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KHN’s Peggy Girshman fellow order viagra online Amanda Michelle Gomez discussed how Washington, D.C., is adopting public health tools to help curb gun violence on Newsy’s “Morning Rush” on Wednesday. KHN interim Southern bureau editor Andy Miller discussed the shortage of beds at state psychiatric facilities on Newsy on Wednesday. KHN freelancer Morgan Gonzales discussed how vigilantes are crowdsourcing erectile dysfunction treatment safety information about local businesses on Newsy on Tuesday order viagra online. Related Topics Contact Us Submit a Story TipPresident Joe Biden’s mammoth domestic spending bill would add hearing benefits to the traditional Medicare program — one of three major new benefits Democrats had sought. The Biden administration appears to have fallen short of its ambition to expand dental and vision along with hearing benefits.

Sen. Bernie Sanders (I-Vt.) and other progressives have long pushed for more generous benefits for seniors. Citing the cost, Sen. Joe Manchin (D-W.Va.) opposed such expansion. Biden and Democratic leaders in Congress pared back the scope of the new benefits after the total budget bill — which funds health care and other domestic initiatives — was whittled from a proposed $3.5 trillion to $1.75 trillion to meet demands of the party’s moderates.

The new hearing benefits would become available in 2023. Democrats have little room for maneuvering on the bill. They need all 50 Democratic senators to support it and can lose only three members of the House on a vote. Those tight margins have made for difficult negotiations and boosted the ability of any one lawmaker to set terms. The progressive and moderate wings of the party have been at odds on the deal for months, and negotiations are ongoing.

Nonetheless, if the hearing proposal survives, it would be a significant change. Here are answers to questions seniors might have about the benefit. Q. What does the plan do?. The draft legislation unveiled in the House proposes adding coverage to traditional Medicare that includes hearing assessment services, management of hearing loss and related treatment.

About 36 million people are enrolled in original Medicare. Many of the private Medicare Advantage plans other seniors have opted to join already offer similar hearing services. According to the Centers for Medicare &. Medicaid Services, roughly 27 million seniors are enrolled in a Medicare Advantage plan this year. CMS projects that number will increase to 29.5 million next year.

The new benefits include coverage of certain hearing aids for “individuals diagnosed with moderately severe, severe, or profound hearing loss,” and allows seniors enrolled in traditional Medicare to get a hearing aid for each ear every five years. The new benefits cover devices furnished after a written order from a physician, audiologist, hearing aid professional or other clinician. The Food and Drug Administration separately has moved to make hearing aids available over the counter, in a bid to make them cheaper. Q. Why are the benefits needed?.

Research has shown that hearing loss can undermine seniors’ overall quality of life, leading to loneliness, isolation, depression, anxiety, communication disorders and more. According to the Centers for Disease Control and Prevention’s National Health Interview Survey, in 2019 nearly 1 in 3 people age 65 and over reported difficulty hearing even with a hearing aid. Biden administration officials said when unveiling the package last week that of seniors who could benefit from hearing aids, only 30% over age 70 have used them. Hispanic adults 65 and up were more likely than other demographic groups to report having severe hearing problems, the survey found. A KFF analysis from September found that the 4.6 million Medicare beneficiaries who used hearing services in 2018 paid $914 out-of-pocket on average.

That figure includes seniors who receive benefits in traditional Medicare as well as people enrolled in Medicare Advantage plans. Q. How many people would benefit?. The total is still up in the air as Democrats continue to negotiate details, but it’s possible the number of beneficiaries could be in the millions. According to the National Institutes of Health, about 1 in 3 Americans ages 65 to 74 have hearing loss, and nearly half of those older than 75 have difficulty hearing.

To date, there’s been an important distinction between seniors enrolled in traditional Medicare and those in Medicare Advantage plans. A research paper published by the Commonwealth Fund in February found that nearly all Medicare Advantage plans offered dental, vision and hearing benefits. Still, even with Medicare Advantage, seniors can struggle to afford care, and what is covered varies by the plan. The KFF analysis found that seniors in Medicare Advantage plans spent less out-of-pocket for dental and vision care than traditional Medicare enrollees in 2018, but there was no difference in spending on hearing care. Q.

Will dental and vision benefits be added?. Leaving dental and vision benefits on the cutting room floor will disappoint progressive lawmakers. €œIn Vermont and all over this country, you’ve got senior citizens whose teeth are rotting in their mouth, older people who can’t talk to their grandchildren because they can’t hear them because they can’t afford a hearing aid, and people can’t read a newspaper because they can’t afford glasses,” Sanders said on NBC earlier this year. €œSo to say that dental care and hearing aids and eyeglasses should be a part of Medicare makes all the sense in the world.” According to KFF, the 31.3 million Medicare beneficiaries who needed dental services in 2018 paid $874 out-of-pocket on average. The 20.3 million who needed vision care spent $230.

Rachana Pradhan. rpradhan@kff.org, @rachanadixit Related Topics Contact Us Submit a Story TipEarlier this year, the World Health Organization announced a global campaign to combat ageism — discrimination against older adults that is pervasive and harmful but often unrecognized. €œWe must change the narrative around age and ageing” and “adopt strategies to counter” ageist attitudes and behaviors, WHO concluded in a major report accompanying the campaign. Several strategies WHO endorsed — educating people about ageism, fostering intergenerational contacts, and changing policies and laws to promote age equity — are being tried in the United States. But a greater sense of urgency is needed in light of the erectile dysfunction viagra’s shocking death toll, including more than 500,000 older Americans, experts suggest.

€œerectile dysfunction treatment hit us over the head with a two-by-four, [showing that] you can’t keep doing the same thing over and over again and expect different results” for seniors, Jess Maurer, executive director of the Maine Council on Aging, said in an October webinar on ageism in health care sponsored by KHN and the John A. Hartford Foundation. €œYou have to address the root cause — and the root cause here is ageism.” Some experts believe there’s a unique opportunity to confront this concern because of what the country has been through. Here are some examples of what’s being done, particularly in health care settings. Distinguishing old age from disease.

In October, a group of experts from the U.S., Canada, India, Portugal, Switzerland and the United Kingdom called for old age to be removed as one of the causes and symptoms of disease in the 11th revision of the International Classification of Diseases, a global resource used to standardize health data worldwide. Aging is a normal process, and equating old age with disease “is potentially detrimental,” the experts wrote in The Lancet. Doing so could result in inadequate clinical evaluation and care and an increase in “societal marginalisation and discrimination” against older adults, they warn. Identifying ageist beliefs and language. Groundbreaking research published in 2015 by the FrameWorks Institute, an organization that studies social issues, showed that many people associate aging with deterioration, dependency and decline — a stereotype that almost surely contributed to policies that harmed older adults during the viagra.

By contrast, experts understand that older adults vary widely in their abilities and that a significant number are healthy, independent and capable of contributing to society. Using this and subsequent research, the Reframing Aging Initiative, an effort to advance cultural change, has been working to shift how people think and talk about aging, training organizations across the country. Instead of expressing fatalism about aging (“a silver tsunami that will swamp society”), it emphasizes ingenuity, as in “we can solve any problem if we resolve to do so,” said Patricia D’Antonio, project director and vice president of policy and professional affairs at the Gerontological Society of America. Also, the initiative promotes justice as a value, as in “we should treat older adults as equals.” Since it began, the American Medical Association, the American Psychological Association and the Associated Press have adopted bias-free language around aging, and communities in Colorado, New Hampshire, Massachusetts, Connecticut, New York and Texas have signed on as partners. Tackling ageism at the grassroots level.

In Colorado, Changing the Narrative, a strategic awareness campaign, has hosted more than 300 workshops educating the public about ageist language, beliefs and practices in the past three years. Now, it’s launching a campaign calling attention to ageism in health care, including a 15-minute video set to debut in November. €œOur goal is to teach people about the connections between ageism and poor health outcomes and to mobilize both older people and [health] professionals to advocate for better medical care,” said Janine Vanderburg, director of Changing the Narrative. Faced with the viagra’s horrific impact, the Maine Council on Aging earlier this year launched the Power in Aging Project, which is sponsoring a series of community conversations around ageism and asking organizations to take an “anti-ageism pledge.” The goal is to educate people about their own “age bias” — largely unconscious assumptions about aging — and help them understand “how age bias impacts everything around them,” said Maurer. For those interested in assessing their own age bias, a test from Harvard University’s Project Implicit is often recommended.

(Sign in and choose the “age IAT” on the next page.) Changing education for health professionals. Two years ago, Harvard Medical School began integrating education in geriatrics and palliative care throughout its curriculum, recognizing that it hadn’t been doing enough to prepare future physicians to care for seniors. Despite the rapid growth of the older population, only 55% of U.S. Medical schools required education in geriatrics in 2020, according to the latest data from the Association of American Medical Colleges. Dr.

Andrea Schwartz, an assistant professor of medicine, directs Harvard’s effort, which teaches students about everything from the sites where older adults receive care (nursing homes, assisted living, home-based programs, community-based settings) to how to manage common geriatric syndromes such as falls and delirium. Also, students learn how to talk with older patients about what’s most important to them and what they most want from their care. Schwartz also chaired a committee of the academic programs in geriatrics that recently published updated minimum competencies in geriatrics that any medical school graduate should have. Altering professional requirements. Dr.

Sharon Inouye, also a professor of medicine at Harvard, suggests additional approaches that could push better care for older adults forward. When a physician seeks board certification in a specialty or doctors, nurses or pharmacists renew their licenses, they should be required to demonstrate training or competency in “the basics of geriatrics,” she said. And far more clinical trials should include a representative range of older adults to build a better evidence base for their care. Inouye, a geriatrician, was particularly horrified during the viagra when doctors and nurses failed to recognize that seniors with erectile dysfunction treatment were presenting in hospital emergency rooms with “atypical” symptoms such as loss of appetite and delirium. Such “atypical” presentations are common in older adults, but instead of receiving erectile dysfunction treatment tests or treatment, these older adults were sent back to nursing homes or community settings where they helped spread s, she said.

Bringing in geriatrics expertise. If there’s a silver lining to the viagra, it’s that medical professionals and health system leaders observed firsthand the problems that ensued and realized that older adults needed special consideration. €œEverything that we as geriatricians have been trying to tell our colleagues suddenly came into sharp focus,” said Dr. Rosanne Leipzig, a professor of geriatrics at the Icahn School of Medicine at Mount Sinai in New York City. Now, more Mount Sinai surgeons are asking geriatricians to help them manage older surgical patients, and orthopedic specialists are discussing establishing a similar program.

€œI think the value of geriatrics has gone up as institutions see how we care for complicated older adults and how that care improves outcomes,” Leipzig said. Building age-friendly health systems. €œI believe we are at an inflection point,” said Terry Fulmer, president of the John A. Hartford Foundation, which is supporting the development of age-friendly health systems with the American Hospital Association, the Catholic Health Association of the United States and the Institute for Healthcare Improvement. (The John A.

Hartford Foundation is a funder of KHN.) More than 2,500 health systems, hospitals, medical clinics and other health care providers have joined this movement, which sets four priorities (“the 4Ms”) in caring for older adults. Attending to their mobility, medications, mentation (cognition and mental health) and what matters most to them — the foundation for person-centered care. Creating a standardized framework for improving care for seniors has helped health care providers and systems know how to proceed, even amid the enormous uncertainty of the past couple of years. €œWe thought [the viagra] would slow us down, but what we found in most cases was the opposite — people could cling to the 4Ms to have a sense of mastery and accomplishment during a time of such chaos,” Fulmer said. We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system.

Visit khn.org/columnists to submit your requests or tips. Judith Graham. khn.navigatingaging@gmail.com, @judith_graham Related Topics Contact Us Submit a Story TipThe Medicare prescription drug pricing plan Democrats unveiled this week is not nearly as ambitious as many lawmakers sought, but they and drug policy experts say the provisions crack open the door to reforms that could have dramatic effects. Tamping down drug expenses has been a longtime rallying cry for consumers beset by rapidly rising prices. Although people in private plans had some protections, those on Medicare often did not.

