet these needs together but, according to experts at the WHO and World Bank, these stakeholders often see the recurrent costs of developing and employing a strong health workforce as a long-term financial burden they are unwilling to sustain over time.erectile dysfunction treatment presents a window of opportunity to change this narrative. As health care workers are applauded for their service, the international community must recognize that the consequences â financial and otherwise â of not investing in the global health workforce are far more devastating than the upfront costs of strengthening it.According to researchers from the WHO, the loss of one physician represents a cost of more than $500,000 in Kenya taking viagra.

And estimates like this donât take into account the potential longer-term consequences of health worker burnout and trauma, which lead to decreased quality of care and migration of health workers out of the health sector or abroad.There are also countless multiplier effects of health workforce employment. Supporting an appropriately planned, taking viagra trained, and distributed workforce can reduce inefficiencies in global health spending in the long term. Investing an additional 2% of gross domestic product (GDP) into the health, social, and education sectors raises overall employment rates by as much as 6%. It might not seem like much, but with the total unemployment rates across lower- and middle-income countries surpassing 6% in 2020, this could taking viagra represent tremendous growth.

Investments in the workforce are also critical to inclusive growth. Supporting safe and secure employment in this sector reduces gender disparities, with women absorbing 60% to 70% of the jobs, and taking viagra builds formal work, social inclusion, and equity. The ultimate return on investment for health is estimated to be 9:1, with each extra year of life expectancy emerging from this investment raising the GDP per capita by 4%. In other words, taking viagra improving population health and investing in the health sector can elevate nations.The World Health Organization declared 2021 to be the Year of Health and Care Workers.

But as the year comes to a close, this declaration will ring hollow unless global commitments to end this viagra and protect the world from future health crises include sustained action to protect and strengthen the health care workforce worldwide.It is not a question of identifying the needs. Those are taking viagra clear. Prioritizing health workers for treatments and protective equipment now while also increasing global and domestic investments required for salaries, training, infrastructure, and morale in the long term. That requires making the choice to no longer taking viagra misrepresent health workers as a cost on the system but appreciate them as catalysts to better health, economic growth, national security, and wellbeing.

It is a choice to recognize them as the âheroesâ that theyâve always been.Pooja Yerramilli is an internal medicine physician at Massachusetts General Hospital and Boston Health Care for the Homeless, and a policy advisor for Seed Global Health, which partners with governments to invest in health care capacity for national, economic, and human security. Vanessa Kerry is a critical care physician at Massachusetts General Hospital in Boston, an associate professor of medicine and director of the Program in Global Public Policy and Social Change at Harvard Medical School, and CEO of Seed Global Health..

A man has been accused of keeping a sloth and a wallaby in unsafe and unsatisfactory conditions in his New York home.The United States Department of Agriculture cited Long Island resident Larry Wallach after how to get a viagra prescription from your doctor searching his East Rockaway home and allegedly found a sloth living in an enclosure in his garage during the June 2021 inspection."Hanging from the ceiling in the interior of the sloth enclosure, is a light fixture and on the floor of the interior is a portable electric humidifier with the cord exposed," the USDA complaint said. "The sloth has access to the exposed light and the humidifier, which could injure the animal by burning, broken glass, or electrical shock. "The slothâs enclosure is covered by a fabric tarp, which is a potential fire hazard as the humidifier and the how to get a viagra prescription from your doctor light fixture have exposed electrical wires."During the inspection, a wallaby was found housed in an outdoor enclosure with a 39-inch back fence, the USDA said. There is not a perimeter fence of sufficient height that functions as a secondary containment system to prevent the wallaby from escaping," the complaint said.In August 2020, Wallach "took a tiger cub, that according to records provided by the licensee was approximately 6 weeks old, to a park where the public had direct contact to handle and pet the cub," the USDA complaint said. "The licensee did not restrict access to the unleashed cub and did not maintain a barrier, allowing the cub how to get a viagra prescription from your doctor to walk among the crowd."Wallach now risks the possibility of having his animal-handling licenses revoked by the USDA.

Click here to sign up for Daily Voice's free daily emails and news alerts.Police said they have located a person who was in crisis following a domestic incident in Westchester County.The North Castle Police Department issued an alert on Wednesday, Oct. 13, saying officers had searched the Windmill area for one of the people involved in a how to get a viagra prescription from your doctor domestic incident who was in a personal crisis.Police said after searching the area, the person was found and taken for appropriate care.Authorities said there is no concern for the safety of area residents. North Castle Police did not provide further details about the incident. Click here to sign up for Daily Voice's free daily emails and news alerts.The White House erectile dysfunction treatment Summit recently convened world leaders, multilateral organizations, global health experts, and the how to get a viagra prescription from your doctor private sector to address the viagra. We were privileged to be among the stakeholders as representatives of Seed Global Health, which partners with governments to strengthen health workforces in countries with critical shortages.The Summitâs main call was for collective action to heal from the erectile dysfunction treatment viagra and protect against future global health threats.