They had no out-of-pocket caps and frequently complained that federal law kept them from using drugmakers’ coupons or other cost-cutting strategies. A plan offered earlier this year by House Democrats — which included robust negotiation over drug prices in Medicare — was blocked by a handful of moderates who argued that the price curbs would stifle innovation. The legislation also was on a course to hit roadblocks among senators. The moderates favored more limited negotiation over drugs only in Medicare Part B — those administered in doctors’ offices and hospitals. Most people in Medicare get their drugs through Part D, which covers medicine dispensed at a pharmacy.

When it appeared that the bill to fund President Joe Biden’s social agenda would move forward without a drug pricing proposal, the pressure built, intense negotiations were held, and a hybrid proposal was unveiled. It includes identifying 100 of the most expensive drugs and targeting 10 of them for negotiations to bring those costs down beginning in 2025. It will also place inflation caps on prescription drug prices for all insurance plans, restrict copays for insulin to no more than $35, and limit Medicare beneficiaries’ annual out-of-pocket drug costs to $2,000. “There was a sense that the government had its hands tied behind its back. Now a precedent is being set,” said Senate Finance Committee Chairman Ron Wyden (D-Ore.), who led the talks for the senators.

€œThere’s going to be negotiation on the most expensive drugs. Cancer drugs, arthritis drugs or the anticoagulants. And that’s a precedent, and once you set a precedent that you can actually negotiate, you are really turning an important corner.” Drugmakers say the changes could stymie consumers’ options. €œUnder the guise of ‘negotiation,’ it gives the government the power to dictate how much a medicine is worth,” Stephen Ubl, CEO of the trade group PhRMA, said in a statement, “and leaves many patients facing a future with less access to medicines and fewer new treatments.” But how, exactly, will the changes be felt by most Americans, and who will be helped?. The answers vary, and many details would still have to be worked out by government agencies if the legislation passes.

House members warned some minor changes were still being made Thursday night, and it all has to pass both chambers. Controlling Insulin Costs One of the most obvious benefits will go to those who need insulin, the lifesaving drug for people with Type 1 diabetes and some with Type 2 diabetes. Although the drug has been around for decades, prices have risen rapidly in recent years. Lawmakers have been galvanized by nightmarish accounts of people dying because they couldn’t afford insulin or driving to Canada or Mexico to get it cheaper. Under the bill, starting in 2023, the maximum out-of-pocket cost for a 30-day supply of insulin would be $35.

The benefit would not be limited to Medicare beneficiaries. That cap is the same as one that was set in a five-year model program in Medicare. In it, the Centers for Medicare &. Medicaid Services estimated that the average patient would save about $466 a year. Detailed analyses of the proposals were not yet available, so it is unclear what the fiscal impact or savings would be for patients outside of Medicare.

Limiting Out-of-Pocket Spending Another obvious benefit for Medicare beneficiaries is the $2,000 cap on out-of-pocket costs for prescription drugs. Currently, drug costs for people in the Part D prescription drug plans are calculated with a complicated formula that features the infamous “doughnut hole,” but there is no limit to how much they might spend. That has led to consumers with serious diseases such as cancer or multiple sclerosis paying thousands of dollars to cover their medication, a recent KFF analysis found. Under current law, when an individual beneficiary and her plan spend $4,130 this year on drugs, the beneficiary enters the doughnut hole coverage gap and pays up to 25% of the price of the drug. Once she has spent $6,500 on drugs, she is responsible for 5% of the cost through the end of the year.

Limiting that expense is an especially big deal for people who get little low-income assistance and have expensive illnesses, said Dr. Jing Luo, an assistant professor of medicine at the University of Pittsburgh’s Center for Research on Health Care. €œThe patient pays 5% of all drug costs, and 5% of $160,000 is still a lot of money,” he said. The legislation would alleviate that fear for consumers. €œRather than having a bill at the end of the year, like over $10,000, maybe their bill at the end of that year for that very expensive multiple myeloma treatment is $2,000,” he said.

Negotiating Drug Prices Medicare price negotiation is probably the highest-profile provision in the legislation — and the most controversial. According to the bill, the Department of Health and Human Services would be responsible for identifying the 100 high-cost drugs and choosing the 10 for price negotiations. That effort wouldn’t start until 2023, but the new prices would go into effect in 2025. Another 10 drugs could be added by 2028. No drugs have been identified yet.

To meet the concerns of some lawmakers, the legislation lays out specific provisions for how HHS would select the drugs to be included. Only drugs identified as one of a kind or the only remedy for a specific health problem would be included. The list would also be limited to drugs that have been on the market beyond the period of exclusivity the government grants them to be free from competition and recoup costs. For most regular drugs, the exclusivity can last nine years. For the more complicated biologic drugs, the period would be 13 years.

Using the exclusivity timing allowed lawmakers to skirt the issue of whether the drugs were still under patent protection. The measure allows for prices to be negotiated to a lower level for older drugs chosen for the program. So, for example, the negotiated price for a non-biologic drug that has been available for less than 12 years would be 75% of the average manufacturer price. That would fall to 65% for drugs that are 12 to 16 years past their initial exclusivity, and 40% for drugs more than 16 years past the initial exclusivity. Drugs from smaller companies with sales under $200 million are excluded because lawmakers were afraid tamping down their prices would harm innovation.

Some experts questioned whether the negotiated prices would be directly felt by consumers. “It helps Medicare, without question, to reduce their expenditures,” said William Comanor, a professor of health policy and management at the UCLA Fielding School of Public Health. €œBut how does that affect consumers?. I bet Medicare doesn’t change the copay.” Yet, he added, the copayment is less of an issue if a consumer’s prescription expenses are capped at $2,000. Linking Prices to Inflation Under the bill, manufacturers would have to report their prices to the HHS secretary, and if the prices increase faster than inflation, the drugmakers would have to pay a rebate to the government.

Manufacturers that don’t pay the rebate would face a civil penalty of 125% of the value of the rebate. The provisions would apply to drugs purchased through Medicare and non-Medicare plans. Over the long term, the idea is to slow the overall inflation of drug prices, which has exceeded general inflation for decades. Drug prices would be pegged to what they were in March, and the system would go into effect in 2023, so there would be little immediate impact. (Some lawmakers had hoped to peg the program to prices from several years ago — which might produce a bigger effect — but that was changed in the negotiations over the weekend.) The long-term impact is also hard to judge, because under the current complicated system, many people who pay for drugs get assistance from the drug companies, and most generics in the U.S.

Are relatively inexpensive, Comanor said. Over the long haul, though, savings are expected to be substantial for the government, as well as for consumers who don’t qualify for other programs to help pay drug expenses and need high-end medication. At the very least, the legislation would move the U.S. In the direction of the rest of the world. “The longer the drug is on the market, the lower the price,” said Gerard Anderson, a professor of health policy at Johns Hopkins’ medical school.

€œIn every other country, the price goes down over time, while in the United States, it is common for prices to increase.” Update. This story was updated at 3:15 p.m. ET on Nov. 5, 2021, to reflect new language added to the measure that would changed the exclusivity period for negotiating the price of biologic drugs from 12 to 13 years. Michael McAuliff.

@mmcauliff ‏ Related Topics Contact Us Submit a Story Tip.

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Baker Tilley, one of the world's largest accounting firms, reported that healthcare M&A activity was up 43% in the first half of 2021 versus the first half of 2020. With that increased M&A activity comes larger attack surfaces, along with more risk.For example, a small healthcare organization being acquired might have around 5,000 viagra patent digital assets on average. A very large organization might have 100,000 digital assets or more. Earlier research by CyCognito showed that about 7% of these smaller organization digital assets are viagra patent at risk. That means around 350 at-risk assets are added to the parent's attack surface when a smaller organization is acquired.To find those 350 among a sea of digital assets, the parent organization needs to discover all of the assets, test them and take corrective action.Many times, these entities continue to operate certain functions – such as cybersecurity – autonomously or at an arm's length with respect to the parent organization for some period of time.

When this is the case the smaller hospitals and facilities do the best they can with the resources they have but, generally speaking, have fewer resources and less-well-trained cybersecurity staff than larger organizations do.Scarily, most of these organizations have digital connections into the critical systems, applications and data of the parent health systems.Attackers are clever, opportunistic and resourceful, and viagra patent they understand the dynamics of health systems and other large organizations very well. They know that as the IT ecosystems of these healthcare providers grow, the pieces that are under dotted-line or indirect control of the "headquarters" security team – and pieces that are effectively IT blind spots, such as cloud and SaaS applications provisioned outside of the control or view of IT staff – are the weakest and least protected of the organization.Therefore, bad actors target those small hospitals and entities because they are the paths of least resistance back into the networks, applications and data of the larger health system.Q. How are viagra patent health systems increasing risk and exposure by not paying enough attention to their smaller entities?. A. "Attack surface" blind spots provide the biggest risk viagra patent.

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Attackers look for an opening, and in the case of ransomware, one of the main attack vectors they use is unpatched or otherwise under-secured systems.For example, ransomware attackers often target remote services like remote desktop protocol (RDP) to gain a foothold and extort money from their victims. CyCognito labs research found that the attack surface of a large organization typically harbors between two to 20 or more easily exploited remote access systems. This initial point of entry is called the "initial access" point, and it is critical to identify these as rapidly as possible, because they are so important to the bad guys.Once initial access is gained, attackers often target patient personally identifiable information (PII). These records are worth as much as $250 per record, which is orders of magnitude more valuable than other PII like email credentials, phone numbers or even credit card numbers, because an individual can't easily change their health history.After data is stolen, the attacker can start making money. Most directly, they can sell the information they find.Secondarily, they can ransom the information, usually to the healthcare provider directly for millions of dollars in bitcoin, and in some cases back to the patients themselves (as seen in the Vastaamo mental health breach of 2019).A third path is to use ransomware to encrypt healthcare IT systems and ask for payment to decrypt them.

This is again particularly impactful, because access to up-to-the-minute health information is critical to business and healthcare operations.Q. How can health systems get a handle on the extended attack surface?. A. Best practices dictate that health systems discover all of their exposed digital assets, test them for security risks, and work with asset owners to quickly focus on, and remediate, the most critical risks. Those basic steps need to be performed on a continuous basis to effectively manage cyber risk in an extended attack surface.Our research showed that cyber risks increase with the number of subsidiaries that are part of the organization.

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Smaller hospitals are often how cyberattackers and nation states gain access to health system networks to steal IP, deploy ransomware or scour data to sell check that on the dark web, according to new research from cybersecurity firm CyCognito.The firm's latest research studied health systems with more than $1 billion in revenue and more than 19 hospitals.Healthcare IT News interviewed Rob Gurzeev, CEO and founder of CyCognito, to discuss the results of his firm's latest research, including order viagra online why smaller hospitals are entry points for bad actors, how health systems are increasing risk by not paying their smaller entities enough attention, exactly how threat actors are using these points for entry, and how health systems can get a handle on extended attack surfaces.Q. Your research found that smaller hospitals are often the entry point for bad actors to get in and steal intellectual property, issue ransomware or sell data on the dark web. Why is this? order viagra online.

A. Our research looked at subsidiary organizations such as the order viagra online smaller hospitals, clinics, healthcare service providers and facilities that a larger health system may acquire, or, at times, divest, as they grow. Baker Tilley, one of the world's largest accounting firms, reported that healthcare M&A activity was up 43% in the first half of 2021 versus the first half of 2020.

With that increased M&A activity comes larger attack surfaces, along with more risk.For example, a small healthcare organization being acquired order viagra online might have around 5,000 digital assets on average. A very large organization might have 100,000 digital assets or more. Earlier research by CyCognito showed that about 7% of these smaller organization digital order viagra online assets are at risk.

That means around 350 at-risk assets are added to the parent's attack surface when a smaller organization is acquired.To find those 350 among a sea of digital assets, the parent organization needs to discover all of the assets, test them and take corrective action.Many times, these entities continue to operate certain functions – such as cybersecurity – autonomously or at an arm's length with respect to the parent organization for some period of time. When this is the case the smaller hospitals and facilities do the best they can with the resources they have but, generally speaking, have fewer resources and less-well-trained cybersecurity staff than larger organizations do.Scarily, most of these order viagra online organizations have digital connections into the critical systems, applications and data of the parent health systems.Attackers are clever, opportunistic and resourceful, and they understand the dynamics of health systems and other large organizations very well. They know that as the IT ecosystems of these healthcare providers grow, the pieces that are under dotted-line or indirect control of the "headquarters" security team – and pieces that are effectively IT blind spots, such as cloud and SaaS applications provisioned outside of the control or view of IT staff – are the weakest and least protected of the organization.Therefore, bad actors target those small hospitals and entities because they are the paths of least resistance back into the networks, applications and data of the larger health system.Q.

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These blind spots frequently include the digital surfaces associated with smaller hospitals, connected partners, cloud providers and other related entities.These are the exact places where organizations get breached. Research firm ESG found that 67% of organizations have been attacked via an unknown or unmanaged order viagra online asset, and 75% expect it to happen again.Q. How are threat actors using these points for entry?.

A. With ransomware and supply chain attacks becoming more prevalent over the last 18 months, the way attackers operate in this context has become clearer. Attackers look for an opening, and in the case of ransomware, one of the main attack vectors they use is unpatched or otherwise under-secured systems.For example, ransomware attackers often target remote services like remote desktop protocol (RDP) to gain a foothold and extort money from their victims.

CyCognito labs research found that the attack surface of a large organization typically harbors between two to 20 or more easily exploited remote access systems. This initial point of entry is called the "initial access" point, and it is critical to identify these as rapidly as possible, because they are so important to the bad guys.Once initial access is gained, attackers often target patient personally identifiable information (PII). These records are worth as much as $250 per record, which is orders of magnitude more valuable than other PII like email credentials, phone numbers or even credit card numbers, because an individual can't easily change their health history.After data is stolen, the attacker can start making money.

Most directly, they can sell the information they find.Secondarily, they can ransom the information, usually to the healthcare provider directly for millions of dollars in bitcoin, and in some cases back to the patients themselves (as seen in the Vastaamo mental health breach of 2019).A third path is to use ransomware to encrypt healthcare IT systems and ask for payment to decrypt them. This is again particularly impactful, because access to up-to-the-minute health information is critical to business and healthcare operations.Q. How can health systems get a handle on the extended attack surface?.

A. Best practices dictate that health systems discover all of their exposed digital assets, test them for security risks, and work with asset owners to quickly focus on, and remediate, the most critical risks. Those basic steps need to be performed on a continuous basis to effectively manage cyber risk in an extended attack surface.Our research showed that cyber risks increase with the number of subsidiaries that are part of the organization.

Therefore, including digital assets that are part of the attack surface of smaller hospitals and other owned providers is a critical part of that process.The research also found that to make the attack surface management process as operationally efficient as possible, respondents favored dedicated attack surface management solutions over a variety of other solutions they had tried, viewing them as the most effective solution category for managing subsidiary risk.​Twitter. @SiwickiHealthITEmail the writer. Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication..

What may interact with Viagra?

Do not take Viagra with any of the following:

  • cisapride
  • methscopolamine nitrate
  • nitrates like amyl nitrite, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin
  • nitroprusside
  • other sildenafil products (Revatio)

Viagra may also interact with the following:

  • certain drugs for high blood pressure
  • certain drugs for the treatment of HIV or AIDS
  • certain drugs used for fungal or yeast s, like fluconazole, itraconazole, ketoconazole, and voriconazole
  • cimetidine
  • erythromycin
  • rifampin

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

Viagra risks

Latest Depression viagra risks News THURSDAY, Nov. 12, 2020 (HealthDay News)Women who struggle with mental health problems will sometimes forgo the most effective forms of birth control because of concerns about worsening those issues, but viagra risks a new study delivers a reassuring finding. The pill and other forms of hormonal birth control do not raise depression risk."This is a very common concern," explained senior study author Dr. Jessica Kiley, chief of general obstetrics and gynecology at Northwestern University Feinberg School of Medicine, viagra risks in Chicago."For some patients with anxiety disorders, when you discuss a contraceptive's potential side effect, they get very worried.

We're hoping to encourage women to focus on their contraceptive needs and learn about options that are unlikely to cause viagra risks depression," Kiley said.The hormonal contraceptives the study authors discussed include birth control pills, IUDs (intrauterine devices) and vaginal rings.The study, which was published online Nov. 10 in the American Journal of Psychiatry, is a comprehensive review of published research of birth control methods for women with psychiatric disorders.According to corresponding author Dr. Katherine Wisner, professor of psychiatry and viagra risks behavioral sciences and obstetrics &. Gynecology at Northwestern, "When you review the entirety of the literature viagra risks and ask, 'Do hormonal contraceptives cause depression?.

,' the answer is definitely no." Wisner is also director of the Asher Center for the Study and Treatment of Depressive Disorders.Clinical studies and trials of women with psychiatric disorders have found similar rates of mood symptoms in women regardless of whether they were using hormonal contraceptives or not. In some cases, the contraceptives may even stabilize the mood symptoms of women with psychiatric disorders, the study authors said.And the physical and mental stress of an unintended pregnancy could trigger a new and recurrent bout of depression, including postpartum depression, Wisner added.The review authors hope the findings viagra risks will lead to more collaboration between gynecologists and psychiatrists, who can work together to help their mutual patients. Psychiatrists don't typically receive enough training on contraceptives to properly counsel viagra risks women on their birth control choices, according to the report. And women also should be screened for depression at routine gynecological appointments, Wisner said."Women should know they always have access to many types of birth control, regardless of their history or likelihood of mental illness," Wisner said.

"They shouldn't feel like they're out there flailing viagra risks on how to not get pregnant."It is important to get a baseline sense of a woman's mental health before contraceptive use, so her psychiatrist can monitor her symptoms after starting it, Wisner added. This is especially critical for women with bipolar disorder, who have mood fluctuations around their menstrual cycle, she explained in a university news release.Although interactions between viagra risks psychiatric drugs and contraceptives are infrequent, doctors do need to be aware of important exceptions, Wisner said.Those exceptions include the antipsychotic clozapine and the bipolar/seizure drug carbamazepine, which can sometimes interfere with certain contraceptives, Wisner said. Natural compounds such as St. John's Wort viagra risks may also decrease the effectiveness of hormonal contraceptives.

SLIDESHOW Sex-Drive viagra risks Killers. The Causes of Low Libido See SlideshowLatest Cancer News By Amy Norton HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Lung cancer patients who harbor certain bacteria in the airways may have a poorer prognosis, a new study finds, adding to viagra risks evidence that the body's "microbiome" may play a role in cancer patients' outlook.The microbiome refers to the trillions of bacteria and other microbes that naturally dwell in the body. Research in recent years has been revealing how important those bugs are to the body's normal functions, including immune system defenses.When it comes to cancer, studies have hinted that the microbiome can influence viagra risks tumor progression, and patients' likelihood of responding to certain treatments.For example, a number of cancers can be treated with immunotherapy -- various approaches to boosting the immune system's natural tumor-fighting capacity.

Research has found that patients who respond well to immunotherapies tend to have a different makeup in the gut microbiome, compared to patients who do not respond.The new study, published Nov. 11 in Cancer Discovery, took a viagra risks different view. Instead of focusing on the gut microbiome, researchers analyzed lung microbes of patients with newly viagra risks diagnosed lung cancer.In microbiome research, "the lung has really been ignored," said lead researcher Dr. Leopoldo Segal, director of the Lung Microbiome Program and an associate professor at New York University Grossman School of Medicine in New York City.Traditionally, he explained, the lungs were believed to be "sterile." But recent research has shown that even in healthy people, the lungs can harbor low amounts of bacteria -- drawn in from the air or the mouth.Segal's team wanted to see whether lung bacteria corresponded to lung cancer patients' prognosis.Looking at tissue samples from 83 patients, the researchers found that those with advanced-stage cancer carried more microbes than patients in the early stage of disease.And when patients did have "enrichment" with certain bacteria types, their odds of survival were lower -- even those with earlier-stage cancer.Specifically, patients harboring Veillonella, Prevotella and Streptococcus bacteria had a worse prognosis.

They also showed signs of an inflammatory immune response that, viagra risks based on past research, may worsen lung cancer patients' outlook.None of that proves the bacteria, themselves, were to blame, Segal said. The cancer itself might make the lungs more "receptive" to being colonized with bacteria.So the researchers viagra risks turned to lab mice. They transferred Veillonella bacteria into mice with lung cancer and found that the microbes revved up "bad" inflammation, fed tumor growth and shortened the animals' survival.That suggests lung bacteria might modulate the immune response in a way that affects lung cancer progression, according to Segal.But the microbiome is complicated, and it's hard to draw conclusions from mouse findings, according to Dr. Thomas Marron of Mount Sinai's Tisch Cancer Institute in New York City.Right now, he said, there is a "huge interest" in understanding the microbiome's influence in cancer."Studies like this are really interesting," said Marron, who was viagra risks not involved with the research, "but we're probably a few decades away from being able to alter the microbiome to treat cancer."Individuals vary in their microbiome makeup, and that's determined by things like genetics and the immune system, Marron explained.

So even if the body's microbial communities directly affect cancer prognosis, he said, it will be a long time before researchers can turn that into therapy."We still don't know how we could effectively target the microbiome," Marron viagra risks said.He pointed to one question from the new findings. Is there any link between the lung microbiome and patients' likelihood of responding to immunotherapy?. Segal said his viagra risks team plans to study that.Dr. John Heymach viagra risks chairs thoracic/head and neck medical oncology at M.D.

Anderson Cancer Center in Houston. He called the findings "a compelling viagra risks starting point," but also emphasized the long research road ahead."At this point, we're not ready to directly act on this in the clinic, by either trying to kill 'bad' bacteria, or add back 'good' bacteria," said Heymach, who was not part of the study.So far, he noted, studies have reached different conclusions as to exactly which types of bacteria are related to better cancer outcomes -- which might be due to differences in how studies look for the microbes.And like Marron, Heymach pointed to the microbiome's complexity. It generally viagra risks differs from one large population to the next and among individuals -- based on numerous factors. QUESTION Lung cancer is a disease in which lung cells grow abnormally in an uncontrolled way.

See Answer Still, Heymach said the recent "explosion" in microbiome research could eventually lead to viagra risks applications in cancer treatment. Besides the possibility of altering the microbiome, he said doctors might be able to use patients' microbiome makeup as a "biomarker" viagra risks of their risk of progression.More informationThe American Cancer Society has more on cancer immunotherapy.SOURCES. Leopoldo Segal, M.D., M.S., director, Lung Microbiome Program, and associate professor, medicine, New York University Grossman School of Medicine, New York City. John Heymach, M.D., Ph.D., chair, thoracic/head and viagra risks neck medical oncology, University of Texas M.D.

Anderson Cancer viagra risks Center, Houston. Thomas Marron, M.D., Ph.D., assistant director, Early Phase and Immunotherapy Trials, Tisch Cancer Institute at Mount Sinai, New York City. Cancer Discovery, online, Nov viagra risks. 11, 2020Copyright © 2020 HealthDay viagra risks.

All rights reserved. From Cancer Resources Featured Centers Health Solutions From Our SponsorsLatest viagra risks Men's Health News By Steven Reinberg HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Young men who consider using the drug Propecia to prevent baldness may be putting themselves at risk for depression and suicide, a new study suggests.Information from the World Health Organization indicates that over the past 10 years, reports viagra risks of suicidal ideation among young men using the drug have increased, rising significantly after 2012, the researchers said."There are many possible explanations for our findings," said senior researcher Dr. Quoc-Dien Trinh, from the division of urologic surgery at Brigham and Women's Hospital, in Boston.Either there is some sort of biological explanation linking Propecia (finasteride) to suicidality and psychological adverse events, or media attention, which heightened awareness and may have increased reporting of adverse events, may have played a role, he said."Patients should be made aware of this potential side effect and speak to their prescribing doctor if they have concerns," Trinh said.Finasteride was developed to shrink enlarged prostates, a condition called benign prostatic hyperplasia.