To this end, we heard dialogue how to get a viagra prescription from your doctor focused on global treatment equity. On improving global manufacturing capacity for erectile dysfunction treatments, personal protective equipment, diagnostics, and treatments, including oxygen. And on financial commitments to ensure global health security and preparedness.What we didnât hear was much discussion about the one factor essential for the success how to get a viagra prescription from your doctor of all of these initiatives. The worldâs âhealth care heroes.â This omission was surprising because health care workers are the foundation of health systems. They deliver every element of viagra response and manage associated crises.advertisement As erectile dysfunction treatment has pushed people into poverty, increased food insecurity, reduced access to health care worldwide, reversed progress in maternal and child mortality, and worsened outcomes for infectious and chronic diseases, these increased disease burdens will only expand the need for health care workers.Despite these truths, and the global loss of more than 100,000 health workers how to get a viagra prescription from your doctor during this viagra, the global community has not yet demonstrated that it will collectively change course.

Without meaningful changes in priorities, the health workforce will continue to be underfunded, undervalued, and underprotected. This failure is most stark in low and middle-income countries (LMICs), feeding longstanding inequities in the global health workforce.advertisement Long before the emergence of erectile dysfunction treatment, health care workers in low- and middle-income countries how to get a viagra prescription from your doctor faced profound occupational hazards. They are at least three times more likely to be diagnosed with tuberculosis and up to six times more likely to be hospitalized with drug-resistant tuberculosis than the general population in high disease-burden countries. Health workers in how to get a viagra prescription from your doctor Guinea, Liberia, and Sierra Leone were at least 21 times more likely to contract Ebola than the populations they served during the outbreak in 2014-2015. At least 513 health workers died of Ebola during this period, leading to a reduction in the health workforce by up to 8% in affected West African countries.The impact is enduring.

Post-Ebola investments for Guinea, Liberia, and Sierra Leone have fallen woefully short of the projected recovery needs. These countries now require up to a 10-fold increase in their health workforces how to get a viagra prescription from your doctor to reach regional averages and minimum international benchmarks for health worker to population ratios.By 2030, there will be a global shortage of more than 18 million health care workers, disproportionately in low- and middle-income countries. Inadequate staffing already worsens the physical and mental demands of providing health care in these countries, fueled by inadequate resources, immense workloads, and emotional exhaustion from the toll of watching people die preventable deaths. Though difficult to quantify, burnout how to get a viagra prescription from your doctor rates among physicians and nurses in African countries are high â upwards of 80% in some hospitals. Burnout and work stressors, in turn, are key drivers of health care workers migration abroad, which further compounds health workforce shortages.According to estimates by the WHO, the average investment required to scale up the health workforce to meet whatâs needed over a 20-year period is about $488 million a year per country.The funds required to close these financing gaps actually exist.

Itâs the international political how to get a viagra prescription from your doctor will thatâs lacking. Domestic governments, donors, philanthropy, and the private sector have the means to meet these needs together but, according to experts at the WHO and World Bank, these stakeholders often see the recurrent costs of developing and employing a strong health workforce as a long-term financial burden they are unwilling to sustain over time.erectile dysfunction treatment presents a window of opportunity to change this narrative. As health care workers how to get a viagra prescription from your doctor are applauded for their service, the international community must recognize that the consequences â financial and otherwise â of not investing in the global health workforce are far more devastating than the upfront costs of strengthening it.According to researchers from the WHO, the loss of one physician represents a cost of more than $500,000 in Kenya. And estimates like this donât take into account the potential longer-term consequences of health worker burnout and trauma, which lead to decreased quality of care and migration of health workers out of the health sector or abroad.There are also countless multiplier effects of health workforce employment. Supporting an how to get a viagra prescription from your doctor appropriately planned, trained, and distributed workforce can reduce inefficiencies in global health spending in the long term.

Investing an additional 2% of gross domestic product (GDP) into the health, social, and education sectors raises overall employment rates by as much as 6%. It might not seem like much, but with the total unemployment rates across lower- and middle-income countries surpassing 6% in 2020, this could how to get a viagra prescription from your doctor represent tremendous growth. Investments in the workforce are also critical to inclusive growth. Supporting safe and secure employment in this how to get a viagra prescription from your doctor sector reduces gender disparities, with women absorbing 60% to 70% of the jobs, and builds formal work, social inclusion, and equity. The ultimate return on investment for health is estimated to be 9:1, with each extra year of life expectancy emerging from this investment raising the GDP per capita by 4%.

In other words, improving population health and investing in the health sector can elevate how to get a viagra prescription from your doctor nations.The World Health Organization declared 2021 to be the Year of Health and Care Workers. But as the year comes to a close, this declaration will ring hollow unless global commitments to end this viagra and protect the world from future health crises include sustained action to protect and strengthen the health care workforce worldwide.It is not a question of identifying the needs. Those are how to get a viagra prescription from your doctor clear. Prioritizing health workers for treatments and protective equipment now while also increasing global and domestic investments required for salaries, training, infrastructure, and morale in the long term. That requires making the choice to no longer misrepresent health workers as a cost on the system but appreciate how to get a viagra prescription from your doctor them as catalysts to better health, economic growth, national security, and wellbeing.

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