Its use was later extended to treat male-pattern baldness.Trinh's team used data from VigiBase, which gathers information from 153 countries on all adverse drug reactions and contains more than 20 million safety reports.The researchers found 356 reports of suicidality and nearly 3,000 reports of other psychological problems among people taking finasteride.Most of these reports for suicidal ideation, depression and anxiety were among men taking finasteride for hair loss who were 45 and younger.These findings were not seen in older patients taking the viagra risks drug for enlarged prostate glands.According to Dr. Michael Irwig, from the division of endocrinology at Beth Israel Deaconess Medical Center, in Boston, "The difference between finasteride in younger men versus older men is likely related to the severe toll this medication can take on younger men who develop persistent sexual side effects."A dramatic loss in sexual function in a younger man can lead to significant dating and relationship difficulties, which is less likely to be an issue in older men who may already have sexual dysfunction due to aging and who are already in a stable relationship, he noted."Sexual dysfunction in younger men can result in depression and, in a subset of these men, suicidal ideation," Irwig said.Trinh said that these findings should not be over-interpreted to say that finasteride causes suicides, only that there seems to be an association.He thinks, however, that many more young men taking finasteride contemplate suicide than reported to VigiBase.Abdulmaged Traish, a professor emeritus of urology at Boston University School of Medicine, believes that finasteride has a biological effect that disrupts the central nervous system in some young patients, which can have psychological effects like viagra risks depression and suicide.The drug can help some people, he said. "But it comes with a high price, especially for a nonthreatening disorder like alopecia [hair loss]," he noted. "It's not a disease that kills people."If a man wants to try finasteride for hair loss, he should at least be told of the risks, Traish said."Physicians should have a frank, viagra risks open discussion with the patient about the potential adverse side effects of the drug," he said.

"If the patient still wants to take it, it's OK, but at least viagra risks tell him, honestly, this is what we know."Traish also thinks that the U.S. Food and Drug Administration should have a "boxed warning" that the drug may cause suicide ideation in some young men. No such warning is on the package insert now.The report was viagra risks published online Nov. 11 in viagra risks JAMA Dermatology.More information QUESTION It is normal to lose 100-150 hairs per day.

See Answer For more on depression in men, head to the National Institute of Mental Health.SOURCES. Quoc-Dien Trinh, MD, division of urologic surgery, Brigham and Women's Hospital, viagra risks Boston. Abdulmaged Traish, Ph.D., professor emeritus, urology, Boston University School of Medicine. Michael Irwig, MD, viagra risks division of endocrinology, Beth Israel Deaconess Medical Center, Boston.

JAMA Dermatology, viagra risks Nov. 11, 2020, onlineCopyright © 2020 HealthDay. All rights viagra risks reserved. From Healthy Resources Featured viagra risks Centers Health Solutions From Our SponsorsLatest Depression News FRIDAY, Nov.

13, 2020The antidepressant drug fluvoxamine -- best known by the brand name Luvox -- may help prevent serious illness in erectile dysfunction treatment patients who aren't yet hospitalized, a new study finds.The study included 152 patients infected with mild-to-moderate erectile dysfunction treatment. Of those, 80 took fluvoxamine and 72 took a placebo for 15 days.By the end of that time, none of the patients who took the drug had seen their progress to serious illness, compared with six (8.3%) of the patients who took the viagra risks placebo, according to researchers at Washington University School of Medicine in St. Louis."The patients viagra risks who took fluvoxamine did not develop serious breathing difficulties or require hospitalization for problems with lung function," said first author Dr. Eric Lenze, professor of psychiatry."Most investigational treatments for erectile dysfunction treatment have been aimed at the very sickest patients, but it's also important to find therapies that prevent patients from getting sick enough to require supplemental oxygen or to have to go to the hospital.

Our study suggests fluvoxamine may help fill that niche," Lenze noted in a university news release.Fluvoxamine -- widely used to treat depression, obsessive-compulsive disorder and social anxiety disorder -- is a viagra risks type of drug called a selective serotonin-reuptake inhibitor (SSRI). This class of drugs also includes viagra risks medicines such as Prozac, Zoloft and Celexa.But unlike other SSRIs, fluvoxamine has a strong interaction with a protein called the sigma-1 receptor, which helps regulate the body's inflammatory response."There are several ways this drug might work to help erectile dysfunction treatment patients, but we think it most likely may be interacting with the sigma-1 receptor to reduce the production of inflammatory molecules," explained study senior author Dr. Angela Reiersen, associate professor of psychiatry."Past research has demonstrated that fluvoxamine can reduce inflammation in animal models of sepsis, and it may be doing something similar in our patients," she said in the release.By reducing inflammation, fluvoxamine may prevent a hyperactive immune response in erectile dysfunction treatment patients. That, in turn, may decrease their risk of serious illness and death, Reiersen said."Our goal is to help patients who are initially well enough to be at home and to prevent them from getting sick enough to be viagra risks hospitalized," Dr.

Caline Mattar, assistant professor of medicine in the Division viagra risks of Infectious Diseases, said in the release. "What we've seen so far suggests that fluvoxamine may be an important tool in achieving that goal."Dr. Amesh Adalja is a senior scholar at the Johns viagra risks Hopkins Center for Health Security in Baltimore. He wasn't involved in the study, but said the research is "notable not only because of its positive outcome -- we desperately need a medication that keeps erectile dysfunction treatment patients out of the hospital -- but also because of the manner in which it was conducted."But Adalja stressed that a larger trial is needed "to see if the promising findings hold up."The researchers said they plan to begin such viagra risks a study in the next few weeks and it will include patients from across the United States.The preliminary study was published online Nov.

12 in the Journal of the American Medical Association.More informationFor more on erectile dysfunction treatment, go to the U.S. Centers for Disease Control and viagra risks Prevention.SOURCES. Amesh Adalja, M.D., senior scholar, Johns Hopkins Center viagra risks for Health Security, Baltimore. Washington University in St.

Louis, news release, Nov viagra risks. 12, 2020Ernie MundellCopyright © 2020 HealthDay viagra risks. All rights reserved. SLIDESHOW Learn viagra risks to Spot Depression.

Symptoms, Warning Signs, viagra risks Medication See SlideshowLatest erectile dysfunction News By Dennis Thompson HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Early erectile dysfunction treatment trial results announced by Pfizer this week caused hopes to soar for a swift end to the viagra that has killed more than 242,000 and infected more than 10 million in the United States alone.But even if the preliminary results released Monday pan out, it will still take many months to produce enough of the treatment to inoculate everyone in the United States, experts warn.The health care industry will also face special distribution challenges related to this particular treatment, which must be maintained in extremely cold storage and delivered in a two-shot regimen."People should be enthusiastic, but realize that the benefits that we get from that treatment are not going to be in the winter, they're not going to be now, in the short range. They're going to be viagra risks going forward, likely in the spring to summer of 2021," said Dr. Amesh Adalja, a senior scholar with the Johns viagra risks Hopkins Center for Health Security, in Baltimore."It shouldn't change your approach to the viagra today, tomorrow, next week, next month," he added.

"We are entering a period of the year where we're seeing intensification of spread all over the country. We need to be very viagra risks vigilant. The cases are viagra risks getting to the point where they are inundating hospitals in some states. The trajectory of the viagra right now looks very bad for the winter."Adalja's words echo those of President-elect Joe Biden, who lauded news of Pfizer's treatment success but asked Americans to stay vigilant."America is still losing over 1,000 people a day from erectile dysfunction treatment, and that number is rising -- and will continue to get worse unless we make progress on masking and other immediate actions," Biden said on Monday.

"That is the viagra risks reality for now, and for the next few months. Today's announcement promises the chance to change that next year, but the tasks before viagra risks us now remain the same."'No serious safety concerns'The early information from Pfizer -- more than 90% effective -- is extremely encouraging, said Dr. Thad Stappenbeck, head of the Lerner Research Institute at the Cleveland Clinic, in Ohio."It means if you get the treatment, based on their early statistics you have a 90% chance if you encounter the viagra of not being infected, which is remarkable," Stappenbeck said. Pfizer had set a goal of 50% effectiveness for its treatment -- the average effectiveness of the annual flu shot.Of more than 43,500 people who got either the treatment or a placebo, there have been 94 confirmed cases of erectile dysfunction treatment, Pfizer said in its early analysis."Nearly all of the new viagra risks s were in the placebo group," Stappenbeck said.Pfizer needs to spend a few more weeks collecting safety data before it can apply for an emergency use authorization from the U.S.

Food and Drug Administration, but Stappenbeck expressed confidence that the treatment would prove safe."They've now gone from just a few dozen people or a few hundred people now to tens of thousands of people, and no serious safety concerns," he said.Pfizer aims to produce up to 50 million doses of the treatment by year's end -- enough to inoculate 25 million people -- and up to 1.3 billion doses in 2021.Pfizer is making the treatment at facilities in Kalamazoo, Mich., and Puurs, Belgium, viagra risks according to The New York Times. Doses distributed in the United States will mostly come from Kalamazoo.The U.S. Government has placed an initial order for 100 million doses of the treatment, at a cost of $1.95 billion, with an option to buy another 500 million doses, Politico reports."There's a goal of viagra risks 660 million doses, so there's two doses for everyone in the United States that wants one," said Anna Legreid Dopp, senior director of clinical guidelines and quality improvement with the American Society of Health-System Pharmacists (ASHP), in Bethesda, Md.Who's first in line?. The early doses likely will be given to health care workers and first responders, Dopp said, followed by people at high risk for severe erectile dysfunction treatment s.But distributing the doses across the country is viagra risks expected to be a challenge in and of itself.The treatment has to be stored at around minus 94 degrees Fahrenheit, which is about as cold as it gets at the South Pole on a winter's day.

The shot can withstand normal refrigeration only for about 24 hours, and room temperature for no more than two hours after thawing, Politico reports.Creating a "cold chain" of distribution that will keep the treatment frozen until it's time for a person's shot "absolutely is going to be an added burden," Adalja said."This doesn't just need to be kept at ordinary refrigerator temperatures. It needs to be kept at minus viagra risks 70, minus 80 Centigrade, which is not something that most places have the ability to do no matter where you are in the United States, let alone the developing world," Adalja said.These sorts of freezers are common at academic centers, and might even be found at community hospitals, Stappenbeck said. "These are not viagra risks super expensive. They're $5,000 or $6,000," he added.Major shipping companies United Parcel Service (UPS) and FedEx are scrambling to build freezer farms in major hub cities across the nation, according to The New York Times.

Airplanes and trucks also will need to be fitted with freezers.Dopp said other innovations are in the works, such as "thermal suitcases that allow some flexibility if you don't have access to a freezer."Two-dose regimenThe other viagra risks distribution problem that must be solved is timing. People need to get the treatment in two doses, separated by about a month, Dopp said.Hospitals, doctors and pharmacies will need to set up computer systems to track patients and make sure they get their second dose in a timely fashion, Dopp said. Otherwise, they won't get full protection from the treatment, and perhaps none at all.One other concern, 10 other erectile dysfunction treatment candidates are in the final stages of testing, Dopp noted. As they get approved, doctors will need to track which patients have received which treatment."A patient can't get one treatment for their first dose and a different treatment from a different manufacturer for their second dose," she said.ASHP was concerned that as hospitals begin handing out the first shots, they would need to keep at least half their initial allotments in reserve so people could get their second shot on time."The answer we received from the U.S.

Centers for Disease Control and Prevention is that they do not, that they will work to provide just-in-time second doses, which I think is encouraging because it does allow for more people to start on their series," Dopp said.More informationLearn more about Pfizer's treatment.SOURCES. Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore. Thad Stappenbeck, MD, PhD, chair, Lerner Research Institute, Cleveland Clinic, Ohio. Anna Legreid Dopp, PharmD, senior director, clinical guidelines and quality improvement, American Society of Health-System Pharmacists, Bethesda, Md..

The New York Times. PoliticoCopyright © 2020 HealthDay. All rights reserved..

Latest Depression News order viagra online THURSDAY, viagra online canada Nov. 12, 2020 (HealthDay News)Women who order viagra online struggle with mental health problems will sometimes forgo the most effective forms of birth control because of concerns about worsening those issues, but a new study delivers a reassuring finding. The pill and other forms of hormonal birth control do not raise depression risk."This is a very common concern," explained senior study author Dr.

Jessica Kiley, chief of general obstetrics and gynecology at Northwestern University Feinberg School of Medicine, in Chicago."For some patients with anxiety disorders, when you discuss a contraceptive's potential side effect, they order viagra online get very worried. We're hoping order viagra online to encourage women to focus on their contraceptive needs and learn about options that are unlikely to cause depression," Kiley said.The hormonal contraceptives the study authors discussed include birth control pills, IUDs (intrauterine devices) and vaginal rings.The study, which was published online Nov. 10 in the American Journal of Psychiatry, is a comprehensive review of published research of birth control methods for women with psychiatric disorders.According to corresponding author Dr.

Katherine Wisner, professor of psychiatry and behavioral order viagra online sciences and obstetrics &. Gynecology at Northwestern, "When you review the entirety of the order viagra online literature and ask, 'Do hormonal contraceptives cause depression?. ,' the answer is definitely no." Wisner is also director of the Asher Center for the Study and Treatment of Depressive Disorders.Clinical studies and trials of women with psychiatric disorders have found similar rates of mood symptoms in women regardless of whether they were using hormonal contraceptives or not.

In some cases, the contraceptives may even stabilize the mood symptoms of women with psychiatric disorders, the study authors said.And the physical and mental order viagra online stress of an unintended pregnancy could trigger a new and recurrent bout of depression, including postpartum depression, Wisner added.The review authors hope the findings will lead to more collaboration between gynecologists and psychiatrists, who can work together to help their mutual patients. Psychiatrists don't typically receive enough order viagra online training on contraceptives to properly counsel women on their birth control choices, according to the report. And women also should be screened for depression at routine gynecological appointments, Wisner said."Women should know they always have access to many types of birth control, regardless of their history or likelihood of mental illness," Wisner said.

"They shouldn't feel like they're out there flailing on how to not get pregnant."It is important to get a baseline sense of a woman's mental health before order viagra online contraceptive use, so her psychiatrist can monitor her symptoms after starting it, Wisner added. This is especially critical for women with bipolar disorder, who have mood fluctuations around their menstrual cycle, she explained in a order viagra online university news release.Although interactions between psychiatric drugs and contraceptives are infrequent, doctors do need to be aware of important exceptions, Wisner said.Those exceptions include the antipsychotic clozapine and the bipolar/seizure drug carbamazepine, which can sometimes interfere with certain contraceptives, Wisner said. Natural compounds such as St.

John's Wort may also decrease the effectiveness of order viagra online hormonal contraceptives. SLIDESHOW Sex-Drive Killers order viagra online. The Causes of Low Libido See SlideshowLatest Cancer News By Amy Norton HealthDay ReporterTHURSDAY, Nov.

12, 2020 (HealthDay News)Lung cancer patients who harbor certain bacteria in the airways may have a poorer prognosis, a new study finds, adding to order viagra online evidence that the body's "microbiome" may play a role in cancer patients' outlook.The microbiome refers to the trillions of bacteria and other microbes that naturally dwell in the body. Research in recent years has been revealing how important those bugs are to the body's normal functions, including immune system defenses.When it comes to cancer, studies have hinted that the microbiome can influence tumor progression, and patients' order viagra online likelihood of responding to certain treatments.For example, a number of cancers can be treated with immunotherapy -- various approaches to boosting the immune system's natural tumor-fighting capacity. Research has found that patients who respond well to immunotherapies tend to have a different makeup in the gut microbiome, compared to patients who do not respond.The new study, published Nov.

11 in Cancer Discovery, order viagra online took a different view. Instead of focusing on the gut microbiome, researchers analyzed lung microbes of patients with order viagra online newly diagnosed lung cancer.In microbiome research, "the lung has really been ignored," said lead researcher Dr. Leopoldo Segal, director of the Lung Microbiome Program and an associate professor at New York University Grossman School of Medicine in New York City.Traditionally, he explained, the lungs were believed to be "sterile." But recent research has shown that even in healthy people, the lungs can harbor low amounts of bacteria -- drawn in from the air or the mouth.Segal's team wanted to see whether lung bacteria corresponded to lung cancer patients' prognosis.Looking at tissue samples from 83 patients, the researchers found that those with advanced-stage cancer carried more microbes than patients in the early stage of disease.And when patients did have "enrichment" with certain bacteria types, their odds of survival were lower -- even those with earlier-stage cancer.Specifically, patients harboring Veillonella, Prevotella and Streptococcus bacteria had a worse prognosis.

They also showed signs of an order viagra online inflammatory immune response that, based on past research, may worsen lung cancer patients' outlook.None of that proves the bacteria, themselves, were to blame, Segal said. The cancer itself might make the lungs more "receptive" order viagra online to being colonized with bacteria.So the researchers turned to lab mice. They transferred Veillonella bacteria into mice with lung cancer and found that the microbes revved up "bad" inflammation, fed tumor growth and shortened the animals' survival.That suggests lung bacteria might modulate the immune response in a way that affects lung cancer progression, according to Segal.But the microbiome is complicated, and it's hard to draw conclusions from mouse findings, according to Dr.

Thomas Marron order viagra online of Mount Sinai's Tisch Cancer Institute in New York City.Right now, he said, there is a "huge interest" in understanding the microbiome's influence in cancer."Studies like this are really interesting," said Marron, who was not involved with the research, "but we're probably a few decades away from being able to alter the microbiome to treat cancer."Individuals vary in their microbiome makeup, and that's determined by things like genetics and the immune system, Marron explained. So even order viagra online if the body's microbial communities directly affect cancer prognosis, he said, it will be a long time before researchers can turn that into therapy."We still don't know how we could effectively target the microbiome," Marron said.He pointed to one question from the new findings. Is there any link between the lung microbiome and patients' likelihood of responding to immunotherapy?.

Segal said his team order viagra online plans to study that.Dr. John Heymach chairs thoracic/head and neck order viagra online medical oncology at M.D. Anderson Cancer Center in Houston.

He called the findings "a compelling starting point," but also emphasized the long research road ahead."At this point, we're not ready to directly act on this in the clinic, by either trying to kill 'bad' bacteria, or add back 'good' bacteria," said Heymach, who was not part of the study.So far, he noted, studies have reached different conclusions as to exactly which types of bacteria are related to better cancer outcomes -- which might be due to differences in how studies look for the microbes.And like Marron, order viagra online Heymach pointed to the microbiome's complexity. It generally differs from one large population to the next and among order viagra online individuals -- based on numerous factors. QUESTION Lung cancer is a disease in which lung cells grow abnormally in an uncontrolled way.

See Answer Still, Heymach said the recent "explosion" in microbiome research could eventually lead to applications in cancer order viagra online treatment. Besides the possibility of altering the microbiome, he said doctors might be able to use patients' microbiome makeup as a "biomarker" of order viagra online their risk of progression.More informationThe American Cancer Society has more on cancer immunotherapy.SOURCES. Leopoldo Segal, M.D., M.S., director, Lung Microbiome Program, and associate professor, medicine, New York University Grossman School of Medicine, New York City.

John Heymach, M.D., Ph.D., chair, thoracic/head and neck medical oncology, University order viagra online of Texas M.D. Anderson Cancer order viagra online Center, Houston. Thomas Marron, M.D., Ph.D., assistant director, Early Phase and Immunotherapy Trials, Tisch Cancer Institute at Mount Sinai, New York City.

Cancer Discovery, order viagra online online, Nov. 11, 2020Copyright © 2020 order viagra online HealthDay. All rights reserved.

From Cancer Resources Featured Centers Health Solutions From Our SponsorsLatest Men's Health News order viagra online By Steven Reinberg HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Young men who consider using the drug Propecia to prevent baldness may be putting themselves at risk for depression and suicide, a new study suggests.Information from the World Health Organization indicates that over the past 10 years, reports of suicidal ideation among young men using the drug have increased, rising significantly after 2012, the researchers order viagra online said."There are many possible explanations for our findings," said senior researcher Dr. Quoc-Dien Trinh, from the division of urologic surgery at Brigham and Women's Hospital, in Boston.Either there is some sort of biological explanation linking Propecia (finasteride) to suicidality and psychological adverse events, or media attention, which heightened awareness and may have increased reporting of adverse events, may have played a role, he said."Patients should be made aware of this potential side effect and speak to their prescribing doctor if they have concerns," Trinh said.Finasteride was developed to shrink enlarged prostates, a condition called benign prostatic hyperplasia.

Its use was later extended to treat male-pattern baldness.Trinh's team used data from VigiBase, which gathers information from 153 countries on all adverse drug reactions and contains more than 20 million safety reports.The researchers found 356 reports of suicidality and nearly 3,000 reports of order viagra online other psychological problems among people taking finasteride.Most of these reports for suicidal ideation, depression and anxiety were among men taking finasteride for hair loss who were 45 and younger.These findings were not seen in older patients taking the drug for enlarged prostate glands.According to Dr. Michael Irwig, from the division of endocrinology at Beth Israel Deaconess Medical Center, in Boston, order viagra online "The difference between finasteride in younger men versus older men is likely related to the severe toll this medication can take on younger men who develop persistent sexual side effects."A dramatic loss in sexual function in a younger man can lead to significant dating and relationship difficulties, which is less likely to be an issue in older men who may already have sexual dysfunction due to aging and who are already in a stable relationship, he noted."Sexual dysfunction in younger men can result in depression and, in a subset of these men, suicidal ideation," Irwig said.Trinh said that these findings should not be over-interpreted to say that finasteride causes suicides, only that there seems to be an association.He thinks, however, that many more young men taking finasteride contemplate suicide than reported to VigiBase.Abdulmaged Traish, a professor emeritus of urology at Boston University School of Medicine, believes that finasteride has a biological effect that disrupts the central nervous system in some young patients, which can have psychological effects like depression and suicide.The drug can help some people, he said. "But it comes with a high price, especially for a nonthreatening disorder like alopecia [hair loss]," he noted.

"It's not a disease that kills people."If a man wants to try finasteride for hair loss, he should at least be told of the risks, Traish said."Physicians should have a frank, open discussion with order viagra online the patient about the potential adverse side effects of the drug," he said. "If the patient still wants to take it, it's OK, but at least tell him, honestly, this is what we know."Traish also thinks that the order viagra online U.S. Food and Drug Administration should have a "boxed warning" that the drug may cause suicide ideation in some young men.

No such warning is on the package insert now.The report was published order viagra online online Nov. 11 in order viagra online JAMA Dermatology.More information QUESTION It is normal to lose 100-150 hairs per day. See Answer For more on depression in men, head to the National Institute of Mental Health.SOURCES.

Quoc-Dien Trinh, order viagra online MD, division of urologic surgery, Brigham and Women's Hospital, Boston. Abdulmaged Traish, Ph.D., professor emeritus, urology, Boston University School of Medicine. Michael Irwig, MD, order viagra online division of endocrinology, Beth Israel Deaconess Medical Center, Boston.

JAMA Dermatology, Nov order viagra online. 11, 2020, onlineCopyright © 2020 HealthDay. All rights order viagra online reserved.

From Healthy Resources Featured Centers Health Solutions From order viagra online Our SponsorsLatest Depression News FRIDAY, Nov. 13, 2020The antidepressant drug fluvoxamine -- best known by the brand name Luvox -- may help prevent serious illness in erectile dysfunction treatment patients who aren't yet hospitalized, a new study finds.The study included 152 patients infected with mild-to-moderate erectile dysfunction treatment. Of those, 80 took fluvoxamine and 72 took a placebo for 15 days.By the end of that time, none of the order viagra online patients who took the drug had seen their progress to serious illness, compared with six (8.3%) of the patients who took the placebo, according to researchers at Washington University School of Medicine in St.

Louis."The patients order viagra online who took fluvoxamine did not develop serious breathing difficulties or require hospitalization for problems with lung function," said first author Dr. Eric Lenze, professor of psychiatry."Most investigational treatments for erectile dysfunction treatment have been aimed at the very sickest patients, but it's also important to find therapies that prevent patients from getting sick enough to require supplemental oxygen or to have to go to the hospital. Our study suggests fluvoxamine order viagra online may help fill that niche," Lenze noted in a university news release.Fluvoxamine -- widely used to treat depression, obsessive-compulsive disorder and social anxiety disorder -- is a type of drug called a selective serotonin-reuptake inhibitor (SSRI).

This class of drugs also includes medicines such as Prozac, Zoloft and Celexa.But unlike other SSRIs, fluvoxamine has a strong interaction with a protein called the sigma-1 receptor, which helps regulate the body's inflammatory response."There are several ways this drug might work to help erectile dysfunction treatment patients, but we think it most likely may be interacting with the sigma-1 receptor order viagra online to reduce the production of inflammatory molecules," explained study senior author Dr. Angela Reiersen, associate professor of psychiatry."Past research has demonstrated that fluvoxamine can reduce inflammation in animal models of sepsis, and it may be doing something similar in our patients," she said in the release.By reducing inflammation, fluvoxamine may prevent a hyperactive immune response in erectile dysfunction treatment patients. That, in turn, may decrease their risk of serious illness order viagra online and death, Reiersen said."Our goal is to help patients who are initially well enough to be at home and to prevent them from getting sick enough to be hospitalized," Dr.

Caline Mattar, assistant professor of medicine in the Division order viagra online of Infectious Diseases, said in the release. "What we've seen so far suggests that fluvoxamine may be an important tool in achieving that goal."Dr. Amesh Adalja is a senior scholar at the Johns Hopkins Center for Health Security order viagra online in Baltimore.

He wasn't involved in the study, but said the research is "notable not only because of its positive outcome -- we desperately need order viagra online a medication that keeps erectile dysfunction treatment patients out of the hospital -- but also because of the manner in which it was conducted."But Adalja stressed that a larger trial is needed "to see if the promising findings hold up."The researchers said they plan to begin such a study in the next few weeks and it will include patients from across the United States.The preliminary study was published online Nov. 12 in the Journal of the American Medical Association.More informationFor more on erectile dysfunction treatment, go to the U.S. Centers for Disease Control and Prevention.SOURCES order viagra online.

Amesh Adalja, M.D., senior scholar, order viagra online Johns Hopkins Center for Health Security, Baltimore. Washington University in St. Louis, news order viagra online release, Nov.

12, 2020Ernie MundellCopyright © order viagra online 2020 HealthDay. All rights reserved. SLIDESHOW Learn to Spot order viagra online Depression.

Symptoms, Warning Signs, Medication See SlideshowLatest order viagra online erectile dysfunction News By Dennis Thompson HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Early erectile dysfunction treatment trial results announced by Pfizer this week caused hopes to soar for a swift end to the viagra that has killed more than 242,000 and infected more than 10 million in the United States alone.But even if the preliminary results released Monday pan out, it will still take many months to produce enough of the treatment to inoculate everyone in the United States, experts warn.The health care industry will also face special distribution challenges related to this particular treatment, which must be maintained in extremely cold storage and delivered in a two-shot regimen."People should be enthusiastic, but realize that the benefits that we get from that treatment are not going to be in the winter, they're not going to be now, in the short range. They're going to be going forward, likely order viagra online in the spring to summer of 2021," said Dr.

Amesh Adalja, a senior scholar with the Johns Hopkins Center for Health Security, in Baltimore."It shouldn't change your approach to the viagra today, tomorrow, next week, next month," he order viagra online added. "We are entering a period of the year where we're seeing intensification of spread all over the country. We need order viagra online to be very vigilant.

The cases are order viagra online getting to the point where they are inundating hospitals in some states. The trajectory of the viagra right now looks very bad for the winter."Adalja's words echo those of President-elect Joe Biden, who lauded news of Pfizer's treatment success but asked Americans to stay vigilant."America is still losing over 1,000 people a day from erectile dysfunction treatment, and that number is rising -- and will continue to get worse unless we make progress on masking and other immediate actions," Biden said on Monday. "That is the reality for now, and for the next order viagra online few months.

Today's announcement promises the chance to change that next year, but the tasks before us now remain the same."'No serious safety order viagra online concerns'The early information from Pfizer -- more than 90% effective -- is extremely encouraging, said Dr. Thad Stappenbeck, head of the Lerner Research Institute at the Cleveland Clinic, in Ohio."It means if you get the treatment, based on their early statistics you have a 90% chance if you encounter the viagra of not being infected, which is remarkable," Stappenbeck said. Pfizer had set a goal of 50% effectiveness for its treatment -- the average effectiveness of the annual order viagra online flu shot.Of more than 43,500 people who got either the treatment or a placebo, there have been 94 confirmed cases of erectile dysfunction treatment, Pfizer said in its early analysis."Nearly all of the new s were in the placebo group," Stappenbeck said.Pfizer needs to spend a few more weeks collecting safety data before it can apply for an emergency use authorization from the U.S.

Food and Drug Administration, but Stappenbeck expressed confidence that the treatment would prove safe."They've now gone from just a few dozen people or a few hundred people now to tens of thousands of people, and no serious safety concerns," he said.Pfizer aims order viagra online to produce up to 50 million doses of the treatment by year's end -- enough to inoculate 25 million people -- and up to 1.3 billion doses in 2021.Pfizer is making the treatment at facilities in Kalamazoo, Mich., and Puurs, Belgium, according to The New York Times. Doses distributed in the United States will mostly come from Kalamazoo.The U.S. Government has placed an initial order for 100 million doses of the treatment, at a cost of $1.95 billion, with an option to buy another 500 million doses, Politico reports."There's a goal of 660 million doses, so order viagra online there's two doses for everyone in the United States that wants one," said Anna Legreid Dopp, senior director of clinical guidelines and quality improvement with the American Society of Health-System Pharmacists (ASHP), in Bethesda, Md.Who's first in line?.

The early doses likely order viagra online will be given to health care workers and first responders, Dopp said, followed by people at high risk for severe erectile dysfunction treatment s.But distributing the doses across the country is expected to be a challenge in and of itself.The treatment has to be stored at around minus 94 degrees Fahrenheit, which is about as cold as it gets at the South Pole on a winter's day. The shot can withstand normal refrigeration only for about 24 hours, and room temperature for no more than two hours after thawing, Politico reports.Creating a "cold chain" of distribution that will keep the treatment frozen until it's time for a person's shot "absolutely is going to be an added burden," Adalja said."This doesn't just need to be kept at ordinary refrigerator temperatures. It needs to be kept at minus 70, minus 80 Centigrade, which is not something that most places have the ability to do no matter where you are in the United order viagra online States, let alone the developing world," Adalja said.These sorts of freezers are common at academic centers, and might even be found at community hospitals, Stappenbeck said.

"These are not order viagra online super expensive. They're $5,000 or $6,000," he added.Major shipping companies United Parcel Service (UPS) and FedEx are scrambling to build freezer farms in major hub cities across the nation, according to The New York Times. Airplanes and trucks also will need to be fitted with freezers.Dopp order viagra online said other innovations are in the works, such as "thermal suitcases that allow some flexibility if you don't have access to a freezer."Two-dose regimenThe other distribution problem that must be solved is timing.

People need to get the treatment in two doses, separated by about a month, Dopp said.Hospitals, doctors and pharmacies order viagra online will need to set up computer systems to track patients and make sure they get their second dose in a timely fashion, Dopp said. Otherwise, they won't get full protection from the treatment, and perhaps none at all.One other concern, 10 other erectile dysfunction treatment candidates are in the final stages of testing, Dopp noted. As they order viagra online get approved, doctors will need to track which patients have received which treatment."A patient can't get one treatment for their first dose and a different treatment from a different manufacturer for their second dose," she said.ASHP was concerned that as hospitals begin handing out the first shots, they would need to keep at least half their initial allotments in reserve so people could get their second shot on time."The answer we received from the U.S.

Centers for Disease Control and Prevention is that they do not, that they will work to provide just-in-time second doses, which I think is encouraging because it does allow for more people to start on their series," Dopp said.More informationLearn more order viagra online about Pfizer's treatment.SOURCES. Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore. Thad Stappenbeck, MD, PhD, chair, Lerner Research Institute, Cleveland order viagra online Clinic, Ohio.

Anna Legreid Dopp, PharmD, senior director, clinical guidelines and quality improvement, American Society of Health-System Pharmacists, Bethesda, Md.. The New York Times. PoliticoCopyright © 2020 HealthDay.

Is viagra safe for 20 year olds

Concord Hospital’s $341 million redevelopment is on track for completion, with the eight-storey Clinical Services Building set to transform healthcare in the inner west.Health Minister Brad Hazzard and Member for Drummoyne John Sidoti visited the site for a traditional topping out http://childrenstherapyassociates.com/?page_id=772 ceremony to mark the building is viagra safe for 20 year olds reaching its highest point. Mr Hazzard said the Clinical Services Building will have more than 200 inpatient is viagra safe for 20 year olds beds, with just over 550 beds across the campus, an increase of more than 100 from previously. €œThe NSW is viagra safe for 20 year olds Government’s $341 million commitment to Concord Hospital has created more than 700 construction jobs to build this modern, state-of-the-art facility,” Mr Hazzard said.

€œNot only does it house the nation’s first dedicated veterans’ health service, a comprehensive cancer centre and an aged care centre, over two-thirds of the new inpatient beds in the new Clinical Services Building are in single rooms with daybeds for carers.” Mr Sidoti said the National Centre for Veterans’ Healthcare has been successfully operating as is viagra safe for 20 year olds a pilot service since August last year. To date 128 people have been referred to the service and 54 have completed their care. €œThis Centre is critical to our veteran community and is viagra safe for 20 year olds continues Concord Hospital’s proud 80-year history of supporting veterans and their families,” viagra cost Mr Sidoti said.

Concord Hospital’s new Clinical is viagra safe for 20 year olds Services Building will include. the Rusty Priest Centre for Rehabilitation and Aged is viagra safe for 20 year olds CareNational Centre for Veterans’ Healthcare a comprehensive Cancer Care Centre with 28 beds and 48 chemotherapy, infusion and haematology chairsa new concourse linking the new building to the existing hospital, providing direct access to operating theatres, radiology and emergency care.Construction of a new $32.4 million multistorey car park will begin following the completion of the Clinical Services Building expected in late 2021. The NSW Government also spent $1.3 million in 2019 refurbishing two theatres at Concord Hospital that are now fully digitally integrated is viagra safe for 20 year olds.

€‹â€‹â€‹The concept design for the new, seven-storey Acute Services Building for John Hunter and John Hunter’s Children’s hospitals has been unveiled, marking a milestone for the NSW Government’s $780 million health precinct.Premier Gladys Berejiklian said the John Hunter Health and Innovation Precinct would drive significant economic growth in the Greater Newcastle region, generating jobs in construction and health.“John Hunter hospital is one of the busiest hospitals in NSW and this investment will provide enhanced health facilities ensuring the region has a world-class hospital to cater to its growing population,” Ms Berejiklian said.“Construction of the precinct will support more than 3,000 jobs over the life of the project helping stimulate the economy, a key component of the NSW Government’s erectile dysfunction treatment recovery plan.”Health Minister Brad Hazzard said the redevelopment will significantly increase critical care capacity, with a 60 per cent increase in the Intensive Care Unit capacity and almost 50 per cent more theatres, interventional suites and procedural spaces.“The Precinct will drive innovative collaborations between the health, education and research sectors, ultimately improving patient outcomes for communities in the Hunter region,” Mr Hazzard said.The new Acute Services Building will include:a new emergency departmentcritical care services (adult and paediatric)operating theatres, interventional and imaging servicesbirthing suite and inpatient maternity unitneonatal intensive care and special care nurserylarger and redeveloped inpatient units androoftop helipad.Stage 1 of an interim Emergency Department expansion has also been completed early as part of NSW Government’s erectile dysfunction treatment response.“I’m also pleased the Emergency Department expansion was delivered five months ahead of schedule, providing an additional 12 dedicated paediatric treatment areas and additional capacity to deal with the viagra, with Stage 2 scheduled for completion early next year,” Mr Hazzard said.Parliamentary Secretary for the Hunter, Catherine Cusack, said the new Acute Services Building will serve the Hunter region for many years to come.“This is a great opportunity to share the future vision of the Precinct, which will transform health care in the Hunter, bringing expanded, enhanced health services closer to home,” Ms Cusack said.Early works on the new Acute Services Building are expected to commence in 2021 with main works construction scheduled to commence in 2022..

Concord Hospital’s $341 million redevelopment is on track for completion, with the eight-storey Clinical Services Building set to transform healthcare in the inner west.Health Minister Brad Hazzard and Member for Drummoyne generic viagra prices John Sidoti visited the site for a traditional topping out ceremony to order viagra online mark the building reaching its highest point. Mr Hazzard order viagra online said the Clinical Services Building will have more than 200 inpatient beds, with just over 550 beds across the campus, an increase of more than 100 from previously. €œThe NSW Government’s $341 million commitment order viagra online to Concord Hospital has created more than 700 construction jobs to build this modern, state-of-the-art facility,” Mr Hazzard said. €œNot only does it house the nation’s first dedicated veterans’ order viagra online health service, a comprehensive cancer centre and an aged care centre, over two-thirds of the new inpatient beds in the new Clinical Services Building are in single rooms with daybeds for carers.” Mr Sidoti said the National Centre for Veterans’ Healthcare has been successfully operating as a pilot service since August last year.

To date 128 people have been referred to the service and 54 have completed their care. €œThis Centre is critical to our veteran community and continues Concord Hospital’s proud 80-year history order viagra online of supporting veterans and their families,” Mr Sidoti said. Concord Hospital’s new Clinical Services Building will order viagra online include. the Rusty Priest Centre for Rehabilitation and Aged CareNational Centre for Veterans’ Healthcare order viagra online a comprehensive Cancer Care Centre with 28 beds and 48 chemotherapy, infusion and haematology chairsa new concourse linking the new building to the existing hospital, providing direct access to operating theatres, radiology and emergency care.Construction of a new $32.4 million multistorey car park will begin following the completion of the Clinical Services Building expected in late 2021.

The NSW Government also spent $1.3 million in 2019 refurbishing two theatres order viagra online at Concord Hospital that are now fully digitally integrated. €‹â€‹â€‹The concept design for the new, seven-storey Acute Services Building for John Hunter and John Hunter’s Children’s hospitals has been unveiled, marking a milestone for the NSW Government’s $780 million health precinct.Premier Gladys Berejiklian said the John Hunter Health and Innovation Precinct would drive significant economic growth in the Greater Newcastle region, generating jobs in construction and health.“John Hunter hospital is one of the busiest hospitals in NSW and this investment will provide enhanced health facilities ensuring the region has a world-class hospital to cater to its growing population,” Ms Berejiklian said.“Construction of the precinct will support more than 3,000 jobs over the life of the project helping stimulate the economy, a key component of the NSW Government’s erectile dysfunction treatment recovery plan.”Health Minister Brad Hazzard said the redevelopment will significantly increase critical care capacity, with a 60 per cent increase in the Intensive Care Unit capacity and almost 50 per cent more theatres, interventional suites and procedural spaces.“The Precinct will drive innovative collaborations between the health, education and research sectors, ultimately improving patient outcomes for communities in the Hunter region,” Mr Hazzard said.The new Acute Services Building will include:a new emergency departmentcritical care services (adult and paediatric)operating theatres, interventional and imaging servicesbirthing suite and inpatient maternity unitneonatal intensive care and special care nurserylarger and redeveloped inpatient units androoftop helipad.Stage 1 of an interim Emergency Department expansion has also been completed early as part of NSW Government’s erectile dysfunction treatment response.“I’m also pleased the Emergency Department expansion was delivered five months ahead of schedule, providing an additional 12 dedicated paediatric treatment areas and additional capacity to deal with the viagra, with Stage 2 scheduled for completion early next year,” Mr Hazzard said.Parliamentary Secretary for the Hunter, Catherine Cusack, said the new Acute Services Building will serve the Hunter region for many years to come.“This is a great opportunity to share the future vision of the Precinct, which will transform health care in the Hunter, bringing expanded, enhanced health services closer to home,” Ms Cusack said.Early works on the new Acute Services Building are expected to commence in 2021 with main works construction scheduled to commence in 2022..

Viagra pills for men

The Centers for Disease Control and Prevention (CDC), located within the Department of Health and Human Services (HHS) announces the award of viagra pills for men approximately $26,000,000 in erectile dysfunction treatment funding to the Council of Medical Specialty Societies (CMSS) and the Society for Post-Acute and Long-Term Care Medicine (AMDA) to address the need to incorporate adult vaccination into the standard of care for subspecialty providers, including occupational health and long term care (LTC), and improve adult vaccination rates. The period for this award will be September 30, 2021 through September 29, 2026. Start Further Info Amy Parker Fiebelkorn, MSN, MPH CAPT, U.S. Public Health Services, National Center for Immunization and Respiratory Diseases, viagra pills for men Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-H24-8, Atlanta, GA 30329, Telephone. 800-232-6348, Email.

Dez8@cdc.gov. End Further Info End Preamble Start Supplemental Information The single-source awards will increase erectile dysfunction treatment, influenza, and routine adult vaccination coverage in viagra pills for men adults with chronic medical conditions, in occupational health clinics, and in adults working and residing in long-term care (LTC) facilities. The Council of Medical Specialty Societies (CMSS) and the Society for Post-Acute and Long-Term Care Medicine (AMDA) will incorporate adult vaccination into the standard of care for subspecialty providers (including occupational health and LTC). CMSS will focus on activities leading to adoption of the Standards for Adult Immunization Practice in its 45 societies, and AMDA will focus on the same with its affiliate organization, the Foundation for Post-Acute and Long-Term Care Medicine. CMSS and AMDA will develop/update treatment policy statements, develop/promote continuing education on adult immunization for viagra pills for men their membership, and award funds to up to 7 subspecialty societies (for CMSS) and to the Foundation (for AMDA) to systematize routine delivery of adult immunizations.

The funded subrecipients (i.e., CMSS subspecialty societies and AMDA's Foundation) should also fund staff at the national level and in regional chapters to update vaccination policies and encourage use of adult vaccinations as quality measures. Funded CMSS subspecialty societies and AMDA's Foundation should also contract with 7-10 Start Printed Page 49536healthcare systems or 7-10 LTC chains each, respectively, to implement adult immunization quality improvement interventions. Summary of viagra pills for men the Award Recipient. Council of Medical Specialty Societies (CMSS) and the Society for Post-Acute and Long-Term Care Medicine (AMDA). Purpose of the Award.

The purpose of these awards is to increase erectile dysfunction treatment, influenza, and routine treatments in adults with chronic medical conditions (e.g., COPD, asthma, diabetes, heart disease, cancer, and renal disease), increase workplace vaccination (occupational health settings), and increase vaccination among adults working and residing in LTCFs through implementation of immunization quality improvement interventions. CMSS will focus viagra pills for men on activities leading to adoption of the Standards for Adult Immunization Practice in its 45 societies. AMDA will focus on the same with its affiliate organization, the Foundation for Post-Acute and Long-Term Care Medicine. CMSS and AMDA will develop/update treatment policy statements, develop/promote continuing education on adult immunization for their membership, and award funds to up to 7 subspecialty societies (for CMSS) and to the Foundation (for AMDA) to systematize routine delivery of adult immunizations. CMSS-funded subspecialty societies and AMDA's Foundation should fund staff at the national level and in regional chapters to update vaccination policies and encourage viagra pills for men use of adult vaccinations as quality measures.

CMSS subspecialty societies and AMDA's Foundation should also contract with 7-10 healthcare systems or 7-10 LTC chains each, respectively, to implement adult immunization quality improvement interventions. Amount of Award. $26,000,000 in Federal Fiscal Year (FFY) 2021 funds, and an estimated total of $66,000,000 over viagra pills for men the five-year period of performance. Period of Performance. September 30, 2021 through September 29, 2026.

Start Signature Dated. August 30, 2021. Joseph I. Hungate III, Deputy Director, Office of Financial Resources, Office of the Chief Operating Officer, Centers for Disease Control and Prevention. End Signature End Supplemental Information [FR Doc.

2021-19050 Filed 9-2-21. 8:45 am]BILLING CODE 4163-18-P.

Start Preamble Centers for Disease Control and Prevention (CDC), Department order viagra online of Health and Human Services (HHS). Notice. The Centers for Disease Control and Prevention (CDC), located within the Department of Health and Human Services (HHS) announces the award of approximately $26,000,000 in erectile dysfunction treatment funding to the Council of Medical Specialty Societies (CMSS) and the Society for Post-Acute and Long-Term Care Medicine (AMDA) to address the need to incorporate adult vaccination into the standard of care for subspecialty providers, including occupational health and long term care (LTC), and improve adult vaccination rates.

The period for this order viagra online award will be September 30, 2021 through September 29, 2026. Start Further Info Amy Parker Fiebelkorn, MSN, MPH CAPT, U.S. Public Health Services, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-H24-8, Atlanta, GA 30329, Telephone.

800-232-6348, Email order viagra online. Dez8@cdc.gov. End Further Info End Preamble Start Supplemental Information The single-source awards will increase erectile dysfunction treatment, influenza, and routine adult vaccination coverage in adults with chronic medical conditions, in occupational health clinics, and in adults working and residing in long-term care (LTC) facilities.

The Council of Medical Specialty Societies (CMSS) and the Society for Post-Acute and Long-Term Care Medicine (AMDA) will incorporate adult vaccination into the standard of care for subspecialty order viagra online providers (including occupational health and LTC). CMSS will focus on activities leading to adoption of the Standards for Adult Immunization Practice in its 45 societies, and AMDA will focus on the same with its affiliate organization, the Foundation for Post-Acute and Long-Term Care Medicine. CMSS and AMDA will develop/update treatment policy statements, develop/promote continuing education on adult immunization for their membership, and award funds to up to 7 subspecialty societies (for CMSS) and to the Foundation (for AMDA) to systematize routine delivery of adult immunizations.

The funded subrecipients (i.e., CMSS subspecialty societies and AMDA's Foundation) should also fund staff at the national level and in regional chapters to update vaccination policies and encourage use of adult vaccinations order viagra online as quality measures. Funded CMSS subspecialty societies and AMDA's Foundation should also contract with 7-10 Start Printed Page 49536healthcare systems or 7-10 LTC chains each, respectively, to implement adult immunization quality improvement interventions. Summary of the Award Recipient.

Council of Medical Specialty Societies (CMSS) and the Society for Post-Acute and Long-Term Care Medicine (AMDA). Purpose order viagra online of the Award. The purpose of these awards is to increase erectile dysfunction treatment, influenza, and routine treatments in adults with chronic medical conditions (e.g., COPD, asthma, diabetes, heart disease, cancer, and renal disease), increase workplace vaccination (occupational health settings), and increase vaccination among adults working and residing in LTCFs through implementation of immunization quality improvement interventions.

CMSS will focus on activities leading to adoption of the Standards for Adult Immunization Practice in its 45 societies. AMDA will focus on the same order viagra online with its affiliate organization, the Foundation for Post-Acute and Long-Term Care Medicine. CMSS and AMDA will develop/update treatment policy statements, develop/promote continuing education on adult immunization for their membership, and award funds to up to 7 subspecialty societies (for CMSS) and to the Foundation (for AMDA) to systematize routine delivery of adult immunizations.

CMSS-funded subspecialty societies and AMDA's Foundation should fund staff at the national level and in regional chapters to update vaccination policies and encourage use of adult vaccinations as quality measures. CMSS subspecialty societies and AMDA's Foundation should order viagra online also contract with 7-10 healthcare systems or 7-10 LTC chains each, respectively, to implement adult immunization quality improvement interventions. Amount of Award.

$26,000,000 in Federal Fiscal Year (FFY) 2021 funds, and an estimated total of $66,000,000 over the five-year period of performance. Period of Performance. September 30, 2021 through September 29, 2026.

Start Signature Dated. August 30, 2021. Joseph I.

Hungate III, Deputy Director, Office of Financial Resources, Office of the Chief Operating Officer, Centers for Disease Control and Prevention. End Signature End Supplemental Information [FR Doc.

Losartan and viagra

How to cite this article:Singh losartan and viagra http://racheljenae.com/journal/jackson-hole/ OP. Psychiatry research in India. Closing the research gap losartan and viagra. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science.

Research in India in general and medical research in particular is always losartan and viagra being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions. Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the losartan and viagra mark and is not commensurate with the magnitude of the disease burden in India.

According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere may not be generalized losartan and viagra to the Indian population owing to differences in biology, health-care systems, health practices, culture, and socioeconomic standards. Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research.

While ICMR losartan and viagra has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research losartan and viagra in India are conducted in medical institutions. The majority of these are done as thesis submission for fulfillment of the requirement of PG degree.

From 2015 onward, publication of papers had been made an obligatory requirement for promotion of losartan and viagra faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore losartan and viagra.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments.

While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country. The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes.

Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure. They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work.

Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications. For example, work on artificial intelligence for mental health.

Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk – the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J.

Updated science-wide author databases of standardized citation indicators. PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim.

The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies. Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme.

Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords.

India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK. Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population.

The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution. They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services.

Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research. Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature.

Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results.

Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated. A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail.

Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality. The CASP shows that out of the 32 studies, the sample size of 21 studies was not representative, sample size of 7 studies was not justified, risk factors were not identified in 28 studies, methods used were not sufficiently described to repeat them in 24 studies, and nonresponse reasons were not addressed in 24 studies. The most common reasons for studies to be of poor-quality included sample size not justified.

Sample is not representative. Nonresponse not addressed. Risk factors not measured correctly. And methods used were not sufficiently described to repeat them.

Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment.

It was observed that wages were used to buy opium. In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women.

This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms. In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together.

Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%). Suicides were associated with depression, anxiety, alcoholism, and eating disorders.

Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers.

Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India. Three-fourth of the children were the first-born child. None of the parents of children with Down syndrome had consanguineous marriage or a history of Down syndrome, intellectual disability, or any other neurological disorder such as cerebral palsy and epilepsy in preceding generations. It is known that tribal population is highly impoverished and disadvantaged in several ways and suffer proportionately higher burden of nutritional and genetic disorders, which are potential factors for Down syndrome.[30]Access to mental health-care servicesIn a study in Ranchi district of Jharkhand, it was found that most people consulted faith healers rather than qualified medical practitioners.

There are few mental health services in the regions.[31] Among ST population, there was less reliance and belief in modern medicine, and it was also not easily accessible, thus the health-care systems must be more holistic and take care of cultural and local health practices.[32]The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health project was implemented in thirty ST villages in West Godavari District of Andhra Pradesh. The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population. The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention.

The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment. Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care.

Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men.

This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors. The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available.

All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles. Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively.

The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date. Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders.

There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder.

Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization. Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings.

Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously. Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population. And use qualitative research to investigate the perceptions and barriers for help-seeking behavior.[48] Conclusion The current review helps not only to collate the existing literature on the mental health of ST communities but also identify gaps in knowledge and provide some indications about the type of research that should be funded in future.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.

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Prevalence and dependancy of tobacco use in an indigenous population of Kerala, India. Oral Hygiene and Health 2016;4:1 23.Manimunda SP, Benegal V, Sugunan AP, Jeemon P, Balakrishna N, Thennarusu K, et al. Tobacco use and nicotine dependency in a cross-sectional representative sample of 18,018 individuals in Andaman and Nicobar Islands, India. BMC Public Health 2012;12:515.

24.Singh PK, Singh RK, Biswas A, Rao VR. High rate of suicide attempt and associated psychological traits in an isolated tribal population of North-East India. J Affect Dis 2013;151:673-8. 25.Sushila J.

Perception of Illness and Health Care among Bhils. A Study of Udaipur District in Southern Rajasthan. 2005. 26.Sobhanjan S, Mukhopadhyay B.

Perceived psychosocial stress and cardiovascular risk. Observations among the Bhutias of Sikkim, India. Stress Health 2008;24:23-34. 27.Ali A, Eqbal S.

Mental Health status of tribal school going adolescents. A study from rural community of Ranchi, Jharkhand. Telangana J Psychiatry 2016;2:38-41. 28.Diwan R.

Stress and mental health of tribal and non tribal female school teachers in Jharkhand, India. Int J Sci Res Publicat 2012;2:2250-3153. 29.Longkumer I, Borooah PI. Knowledge about attitudes toward mental disorders among Nagas in North East India.

IOSR J Humanities Soc Sci 2013;15:41-7. 30.Lakhan R, Kishore MT. Down syndrome in tribal population in India. A field observation.

J Neurosci Rural Pract 2016;7:40-3. [PUBMED] [Full text] 31.Nizamie HS, Akhtar S, Banerjee S, Goyal N. Health care delivery model in epilepsy to reduce treatment gap. WHO study from a rural tribal population of India.

Epilepsy Res Elsevier 2009;84:146-52. 32.Prabhakar H, Manoharan R. The Tribal Health Initiative model for healthcare delivery. A clinical and epidemiological approach.

Natl Med J India 2005;18:197-204. 33.Nimgaonkar AU, Menon SD. A task shifting mental health program for an impoverished rural Indian community. Asian J Psychiatr 2015;16:41-7.

34.Yalsangi M. Evaluation of a Community Mental Health Programme in a Tribal Area- South India. Achutha Menon Centre For Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Working Paper No 12. 2012.

35.Tripathy P, Nirmala N, Sarah B, Rajendra M, Josephine B, Shibanand R, et al. Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India. A cluster-randomised controlled trial. Lancet 2010;375:1182-92.

36.Aparajita C, Anita KM, Arundhati R, Chetana P. Assessing Social-support network among the socio culturally disadvantaged children in India. Early Child Develop Care 1996;121:37-47. 37.Chowdhury AN, Mondal R, Brahma A, Biswas MK.

Eco-psychiatry and environmental conservation. Study from Sundarban Delta, India. Environ Health Insights 2008;2:61-76. 38.Jeffery GS, Chakrapani U.

Eco-psychiatry and Environmental Conservation. Study from Sundarban Delta, India. Working Paper- Research Gate.net. September, 2016.

39.Ozer S, Acculturation, adaptation, and mental health among Ladakhi College Students a mixed methods study of an indigenous population. J Cross Cultl Psychol 2015;46:435-53. 40.Giri DK, Chaudhary S, Govinda M, Banerjee A, Mahto AK, Chakravorty PK. Utilization of psychiatric services by tribal population of Jharkhand through community outreach programme of RINPAS.

Eastern J Psychiatry 2007;10:25-9. 41.Nandi DN, Banerjee G, Chowdhury AN, Banerjee T, Boral GC, Sen B. Urbanization and mental morbidity in certain tribal communities in West Bengal. Indian J Psychiatry 1992;34:334-9.

[PUBMED] [Full text] 42.Hackett RJ, Sagdeo D, Creed FH. The physical and social associations of common mental disorder in a tribal population in South India. Soc Psychiatry Psychiatr Epidemiol 2007;42:712-5. 43.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A.

Development of a cognitive screening instrument for tribal elderly population of Himalayan region in northern India. J Neurosci Rural Pract 2013;4:147-53. [PUBMED] [Full text] 44.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A. Identifying risk for dementia across populations.

A study on the prevalence of dementia in tribal elderly population of Himalayan region in Northern India. Ann Indian Acad Neurol 2013;16:640-4. [PUBMED] [Full text] 45.Raina SK, Chander V, Raina S, Kumar D. Feasibility of using everyday abilities scale of India as alternative to mental state examination as a screen in two-phase survey estimating the prevalence of dementia in largely illiterate Indian population.

Indian J Psychiatry 2016;58:459-61. [PUBMED] [Full text] 46.Diwan R. Mental health of tribal male-female factory workers in Jharkhand. IJAIR 2012;2278:234-42.

47.Banerjee T, Mukherjee SP, Nandi DN, Banerjee G, Mukherjee A, Sen B, et al. Psychiatric morbidity in an urbanized tribal (Santal) community - A field survey. Indian J Psychiatry 1986;28:243-8. [PUBMED] [Full text] 48.Leske S, Harris MG, Charlson FJ, Ferrari AJ, Baxter AJ, Logan JM, et al.

Systematic review of interventions for Indigenous adults with mental and substance use disorders in Australia, Canada, New Zealand and the United States. Aust N Z J Psychiatry 2016;50:1040-54. 49.Pollock NJ, Naicker K, Loro A, Mulay S, Colman I. Global incidence of suicide among Indigenous peoples.

A systematic review. BMC Med 2018;16:145. 50.Silburn K, et al. Evaluation of the Cooperative Research Centre for Aboriginal Health (Australian institute for primary care, trans.).

Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

How to cite this order viagra online article:Singh where to buy viagra pills OP. Psychiatry research in India. Closing the research gap order viagra online. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science.

Research in India in general and medical research in particular order viagra online is always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions. Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy order viagra online or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India.

According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere may not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, order viagra online culture, and socioeconomic standards. Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research.

While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on biomedical research which is order viagra online 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical order viagra online institutions. The majority of these are done as thesis submission for fulfillment of the requirement of PG degree.

From 2015 onward, publication of papers order viagra online had been made an obligatory requirement for promotion of faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore order viagra online.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments.

While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country. The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes.

Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure. They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work.

Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications. For example, work on artificial intelligence for mental health.

Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk – the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J.

Updated science-wide author databases of standardized citation indicators. PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim.

The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies. Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme.

Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords.

India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK. Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population.

The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution. They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services.

Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research. Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature.

Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results.

Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated. A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail.

Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality. The CASP shows that out of the 32 studies, the sample size of 21 studies was not representative, sample size of 7 studies was not justified, risk factors were not identified in 28 studies, methods used were not sufficiently described to repeat them in 24 studies, and nonresponse reasons were not addressed in 24 studies. The most common reasons for studies to be of poor-quality included sample size not justified.

Sample is not representative. Nonresponse not addressed. Risk factors not measured correctly. And methods used were not sufficiently described to repeat them.

Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment.

It was observed that wages were used to buy opium. In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women.

This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms. In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together.

Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%). Suicides were associated with depression, anxiety, alcoholism, and eating disorders.

Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers.

Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India. Three-fourth of the children were the first-born child. None of the parents of children with Down syndrome had consanguineous marriage or a history of Down syndrome, intellectual disability, or any other neurological disorder such as cerebral palsy and epilepsy in preceding generations. It is known that tribal population is highly impoverished and disadvantaged in several ways and suffer proportionately higher burden of nutritional and genetic disorders, which are potential factors for Down syndrome.[30]Access to mental health-care servicesIn a study in Ranchi district of Jharkhand, it was found that most people consulted faith healers rather than qualified medical practitioners.

There are few mental health services in the regions.[31] Among ST population, there was less reliance and belief in modern medicine, and it was also not easily accessible, thus the health-care systems must be more holistic and take care of cultural and local health practices.[32]The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health project was implemented in thirty ST villages in West Godavari District of Andhra Pradesh. The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population. The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention.

The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment. Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care.

Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men.

This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors. The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available.

All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles. Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively.

The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date. Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders.

There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder.

Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization. Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings.

Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously. Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population. And use qualitative research to investigate the perceptions and barriers for help-seeking behavior.[48] Conclusion The current review helps not only to collate the existing literature on the mental health of ST communities but also identify gaps in knowledge and provide some indications about the type of research that should be funded in future.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.

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Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].